1
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Pfeffer MA, Kohs TC, Vu HH, Jordan KR, Wang JSH, Lorentz CU, Tucker EI, Puy C, Olson SR, DeLoughery TG, Hinds MT, Keshari RS, Gailani D, Lupu F, McCarty OJ, Shatzel JJ. Factor XI Inhibition for the Prevention of Catheter-Associated Thrombosis in Patients With Cancer Undergoing Central Line Placement: A Phase 2 Clinical Trial. Arterioscler Thromb Vasc Biol 2024; 44:290-299. [PMID: 37970718 PMCID: PMC10877270 DOI: 10.1161/atvbaha.123.319692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 10/24/2023] [Indexed: 11/17/2023]
Abstract
BACKGROUND Despite the ubiquitous utilization of central venous catheters in clinical practice, their use commonly provokes thromboembolism. No prophylactic strategy has shown sufficient efficacy to justify routine use. Coagulation factors FXI (factor XI) and FXII (factor XII) represent novel targets for device-associated thrombosis, which may mitigate bleeding risk. Our objective was to evaluate the safety and efficacy of an anti-FXI mAb (monoclonal antibody), gruticibart (AB023), in a prospective, single-arm study of patients with cancer receiving central line placement. METHODS We enrolled ambulatory cancer patients undergoing central line placement to receive a single dose of gruticibart (2 mg/kg) administered through the venous catheter within 24 hours of placement and a follow-up surveillance ultrasound at day 14 for evaluation of catheter thrombosis. A parallel, noninterventional study was used as a comparator. RESULTS In total, 22 subjects (n=11 per study) were enrolled. The overall incidence of catheter-associated thrombosis was 12.5% in the interventional study and 40.0% in the control study. The anti-FXI mAb, gruticibart, significantly prolonged the activated partial thromboplastin time in all subjects on day 14 compared with baseline (P<0.001). Gruticibart was well tolerated and without infusion reactions, drug-related adverse events, or clinically relevant bleeding. Platelet flow cytometry demonstrated no difference in platelet activation following administration of gruticibart. T (thrombin)-AT (antithrombin) and activated FXI-AT complexes increased following central line placement in the control study, which was not demonstrated in our intervention study. CRP (C-reactive protein) did not significantly increase on day 14 in those who received gruticibart, but it did significantly increase in the noninterventional study. CONCLUSIONS FXI inhibition with gruticibart was well tolerated without any significant adverse or bleeding-related events and resulted in a lower incidence of catheter-associated thrombosis on surveillance ultrasound compared with the published literature and our internal control study. These findings suggest that targeting FXI could represent a safe intervention to prevent catheter thrombosis. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT04465760.
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Affiliation(s)
- Michael A. Pfeffer
- Division of Hematology and Medical Oncology, Oregon Health
& Science University, Portland, OR
| | - Tia C.L. Kohs
- Department of Biomedical Engineering, Oregon Health &
Science University, Portland, OR
| | - Helen H. Vu
- Department of Biomedical Engineering, Oregon Health &
Science University, Portland, OR
| | - Kelley R. Jordan
- Department of Biomedical Engineering, Oregon Health &
Science University, Portland, OR
| | - Jenny Si Han Wang
- Department of Biomedical Engineering, Oregon Health &
Science University, Portland, OR
| | - Christina U. Lorentz
- Department of Biomedical Engineering, Oregon Health &
Science University, Portland, OR
- Aronora, Inc., Portland, OR
| | - Erik I. Tucker
- Department of Biomedical Engineering, Oregon Health &
Science University, Portland, OR
- Aronora, Inc., Portland, OR
| | - Cristina Puy
- Department of Biomedical Engineering, Oregon Health &
Science University, Portland, OR
| | - Sven R. Olson
- Division of Hematology and Medical Oncology, Oregon Health
& Science University, Portland, OR
| | - Thomas G. DeLoughery
- Division of Hematology and Medical Oncology, Oregon Health
& Science University, Portland, OR
| | - Monica T. Hinds
- Department of Biomedical Engineering, Oregon Health &
Science University, Portland, OR
| | - Ravi S. Keshari
- Cardiovascular Biology Research Program, Oklahoma Medical
Research Foundation, Oklahoma City, OK
| | - David Gailani
- Department of Pathology, Microbiology and Immunology,
Vanderbilt University Medical Center, Nashville, TN
| | - Florea Lupu
- Cardiovascular Biology Research Program, Oklahoma Medical
Research Foundation, Oklahoma City, OK
| | - Owen J.T. McCarty
- Department of Biomedical Engineering, Oregon Health &
Science University, Portland, OR
| | - Joseph J. Shatzel
- Division of Hematology and Medical Oncology, Oregon Health
& Science University, Portland, OR
- Department of Biomedical Engineering, Oregon Health &
Science University, Portland, OR
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2
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Santagata D, Donadini MP, Ageno W. Factor XI inhibitors for the prevention of cardiovascular disease: A new therapeutic approach on the horizon? Blood Rev 2023; 62:101119. [PMID: 37580207 DOI: 10.1016/j.blre.2023.101119] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 08/06/2023] [Accepted: 08/08/2023] [Indexed: 08/16/2023]
Abstract
Anticoagulant drugs that are currently used to prevent and/or treat thrombosis have some limitations that hinder their ability to meet specific clinical requirements. While these drugs effectively reduce the rates of thrombotic events, they simultaneously increase the risk of bleeding. Moreover, their risk-to-benefit balance is problematic in some patients, such as those with severe chronic kidney disease or those at high bleeding risk. A novel anticoagulation method, FXI inhibition has emerged as a promising alternative. It demonstrates a strong rationale for the prevention and treatment of venous thromboembolism and the potential fulfillment of unmet clinical needs in the cardiovascular field. A number of FXI inhibitors are currently undergoing clinical investigation. The objective of this review is to provide an overview of early results of research on FXI inhibitors in the cardiovascular setting, offering valuable insights into their potential role in shaping the future of anticoagulation.
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Affiliation(s)
- D Santagata
- Research Center on Thromboembolic Diseases and Antithrombotic Therapies, Department of Medicine and Surgery, University of Insubria, Varese, Italy.
| | - M P Donadini
- Research Center on Thromboembolic Diseases and Antithrombotic Therapies, Department of Medicine and Surgery, University of Insubria, Varese, Italy.
| | - W Ageno
- Research Center on Thromboembolic Diseases and Antithrombotic Therapies, Department of Medicine and Surgery, University of Insubria, Varese, Italy.
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3
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Cohen O, Ageno W. Coming soon to a pharmacy near you? FXI and FXII inhibitors to prevent or treat thromboembolism. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2022; 2022:495-505. [PMID: 36485148 PMCID: PMC9821115 DOI: 10.1182/hematology.2022000386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
Anticoagulants have been in use for nearly a century for the treatment and prevention of venous and arterial thromboembolic disorders. The most dreaded complication of anticoagulant treatment is the occurrence of bleeding, which may be serious and even life-threatening. All available anticoagulants, which target either multiple coagulation factors or individual components of the tissue factor (TF) factor VIIa or the common pathways, have the potential to affect hemostasis and thus to increase bleeding risk in treated patients. While direct oral anticoagulants introduced an improvement in care for eligible patients in terms of safety, efficacy, and convenience of treatment, there remain unmet clinical needs for patients requiring anticoagulant drugs. Anticoagulant therapy is sometimes avoided for fear of hemorrhagic complications, and other patients are undertreated due to comorbidities and the perception of increased bleeding risk. Evidence suggests that the contact pathway of coagulation has a limited role in initiating physiologic in vivo coagulation and that it contributes to thrombosis more than it does to hemostasis. Because inhibition of the contact pathway is less likely to promote bleeding, it is an attractive target for the development of anticoagulants with improved safety. Preclinical and early clinical data indicate that novel agents that selectively target factor XI or factor XII can reduce venous and arterial thrombosis without an increase in bleeding complications.
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Affiliation(s)
- Omri Cohen
- National Hemophilia Center, Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel-Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Israel
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
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4
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Park S, Gu JY, Kim HK. Contact system activation in disseminated intravascular coagulation: activities of prekallikrein and high-molecular-weight kininogen are significant risk factors. J Thromb Thrombolysis 2022; 54:11-14. [PMID: 34993714 DOI: 10.1007/s11239-021-02598-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/25/2021] [Indexed: 11/25/2022]
Abstract
The contact system activation can play a role in microthrombus formation of disseminated intravascular coagulation (DIC). This study investigated whether the activity of prekallikrein and high-molecular-weight kininogen (HMWK) correlated DIC progression. Contact system factors (prekallikrein, HMWK, activated factor XII), coagulation factors (IX, XI, XII) and tissue factor were measured in 140 patients who clinically suspected of having DIC. Prekallikrein and HMWK activity levels showed significant linear relationships with DIC score and antithrombin level, whereas prekallikrein and HMWK antigen levels did not. The activated factor XII, factor XII, factor XI and tissue factor were significant risk factors of overt-DIC. This finding suggests that consumption of prekallikrein and HMWK contributes to microvascular thrombosis in DIC. Measurements of prekallikrein and HMWK activity could be used as potential diagnostic markers for overt-DIC.
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Affiliation(s)
- Sooyong Park
- Department of Laboratory Medicine and Cancer Research Institute, Seoul National University College of Medicine, 101, Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Ja-Yoon Gu
- Department of Laboratory Medicine and Cancer Research Institute, Seoul National University College of Medicine, 101, Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.,Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hyun Kyung Kim
- Department of Laboratory Medicine and Cancer Research Institute, Seoul National University College of Medicine, 101, Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea. .,Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea.
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5
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Morrison JM, Betensky M, Kiskaddon AL, Goldenberg NA. Venous Thromboembolism among Noncritically Ill Hospitalized Children: Key Considerations for the Pediatric Hospital Medicine Specialist. Semin Thromb Hemost 2021; 48:434-445. [PMID: 33962474 DOI: 10.1055/s-0041-1729170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Venous thromboembolism (VTE) is a leading cause of morbidity and preventable harm among noncritically ill hospitalized children. Several clinical factors relevant to the noncritically ill hospitalized child significantly increase the risk of VTE including the presence of central venous catheters, systemic inflammation, and prolonged immobilization. Although risk mitigation strategies have been described, the diagnosis, treatment, and prevention of VTE require standardization of institutional practices combined with multidisciplinary collaboration among pediatric hospitalists, hematologists, and other care providers. In this narrative review, we summarize the epidemiology of VTE, risk models identifying high-risk conditions associated with VTE, and prevention and treatment strategies. We further describe successful quality improvement efforts implementing institutional VTE risk stratification and thromboprophylaxis procedures. Finally, we highlight unique challenges facing pediatric hospital medicine specialists in the era of the COVID-19 pandemic, including caring for adults admitted to pediatric hospital units, and describe future research opportunities for VTE in the noncritically ill hospitalized child.
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Affiliation(s)
- John M Morrison
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Division of Pediatric Hospital Medicine, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Marisol Betensky
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Division of Pediatric Hematology, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Amy L Kiskaddon
- Department of Pharmacy, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Neil A Goldenberg
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Division of Pediatric Hematology, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
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6
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Meng Y, Yin Q, Ma Q, Qin H, Zhang J, Zhang B, Pang H, Tian H. FXII regulates the formation of deep vein thrombosis via the PI3K/AKT signaling pathway in mice. Int J Mol Med 2021; 47:87. [PMID: 33760144 PMCID: PMC8018183 DOI: 10.3892/ijmm.2021.4920] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Accepted: 01/29/2021] [Indexed: 12/12/2022] Open
Abstract
Deep vein thrombosis (DVT) is a common peripheral vascular disease, which may result in pulmonary embolism and is accompanied by endothelial injury. However, the pathogenesis of DVT remains unclear. Coagulation factor XII (FXII), as an important coagulation factor, has been reported to be closely associated with thrombosis. However, the association between FXII protein and DVT formation is not yet fully understood. The present study examined the effects of FXII protein on DVT formation and aimed to reveal the underlying mechanism. In the present study, histological characterization of the femoral vein tissue was examined by hematoxylin and eosin staining. The damage to the femoral vein tissue was examined by TUNEL assay. Superoxide dismutase (SOD) and malondialdehyde (MDA) concentrations were examined using ELISA. Tumor necrosis factor (TNF)‑α, interleukin (IL)‑6, IL‑8 and phosphoinositide 3‑kinase (PI3K)/AKT signaling were determined by ELISA, immunohistochemical staining and western blot analysis. The results demonstrated that thrombosis, FXII protein, cell apoptosis and the SOD concentrations were decreased, while the MDA concentrations were increased in mice with DVT compared with the control or sham groups. TNF‑α, IL‑6, IL‑8 and PI3K/AKT signaling was also upregulated in the mice with DVT. Furthermore, the knockdown of FXII significantly upregulated the SOD concentrations and downregulated thrombosis and cell apoptosis, as well as the MDA concentrations in mice with DVT. The knockdown of FXII also significantly downregulated the protein expression of TNF‑α, IL‑6 and IL‑8, and the activation of PI3K/AKT signaling. Additionally, LY294002 pre‑treatment markedly downregulated thrombosis and cell apoptosis and the MDA content, whereas it upregulated the SOD concentrations in mice with DVT. LY294002 pre‑treatment also significantly downregulated the TNF‑α, IL‑6 and IL‑8 protein levels. Taken together, the present study demonstrates that FXII protein promotes DVT via the activation of PI3K/AKT signaling by inducing an inflammatory response. Targeting FXII protein may thus prove to be a potential approach for the treatment of DVT.
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Affiliation(s)
- Yan Meng
- Department of Peripheral Vascular Diseases, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China
| | - Qian Yin
- Department of Peripheral Vascular Diseases, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China
| | - Qiang Ma
- Department of Peripheral Vascular Diseases, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China
| | - Hao Qin
- Department of Peripheral Vascular Diseases, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China
| | - Junbo Zhang
- Department of Peripheral Vascular Diseases, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China
| | - Bo Zhang
- Department of Peripheral Vascular Diseases, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China
| | - Honggang Pang
- Department of Peripheral Vascular Diseases, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China
| | - Hongyan Tian
- Department of Peripheral Vascular Diseases, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China
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7
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Valdivia A, Ortega KJ, Bhattacharya SK, Cray C. Capillary Electrophoresis Assessment of Plasma Protein Changes in an African Penguin ( Spheniscus demersus) With Aspergillosis. ACS OMEGA 2020; 5:33280-33289. [PMID: 33403290 PMCID: PMC7774288 DOI: 10.1021/acsomega.0c04983] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 12/03/2020] [Indexed: 05/12/2023]
Abstract
A decrease of avian biodiversity in the African continent has been the result of anthropogenic pressure in the region. This has resulted in the African penguin (Spheniscus demersus) being placed on the endangered species list and requires conservation efforts to maintain its free-ranging population and placement under managed care. In the latter environment, infection by Aspergillus fumigatus can be common. The diagnosis and treatment of this fungal disease in birds has presented with many difficulties, largely due to the diversity and limited knowledge that exists about this species. In this study, we implement a high-resolution capillary electrophoresis system for the fractionation of African penguin plasma, followed by mass spectrometry analysis for the identification of proteins associated with aspergillosis. Several protein differences were revealed, including changes in acute phase proteins and lipid metabolism. In addition, our results demonstrated that fibrinogen β chain is a protein largely present during the inflammatory process in an African penguin infected with A. fumigatus. These findings present a new avenue for the measurement of plasma proteins as a potential method for identifying important biomarkers to aid in monitoring African penguin health.
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Affiliation(s)
- Anddre
Osmar Valdivia
- Bascom
Palmer Eye Institute, University of Miami, Miami, Florida 33136, United States
- Neuroscience
Graduate Program, University of Miami, Miami, Florida 33136, United States
- Miami
Integrative Metabolomics Research Center, University of Miami, Miami, Florida 33136, United States
| | - Kristen Jasmin Ortega
- Bascom
Palmer Eye Institute, University of Miami, Miami, Florida 33136, United States
- Miami
Integrative Metabolomics Research Center, University of Miami, Miami, Florida 33136, United States
| | - Sanjoy K. Bhattacharya
- Bascom
Palmer Eye Institute, University of Miami, Miami, Florida 33136, United States
- Miami
Integrative Metabolomics Research Center, University of Miami, Miami, Florida 33136, United States
| | - Carolyn Cray
- Miami
Integrative Metabolomics Research Center, University of Miami, Miami, Florida 33136, United States
- Division
of Comparative Pathology, Department of Pathology & Laboratory
Medicine, University of Miami, Miami, Florida 33136, United States
- . Tel.: (305) 243-6700. Fax: (305) 243-5662
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8
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Mechanisms and biomarkers of cancer-associated thrombosis. Transl Res 2020; 225:33-53. [PMID: 32645431 PMCID: PMC8020882 DOI: 10.1016/j.trsl.2020.06.012] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 06/24/2020] [Accepted: 06/30/2020] [Indexed: 02/07/2023]
Abstract
Cancer-associated thrombosis is a leading cause of non-cancer death in cancer patients and is comprised of both arterial and venous thromboembolism (VTE). There are multiple risk factors for developing VTE, including cancer type, stage, treatment, and other medical comorbidities, which suggests that the etiology of thrombosis is multifactorial. While cancer-associated thrombosis can be treated with anticoagulation, benefits of therapy must be balanced with the increased bleeding risks seen in patients with cancer. Although risk models exist for primary and recurrent VTE, additional predictors are needed to improve model performance and discrimination of high-risk patients. This review will outline the diverse mechanisms driving thrombosis in cancer patients, as well as provide an overview of biomarkers studied in thrombosis risk and important considerations when selecting candidate biomarkers.
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9
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Ten Cate H, Guzik TJ, Eikelboom J, Spronk HMH. Pleiotropic actions of factor Xa inhibition in cardiovascular prevention: mechanistic insights and implications for anti-thrombotic treatment. Cardiovasc Res 2020; 117:2030-2044. [PMID: 32931586 PMCID: PMC8318102 DOI: 10.1093/cvr/cvaa263] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 07/10/2020] [Accepted: 09/03/2020] [Indexed: 12/12/2022] Open
Abstract
Atherosclerosis is a chronic inflammatory disease in which atherothrombotic complications lead to cardiovascular morbidity and mortality. At advanced stages, myocardial infarction, ischaemic stroke, and peripheral artery disease, including major adverse limb events, are caused either by acute occlusive atherothrombosis or by thromboembolism. Endothelial dysfunction, vascular smooth muscle cell activation, and vascular inflammation are essential in the development of acute cardiovascular events. Effects of the coagulation system on vascular biology extend beyond thrombosis. Under physiological conditions, coagulation proteases in blood are pivotal in maintaining haemostasis and vascular integrity. Under pathological conditions, including atherosclerosis, the same coagulation proteases (including factor Xa, factor VIIa, and thrombin) become drivers of atherothrombosis, working in concert with platelets and vessel wall components. While initially atherothrombosis was attributed primarily to platelets, recent advances indicate the critical role of fibrin clot and plasma coagulation factors. Mechanisms of atherothrombosis and hypercoagulability vary depending on plaque erosion or plaque rupture. In addition to contributing to thrombus formation, factor Xa and thrombin can affect endothelial dysfunction, oxidative stress, vascular smooth muscle cell function as well as immune cell activation and vascular inflammation. By these mechanisms, they promote atherosclerosis and contribute to plaque instability. In this review, we first discuss the postulated vasoprotective mechanisms of protease-activated receptor signalling induced by coagulation enzymes under physiological conditions. Next, we discuss preclinical studies linking coagulation with endothelial cell dysfunction, thromboinflammation, and atherogenesis. Understanding these mechanisms is pivotal for the introduction of novel strategies in cardiovascular prevention and therapy. We therefore translate these findings to clinical studies of direct oral anticoagulant drugs and discuss the potential relevance of dual pathway inhibition for atherothrombosis prevention and vascular protection.
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Affiliation(s)
- Hugo Ten Cate
- Department of Internal Medicine, Thrombosis Expertise Center, Cardiovascular Research Institute Maastricht, Maastricht University, Universiteitssingel 50, PO Box 616, 6200 MD, Maastricht, The Netherlands.,Department of Biochemistry, Thrombosis Expertise Center, Cardiovascular Research Institute Maastricht, Maastricht University, Universiteitssingel 50, PO Box 616, 6200 MD, Maastricht, The Netherlands
| | - Tomasz J Guzik
- Institute of Cardiovascular & Medical Sciences, British Heart Foundation Glasgow Cardiovascular Research Centre, Glasgow, UK.,Department of Medicine, Jagiellonian University, Collegium Medicum, Krakow, Poland
| | - John Eikelboom
- Population Health Research Institute, Hamilton General Hospital and McMaster University, Hamilton, L8L 2x2, ON, Canada
| | - Henri M H Spronk
- Department of Internal Medicine, Thrombosis Expertise Center, Cardiovascular Research Institute Maastricht, Maastricht University, Universiteitssingel 50, PO Box 616, 6200 MD, Maastricht, The Netherlands.,Department of Biochemistry, Thrombosis Expertise Center, Cardiovascular Research Institute Maastricht, Maastricht University, Universiteitssingel 50, PO Box 616, 6200 MD, Maastricht, The Netherlands
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10
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Liu C, Zhan HL, Huang ZH, Hu C, Tong YX, Fan ZY, Zheng MY, Zhao CL, Ma GY. Prognostic role of the preoperative neutrophil-to-lymphocyte ratio and albumin for 30-day mortality in patients with postoperative acute pulmonary embolism. BMC Pulm Med 2020; 20:180. [PMID: 32580706 PMCID: PMC7315518 DOI: 10.1186/s12890-020-01216-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Accepted: 06/15/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND This retrospective study aimed to investigate the prognostic value of the neutrophil-to-lymphocyte ratio (NLR) and albumin for 30-day mortality in patients with postoperative acute pulmonary embolism (PAPE). METHODS We retrospectively reviewed the medical records of 101 patients with PAPE admitted from September 1, 2012, to March 31, 2019. The characteristics, surgical information, admission examination data and mortality within 30 days after PAPE were obtained from our electronic medical recording system and follow-up. The associations between the NLR, PLR, and other predictors and 30-day mortality were analyzed with univariate and multivariate analyses. Then, the nomogram including the independent predictors was established and evaluated. RESULTS Twenty-four patients died within 30 days, corresponding to a 30-day mortality rate of 23.8%. The results of the multivariate analysis indicated that both the NLR and albumin were independent predictors for 30-day mortality in patients with PAPE. The probability of death increased by approximately 17.1% (OR = 1.171, 95% CI: 1.073-1.277, P = 0.000) with a one-unit increase in the NLR, and the probability of death decreased by approximately 15.4% (OR = 0.846, 95% CI: 0.762c-0.939, P = 0.002) with a one-unit increase in albumin. The area under the curve of the nomogram was 0.888 (95% CI: 0.812-0.964). CONCLUSION Our findings showed that an elevated NLR and decreased albumin were related to poor prognosis in patients with PAPE. The NLR and albumin were independent prognostic factors for PAPE.
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Affiliation(s)
- Chuan Liu
- Department of Orthopedic, Affiliated Hospital of Chengde Medical University, Chengde, China
- Graduate School of China Medical University, Shenyang, China
| | - Hui-Lu Zhan
- Department of Orthopedic, Affiliated Hospital of Chengde Medical University, Chengde, China
- School and Hospital of Stomatology, Wenzhou Medical University, Wenzhou, China
| | - Zhang-Heng Huang
- Department of Orthopedic, Affiliated Hospital of Chengde Medical University, Chengde, China
| | - Chuan Hu
- Qingdao University medical college, Qingdao, China
| | - Yue-Xin Tong
- Department of Orthopedic, Affiliated Hospital of Chengde Medical University, Chengde, China
| | - Zhi-Yi Fan
- Department of Orthopedic, Affiliated Hospital of Chengde Medical University, Chengde, China
| | - Meng-Ying Zheng
- Second Clinical Medical College of Wenzhou Medical University, Wenzhou, China
| | - Cheng-Liang Zhao
- Department of Orthopedic, Affiliated Hospital of Chengde Medical University, Chengde, China.
| | - Gui-Yun Ma
- Department of Orthopedic, Affiliated Hospital of Chengde Medical University, Chengde, China.
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11
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Siemens N, Oehmcke-Hecht S, Hoßmann J, Skorka SB, Nijhuis RHT, Ruppen C, Skrede S, Rohde M, Schultz D, Lalk M, Itzek A, Pieper DH, van den Bout CJ, Claas ECJ, Kuijper EJ, Mauritz R, Sendi P, Wunderink HF, Norrby-Teglund A. Prothrombotic and Proinflammatory Activities of the β-Hemolytic Group B Streptococcal Pigment. J Innate Immun 2019; 12:291-303. [PMID: 31743913 DOI: 10.1159/000504002] [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: 03/12/2019] [Accepted: 10/06/2019] [Indexed: 12/29/2022] Open
Abstract
A prominent feature of severe streptococcal infections is the profound inflammatory response that contributes to systemic toxicity. In sepsis the dysregulated host response involves both immunological and nonimmunological pathways. Here, we report a fatal case of an immunocompetent healthy female presenting with toxic shock and purpura fulminans caused by group B streptococcus (GBS; serotype III, CC19). The strain (LUMC16) was pigmented and hyperhemolytic. Stimulation of human primary cells with hyperhemolytic LUMC16 and STSS/NF-HH strains and pigment toxin resulted in a release of proinflammatory mediators, including tumor necrosis factor, interleukin (IL)-1β, and IL-6. In addition, LUMC16 induced blood clotting and showed factor XII activity on its surface, which was linked to the presence of the pigment. The expression of pigment was not linked to a mutation within the CovR/S region. In conclusion, our study shows that the hemolytic lipid toxin contributes to the ability of GBS to cause systemic hyperinflammation and interferes with the coagulation system.
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Affiliation(s)
- Nikolai Siemens
- Center for Infectious Medicine, Department of Medicine Huddinge, Karolinska Institutet, Karolinska University Hospital, Huddinge, Sweden, .,Center for Functional Genomics of Microbes, Department of Molecular Genetics and Infection Biology, University of Greifswald, Greifswald, Germany,
| | - Sonja Oehmcke-Hecht
- Institute of Medical Microbiology, Virology, and Hygiene, University Medicine Rostock, Rostock, Germany
| | - Jörn Hoßmann
- Microbial Interactions and Processes, Helmholtz Centre for Infection Research - HZI, Braunschweig, Germany
| | - Sebastian B Skorka
- Center for Functional Genomics of Microbes, Department of Molecular Genetics and Infection Biology, University of Greifswald, Greifswald, Germany
| | - Roel H T Nijhuis
- Department of Medical Microbiology, Leiden University Medical Center, Leiden, The Netherlands.,Department of Medical Microbiology and Medical Immunology, Meander Medical Center, Amersfoort, The Netherlands
| | - Corinne Ruppen
- Institute for Infectious Diseases, University of Bern, Bern, Switzerland
| | - Steinar Skrede
- Department of Medicine, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Manfred Rohde
- Central Facility for Microscopy, Helmholtz Centre for Infection Research - HZI, Braunschweig, Germany
| | - Daniel Schultz
- Institute of Biochemistry, University of Greifswald, Greifswald, Germany
| | - Michael Lalk
- Institute of Biochemistry, University of Greifswald, Greifswald, Germany
| | - Andreas Itzek
- Microbial Interactions and Processes, Helmholtz Centre for Infection Research - HZI, Braunschweig, Germany
| | - Dietmar H Pieper
- Microbial Interactions and Processes, Helmholtz Centre for Infection Research - HZI, Braunschweig, Germany
| | | | - Eric C J Claas
- Department of Medical Microbiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Ed J Kuijper
- Department of Medical Microbiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Robert Mauritz
- Department of Intensive Care Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Parham Sendi
- Institute for Infectious Diseases, University of Bern, Bern, Switzerland
| | - Herman F Wunderink
- Department of Medical Microbiology, Leiden University Medical Center, Leiden, The Netherlands.,Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Anna Norrby-Teglund
- Center for Infectious Medicine, Department of Medicine Huddinge, Karolinska Institutet, Karolinska University Hospital, Huddinge, Sweden
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12
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van Os HJ, Wermer MJH, Rosendaal FR, Govers-Riemslag JW, Algra A, Siegerink BS. Intrinsic Coagulation Pathway, History of Headache, and Risk of Ischemic Stroke. Stroke 2019; 50:2181-2186. [DOI: 10.1161/strokeaha.118.023124] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Hypercoagulable states in migraine patients may play a role in the pathophysiology underlying the association between migraine and ischemic stroke. This study aims to provide more insight into the potential association of headache, ischemic stroke, and the intrinsic coagulation pathway.
Methods—
We included patients from the RATIO study (Risk of Arterial Thrombosis in Relation to Oral Contraceptives), a Dutch population-based case-control study including young women (age <50) with ischemic stroke and healthy controls. We defined a headache group based on a questionnaire on headache history. Intrinsic coagulation proteins were measured through both antigen levels (FXII, FXI, prekallikrein, HK [high molecular weight kininogen]) and protein activation, determined by measuring activated protein complex with C1esterase-inhibitor (FXIIa-C1-INH, FXIa-C1-INH, Kallikrein-C1-INH) or antitrypsin-inhibitor (FXIa-AT-INH). We calculated adjusted odds ratios and performed an interaction analysis assessing the increase in stroke risk associated with high levels of intrinsic coagulation and history of headache.
Results—
We included 113 ischemic stroke cases and 598 healthy controls. In total, 134 (19%) patients had a history of headache, of whom 38 were cases and 96 controls. The combination of headache and high intrinsic coagulation protein levels (all but FXII antigen level and both FXIa-inhibitors) was associated with an increase in ischemic stroke risk higher than was expected based on their individual effects (adjusted odds ratio FXI antigen level alone: 1.7, 95% CI, 1.0–2.9; adjusted odds ratio headache alone: 2.0, 95% CI, 1.1−3.7; combination: 5.2, 95% CI, 2.3−11.6)
Conclusions—
Headache and high intrinsic coagulation protein levels may biologically interact, increasing risk for ischemic stroke.
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Affiliation(s)
- Hendrikus J.A. van Os
- From the Department of Neurology (H.J.A.v.O., M.J.H.W.), Leiden University Medical Center, the Netherlands
| | - Marieke J. H. Wermer
- From the Department of Neurology (H.J.A.v.O., M.J.H.W.), Leiden University Medical Center, the Netherlands
| | - Frits R. Rosendaal
- Department of Epidemiology (F.R.R., B.S.S.), Leiden University Medical Center, the Netherlands
| | - José W. Govers-Riemslag
- School for Cardiovascular Diseases, Maastricht University Medical Center, the Netherlands (J.W.G.-R.)
| | - Ale Algra
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, and Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht and Utrecht University, the Netherlands (A.A.)
| | - Bob S. Siegerink
- Department of Epidemiology (F.R.R., B.S.S.), Leiden University Medical Center, the Netherlands
- Center for Stroke Research, Charité Universitätsmedizin, Berlin, Germany (B.S.S)
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13
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Seo JD, Gu JY, Jung HS, Kim YJ, Kim HK. Contact System Activation and Neutrophil Extracellular Trap Markers: Risk Factors for Portal Vein Thrombosis in Patients With Hepatocellular Carcinoma. Clin Appl Thromb Hemost 2019; 25:1076029618825310. [PMID: 30808222 PMCID: PMC6715110 DOI: 10.1177/1076029618825310] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Although portal vein thrombosis (PVT) commonly occurs in patients with hepatocellular carcinoma (HCC), the hypercoagulability mechanism in patients with HCC is not entirely clear. Recently, tumor-induced formation of neutrophil extracellular traps (NET) has been shown to trigger contact system activation, and contact system activation has been shown to be a new mechanism of thrombosis. Therefore, we investigated whether contact system activation and NET formation occurred in relation to PVT in HCC patients. The circulating levels of NET formation markers (DNA-histone complex, double-stranded DNA, neutrophil elastase) and contact system activation markers (factor XIIa and high-molecular-weight kininogen) were measured in 177 patients who had been diagnosed with HCC and 48 healthy controls. Presence of PVT was confirmed in 77 HCC patients. The levels of NET formation and contact system activation markers were significantly higher in patients than in healthy controls and they increased significantly with the increase in the model for end-stage liver disease (MELD) scores. Of note, these markers were significantly higher in HCC patients with PVT than in those without PVT. These NET formation markers and the contact system activation markers were significant thrombotic risk factors in HCC patients. The well-known liver injury markers (alanine transaminase, prothrombin time) significantly contributed to factor XIIa level. Contact system activation and NET formation are well correlated with liver disease severity and the markers of these can be used as thrombotic risk factors in HCC patients. In addition, therapeutics inhibiting the contact system can be potentially used to manage PVT in HCC patients.
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Affiliation(s)
- Jong Do Seo
- 1 Department of Laboratory Medicine and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Ja-Yoon Gu
- 1 Department of Laboratory Medicine and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Hye Soo Jung
- 1 Department of Laboratory Medicine and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Yoon Jun Kim
- 2 Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Hyun Kyung Kim
- 1 Department of Laboratory Medicine and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
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14
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Boldrini-França J, Pinheiro-Junior EL, Arantes EC. Functional and biological insights of rCollinein-1, a recombinant serine protease from Crotalus durissus collilineatus. J Venom Anim Toxins Incl Trop Dis 2019; 25:e147118. [PMID: 31131001 PMCID: PMC6483414 DOI: 10.1590/1678-9199-jvatitd-1471-18] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 10/01/2018] [Indexed: 12/03/2022] Open
Abstract
Background: The prevalent class of snake venom serine proteases (SVSP) in Viperidae
venoms is the thrombin-like enzymes, which, similarly to human thrombin,
convert fibrinogen into insoluble fibrin monomers. However, thrombin-like
serine proteases differ from thrombin by being unable to activate factor
XIII, thus leading to the formation of loose clots and fibrinogen
consumption. We report the functional and biological characterization of a
recombinant thrombin-like serine protease from Crotalus durissus
collilineatus, named rCollinein-1. Methods: Heterologous expression of rCollinein-1 was performed in Pichia
pastoris system according to a previously standardized
protocol, with some modifications. rCollinein-1 was purified from the
culture medium by a combination of three chromatographic steps. The
recombinant toxin was tested in vitro for its thrombolytic
activity and in mice for its edematogenicity, blood incoagulability and
effect on plasma proteins. Results: When tested for the ability to induce mouse paw edema, rCollinein-1
demonstrated low edematogenic effect, indicating little involvement of this
enzyme in the inflammatory processes resulting from ophidian accidents. The
rCollinein-1 did not degrade blood clots in vitro, which
suggests that this toxin lacks fibrinolytic activity and is not able to
directly or indirectly activate the fibrinolytic system. The minimal dose of
rCollinein-1 that turns the blood incoagulable in experimental mice is 7.5
mg/kg. The toxin also led to a significant increase in activated partial
thromboplastin time at the dose of 1 mg/kg in the animals. Other parameters
such as plasma fibrinogen concentration and prothrombin time were not
significantly affected by treatment with rCollinein-1 at this dose. The
toxin was also able to alter plasma proteins in mouse after 3 h of injection
at a dose of 1 mg/kg, leading to a decrease in the intensity of beta zone
and an increase in gamma zone in agarose gel electrophoresis Conclusion: These results suggest that the recombinant enzyme has no potential as a
thrombolytic agent but can be applied in the prevention of thrombus
formation in some pathological processes and as molecular tools in studies
related to hemostasis.
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Affiliation(s)
- Johara Boldrini-França
- School of Pharmaceutical Sciences of Ribeirão Preto - FCFRP/USP, Ribeirão Preto, São Paulo, Brazil.,Graduate Program in Ecosystem Ecology, University of Vila Velha, Av. Comissário José Dantas de Melo, 21, Boa Vista II, 29102-920, Vila Velha, ES, Brazil
| | | | - Eliane Candiani Arantes
- School of Pharmaceutical Sciences of Ribeirão Preto - FCFRP/USP, Ribeirão Preto, São Paulo, Brazil
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15
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Székely O, Borgi M, Lip GYH. Factor XI inhibition fulfilling the optimal expectations for ideal anticoagulation. Expert Opin Emerg Drugs 2019; 24:55-61. [DOI: 10.1080/14728214.2019.1591368] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
- Orsolya Székely
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Marco Borgi
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Gregory Y. H. Lip
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
- Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
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16
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Factor XI contributes to myocardial ischemia-reperfusion injury in mice. Blood Adv 2019; 2:85-88. [PMID: 29365314 DOI: 10.1182/bloodadvances.2017004879] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Accepted: 12/06/2017] [Indexed: 11/20/2022] Open
Abstract
Key Points
Inhibiting contact activation of factor XI during reperfusion of acute myocardial ischemia reduces infarct size in mice. Factor XII/XI contact axis inhibition may improve the outcome of coronary artery recanalization in acute myocardial infarction.
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17
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Abstract
Leukemic cells release their nuclear contents into the extracellular space upon activation. The released nuclear contents, called extracellular traps, can activate the contact system of coagulation. This study accessed the extent of contact system activation, the levels of extracellular traps, and coagulation activation in hematologic malignancies including acute leukemia. In 154 patients with hematologic malignancies (acute leukemia, n = 29; myelodysplastic syndrome, n = 20; myeloproliferative neoplasms, n = 69; plasma cell myeloma, n = 36) and 48 normal controls, the levels of coagulation factors (fibrinogen and factor VII, VIII, IX, and XII), D-dimer, thrombin generation, extracellular trap markers (histone-DNA complex, cell-free dsDNA, leukocyte elastase), and contact system markers (activated factor XII [XIIa], high-molecular-weight kininogen, prekallikrein, bradykinin) were measured. Patients with acute leukemia showed the highest levels of peak thrombin, extracellular trap markers, and factor XIIa. Factor XIIa level was significantly associated with the presence of acute leukemia. The histone-DNA complex and cell-free dsDNA were revealed as significant associated factors with the factor XIIa level. Three markers of extracellular traps and two markers of thrombin generation significantly contributed to the hemostatic abnormalities in hematologic malignancies. Contact system was activated in acute leukemia and its activation was significantly associated with the extent of extracellular trap formation. This finding suggests that extracellular traps might be a major source of contact system activation and therapeutic strategies targeting extracellular trap formation or contact system activation may be beneficial in acute leukemia.
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18
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Tillman BF, Gruber A, McCarty OJT, Gailani D. Plasma contact factors as therapeutic targets. Blood Rev 2018; 32:433-448. [PMID: 30075986 PMCID: PMC6185818 DOI: 10.1016/j.blre.2018.04.001] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Revised: 03/27/2018] [Accepted: 04/06/2018] [Indexed: 12/20/2022]
Abstract
Direct oral anticoagulants (DOACs) are small molecule inhibitors of the coagulation proteases thrombin and factor Xa that demonstrate comparable efficacy to warfarin for several common indications, while causing less serious bleeding. However, because their targets are required for the normal host-response to bleeding (hemostasis), DOACs are associated with therapy-induced bleeding that limits their use in certain patient populations and clinical situations. The plasma contact factors (factor XII, factor XI, and prekallikrein) initiate blood coagulation in the activated partial thromboplastin time assay. While serving limited roles in hemostasis, pre-clinical and epidemiologic data indicate that these proteins contribute to pathologic coagulation. It is anticipated that drugs targeting the contact factors will reduce risk of thrombosis with minimal impact on hemostasis. Here, we discuss the biochemistry of contact activation, the contributions of contact factors in thrombosis, and novel antithrombotic agents targeting contact factors that are undergoing pre-clinical and early clinical testing.
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Affiliation(s)
- Benjamin F Tillman
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Andras Gruber
- Department of Biomedical Engineering, Oregon Health & Sciences University, Portland, OR, USA; Division of Hematology and Medical Oncology School of Medicine, Oregon Health & Sciences University, Portland, OR, USA; Aronora, Inc., Portland, OR, USA
| | - Owen J T McCarty
- Department of Biomedical Engineering, Oregon Health & Sciences University, Portland, OR, USA; Division of Hematology and Medical Oncology School of Medicine, Oregon Health & Sciences University, Portland, OR, USA
| | - David Gailani
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
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19
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Lip GY, Banerjee A, Boriani G, Chiang CE, Fargo R, Freedman B, Lane DA, Ruff CT, Turakhia M, Werring D, Patel S, Moores L. Antithrombotic Therapy for Atrial Fibrillation. Chest 2018; 154:1121-1201. [DOI: 10.1016/j.chest.2018.07.040] [Citation(s) in RCA: 481] [Impact Index Per Article: 80.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 07/11/2018] [Accepted: 07/24/2018] [Indexed: 02/08/2023] Open
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20
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Székely O, Miyazawa K, Lip GYH. Current and emerging pharmacotherapy for ischemic stroke prevention in patients with atrial fibrillation. Expert Opin Pharmacother 2018; 19:1999-2009. [PMID: 30359142 DOI: 10.1080/14656566.2018.1537368] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Introduction: Atrial fibrillation (AF) is associated with high morbidity and mortality rates due to thromboembolic complications, and anticoagulation is central to the management of this common arrhythmia to prevent acute thromboembolic events. The traditional anticoagulants: heparin, fondaparinux, and vitamin K antagonists (VKA, e.g. warfarin, acenocoumarol or phenprocoumin) have long served as pharmacotherapy for ischemic stroke prophylaxis. Areas covered: In this review article, the authors provide an overview on current and emerging pharmacotherapy for ischemic stroke prevention. Furthermore, they review the data from novel therapeutic targets in the coagulation cascade, and investigational anticoagulant drugs currently assessed in preclinical and clinical studies. Expert opinion: The introduction of nonvitamin K antagonist oral anticoagulants (NOACs) was an important milestone, as these drugs show relative efficacy, safety, and convenience compared to the VKAs. Nevertheless, their clinical use still has some limitations with, for example, patients with severe renal impairment and those with mechanical heart valves, high bleeding risks, lack of standard laboratory monitoring and (some) reversal agents. To overcome some of these limitations, various attempts are now underway to discover new strategies and targets via the hemostatic pathway in order to develop new coagulation inhibiting drugs.
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Affiliation(s)
- Orsolya Székely
- a Institute of Cardiovascular Sciences , University of Birmingham , Birmingham , UK
| | - Kazuo Miyazawa
- a Institute of Cardiovascular Sciences , University of Birmingham , Birmingham , UK
| | - Gregory Yoke Hong Lip
- a Institute of Cardiovascular Sciences , University of Birmingham , Birmingham , UK.,b Liverpool Centre for Cardiovascular Science , University of Liverpool and Liverpool Heart & Chest Hospital , Liverpool , UK.,c Aalborg Thrombosis Research Unit , Aalborg University , Aalborg , Denmark
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21
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Yamamoto-Imoto H, Zamolodchikov D, Chen ZL, Bourne SL, Rizvi S, Singh P, Norris EH, Weis-Garcia F, Strickland S. A novel detection method of cleaved plasma high-molecular-weight kininogen reveals its correlation with Alzheimer's pathology and cognitive impairment. ALZHEIMER'S & DEMENTIA: DIAGNOSIS, ASSESSMENT & DISEASE MONITORING 2018; 10:480-489. [PMID: 30310850 PMCID: PMC6178129 DOI: 10.1016/j.dadm.2018.06.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Introduction Accumulation of β-amyloid is a pathological hallmark of Alzheimer's disease (AD). β-Amyloid activates the plasma contact system leading to kallikrein-mediated cleavage of intact high-molecular-weight kininogen (HKi) to cleaved high-molecular-weight kininogen (HKc). Increased HKi cleavage is observed in plasma of AD patients and mouse models by Western blot. For potential diagnostic purposes, a more quantitative method that can measure HKc levels in plasma with high sensitivity and specificity is needed. Methods HKi/c, HKi, and HKc monoclonal antibodies were screened from hybridomas using direct ELISA with a fluorescent substrate. Results We generated monoclonal antibodies recognizing HKi or HKc specifically and developed sandwich ELISAs that can quantitatively detect HKi and HKc levels in human. These new assays show that decreased HKi and increased HKc levels in AD plasma correlate with dementia and neuritic plaque scores. Discussion High levels of plasma HKc could be used as an innovative biomarker for AD. Assay discriminates between intact and cleaved high molecular weight kininogen (HKi vs. HKc). New enzyme-linked immunosorbent assay (ELISA) detects more HKc in Alzheimer's disease plasma. Plasma HKc correlates with dementia and neuritic plaque scores in Alzheimer's disease. Plasma HKc levels could be used as an innovative biomarker for Alzheimer's disease.
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Affiliation(s)
- Hitomi Yamamoto-Imoto
- Patricia and John Rosenwald Laboratory of Neurobiology and Genetics, The Rockefeller University, New York, NY, USA.,Research fellow of Japan Society for the Promotion of Science, Chiyoda-ku, Tokyo, Japan
| | - Daria Zamolodchikov
- Patricia and John Rosenwald Laboratory of Neurobiology and Genetics, The Rockefeller University, New York, NY, USA
| | - Zu-Lin Chen
- Patricia and John Rosenwald Laboratory of Neurobiology and Genetics, The Rockefeller University, New York, NY, USA
| | - S Lloyd Bourne
- Antibody and Bioresource Core Facility, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Syeda Rizvi
- Antibody and Bioresource Core Facility, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Pradeep Singh
- Patricia and John Rosenwald Laboratory of Neurobiology and Genetics, The Rockefeller University, New York, NY, USA
| | - Erin H Norris
- Patricia and John Rosenwald Laboratory of Neurobiology and Genetics, The Rockefeller University, New York, NY, USA
| | - Frances Weis-Garcia
- Antibody and Bioresource Core Facility, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sidney Strickland
- Patricia and John Rosenwald Laboratory of Neurobiology and Genetics, The Rockefeller University, New York, NY, USA
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22
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Li J, Guan X, Liu O, Wang X, Liu Y, Li H, Lan F, Gong M, Zhang H. Changes in coagulation factor XII and its function during aortic arch surgery for acute aortic dissection-a prospective observational study. J Thorac Dis 2018; 10:4006-4016. [PMID: 30174843 DOI: 10.21037/jtd.2018.06.127] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background Changes in the intrinsic coagulation pathway during aortic arch surgery in patients with acute aortic dissection (AAD) have not yet been reported. The aim of this study is to describe the changes in intrinsic coagulation factor XII, explore its function and find a new target for the treatment of coagulopathy during surgery. Methods Eighty-eight patients undergoing emergent surgery for AAD were enrolled. Changes in the intrinsic and extrinsic coagulation pathways were evaluated at 5 different timepoints during the perioperative period by measuring intrinsic coagulation factor XII, extrinsic coagulation factor VII and some intrinsic upstream stimulating factors. The 88 patients were also divided into two groups according to whether reoperation for coagulopathy was required after surgery. Results Both coagulation factors XII and VII demonstrated a significant and similar change during the perioperative period. These factors decreased significantly during hypothermia circulation arrest (P<0.001) and recovered to normal levels by 24 hours after surgery. Among the intrinsic upstream stimulating factors, bradykinin (BK) demonstrated a similar changing trend with coagulation factors XII and VII, while other stimulating factors did not. However, compared with factor VII, factor XII demonstrated a greater decline during surgery. The proportion of decline of factor XII from anesthesia induction to hypothermia circulation arrest was 42%, whereas the proportion of decline of factor VII during the same period was 20% (P<0.001). Moreover, factor VII recovered to preoperative levels 4 hours after surgery with a relatively faster speed (P<0.001) while factor XII had not recovered (P=0.010). The independent t-test and Wilcoxon test showed that coagulation factor XII levels during hypothermia circulation arrest (P=0.002), total dosage of fibrinogen (P=0.027), total dosage of packed red blood cells (PRBCs) (P=0.006) and total dosage of fresh frozen plasma (FFP) (P=0.022) during the perioperative period were significantly different between the patients who did or did not require reoperation for coagulopathy. Multivariable logistic regression analysis suggested that the factor XII level during hypothermia circulation arrest was an independent risk factor for reoperation for coagulopathy [odds ratio (OR): 1.342, 95% confidence interval (CI): 1.058-1.570; P=0.012]. Conclusions Factor XII levels are more influenced by surgery and require a longer period of time to recover to preoperative levels compared with factor VII, and the level of factor XII during hypothermia circulation arrest might be an independent risk factor for reoperation for coagulopathy. Therefore, supplementation of coagulation factor XII and its upstream stimulating factors might be a promising therapeutic modality in the future.
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Affiliation(s)
- Jiachen Li
- Department of Cardiac Surgery, Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing 100069, China.,Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing 100029, China.,Beijing Lab for Cardiovascular Precision Medicine, Beijing 100029, China.,Beijing Engineering Research Center of Vascular Prostheses, Beijing 100069, China
| | - Xinliang Guan
- Department of Cardiac Surgery, Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing 100069, China.,Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing 100029, China.,Beijing Lab for Cardiovascular Precision Medicine, Beijing 100029, China.,Beijing Engineering Research Center of Vascular Prostheses, Beijing 100069, China
| | - Ou Liu
- Department of Cardiac Surgery, Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing 100069, China.,Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing 100029, China.,Beijing Lab for Cardiovascular Precision Medicine, Beijing 100029, China.,Beijing Engineering Research Center of Vascular Prostheses, Beijing 100069, China
| | - Xiaolong Wang
- Department of Cardiac Surgery, Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing 100069, China.,Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing 100029, China.,Beijing Lab for Cardiovascular Precision Medicine, Beijing 100029, China.,Beijing Engineering Research Center of Vascular Prostheses, Beijing 100069, China
| | - Yuyong Liu
- Department of Cardiac Surgery, Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing 100069, China.,Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing 100029, China.,Beijing Lab for Cardiovascular Precision Medicine, Beijing 100029, China.,Beijing Engineering Research Center of Vascular Prostheses, Beijing 100069, China
| | - Haiyang Li
- Department of Cardiac Surgery, Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing 100069, China.,Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing 100029, China.,Beijing Lab for Cardiovascular Precision Medicine, Beijing 100029, China.,Beijing Engineering Research Center of Vascular Prostheses, Beijing 100069, China
| | - Feng Lan
- Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing 100029, China.,Beijing Lab for Cardiovascular Precision Medicine, Beijing 100029, China.,Beijing Engineering Research Center of Vascular Prostheses, Beijing 100069, China
| | - Ming Gong
- Department of Cardiac Surgery, Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing 100069, China.,Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing 100029, China.,Beijing Lab for Cardiovascular Precision Medicine, Beijing 100029, China.,Beijing Engineering Research Center of Vascular Prostheses, Beijing 100069, China
| | - Hongjia Zhang
- Department of Cardiac Surgery, Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing 100069, China.,Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing 100029, China.,Beijing Lab for Cardiovascular Precision Medicine, Beijing 100029, China.,Beijing Engineering Research Center of Vascular Prostheses, Beijing 100069, China
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23
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Weitz JI, Fredenburgh JC. 2017 Scientific Sessions Sol Sherry Distinguished Lecture in Thrombosis. Arterioscler Thromb Vasc Biol 2018; 38:304-310. [DOI: 10.1161/atvbaha.117.309664] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Accepted: 12/05/2017] [Indexed: 01/08/2023]
Affiliation(s)
- Jeffrey I. Weitz
- From the Department of Medicine (J.I.W., J.C.F.) and Department of Biochemistry and Biomedical Sciences (J.I.W.), McMaster University, Hamilton, Ontario, Canada; and Thrombosis and Atherosclerosis Research Institute (J.I.W., J.C.F.), Hamilton, Ontario, Canada
| | - James C. Fredenburgh
- From the Department of Medicine (J.I.W., J.C.F.) and Department of Biochemistry and Biomedical Sciences (J.I.W.), McMaster University, Hamilton, Ontario, Canada; and Thrombosis and Atherosclerosis Research Institute (J.I.W., J.C.F.), Hamilton, Ontario, Canada
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24
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Abstract
PURPOSE OF REVIEW Exposure of blood to foreign surfaces induces reciprocal conversion of the plasma proteins factor XII (fXII) and plasma prekallikrein (PPK) to the proteases α-fXIIa and α-kallikrein. This process, called contact activation, has a range of effects on host defence mechanisms, including promoting coagulation. The nature of the triggering mechanism for contact activation is debated. One hypothesis predicts that fXII has protease activity, either intrinsically or upon surface-binding, that initiates contact activation. We tested this by assessing the proteolytic activity of a recombinant fXII variant that cannot be converted to α-fXIIa. RECENT FINDINGS The proteolytic activity of fXII-T (for 'triple' mutant), a variant with alanine substitutions for arginine at activation cleavage sites (Arg334, Arg344, and Arg353) was tested with known α-fXIIa substrates. FXII-T activates PPK in solution, and the reaction is enhanced by polyphosphate, an inducer of contact activation released from platelets. In the presence of polyphosphate, fXII-T converts fXII to α-fXIIa, and also converts the coagulation protein factor XI to its active form. SUMMARY The findings support the hypothesis that contact activation is initiated through activity intrinsic to single-chain fXII, and indicate that preexisting α-fXIIa is not required for induction of contact activation.
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COAGULATION ASSESSMENT: UNDERUTILIZED DIAGNOSTIC TOOLS IN ZOO AND AQUATIC ANIMAL MEDICINE. J Zoo Wildl Med 2018; 48:947-953. [PMID: 29297814 DOI: 10.1638/2016-0145r.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Veterinarians specializing in nondomestic species are faced with unique challenges regarding research and diagnostic capabilities given the wild and frequently dangerous nature of their patients. Standard diagnostic techniques used in small or large animal practice are not always possible due to anatomical constraints, size, tractability, or the inherent risk of anesthesia in highly valued, rare species. Diagnostic modalities that utilize simple, relatively noninvasive techniques show promise in evaluating nondomestic species and elucidating the pathophysiology behind poorly characterized disease processes in both wild and captive populations. Coagulation profiles, which may include prothrombin time (PT), partial thromboplastin time (PTT), D-dimer concentration, platelet count, and thromboelastography (TEG) are frequently used in domestic species but often overlooked in exotic medicine due to lack of normal reference values and/or availability. Whenever possible, coagulation profiles should be utilized in the evaluation of various disease processes including neoplasia, sepsis, trauma, inflammation, toxin exposure, and envenomation. There are several reports of coagulopathies in both wild and captive species; however, few studies on coagulation profiles have been published on nondomestic species. Clinicians should consider coagulation testing as part of the diagnostic work-up in nondomestic species. A review of available coagulation diagnostic tests is provided here in addition to summarizing the pertinent coagulation disorders currently established in the literature.
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Branchford BR, Carpenter SL. The Role of Inflammation in Venous Thromboembolism. Front Pediatr 2018; 6:142. [PMID: 29876337 PMCID: PMC5974100 DOI: 10.3389/fped.2018.00142] [Citation(s) in RCA: 220] [Impact Index Per Article: 36.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Accepted: 04/27/2018] [Indexed: 12/12/2022] Open
Abstract
Venous thromboembolism (VTE), comprising deep vein thrombosis (DVT), and pulmonary embolism (PE), is becoming increasingly recognized as a cause of morbidity and mortality in pediatrics, particularly among hospitalized children. Furthermore, evidence is accumulating that suggests the inflammatory response may be a cause, as well as consequence, of VTE, but current anticoagulation treatment regimens are not designed to inhibit inflammation. In fact, many established clinical VTE risk factors such as surgery, obesity, cystic fibrosis, sepsis, systemic infection, cancer, inflammatory bowel disease, and lupus likely modulate thrombosis through inflammatory mediators. Unlike other traumatic mechanisms of thrombosis involving vascular transection and subsequent exposure of subendothelial collagen and other procoagulant extracellular matrix materials, inflammation of the vessel wall may initiate thrombosis on an intact vein. Activation of endothelial cells, platelets, and leukocytes with subsequent formation of microparticles can trigger the coagulation system through the induction of tissue factor (TF). Identification of biomarkers to evaluate VTE risk could be of great use to the clinician caring for a patient with inflammatory disease to guide decisions regarding the risk:benefit ratio of various types of potential thromboprophylaxis strategies, or suggest a role for anti-inflammatory therapy. Unfortunately, no such validated inflammatory scoring system yet exists, though research in this area is ongoing. Elevation of C-reactive protein, IL-6, IL-8, and TNF-alpha during a response to systemic inflammation have been associated with increased VTE risk. Consequent platelet activation enhances the prothrombotic state, leading to VTE development, particularly in patients with other risk factors, most notably central venous catheters.
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Affiliation(s)
- Brian R Branchford
- University of Colorado Hemophilia and Thrombosis Center, Pediatric Hematology, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, United States
| | - Shannon L Carpenter
- Kansas City Regional Hemophilia Treatment Center, Pediatric Hematology, UMKC School of Medicine and Children's Mercy Hospital, Kansas, CO, United States
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Tillman B, Gailani D. Inhibition of Factors XI and XII for Prevention of Thrombosis Induced by Artificial Surfaces. Semin Thromb Hemost 2017; 44:60-69. [PMID: 28898903 DOI: 10.1055/s-0037-1603937] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Exposure of blood to a variety of artificial surface induces contact activation, a process that contributes to the host innate response to foreign substances. On the foreign surface, the contact factors, factor XII (FXII), and plasma prekallikrein undergo reciprocal conversion to their fully active protease forms (FXIIa and α-kallikrein, respectively) by a process supported by the cofactor high-molecular-weight kininogen. Contact activation can trigger blood coagulation by conversion of factor XI (FXI) to the protease FXIa. There is interest in developing therapeutic inhibitors to FXIa and FXIIa because these activated factors can contribute to thrombosis in certain situations. Drugs targeting these proteases may be particularly effective in thrombosis triggered by exposure of blood to the surfaces of implantable medical devices. Here, we review clinical data supporting roles for FXII and FXI in thrombosis induced by medical devices, and preclinical data suggesting that therapeutic targeting of these proteins may limit surface-induced thrombosis.
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Affiliation(s)
- Benjamin Tillman
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - David Gailani
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee.,Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee
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Woodruff RS, Ivanov I, Verhamme IM, Sun MF, Gailani D, Sullenger BA. Generation and characterization of aptamers targeting factor XIa. Thromb Res 2017. [PMID: 28644959 DOI: 10.1016/j.thromres.2017.06.015] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND The plasma protease factor XIa (FXIa) has become a target of interest for therapeutics designed to prevent or treat thrombotic disorders. METHODS We used a solution-based, directed evolution approach called systematic evolution of ligands by exponential enrichment (SELEX) to isolate RNA aptamers that target the FXIa catalytic domain. RESULTS Two aptamers, designated 11.16 and 12.7, were identified that bound to previously identified anion binding and serpin bindings sites on the FXIa catalytic domain. The aptamers were non-competitive inhibitors of FXIa cleavage of a tripeptide chromogenic substrate and of FXIa activation of factor IX. In normal human plasma, aptamer 12.7 significantly prolonged the aPTT clotting time. CONCLUSIONS The results show that novel inhibitors of FXIa can be prepared using SELEX techniques. RNA aptamers can bind to distinct sites on the FXIa catalytic domain and noncompetitively inhibit FXIa activity toward its primary macromolecular substrate factor IX with different levels of potency. Such compounds can be developed for use as therapeutic inhibitors.
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Affiliation(s)
- R S Woodruff
- Department of Surgery, Duke University Medical Center, Durham, NC, United States; University Program in Genetics and Genomics, Duke University, Durham, NC, United States
| | - I Ivanov
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, United States
| | - I M Verhamme
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, United States
| | - M-F Sun
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, United States
| | - D Gailani
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, United States
| | - B A Sullenger
- Department of Surgery, Duke University Medical Center, Durham, NC, United States.
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Weitz JI, Fredenburgh JC. Factors XI and XII as Targets for New Anticoagulants. Front Med (Lausanne) 2017; 4:19. [PMID: 28286749 PMCID: PMC5323386 DOI: 10.3389/fmed.2017.00019] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Accepted: 02/10/2017] [Indexed: 01/01/2023] Open
Abstract
Compared with vitamin K antagonists, the direct oral anticoagulants (DOACs) are simpler to administer and are associated with less intracranial bleeding. Nonetheless, even with the DOACs, bleeding still occurs and many patients with atrial fibrillation fail to receive anticoagulant thromboprophylaxis because of the fear of bleeding. Therefore, there is an urgent need for safer anticoagulants. Recent investigations into the biochemistry of hemostasis and thrombosis have identified new targets for development of novel anticoagulants. Using data from complementary sources, including epidemiological studies and investigations in various animal models, the contact pathway has emerged as a potential mediator of thrombosis that plays a minor part in hemostasis. Consequently, factor (F) XII of the contact system and FXI in the intrinsic pathway have been identified as potentially safer targets of anticoagulation than thrombin or FXa. However, further studies are needed to identify which is the better target for the appropriate indication. This review highlights the evidence for focusing on FXI and FXII and examines the novel approaches directed at these new targets. These emerging strategies should address current unmet medical needs and provide new avenues by which to improve anticoagulant therapy by reducing the risk of bleeding.
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Affiliation(s)
- Jeffrey I. Weitz
- Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- The Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, ON, Canada
- *Correspondence: Jeffrey I. Weitz,
| | - James C. Fredenburgh
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- The Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, ON, Canada
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30
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Proteolytic properties of single-chain factor XII: a mechanism for triggering contact activation. Blood 2017; 129:1527-1537. [PMID: 28069606 DOI: 10.1182/blood-2016-10-744110] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Accepted: 12/30/2016] [Indexed: 12/28/2022] Open
Abstract
When blood is exposed to variety of artificial surfaces and biologic substances, the plasma proteins factor XII (FXII) and prekallikrein undergo reciprocal proteolytic conversion to the proteases αFXIIa and α-kallikrein by a process called contact activation. These enzymes contribute to host-defense responses including coagulation, inflammation, and fibrinolysis. The initiating event in contact activation is debated. To test the hypothesis that single-chain FXII expresses activity that could initiate contact activation, we prepared human FXII variants lacking the Arg353 cleavage site required for conversion to αFXIIa (FXII-R353A), or lacking the 3 known cleavage sites at Arg334, Arg343, and Arg353 (FXII-T, for "triple" mutant), and compared their properties to wild-type αFXIIa. In the absence of a surface, FXII-R353A and FXII-T activate prekallikrein and cleave the tripeptide S-2302, demonstrating proteolytic activity. The activity is several orders of magnitude weaker than that of αFXIIa. Polyphosphate, an inducer of contact activation, enhances PK activation by FXII-T, and facilitates FXII-T activation of FXII and FXI. In plasma, FXII-T and FXII-R353A, but not FXII lacking the active site serine residue (FXII-S544A), shortened the clotting time of FXII-deficient plasma and enhanced thrombin generation in a surface-dependent manner. The effect was not as strong as for wild-type FXII. Our results support a model for induction of contact activation in which activity intrinsic to single-chain FXII initiates αFXIIa and α-kallikrein formation on a surface. αFXIIa, with support from α-kallikrein, subsequently accelerates contact activation and is responsible for the full procoagulant activity of FXII.
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Abstract
Despite the introduction of direct oral anticoagulants (DOACs), the search for more effective and safer antithrombotic strategies continues. Better understanding of the pathogenesis of thrombosis has fostered 2 new approaches to achieving this goal. First, evidence that thrombin may be as important as platelets to thrombosis at sites of arterial injury and that platelets contribute to venous thrombosis has prompted trials comparing anticoagulants with aspirin for secondary prevention in arterial thrombosis and aspirin with anticoagulants for primary and secondary prevention of venous thrombosis. These studies will help identify novel treatment strategies. Second, emerging data that naturally occurring polyphosphates activate the contact system and that this system is critical for thrombus stabilization and growth have identified factor XII (FXII) and FXI as targets for new anticoagulants that may be even safer than the DOACs. Studies are needed to determine whether FXI or FXII is the better target and to compare the efficacy and safety of these new strategies with current standards of care for the prevention or treatment of thrombosis. Focusing on these advances, this article outlines how treatment strategies for thrombosis are evolving and describes the rationale and approaches to targeting FXII and FXI. These emerging anticoagulant strategies should address unmet needs and reduce the systemic underuse of anticoagulation because of the fear of bleeding.
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ten Cate-Hoek AJ, Weitz JI, Gailani D, Meijer K, Philippou H, Bouman AC, Whitney Cheung Y, van Mens TE, Govers-Riemslag JW, Vries M, Bleker S, Biedermann JS, Stoof SCM, Buller HR. Theme 3: Non-invasive management of (recurrent) venous thromboembolism (VTE) and post thrombotic syndrome (PTS). Thromb Res 2016; 136 Suppl 1:S13-8. [PMID: 26387731 DOI: 10.1016/j.thromres.2015.07.036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Arina J ten Cate-Hoek
- Maastricht University Medical Center, Laboratory for Clinical Thrombosis and Hemostasis, Cardiovascular Research Institute Maastricht (CARIM), Netherlands; Thrombosis Center, USA.
| | - Jeffrey I Weitz
- McMaster University and Thrombosis and Atherosclerosis Research Institute, Canada
| | - David Gailani
- Vanderbilt University, Department of Pathology, Microbiology and Immunology, Nashville, USA
| | - Karina Meijer
- University of Groningen, University Medical Center Groningen, Department of Hematology, Netherlands
| | - Helen Philippou
- University of Leeds, Division of Cardiovascular and Diabetes Research, The LIGHT Labs, Leeds, UK
| | - Annemieke C Bouman
- Maastricht University Medical Center, Laboratory for Clinical Thrombosis and Hemostasis, Cardiovascular Research Institute Maastricht (CARIM), Netherlands; Thrombosis Center, USA
| | - Y Whitney Cheung
- University of Amsterdam, Academic Medical Center, Department of Vascular Medicine, Netherlands
| | - Thijs E van Mens
- University of Amsterdam, Academic Medical Center, Department of Vascular Medicine, Netherlands
| | - Jose W Govers-Riemslag
- Maastricht University Medical Center, Laboratory for Clinical Thrombosis and Hemostasis, Cardiovascular Research Institute Maastricht (CARIM), Netherlands
| | - Minka Vries
- Maastricht University Medical Center, Laboratory for Clinical Thrombosis and Hemostasis, Cardiovascular Research Institute Maastricht (CARIM), Netherlands
| | - Suzanne Bleker
- University of Amsterdam, Academic Medical Center, Department of Vascular Medicine, Netherlands
| | - Jossi S Biedermann
- Erasmus University Medical Center, Rotterdam, Department of Hematology, Netherlands
| | - S Carina M Stoof
- Erasmus University Medical Center, Rotterdam, Department of Hematology, Netherlands
| | - Harry R Buller
- University of Amsterdam, Academic Medical Center, Department of Vascular Medicine, Netherlands
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Gailani D, Gruber A. Factor XI as a Therapeutic Target. Arterioscler Thromb Vasc Biol 2016; 36:1316-22. [PMID: 27174099 DOI: 10.1161/atvbaha.116.306925] [Citation(s) in RCA: 82] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Accepted: 04/29/2016] [Indexed: 11/16/2022]
Abstract
Factor XIa is a plasma serine protease that contributes to thrombin generation primarily through proteolytic activation of factor IX. Traditionally considered part of the intrinsic pathway of coagulation, several lines of evidence now suggest that factor XIa serves as an interface between the vitamin-K-dependent thrombin generation mechanism and the proinflammatory kallikrein-kinin system, allowing the 2 systems to influence each other. Work with animal models and results from epidemiological surveys of human populations support a role for factor XIa in thromboembolic disease. These data and the clinical observation that deficiency of factor XI, the zymogen of factor XIa, produces a relatively mild bleeding disorder suggest that drugs targeting factor XI or XIa could produce an antithrombotic effect while leaving hemostasis largely intact. Results of a recent trial comparing antisense-induced factor XI reduction to standard-dose low molecular-weight heparin as prophylaxis for venous thrombosis during knee replacement are encouraging in this regard. Here, we discuss recent findings on the biochemistry, physiology, and pathology of factor XI as they relate to thromboembolic disease.
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Affiliation(s)
- David Gailani
- From the Department of Pathology, Microbiology and Immunology and Department of Medicine, Vanderbilt University, Nashville, TN (D.G.); and Aronora, Inc, Portland, OR (A.G.).
| | - Andras Gruber
- From the Department of Pathology, Microbiology and Immunology and Department of Medicine, Vanderbilt University, Nashville, TN (D.G.); and Aronora, Inc, Portland, OR (A.G.)
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Bane CE, Ivanov I, Matafonov A, Boyd KL, Cheng Q, Sherwood ER, Tucker EI, Smiley ST, McCarty OJT, Gruber A, Gailani D. Factor XI Deficiency Alters the Cytokine Response and Activation of Contact Proteases during Polymicrobial Sepsis in Mice. PLoS One 2016; 11:e0152968. [PMID: 27046148 PMCID: PMC4821616 DOI: 10.1371/journal.pone.0152968] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Accepted: 03/22/2016] [Indexed: 11/18/2022] Open
Abstract
Sepsis, a systemic inflammatory response to infection, is often accompanied by abnormalities of blood coagulation. Prior work with a mouse model of sepsis induced by cecal ligation and puncture (CLP) suggested that the protease factor XIa contributed to disseminated intravascular coagulation (DIC) and to the cytokine response during sepsis. We investigated the importance of factor XI to cytokine and coagulation responses during the first 24 hours after CLP. Compared to wild type littermates, factor XI-deficient (FXI-/-) mice had a survival advantage after CLP, with smaller increases in plasma levels of TNF-α and IL-10 and delayed IL-1β and IL-6 responses. Plasma levels of serum amyloid P, an acute phase protein, were increased in wild type mice 24 hours post-CLP, but not in FXI-/- mice, supporting the impression of a reduced inflammatory response in the absence of factor XI. Surprisingly, there was little evidence of DIC in mice of either genotype. Plasma levels of the contact factors factor XII and prekallikrein were reduced in WT mice after CLP, consistent with induction of contact activation. However, factor XII and PK levels were not reduced in FXI-/- animals, indicating factor XI deficiency blunted contact activation. Intravenous infusion of polyphosphate into WT mice also induced changes in factor XII, but had much less effect in FXI deficient mice. In vitro analysis revealed that factor XIa activates factor XII, and that this reaction is enhanced by polyanions such polyphosphate and nucleic acids. These data suggest that factor XI deficiency confers a survival advantage in the CLP sepsis model by altering the cytokine response to infection and blunting activation of the contact (kallikrein-kinin) system. The findings support the hypothesis that factor XI functions as a bidirectional interface between contact activation and thrombin generation, allowing the two processes to influence each other.
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Affiliation(s)
- Charles E. Bane
- Department of Pathology, Microbiology and Immunology, Vanderbilt University, Nashville, Tennessee, United States of America
| | - Ivan Ivanov
- Department of Pathology, Microbiology and Immunology, Vanderbilt University, Nashville, Tennessee, United States of America
| | - Anton Matafonov
- Department of Pathology, Microbiology and Immunology, Vanderbilt University, Nashville, Tennessee, United States of America
- Department of Bioengineering and Organic Chemistry, Tomsk Polytechnic University, Tomsk, Russia
| | - Kelli L. Boyd
- Department of Pathology, Microbiology and Immunology, Vanderbilt University, Nashville, Tennessee, United States of America
| | - Qiufang Cheng
- Department of Pathology, Microbiology and Immunology, Vanderbilt University, Nashville, Tennessee, United States of America
| | - Edward R. Sherwood
- Department of Anesthesiology, Vanderbilt University, Nashville, Tennessee, United States of America
| | - Erik I. Tucker
- Aronora, Inc., Portland, Oregon, United States of America
| | - Stephen T. Smiley
- National Institute of Allergy and Infectious Disease, Bethesda, Maryland, United States of America
| | - Owen J. T. McCarty
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, Oregon, United States of America
| | - Andras Gruber
- Aronora, Inc., Portland, Oregon, United States of America
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, Oregon, United States of America
| | - David Gailani
- Department of Pathology, Microbiology and Immunology, Vanderbilt University, Nashville, Tennessee, United States of America
- * E-mail:
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Park HS, Gu J, You HJ, Kim JE, Kim HK. Factor XII-mediated contact activation related to poor prognosis in disseminated intravascular coagulation. Thromb Res 2015; 138:103-107. [PMID: 26706311 DOI: 10.1016/j.thromres.2015.12.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Revised: 12/02/2015] [Accepted: 12/12/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND The contact system that initiates the intrinsic coagulation pathway plays a role in thrombus formation. Since neutrophil extracellular traps (NET), which are mainly composed of histone and DNA, are actively formed in disseminated intravascular coagulation (DIC) and the NET can activate factor XII, it is plausible that a NET component strongly activates the contact system in patients with DIC. METHODS In 146 patients suspected of having DIC, the plasma levels of contact system factors including factor XII, activated factor XII (XIIa), prekallikrein, high-molecular-weight kininogen (HMWK), bradykinin, extrinsic factor VII and histone–DNA complex were measured. In an in vitro plasma clotting assay, factor XII–deficient plasma was stimulated with silica or histone. RESULTS The levels of not only extrinsic coagulation factor VII but also intrinsic coagulation factors including factors XI and XII were significantly decreased in patients with overt DIC in comparison with those with no overt DIC. Factor XIIa and histone-DNA complex were also significantly increased in patients with overt DIC. However,HMWK, prekallikrein and bradykin inw ere not significantly different between patients with and without overt DIC. Interestingly, factors XII and XIIa were revealed as significantly independent potential prognostic markers for DIC. The histone-DNA complex level significantly contributed to the factor XIIa level (20.6%). In an in vitro clotting assay, histone, a major component of NET, activated coagulation that was dependent, in part, on the presence of factor XII. CONCLUSION These findings suggest that active NET formation can induce factor XII-mediated coagulation activation in patients with DIC with poor prognosis. The resulting factor XIIa release can be used as an independent potential prognostic marker for DIC. Activation of factor XII-mediated coagulation may be a potential therapeutic target in DIC,
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Affiliation(s)
- Hee Sue Park
- Department of Laboratory Medicine and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - JaYoon Gu
- Department of Laboratory Medicine and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hyun Ju You
- Department of Laboratory Medicine and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Ji-Eun Kim
- Department of Laboratory Medicine and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hyun Kyung Kim
- Department of Laboratory Medicine and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea.
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36
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Gailani D, Bane CE, Gruber A. Factor XI and contact activation as targets for antithrombotic therapy. J Thromb Haemost 2015; 13:1383-95. [PMID: 25976012 PMCID: PMC4516614 DOI: 10.1111/jth.13005] [Citation(s) in RCA: 96] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Accepted: 05/01/2015] [Indexed: 11/26/2022]
Abstract
The most commonly used anticoagulants produce therapeutic antithrombotic effects either by inhibiting thrombin or factor Xa (FXa) or by lowering the plasma levels of the precursors of these key enzymes, prothrombin and FX. These drugs do not distinguish between thrombin generation contributing to thrombosis from thrombin generation required for hemostasis. Thus, anticoagulants increase bleeding risk, and many patients who would benefit from therapy go untreated because of comorbidities that place them at unacceptable risk for hemorrhage. Studies in animals demonstrate that components of the plasma contact activation system contribute to experimentally induced thrombosis, despite playing little or no role in hemostasis. Attention has focused on FXII, the zymogen of a protease (FXIIa) that initiates contact activation when blood is exposed to foreign surfaces, and FXI, the zymogen of the protease FXIa, which links contact activation to the thrombin generation mechanism. In the case of FXI, epidemiologic data indicate this protein contributes to stroke and venous thromboembolism, and perhaps myocardial infarction, in humans. A phase 2 trial showing that reduction of FXI may be more effective than low molecular weight heparin at preventing venous thrombosis during knee replacement surgery provides proof of concept for the premise that an antithrombotic effect can be uncoupled from an anticoagulant effect in humans by targeting components of contact activation. Here, we review data on the role of FXI and FXII in thrombosis and results of preclinical and human trials for therapies targeting these proteins.
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Affiliation(s)
- David Gailani
- Department of Pathology, Microbiology and Immunology, Vanderbilt University, Nashville, Tennessee, USA
| | - Charles E. Bane
- Department of Pathology, Microbiology and Immunology, Vanderbilt University, Nashville, Tennessee, USA
| | - Andras Gruber
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR
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