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Christiansen SC, Zuraw BL. Contact System Activation and Bradykinin Generation in Angioedema: Laboratory Assessment and Biomarker Utilization. Immunol Allergy Clin North Am 2024; 44:543-560. [PMID: 38937015 DOI: 10.1016/j.iac.2024.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/29/2024]
Abstract
The role of contact system activation has been clearly established in the pathogenesis of hereditary angioedema due to C1 inhibitor deficiency (HAE-C1INH). C1 inhibitor (C1INH)-protease complexes, levels of functional C1INH, plasma kallikrein activation, and cleavage of high-molecular-weight kininogen have each been associated with disease activity. More recently, HAE with normal levels of C1INH (HAE-nl-C1INH) has been recognized. Six genetic mutations have been identified which are linked to HAE-nl-C1INH phenotypes. The majority of individuals with HAE-nl-C1INH fall into the unknown category. There is substantial evidence that bradykinin generation underlies the recurrent attacks of swelling in some of these cohorts.
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Affiliation(s)
- Sandra C Christiansen
- Department of Medicine, University of California San Diego, 9500 Gilman Drive, Mail Code 0732, La Jolla, CA 92093, USA
| | - Bruce L Zuraw
- Department of Medicine, University of California San Diego, 9500 Gilman Drive, Mail Code 0732, La Jolla, CA 92093, USA; Medicine Service, San Diego Veterans Administration Healthcare System, 3350 La Jolla Village Drive, San Diego, CA 92161, USA.
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2
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Radojicic C, Anderson J. Hereditary angioedema with normal C1 esterase inhibitor: Current paradigms and clinical dilemmas. Allergy Asthma Proc 2024; 45:147-157. [PMID: 38755781 DOI: 10.2500/aap.2024.45.240010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2024]
Abstract
Background: A diagnosis of hereditary angioedema (HAE) with normal C1 esterase inhibitor (HAE-nl-C1-INH) can be challenging and pharmacologic management is not well defined. Objective: The objective was to discuss practical considerations in the clinical management of HAE-nl-C1-INH by using illustrative clinical vignettes to highlight and/or address select challenges. Methods: This was a narrative review. Results: Symptoms of HAE-nl-C1-INH overlap with HAE types I and II; the heterogeneity of presentation and symptom burden are diagnostic challenges. A patient history, with particular attention to whether urticaria or other symptoms of mast cell mediator release are present, is important because such symptoms would strongly suggest a mast cell-mediated pathway. A family history of angioedema is informative but a lack thereof does not rule out diagnosis. Expected laboratory findings would be normal for C4, C1-INH level and function, and Complement 1q; a genetic mutational analysis may be helpful, but current assays do not include all known mutations; most cases are categorized as unknown. To align with guideline-directed treatment approaches, the following stepwise approach is suggested for suspected HAE-nl-C1-INH: (1) thoroughly investigate the possibility of response to histaminergic and/or mast cell-targeting treatments; (2) if patients with normal C4, C1-INH level and/or function fail adequate trials with histamine/mast cell-directed therapy or have a mutation that suggests bradykinin pathway involvement, follow HAE type I and II treatment guidelines. Response to medications approved for HAE types I/II provides compelling support for a high clinical suspicion of HAE-nl-C1-INH. De-labeling an HAE-nl-C1-INH diagnosis may be appropriate if the initial diagnosis was made without adequate evaluation or if new information and/or testing indicates that the patient does not actually have HAE. Conclusion: Key unmet needs in HAE-nl-C1-INH include lack of confirmatory biomarker(s) for diagnosis and lack of prospective controlled clinical studies of pharmacologic products in this patient population.
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Affiliation(s)
- Cristine Radojicic
- From the Division of Pulmonary, Allergy and Critical Care, Department of Medicine, Duke University, Durham, North Carolina
| | - John Anderson
- Division of Pulmonary Allergy, Critical Care in Sleep Medicine, Department of Internal Medicine, University of Alabama, Birmingham, Alabama, and
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3
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Vincent D, Parsopoulou F, Martin L, Gaboriaud C, Demongeot J, Loules G, Fischer S, Cichon S, Germenis AE, Ghannam A, Drouet C. Hereditary angioedema with normal C1 inhibitor associated with carboxypeptidase N deficiency. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. GLOBAL 2024; 3:100223. [PMID: 38445235 PMCID: PMC10912455 DOI: 10.1016/j.jacig.2024.100223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 11/18/2023] [Accepted: 11/19/2023] [Indexed: 03/07/2024]
Abstract
Background Hereditary angioedema (HAE) is a potentially life-threatening disorder characterized by recurrent episodes of subcutaneous or submucosal swelling. HAE with normal C1 inhibitor (HAE-nC1-INH) is an underdiagnosed condition. Although the association with genetic variants has been identified for some families, the genetic causes in many patients with HAE-nC1-INH remain unknown. The role of genes associated with bradykinin catabolism is not fully understood. Objective We sought to investigate the biological parameters and the genes related to kallikrein-kinin system in families with a clinical phenotype of HAE-nC1-INH and presenting with a carboxypeptidase N (CPN) deficiency. Methods This study includes 4 families presenting with HAE-nC1-INH and CPN deficiency. Patients' clinical records were examined, biological parameters of kallikrein-kinin system were measured, and genetics was analyzed by next-generation sequencing and Sanger sequencing. Predictive algorithms (Human Splicing Finder, Sorting Intolerant From Tolerant, Polymorphism Phenotyping v2, MutationTaster, and ClinPred) were used to classify variants as affecting splicing, as benign to deleterious, or as disease-causing. Results Patients presented with angioedema and urticaria, mainly on face/lips, but also with abdominal pain or laryngeal symptoms. Affected patients displayed low CPN activity-30% to 50% of median value in plasma. We identified 3 variants of the CPN1 gene encoding the catalytic 55-kDa subunit of CPN: c.533G>A, c.582A>G, and c.734C>T. CPN deficiency associated with genetic variants segregated with HAE-nC1-INH symptoms in affected family members. Conclusions CPN1 gene variants are associated with CPN deficiency and HAE-nC1-INH symptoms in 4 unrelated families. Genetic CPN deficiency may contribute to bradykinin and anaphylatoxin accumulation, with synergistic effects in angioedema and urticarial symptoms.
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Affiliation(s)
- Denis Vincent
- Allergy and Internal Medicine Unit, University Hospital, Nîmes, France
- Centre de compétence, Centre de Référence des Angioedèmes (CREAK), Nîmes
| | | | - Ludovic Martin
- Dermatology Department, University Hospital, Angers, France
- Centre de Référence des Maladies Rares de la peau et des muqueuses d’origine génétique-Nord (MAGEC), filière FIMARAD, CHU Angers, Angers, France
| | | | | | | | - Sascha Fischer
- Human Genomics Research Group, Department of Biomedicine, University of Basel, Basel, Switzerland
- Institute of Medical Genetics and Pathology, University Hospital Basel, Basel, Switzerland
| | - Sven Cichon
- Human Genomics Research Group, Department of Biomedicine, University of Basel, Basel, Switzerland
- Institute of Medical Genetics and Pathology, University Hospital Basel, Basel, Switzerland
| | - Anastasios E. Germenis
- Department of Immunology and Histocompatibility, University of Thessaly, Larissa, Greece
| | | | - Christian Drouet
- Université Grenoble Alpes, CHU Grenoble Alpes, Grenoble, France
- Institut Cochin, INSERM, CNRS, Université Paris Cité, 75679, Paris, France
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4
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Petersen RS, Bordone L, Riedl MA, Tachdjian R, Craig TJ, Lumry WR, Manning ME, Bernstein JA, Raasch J, Zuraw BL, Deng Y, Newman KB, Alexander VJ, Lui C, Schneider E, Cohn DM. A phase 2 open-label extension study of prekallikrein inhibition with donidalorsen for hereditary angioedema. Allergy 2024; 79:724-734. [PMID: 38009241 DOI: 10.1111/all.15948] [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: 08/12/2023] [Revised: 10/20/2023] [Accepted: 10/31/2023] [Indexed: 11/28/2023]
Abstract
BACKGROUND Hereditary angioedema (HAE) is a potentially fatal disease characterized by unpredictable, recurrent, often disabling swelling attacks. In a randomized phase 2 study, donidalorsen reduced HAE attack frequency and improved patient quality-of-life (ISIS721744-CS2, NCT04030598). We report the 2-year interim analysis of the phase 2 open-label extension (OLE) study (ISIS 721744-CS3, NCT04307381). METHODS In the OLE, the on-treatment study period consisted of fixed (weeks 1-13, donidalorsen 80 mg subcutaneously every 4 weeks [Q4W]) and flexible (weeks 17-105, donidalorsen 80 mg Q4W, 80 mg every 8 weeks [Q8W], or 100 mg Q4W) dosing periods. The primary outcome was incidence and severity of treatment-emergent adverse events (TEAEs). The secondary outcomes included efficacy, pharmacodynamic, and quality-of-life assessments. RESULTS Seventeen patients continued in the OLE study. No serious TEAEs or TEAEs leading to treatment discontinuation were reported. Mean monthly HAE attack rate was 96% lower than the study run-in baseline rate (mean, 0.06/month; 95% confidence interval [CI], 0.02-0.10; median, 0.04 on-treatment vs. mean, 2.70/month; 95% CI, 1.94-3.46; median, 2.29 at baseline). Mean monthly attack rate for Q8W dosing (n = 8) was 0.29 (range, 0.0-1.7; 95% CI, -0.21 to 0.79; median, 0.00). Mean plasma prekallikrein and D-dimer concentrations decreased, and Angioedema Quality of Life Questionnaire total score improved from baseline to week 105 with donidalorsen. CONCLUSION The 2-year interim results of this phase 2 OLE study of donidalorsen in patients with HAE demonstrated no new safety signals; donidalorsen was well tolerated. There was durable efficacy with a 96% reduction in HAE attacks.
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Affiliation(s)
- Remy S Petersen
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Laura Bordone
- Ionis Pharmaceuticals, Inc., Carlsbad, California, USA
| | - Marc A Riedl
- University of California San Diego, La Jolla, California, USA
| | - Raffi Tachdjian
- Department of Pediatrics, University of California, Los Angeles, California, USA
- Providence Saint John's Health Center, Santa Monica, California, USA
| | - Timothy J Craig
- Department of Medicine, Pediatrics, and Biomedical Sciences, Pennsylvania State University, Hershey, Pennsylvania, USA
- Vinmec International Hospital, Times City, Hanoi, Vietnam
| | - William R Lumry
- Allergy and Asthma Research Associates Research Center, Dallas, Texas, USA
| | | | - Jonathan A Bernstein
- Department of Internal Medicine, University of Cincinnati College of Medicine, and Bernstein Clinical Research Center, Cincinnati, Ohio, USA
| | - Jason Raasch
- Midwest Immunology Clinic, Plymouth, Minnesota, USA
| | - Bruce L Zuraw
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, University of California San Diego, La Jolla, California, USA
| | - Yiwen Deng
- Ionis Pharmaceuticals, Inc., Carlsbad, California, USA
| | | | | | - Cindy Lui
- Ionis Pharmaceuticals, Inc., Carlsbad, California, USA
| | | | - Danny M Cohn
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
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Schmaier AH, Ghannam A, Drouet C. Editorial: Kinin 2022 Meeting, Annecy, France. J Clin Med 2023; 12:jcm12093276. [PMID: 37176717 PMCID: PMC10179192 DOI: 10.3390/jcm12093276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 04/18/2023] [Indexed: 05/15/2023] Open
Abstract
The Kinin 2022 meeting took place at the Imperial Palace, Annecy, France, from 5-8 June 2022 [...].
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Affiliation(s)
- Alvin H Schmaier
- The Division of Hematology and Cell Therapy, University Hospitals Cleveland Medical Center, Case Western Reserve University, 2103 Cornell Road, WRB 2-130, Cleveland, OH 44106-7824, USA
| | | | - Christian Drouet
- Institut Cochin, Université Paris Cité, INSERM UMR1016, 75006 Paris, France
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6
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Hereditary Angioedema: Diagnosis, Pathogenesis, and Therapy. CURRENT TREATMENT OPTIONS IN ALLERGY 2022. [DOI: 10.1007/s40521-022-00308-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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7
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Marceau F, Rivard GE, Hébert J, Gauthier J, Bachelard H, Gangnus T, Burckhardt BB. Picomolar Sensitivity Analysis of Multiple Bradykinin-Related Peptides in the Blood Plasma of Patients With Hereditary Angioedema in Remission: A Pilot Study. FRONTIERS IN ALLERGY 2022; 3:837463. [PMID: 35386662 PMCID: PMC8974669 DOI: 10.3389/falgy.2022.837463] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 01/11/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundHereditary angioedema (HAE) is a rare autosomal dominant disease; the most well understood forms concern the haplodeficiency of C1 esterase inhibitor (C1INH) and a gain of function mutation of factor XII (FXII). The acute forms of these conditions are mediated by an excessive bradykinin (BK) formation by plasma kallikrein.MethodsA validated LC-MS/MS platform of picomolar sensitivity developed for the analysis of eleven bradykinin-related peptides was applied to the plasma of HAE-C1INH and HAE-FXII sampled during remission.ResultsIn HAE-C1INH plasma, the concentrations of the relatively stable BK1−5 fragment (mean ± S.E.M.: 12.0 ± 4.2 pmol/L), of BK2−9 (0.7 ± 0.2 pmol/L) and of the sums of BK and its tested fragments (18.0 ± 6.4 pmol/L) are significantly greater than those recorded in the plasma of healthy volunteers (1.9 ± 0.6, 0.03 ± 0.03 and 4.3 ± 0.8 pmol/L, respectively), consistent with the previous evidence of permanent plasma kallikrein activity in this disease. Kinin levels in the plasma of HAE-FXII patients did not differ from controls, suggesting that triggering factors for contact system activation are not active during remission.ConclusionBK1−5, BK2−9 and the sum of BK and its fragments determined by the sensitive LC-MS/MS technique are proposed as potential biomarkers of HAE-C1INH in remission while this was not applicable to HAE-FXII patients.
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Affiliation(s)
- François Marceau
- Axe Maladies Infectieuses et Immunitaires, Centre de Recherche du CHU de Québec-Université Laval, Québec, QC, Canada
- *Correspondence: François Marceau
| | - Georges-Etienne Rivard
- Division of Hematology/Oncology, CHU Sainte-Justine, Université de Montréal, Montréal, QC, Canada
| | - Jacques Hébert
- Service d'allergie, CHU de Québec-Université Laval, Québec, QC, Canada
| | - Julie Gauthier
- Molecular Diagnostic Laboratory, Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montréal, QC, Canada
- Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montréal, QC, Canada
| | - Hélène Bachelard
- Axe Endocrinologie et Néphrologie, Centre de Recherche du CHU de Québec-Université Laval, Québec, QC, Canada
| | - Tanja Gangnus
- Institute of Clinical Pharmacy and Pharmacotherapy, Heinrich Heine Universität Düsseldorf, Düsseldorf, Germany
| | - Bjoern B. Burckhardt
- Institute of Clinical Pharmacy and Pharmacotherapy, Heinrich Heine Universität Düsseldorf, Düsseldorf, Germany
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8
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Radojicic C. Guidelines for management of hereditary angioedema: What is new? What is missing? Allergy Asthma Proc 2022; 43:12-19. [PMID: 34983705 DOI: 10.2500/aap.2022.43.210086] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Background: Hereditary angioedema is an autosomal dominant disease that presents with recurrent episodic swelling of the submucosal and/or subcutaneous tissues of the cutaneous, gastrointestinal, and respiratory systems. Evaluation and treatment guidelines have been published nationally and internationally to aid the treating provider. Methods: A review of the most cited and most recent updated guidelines was undertaken to review key points and to explore real-world feasibility of incorporating them into clinical practice. The International World Allergy Organization/European Academy of Allergy and Clinical Immunology (WAO/EAACI) Guideline for the Management of Angioedema - The 2017 Revision and Update, and the consensus reports from the Hereditary Angioedema International Working Group, the Joint Task Force on Practice Parameters focused practice parameter update, and the most recently updated US HAEA Medical Advisory Board 2020 Guidelines for the Management of Hereditary Angioedema were reviewed and summarized. Results: Key points that have been consistent throughout the guidelines include recommendations for evaluation and classification of hereditary angioedema as well as evidence-based guidelines for treatment. Further attention is required on the evaluation and continuous assessment of the burden of illness and quality of life (QoL). Conclusion: The guidelines for management of hereditary angioedema provide a framework for the clinician. However, the physician-patient dialog with regard to the patient disease experience, which includes attack frequency, severity, and Qol, must be continually assessed.
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9
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Grumach AS, Veronez CL, Csuka D, Farkas H. Angioedema Without Wheals: Challenges in Laboratorial Diagnosis. Front Immunol 2021; 12:785736. [PMID: 34956216 PMCID: PMC8694242 DOI: 10.3389/fimmu.2021.785736] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 11/03/2021] [Indexed: 11/13/2022] Open
Abstract
Angioedema is a prevailing symptom in different diseases, frequently occurring in the presence of urticaria. Recurrent angioedema without urticaria (AE) can be hereditary (HAE) and acquired (AAE), and several subtypes can be distinguished, although clinical presentation is quite similar in some of them. They present with subcutaneous and mucosal swellings, affecting extremities, face, genitals, bowels, and upper airways. AE is commonly misdiagnosed due to restricted access and availability of appropriate laboratorial tests. HAE with C1 inhibitor defect is associated with quantitative and/or functional deficiency. Although bradykinin-mediated disease results mainly from disturbance in the kallikrein–kinin system, traditionally complement evaluation has been used for diagnosis. Diagnosis is established by nephelometry, turbidimetry, or radial immunodiffusion for quantitative measurement of C1 inhibitor, and chromogenic assay or ELISA has been used for functional C1-INH analysis. Wrong handling of the samples can lead to misdiagnosis and, consequently, mistaken inappropriate approaches. Dried blood spot (DBS) tests have been used for decades in newborn screening for certain metabolic diseases, and there has been growing interest in their use for other congenital conditions. Recently, DBS is now proposed as an efficient tool to diagnose HAE with C1 inhibitor deficiency, and its use would improve the access to outbound areas and family members. Regarding HAE with normal C1 inhibitor, complement assays’ results are normal and the genetic sequencing of target genes, such as exon 9 of F12 and PLG, is the only available method. New methods to measure cleaved high-molecular-weight kininogen and activated plasma kallikrein have emerged as potential biochemical tests to identify bradykinin-mediated angioedema. Validated biomarkers of kallikrein–kinin system activation could be helpful in differentiating mechanisms of angioedema. Our aim is to focus on the capability to differentiate histaminergic AE from bradykinin-mediated AE. In addition, we will describe the challenges developing specific tests like direct bradykinin measurements. The need for quality tests to improve the diagnosis is well represented by the variability of results in functional assays.
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Affiliation(s)
- Anete S Grumach
- Clinical Immunology, Faculdade de Medicina, Centro Universitario Faculdade de Medicina ABC (FMABC), Santo Andre, Brazil
| | - Camila L Veronez
- Division of Rheumatology, Allergy and Immunology, Department of Medicine, University of California San Diego, San Diego, CA, United States.,Research Service, San Diego Veterans Affairs Healthcare, San Diego, CA, United States
| | - Dorottya Csuka
- Hungarian Angioedema Center of Reference and Excellence, Department of Internal Medicine and Haematology, Semmelweis University, Budapest, Hungary
| | - Henriette Farkas
- Hungarian Angioedema Center of Reference and Excellence, Department of Internal Medicine and Haematology, Semmelweis University, Budapest, Hungary
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Porebski G, Kwitniewski M, Reshef A. Biomarkers in Hereditary Angioedema. Clin Rev Allergy Immunol 2021; 60:404-415. [PMID: 33560480 PMCID: PMC8272698 DOI: 10.1007/s12016-021-08845-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/24/2021] [Indexed: 12/20/2022]
Abstract
A biomarker is a defined characteristic measured as an indicator of normal, biologic, pathogenic processes, or biological responses to an exposure or intervention. Diagnostic biomarkers are used to detect a disease or a subtype of a disease; monitoring biomarkers are measured serially to assess a medical condition; response biomarkers are used to check biologic response following a medical intervention; predictive biomarkers are used to identify patients who are more likely to respond to a medical intervention; and prognostic biomarkers are used to assess the future likelihood of a clinical event. Although biomarkers have been extensively investigated and validated in many diseases and pathologies, very few are currently useful for the diagnosis, evaluation of disease activity, and treatment of hereditary angioedema (HAE). Pathophysiologic pathways involved in HAE reveal a plethora of molecules from the complement, coagulation, and fibrinolysis systems or from the vascular endothelium, which may serve as biomarkers. The most promising candidates, together with their laboratory readout systems, should be evaluated with regard to their analytical and clinical validity and utility. To be highly specific, such biomarkers should be linked to the pathomechanisms of HAE, particularly the bradykinin-generating cascade. Additionally, major advances in high-throughput omics-based technologies may facilitate the discovery of new candidate biomarkers in the future. This review will cover the existing as well as future potential biomarkers that will support the diagnosis, monitor disease activity, and can be used to assess the efficacy of new avenues of therapy of HAE and other forms of angioedema.
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Affiliation(s)
- Grzegorz Porebski
- Department of Clinical and Environmental Allergology, Jagiellonian University Medical College, Krakow, Poland.
| | - Mateusz Kwitniewski
- Department of Immunology, Faculty of Biochemistry, Biophysics and Biotechnology, Jagiellonian University, Krakow, Poland
| | - Avner Reshef
- Barzilai University Medical Centre, Ashkelon, Israel
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11
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Reshef A, Levy D, Longhurst H, Cicardi M, Craig T, Keith PK, Feussner A, Feuersenger H, Machnig T, Prusty S, Pragst I. Effects of Continuous Plasma-Derived Subcutaneous C1-Esterase Inhibitor on Coagulation and Fibrinolytic Parameters. Thromb Haemost 2020; 121:690-693. [PMID: 33202446 DOI: 10.1055/s-0040-1721147] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Avner Reshef
- Division of Allergy, Immunology, and Angioedema, Barzilai Medical Center, Ashkelon, Israel
| | - Donald Levy
- Division of Basic and Clinical Immunology, Department of Medicine, University of California at Irvine, Orange, California, United States
| | - Hilary Longhurst
- Department of Immunology, Addenbrooke's Hospital, Cambridge and UCLH, London, United Kingdom
| | - Marco Cicardi
- Ospedale Luigi Sacco/U.O. Medicina Generale, Milano, Italy
| | - Timothy Craig
- Allergy, Immunology and Respiratory Research, Department of Medicine and Pediatrics, Penn State University, Hershey, Pennsylvania, United States
| | - Paul K Keith
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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12
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Corvillo F, de la Morena-Barrio ME, Marcos-Bravo C, López-Trascasa M, Vicente V, Emsley J, Caballero T, Corral J, López-Lera A. The FXII c.-4T>C Polymorphism as a Disease Modifier in Patients With Hereditary Angioedema Due to the FXII p.Thr328Lys Variant. Front Genet 2020; 11:1033. [PMID: 33133137 PMCID: PMC7549737 DOI: 10.3389/fgene.2020.01033] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 08/11/2020] [Indexed: 11/30/2022] Open
Abstract
Background Hereditary angioedema due to the Thr328Lys variant in the coagulation factor XII (HAE-FXII) affects mainly women in whom the symptomatology is dependent on high estrogen levels. Clinical variability and incomplete penetrance are challenging features that hinder the diagnosis and management of HAE-FXII. The c.-4T>C Kozak polymorphism is the only common variation accounting for FXII plasma levels and was previously shown to modify the course of HAE due to C1-Inhibitor deficiency. Objectives To assess the influence of the c.-4T>C polymorphism on disease expression in 39 Spanish HAE-FXII index patients. Methods The c.-4T>C polymorphism was sequenced by the standard Sanger method, and HAE severity was calculated according to the score by Cumming et al. (2003) The activation of the contact system was quantified by the kallikrein-like activity of plasma in chromogenic assays upon activation with high-molecular-weight dextran sulfate. Results The c.-4CC genotype was overrepresented in the studied cohort: 82% were CC-homozygous (expected frequency = 59%) and 18% were CT-heterozygous (expected frequency = 39%) (p = 0.001). Patients with a c.-4CC genotype exhibited higher kallikrein-like activity (0.9659 ± 0.1136) than those with a c.-4TC genotype (0.7645 ± 0.1235) (p = 0.024) or healthy donors. Moreover, the polymorphism influenced HAE-FXII severity score (c.-4CC = 4.43 ± 2.28 vs c.-4TC = 2.0 ± 1.15; p = 0.006) but not the degree of estrogen dependence or time until remission. Conclusion The c.-4T>C polymorphism is overrepresented in a Spanish HAE-FXII cohort and significantly influences the degree of contact system activation and the clinical severity of the disease.
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Affiliation(s)
- Fernando Corvillo
- Centre for Biomedical Network Research on Rare Diseases (CIBERER), Madrid, Spain.,Hospital La Paz Institute for Health Research (IdiPaz), Madrid, Spain
| | - María Eugenia de la Morena-Barrio
- Centre for Biomedical Network Research on Rare Diseases (CIBERER), Madrid, Spain.,Hematology and Medical Oncology Department, University Hospital Morales Meseguer, Centro Regional de Hemodonación, University of Murcia, IMIB-Arrixaca, Murcia, Spain
| | - Carmen Marcos-Bravo
- Allergy Department, University Hospital Complex of Vigo, Hospital Meixoeiro, Vigo, Spain
| | - Margarita López-Trascasa
- Hospital La Paz Institute for Health Research (IdiPaz), Madrid, Spain.,Faculty of Medicine, Autonomous University of Madrid, Madrid, Spain
| | - Vicente Vicente
- Centre for Biomedical Network Research on Rare Diseases (CIBERER), Madrid, Spain.,Hematology and Medical Oncology Department, University Hospital Morales Meseguer, Centro Regional de Hemodonación, University of Murcia, IMIB-Arrixaca, Murcia, Spain
| | - Jonas Emsley
- Centre for Biomolecular Sciences, School of Pharmacy, University of Nottingham, Nottingham, United Kingdom
| | - Teresa Caballero
- Centre for Biomedical Network Research on Rare Diseases (CIBERER), Madrid, Spain.,Hospital La Paz Institute for Health Research (IdiPaz), Madrid, Spain.,Allergy Department, La Paz University Hospital, Madrid, Spain
| | - Javier Corral
- Centre for Biomedical Network Research on Rare Diseases (CIBERER), Madrid, Spain.,Hematology and Medical Oncology Department, University Hospital Morales Meseguer, Centro Regional de Hemodonación, University of Murcia, IMIB-Arrixaca, Murcia, Spain
| | - Alberto López-Lera
- Centre for Biomedical Network Research on Rare Diseases (CIBERER), Madrid, Spain.,Hospital La Paz Institute for Health Research (IdiPaz), Madrid, Spain
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Parsopoulou F, Charignon D, Tengo M, Psarros F, Maas C, Gonzalez‐Quevedo T, Drouet C, Germenis AE, Ghannam A. Plasminogen glycoforms alteration and activation susceptibility associated with the missense variant p.Lys330Glu in HAE-PLG patients. Allergy 2020; 75:2099-2102. [PMID: 32181895 DOI: 10.1111/all.14280] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 02/24/2020] [Accepted: 03/11/2020] [Indexed: 12/16/2022]
Affiliation(s)
- Faidra Parsopoulou
- Department of Immunology & Histocompatibility Faculty of Medicine University of Thessaly Larissa Greece
- CeMIA SA Larissa Greece
- GREPI EA7408 EFS Rhône‐Alpes Université Grenoble Alpes Grenoble France
| | | | | | - Fotis Psarros
- Department of Allergology Navy Hospital Athens Greece
| | - Coen Maas
- Department of Clinical Chemistry and Haematology University Medical Center Utrecht Utrecht University Utrecht The Netherlands
| | - Teresa Gonzalez‐Quevedo
- Reference Unit for Angioedema in Andalusia Allergy Department Virgen del Rocío University Hospital Seville Spain
| | - Christian Drouet
- GREPI EA7408 EFS Rhône‐Alpes Université Grenoble Alpes Grenoble France
- INSERM U1016 CNRS UMR8104 Institut Cochin Université de Paris Paris France
| | - Anastasios E. Germenis
- Department of Immunology & Histocompatibility Faculty of Medicine University of Thessaly Larissa Greece
- CeMIA SA Larissa Greece
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14
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Firinu D, Arba M, Vincenzoni F, Iavarone F, Costanzo G, Cabras T, Castagnola M, Messana I, Del Giacco SR, Sanna MT. Proteomic Analysis of the Acid-Insoluble Fraction of Whole Saliva from Patients Affected by Different Forms of Non-histaminergic Angioedema. J Clin Immunol 2020; 40:840-850. [PMID: 32519288 DOI: 10.1007/s10875-020-00802-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Accepted: 06/01/2020] [Indexed: 01/17/2023]
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Longhurst H, Farkas H. Biological therapy in hereditary angioedema: transformation of a rare disease. Expert Opin Biol Ther 2020; 20:493-501. [PMID: 31994957 DOI: 10.1080/14712598.2020.1724280] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Introduction: Hereditary angioedema, a disabling condition, with high mortality when untreated, is caused by C1 inhibitor deficiency and other regulatory disorders of bradykinin production or metabolism. This review covers the remarkable progress made in biological therapies for this rare disorder.Areas covered: Over the past 10 years, several evidence-based parenteral treatments have been licensed, including two plasma-derived C1 inhibitor replacement therapies and one recombinant C1 inhibitor replacement for acute treatment of angioedema attacks and synthetic peptides for inhibition of kallikrein or bradykinin B2 receptors, with oral small molecule treatments currently in clinical trial. Moreover, recent advances in prophylaxis by subcutaneous C1 inhibitor to restore near-normal plasma function or by humanized antibody inhibition of kallikrein have resulted in freedom from symptoms for a high proportion of those treated.Expert opinion: This plethora of treatment possibilities has come about as a result of recent scientific advances. Collaboration between patient groups, basic and clinical scientists, physicians, nurses, and the pharmaceutical industry has underpinned this translation of basic science into treatments and protocols. These in their turn have brought huge improvements in prognosis, quality of life and economic productivity to patients, their families, and the societies in which they live.
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Affiliation(s)
- Hilary Longhurst
- Department of Clinical Immunology, Addenbrooke's Hospital, Cambridge and University College Hospitals, London, UK
| | - Henriette Farkas
- 3rd Department of Internal Medicine, Semmelweis University, Budapest, Hungary
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Ferrone JD, Bhattacharjee G, Revenko AS, Zanardi TA, Warren MS, Derosier FJ, Viney NJ, Pham NC, Kaeser GE, Baker BF, Schneider E, Hughes SG, Monia BP, MacLeod AR. IONIS-PKK Rx a Novel Antisense Inhibitor of Prekallikrein and Bradykinin Production. Nucleic Acid Ther 2019; 29:82-91. [PMID: 30817230 PMCID: PMC6461157 DOI: 10.1089/nat.2018.0754] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Kallikrein is the key contact system mediator responsible for the conversion of high-molecular-weight kininogen into the inflammatory vasodilator peptide bradykinin, a process regulated by C1-esterase inhibitor (C1-INH). In hereditary angioedema (HAE), genetic mutations result in deficient or dysfunctional C1-INH and dysregulation of the contact system leading to recurrent, sometimes fatal, angioedema attacks. IONIS-PKKRx is a second-generation 2'-O-(2-methoxyethyl)-modified chimeric antisense oligonucleotide, designed to bind and selectively reduce prekallikrein (PKK) mRNA in the liver. IONIS-PKKRx demonstrated dose-dependent reduction of human prekallikrein hepatic mRNA and plasma protein in transgenic mice and dose- and time-dependent reductions of plasma PKK in Cynomolgus monkeys. Similar dose-dependent reductions of plasma PKK levels were observed in healthy human volunteers accompanied by decreases in bradykinin generation capacity with an acceptable safety and tolerability profile. These results highlight a novel and specific approach to target PKK for the treatment of HAE and other diseases involving contact system activation and overproduction of bradykinin.
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Charest-Morin X, Betschel S, Borici-Mazi R, Kanani A, Lacuesta G, Rivard GÉ, Wagner E, Wasserman S, Yang B, Drouet C. The diagnosis of hereditary angioedema with C1 inhibitor deficiency: a survey of Canadian physicians and laboratories. Allergy Asthma Clin Immunol 2018; 14:83. [PMID: 30479631 PMCID: PMC6249925 DOI: 10.1186/s13223-018-0307-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Accepted: 11/10/2018] [Indexed: 12/20/2022] Open
Abstract
Background Hereditary angioedema due to C1 inhibitor deficiency (C1-INH-HAE) is an autosomal dominant disease resulting in random and unpredictable attacks of swelling. The swelling in C1-INH-HAE is a result of impaired regulation of bradykinin production. The fact that the array of tests needed to diagnose HAE is not always available to the treating physicians is challenging for them and their patients. Methods The data for this article were extracted from two distinct surveys. The first survey was conducted among HAE treating physicians and aimed to determine the availability and utilization of the various assays performed to help the diagnosis of C1-INH-HAE. The second survey was conducted with the various laboratories across Canada that performs the assays used in the diagnosis of HAE. The aim of this survey was to determine the availability and profile of the various assays used in the diagnosis of C1-INH-HAE in Canada, thereby ultimately bringing a rational basis for the biological testing. Results C1-INH functional assay was widely available in Canada (93%), but was only offered by a small numbers of hospitals meaning that there could be longer delays in the analysis of these samples that may explain why the physicians expressed a lower level of confidence in this assay (59%). Antigenic C1-INH was available to the vast majority of the physicians treating C1-INH-HAE (93%) and was considered reliable by 96% of the respondents. Antigenic C4 was found available to all Canadian physicians and, although with limited specificity, was considered very reliable by all the participants. This study revealed that 81% of physicians were able to order the antigenic C1q and the confidence in this assay was moderate (70%). Concerning genetic testing, the survey revealed that most of the CHAEN members never had to or couldn't order this test. Conclusion This study highlights the need for improved education and knowledge exchange, about biological assays available to Canadian physicians and their performance in proper diagnosis of C1-INH-HAE to improve confidence and access to relevant tests.
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Affiliation(s)
- Xavier Charest-Morin
- 1Department of Microbiology-Infectious Disease and Immunology, Laval University, Quebec, QC Canada
| | - Stephen Betschel
- 2Division of Clinical Immunology and Allergy, St. Michael's Hospital, University of Toronto, Toronto, ON Canada
| | - Rozita Borici-Mazi
- 3Division of Allergy and Immunology, Department of Medicine, Queen's University, Kingston, Canada
| | - Amin Kanani
- 4Division of Allergy and Immunology, Department of Medicine, University of British Columbia, Vancouver, BC Canada
| | - Gina Lacuesta
- 5Department of Medicine, Dalhousie University, Halifax, NS Canada
| | - Georges-Étienne Rivard
- 6Hematology/Oncology, Centre Hospitalier Universitaire Sainte-Justine, Montreal, QC Canada
| | - Eric Wagner
- 7Immunology and Histocompatibility Laboratory, CHU de Quebec, Laval University, Quebec, QC Canada
| | - Susan Wasserman
- 8Department of Medicine, McMaster University, Hamilton, ON Canada
| | - Bill Yang
- 9University of Ottawa Medical School, Ottawa, ON Canada
| | - Christian Drouet
- 10GREPI EA7408, University Grenoble Alpes, Grenoble, France.,Filière de santé Maladies Rares Immuno-Hématologiques (MaRIH), CHU Grenoble Alpes, Grenoble, France.,12Present Address: INSERM U1016, Institut Cochin and Laboratoire d'Immunologie, Hôpital Cochin, AP-HP, Université Paris-Descartes, Paris, France
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Lara-Marquez ML, Christiansen SC, Riedl MA, Herschbach J, Zuraw BL. Threshold-stimulated kallikrein activity distinguishes bradykinin- from histamine-mediated angioedema. Clin Exp Allergy 2018; 48:1429-1438. [DOI: 10.1111/cea.13219] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 06/17/2018] [Indexed: 11/27/2022]
Affiliation(s)
- Maria L. Lara-Marquez
- Division of Rheumatology, Allergy and Immunology; Department of Medicine; UC San Diego; La Jolla California
| | - Sandra C. Christiansen
- Division of Rheumatology, Allergy and Immunology; Department of Medicine; UC San Diego; La Jolla California
| | - Marc A. Riedl
- Division of Rheumatology, Allergy and Immunology; Department of Medicine; UC San Diego; La Jolla California
| | - Jack Herschbach
- Medicine Service; San Diego VA Healthcare; San Diego California
| | - Bruce L. Zuraw
- Division of Rheumatology, Allergy and Immunology; Department of Medicine; UC San Diego; La Jolla California
- Medicine Service; San Diego VA Healthcare; San Diego California
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Angioedema: Systemic activation process during prodromes. Ann Allergy Asthma Immunol 2018; 121:248-249. [PMID: 29730014 DOI: 10.1016/j.anai.2018.04.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 04/03/2018] [Accepted: 04/30/2018] [Indexed: 02/02/2023]
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Bender L, Weidmann H, Rose-John S, Renné T, Long AT. Factor XII-Driven Inflammatory Reactions with Implications for Anaphylaxis. Front Immunol 2017; 8:1115. [PMID: 28966616 PMCID: PMC5605561 DOI: 10.3389/fimmu.2017.01115] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 08/24/2017] [Indexed: 12/14/2022] Open
Abstract
Anaphylaxis is a life-threatening allergic reaction. It is triggered by the release of pro-inflammatory cytokines and mediators from mast cells and basophils in response to immunologic or non-immunologic mechanisms. Mediators that are released upon mast cell activation include the highly sulfated polysaccharide and inorganic polymer heparin and polyphosphate (polyP), respectively. Heparin and polyP supply a negative surface for factor XII (FXII) activation, a serine protease that drives contact system-mediated coagulation and inflammation. Activation of the FXII substrate plasma kallikrein leads to further activation of zymogen FXII and triggers the pro-inflammatory kallikrein-kinin system that results in the release of the mediator bradykinin (BK). The severity of anaphylaxis is correlated with the intensity of contact system activation, the magnitude of mast cell activation, and BK formation. The main inhibitor of the complement system, C1 esterase inhibitor, potently interferes with FXII activity, indicating a meaningful cross-link between complement and kallikrein-kinin systems. Deficiency in a functional C1 esterase inhibitor leads to a severe swelling disorder called hereditary angioedema (HAE). The significance of FXII in these disorders highlights the importance of studying how these processes are integrated and can be therapeutically targeted. In this review, we focus on how FXII integrates with inflammation and the complement system to cause anaphylaxis and HAE as well as highlight current diagnosis and treatments of BK-related diseases.
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Affiliation(s)
- Lysann Bender
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Henri Weidmann
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Thomas Renné
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Clinical Chemistry, Department of Molecular Medicine and Surgery, L1:00 Karolinska Institutet and University Hospital, Stockholm, Sweden
| | - Andy T. Long
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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21
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Christiansen SC, Zuraw BL. Laboratory Approaches for Assessing Contact System Activation. Immunol Allergy Clin North Am 2017; 37:527-539. [DOI: 10.1016/j.iac.2017.04.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Magerl M, Germenis AE, Maas C, Maurer M. Hereditary Angioedema with Normal C1 Inhibitor. Immunol Allergy Clin North Am 2017; 37:571-584. [DOI: 10.1016/j.iac.2017.04.004] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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23
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Hwang JH, An SM, Kwon SG, Park DH, Kim TW, Kang DG, Yu GE, Kim IS, Park HC, Ha J, Kim CW. Associations of the Polymorphisms in DHRS4, SERPING1, and APOR Genes with Postmortem pH in Berkshire Pigs. Anim Biotechnol 2017; 28:288-293. [PMID: 28489967 DOI: 10.1080/10495398.2017.1279171] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Postmortem pH is a main factor influencing the meat quality in pigs. This study investigated the association of postmortem pH with single-nucleotide polymorphisms (SNPs) in the fourth member of the short-chain dehydrogenase/reductase family (DHRS4), the first member of serpin peptidase inhibitor, clade G (complement inhibitor) (SERPING1), and the apolipoprotein R precursor (APOR) genes in Berkshire pigs. The study included 437 pigs, and genotyping was conducted using the GoldenGate Assay (Illumina, San Diego, CA, USA). DHRS4, SERPING1, and APOR polymorphisms were significantly associated with pH45 or pH24 (p < 0.05). SERPING1 was also statistically significantly associated with water holding capacity (p < 0.05), which is closely associated with postmortem pH. These results suggest that SNPs in the DHRS4, SERPING1, and APOR genes have potential for use as genetic markers for the meat quality in pigs.
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Affiliation(s)
- Jung Hye Hwang
- a Swine Science and Technology Center, Gyeongnam National University of Science & Technology , Jinju , South Korea
| | - Sang Mi An
- a Swine Science and Technology Center, Gyeongnam National University of Science & Technology , Jinju , South Korea
| | - Seul Gi Kwon
- a Swine Science and Technology Center, Gyeongnam National University of Science & Technology , Jinju , South Korea
| | - Da Hye Park
- a Swine Science and Technology Center, Gyeongnam National University of Science & Technology , Jinju , South Korea
| | - Tae Wan Kim
- b Department of Animal Resource Technology, Gyeongnam National University of Science and Technology , Jinju , South Korea
| | - Deok Gyung Kang
- a Swine Science and Technology Center, Gyeongnam National University of Science & Technology , Jinju , South Korea
| | - Go Eun Yu
- a Swine Science and Technology Center, Gyeongnam National University of Science & Technology , Jinju , South Korea
| | - Il-Suk Kim
- b Department of Animal Resource Technology, Gyeongnam National University of Science and Technology , Jinju , South Korea
| | | | - Jeongim Ha
- a Swine Science and Technology Center, Gyeongnam National University of Science & Technology , Jinju , South Korea
| | - Chul Wook Kim
- a Swine Science and Technology Center, Gyeongnam National University of Science & Technology , Jinju , South Korea
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Hereditary C1 inhibitor deficiency is associated with high spontaneous amidase activity. Mol Immunol 2017; 85:120-122. [PMID: 28222330 DOI: 10.1016/j.molimm.2017.01.028] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Revised: 01/26/2017] [Accepted: 01/31/2017] [Indexed: 10/20/2022]
Abstract
BACKGROUND Angioedema diagnosis classically targets the complement system (via C1 inhibitor (C1Inh) function and antigenic C4 level) and contact phase activation (via amidase activity). Bradykinin is responsible for angioedema attacks and is produced from contact phase activation secondary to failed C1Inh control. OBJECTIVE We aimed to compare the diagnostic performances of spontaneous amidase activity and antigenic C4 level in C1Inh hereditary angioedema (C1Inh-HAE) patients. METHODS Samples from 185 C1Inh-HAE patients (81 men, 104 women; confirmed by SERPING1 gene mutations) and from 99 blood donors (50 men, 49 women) were tested for C1Inh function, antigenic C4 level and spontaneous amidase activity. RESULTS In the C1Inh-HAE group, antigenic C4 level was decreased (n=135) and amidase activity was increased (n=181). Receiver operating characteristic analyses showed higher diagnostic performance values for the spontaneous amidase assay compared to those of antigenic C4. CONCLUSION The spontaneous amidase activity assay should replace antigenic C4 level testing and should be tested alongside the C1Inh function for both AE screening and follow up of HAE patients.
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Abstract
Remarkable progress in understanding the pathophysiology and underlying mechanisms of hereditary angioedema has led to the development of effective treatment for this disorder. Progress in three separate areas has catalyzed our understanding of hereditary angioedema. The first is the recognition that HAE type I and type II result from a deficiency in the plasma level of functional C1 inhibitor. This observation has led to a detailed understanding of the SERPING1 mutations responsible for this deficiency as well as the molecular regulation of C1 inhibitor expression and function. The second is that the fundamental cause of swelling is enhanced contact system activation leading to increased generation of bradykinin. Substantial progress has been made in defining the parameters regulating bradykinin generation and catabolism as well as the receptors that transduce the biologic effects of kinins. The third is the understanding that tissue swelling in hereditary angioedema primarily involves the function of endothelial cell adherens junctions. This knowledge is driving increased attention to the role of endothelial biology in determining disease activity in hereditary angioedema. While there has been considerable progress made, large gaps still remain in our knowledge. Important areas that remain poorly understood include the factors that lead to very low plasma functional C1 inhibitor levels, the triggers of contact system activation in hereditary angioedema, and the role of the bradykinin B1 receptor. The phenotypic variability of hereditary angioedema has been extensively documented but never understood. The mechanisms discussed in this chapter likely contribute to this variability. Future progress in understanding these mechanisms should provide new means to improve the diagnosis and treatment of hereditary angioedema.
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Wu MA, Perego F, Zanichelli A, Cicardi M. Angioedema Phenotypes: Disease Expression and Classification. Clin Rev Allergy Immunol 2017; 51:162-9. [PMID: 27113957 DOI: 10.1007/s12016-016-8541-z] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Due to marked heterogeneity of clinical presentations, comprehensive knowledge of angioedema phenotypes is crucial for correct diagnosis and choosing the appropriate therapeutic approach. One of the ways to a meaningful clinical distinction can be made between forms of angioedema occurring "with or without wheals." Angioedema with wheals (rash) is a hallmark of urticaria, either acute or chronic, spontaneous or inducible. Angioedema without wheals may still be manifested in about 10 % of patients with urticaria, but it may also occur as a separate entity. Several classifications of angioedema as part of urticaria were published over time, while a latest one, released in 2014 (HAWK group consensus, see below), provided a classification of all forms of "angioedema without wheals" distinct from urticaria, which will be the focus of the present review. At this time, the HAWK consensus classification is the best in terms of covering the pathophysiology, mediators involved, angioedema triggers, and clinical expression. According to this classification, three types of hereditary angioedema (genetic C1-INH deficiency, normal C1-INH with factor XII mutations, and unknown origin) and four types of acquired angioedema (C1-INH deficiency, related to ACE inhibitors intake, idiopathic histaminergic, and idiopathic non-histaminergic) are presented. We will review the distinctive clinical features of each phenotype in details.
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Affiliation(s)
- Maddalena Alessandra Wu
- Department of Biomedical and Clinical Sciences "Luigi Sacco", University of Milan, Luigi Sacco Hospital, Milan, Italy
| | - Francesca Perego
- Department of Biomedical and Clinical Sciences "Luigi Sacco", University of Milan, Luigi Sacco Hospital, Milan, Italy
| | - Andrea Zanichelli
- Department of Biomedical and Clinical Sciences "Luigi Sacco", University of Milan, Luigi Sacco Hospital, Milan, Italy
| | - Marco Cicardi
- Department of Biomedical and Clinical Sciences "Luigi Sacco", University of Milan, Luigi Sacco Hospital, Milan, Italy.
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Abstract
Angioedema, as a distinct disease entity, often becomes a clinical challenge for physicians, because it may cause a life-threatening condition, whereas prompt and accurate laboratory diagnostics may not be available. Although the bedside diagnosis needs to be established based on clinical symptoms and signs, family history, and the therapeutic response, later, laboratory tests are available. Currently, only for five out of the nine different types of angioedema can be diagnosed by laboratory testing, and these occur only in a minority of the patient population. Hereditary angioedema with C1-inhibitor (C1-INH) deficiency type I can be diagnosed by the low C1-INH function and concentration, whereas in type II, C1-INH function is low, but its concentration is normal or even elevated. C1q concentration is normal in both forms. Acquired angioedema with C1-INH deficiency type I is characterized by the low C1-INH function and concentration; however, C1q concentration is also low, and autoantibodies against C1-INH cannot be detected. Complement profile of acquired angioedema with C1-INH deficiency type II is similar to that of type I, but in this form, autoantibodies against C1-INH are present. Hereditary angioedema due to a mutation of the coagulation factor XII can be diagnosed exclusively by mutation analysis of FXII gene. Diagnostic metrics are not available for idiopathic histaminergic acquired angioedema, idiopathic non-histaminergic acquired angioedema, acquired angioedema related to angiotensin-converting enzyme inhibitor, and hereditary angioedema of unknown origin; these angioedemas can be diagnosed by medical and family history, clinical symptoms, and therapeutic response and by excluding the forms previously described. Several potential biomarkers of angioedema are used to date only in research. In the future, they could be utilized into the clinical practice to improve the differential diagnosis, therapy, as well as the prognosis of angioedema.
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de Maat S, Björkqvist J, Suffritti C, Wiesenekker CP, Nagtegaal W, Koekman A, van Dooremalen S, Pasterkamp G, de Groot PG, Cicardi M, Renné T, Maas C. Plasmin is a natural trigger for bradykinin production in patients with hereditary angioedema with factor XII mutations. J Allergy Clin Immunol 2016; 138:1414-1423.e9. [DOI: 10.1016/j.jaci.2016.02.021] [Citation(s) in RCA: 97] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Revised: 02/11/2016] [Accepted: 02/26/2016] [Indexed: 10/22/2022]
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Baroso R, Sellier P, Defendi F, Charignon D, Ghannam A, Habib M, Drouet C, Favier B. Kininogen Cleavage Assay: Diagnostic Assistance for Kinin-Mediated Angioedema Conditions. PLoS One 2016; 11:e0163958. [PMID: 27685806 PMCID: PMC5042432 DOI: 10.1371/journal.pone.0163958] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Accepted: 09/16/2016] [Indexed: 12/15/2022] Open
Abstract
Background Angioedema without wheals (AE) is a symptom characterised by localised episodes of oedema presumably caused by kinin release from kininogen cleavage. It can result from a hereditary deficiency in C1 Inhibitor (C1Inh), but it can present with normal level of C1Inh. These forms are typically difficult to diagnose although enhanced kinin production is suspected or demonstrated in some cases. Objectives We wanted to investigate bradykinin overproduction in all AE condition with normal C1Inh, excluding cases with enhanced kinin catabolism, and to propose this parameter as a disease biomarker. Methods We retrospectively investigated high molecular weight kininogen (HK) cleavage pattern, using gel electrophoresis and immunorevelation. Plasma samples were drawn using the same standardised procedure from blood donors or AE patients with normal C1Inh conditions, normal kinin catabolism, and without prophylaxis. Results Circulating native HK plasma concentrations were similar in the healthy men (interquartile range: 98–175μg/mL, n = 51) and in healthy women (90–176μg/mL, n = 74), while HK cleavage was lower (p<0.001) in men (0–5%) than women (3–9%). Patients exhibited lower native HK concentration (p<10−4; 21–117μg/mL, n = 31 for men; 0–84μg/mL, n = 41 for women) and higher HK cleavage (p<10−4; 10–30% and 14–89%, respectively) than healthy donors. Pathological thresholds were set at: <72μg/mL native HK, >14.4% HK cleavage for men; <38μg/mL; native HK, >33.0% HK cleavage for women, with >98% specificity achieved for all parameters. In plasma from patients undergoing recovery two months after oestrogen/progestin combination withdrawal (n = 13) or two weeks after AE attack (n = 2), HK cleavage was not fully restored, suggesting its use as a post-attack assay. Conclusion As a diagnostic tool, HK cleavage can offer physicians supportive arguments for kinin production in suspected AE cases and improve patient follow-up in clinical trials or prophylactic management.
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Affiliation(s)
- Rémi Baroso
- GREPI EA7408, Université Grenoble Alpes, Grenoble, France
| | - Pauline Sellier
- GREPI EA7408, Université Grenoble Alpes, Grenoble, France
- KininX SAS, Grenoble, France
| | - Federica Defendi
- GREPI EA7408, Université Grenoble Alpes, Grenoble, France
- National Reference Center for Angioedema Grenoble, France
| | - Delphine Charignon
- GREPI EA7408, Université Grenoble Alpes, Grenoble, France
- National Reference Center for Angioedema Grenoble, France
| | - Arije Ghannam
- GREPI EA7408, Université Grenoble Alpes, Grenoble, France
- KininX SAS, Grenoble, France
| | - Mohammed Habib
- GREPI EA7408, Université Grenoble Alpes, Grenoble, France
- Qalam-Antibody, La Tronche, France
| | - Christian Drouet
- GREPI EA7408, Université Grenoble Alpes, Grenoble, France
- National Reference Center for Angioedema Grenoble, France
| | - Bertrand Favier
- GREPI EA7408, Université Grenoble Alpes, Grenoble, France
- * E-mail:
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Kallikrein in the Interstitial Space. Protein Sci 2016. [DOI: 10.1201/9781315374307-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Hofman ZL, Relan A, Zeerleder S, Drouet C, Zuraw B, Hack CE. Angioedema attacks in patients with hereditary angioedema: Local manifestations of a systemic activation process. J Allergy Clin Immunol 2016; 138:359-66. [DOI: 10.1016/j.jaci.2016.02.041] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Revised: 01/31/2016] [Accepted: 02/18/2016] [Indexed: 11/17/2022]
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Zuraw BL, Christiansen SC. How we manage persons with hereditary angioedema. Br J Haematol 2016; 173:831-43. [DOI: 10.1111/bjh.14059] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Bruce L. Zuraw
- University of California, San Diego; La Jolla CA USA
- San Diego VA Health System; San Diego CA USA
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Zeerleder S, Levi M. Hereditary and acquired C1-inhibitor-dependent angioedema: from pathophysiology to treatment. Ann Med 2016; 48:256-67. [PMID: 27018196 DOI: 10.3109/07853890.2016.1162909] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Uncontrolled generation of bradykinin (BK) due to insufficient levels of protease inhibitors controlling contact phase (CP) activation, increased activity of CP proteins, and/or inadequate degradation of BK into inactive peptides increases vascular permeability via BK-receptor 2 (BKR2) and results in subcutaneous and submucosal edema formation. Hereditary and acquired angioedema due to C1-inhibitor deficiency (C1-INH-HAE and -AAE) are diseases characterized by serious and potentially fatal attacks of subcutaneous and submucosal edemas of upper airways, facial structures, abdomen, and extremities, due to inadequate control of BK generation. A decreased activity of C1-inhibitor is the hallmark of C1-INH-HAE (types 1 and 2) due to a mutation in the C1-inhibitor gene, whereas the deficiency in C1-inhibitor in C1-INH-AAE is the result of autoimmune phenomena. In HAE with normal C1-inhibitor, a significant percentage of patients have an increased activity of factor XIIa due to a FXII mutation (FXII-HAE). Treatment of C1-inhibitor-dependent angioedema focuses on restoring control of BK generation by inhibition of CP proteases by correcting the balance between CP inhibitors and BK breakdown or by inhibition of BK-mediated effects at the BKR2 on endothelial cells. This review will address the pathophysiology, clinical picture, diagnosis and available treatment in C1-inhibitor-dependent angioedema focusing on BK-release and its regulation. Key Messages Inadequate control of bradykinin formation results in the formation of characteristic subcutaneous and submucosal edemas of the skin, upper airways, facial structures, abdomen and extremities as seen in hereditary and acquired C1-inhibitor-dependent angioedema. Diagnosis of hereditary and acquired C1-inhibitor-dependent angioedema may be troublesome as illustrated by the fact that there is a significant delay in diagnosis; a certain grade of suspicion is therefore crucial for quick diagnosis. Submucosal edema formation in hereditary and acquired C1-inhibitor-dependent angioedema is potentially life threatening and can occur at any age. To date effective therapies for acute and prophylactic treatment are available.
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Affiliation(s)
- Sacha Zeerleder
- a Department of Immunopathology, Sanquin Research and Landsteiner Laboratory of the AMC , Amsterdam , The Netherlands ;,b Department of Hematology , Academic Medical Center, University of Amsterdam , The Netherlands
| | - Marcel Levi
- c Department of Internal Medicine , Academic Medical Center, University of Amsterdam , The Netherlands
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Engel R, Rensink I, Roem D, Brouwer M, Kalei A, Perry D, Zeerleder S, Wouters D, Hamann D. ELISA to measure neutralizing capacity of anti-C1-inhibitor antibodies in plasma of angioedema patients. J Immunol Methods 2015; 426:114-9. [DOI: 10.1016/j.jim.2015.08.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2015] [Revised: 08/24/2015] [Accepted: 08/25/2015] [Indexed: 11/29/2022]
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Wu MA, Zanichelli A, Mansi M, Cicardi M. Current treatment options for hereditary angioedema due to C1 inhibitor deficiency. Expert Opin Pharmacother 2015; 17:27-40. [DOI: 10.1517/14656566.2016.1104300] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Mansi M, Zanichelli A, Coerezza A, Suffritti C, Wu MA, Vacchini R, Stieber C, Cichon S, Cicardi M. Presentation, diagnosis and treatment of angioedema without wheals: a retrospective analysis of a cohort of 1058 patients. J Intern Med 2015; 277:585-93. [PMID: 25196353 DOI: 10.1111/joim.12304] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND The first classification of angioedema without wheals was recently reported and comprises different forms of the disease distinguished by aetiology, mediator of oedema and inheritance. METHODS In total, 1725 consecutive patients with angioedema without wheals were examined at our centre between 1993 and 2012. We excluded from the analysis 667 patients because of incomplete data or because angioedema was related to a specific factor. RESULTS According to the new classification of angioedema, the 1058 patients included in this analysis were diagnosed with hereditary (HAE; n = 377) or acquired angioedema (AAE; n = 681). The former group included HAE with C1-inhibitor (C1-INH) deficiency (C1-INH-HAE; n = 353) and HAE with normal C1-INH levels (n = 24), of which six had a factor XII mutation (FXII-HAE) and 18 had disease of unknown origin (U-HAE). The AAE group included disease with C1-INH deficiency (C1-INH-AAE; n = 49), AAE related to angiotensin-converting enzyme inhibitor treatment (n = 183), idiopathic histaminergic (IH-AAE; n = 379) and idiopathic nonhistaminergic angioedema (InH-AAE; n = 70). We compared hereditary and AAE with uncertain aetiopathogenesis: the FXII-HAE and U-HAE groups pooled (FXII/U-HAE) versus InH-AAE. The median age at onset of FXII/U-HAE and InH-AAE was 26 and 38 years, respectively. In addition, 56% of patients with FXII/U-HAE and 81% of those with InH-AAE reported more than five attacks per year (median duration of 48 h). The location of angioedema in patients with FXII/U-HAE versus those with InH-AAE was the following: face, 70% versus 86%; tongue, oral cavity or larynx, 55% versus 68%; limbs, 70% versus 56%; and gastrointestinal mucosa, 50% versus 20%. Prophylaxis with tranexamic acid was effective in all six patients with U-HAE and in 37 of 38 with InH-AAE who were started on this treatment. CONCLUSION Our findings in this cohort of patients with angioedema provide new information on the clinical characteristics, diagnosis and treatment of this disease.
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Affiliation(s)
- M Mansi
- Department of Biomedical and Clinical Science "Luigi Sacco", Università degli Studi di Milano, Ospedale Luigi Sacco, Milan, Italy
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Firinu D, Bafunno V, Vecchione G, Barca MP, Manconi PE, Santacroce R, Margaglione M, Del Giacco SR. Characterization of patients with angioedema without wheals: the importance of F12 gene screening. Clin Immunol 2015; 157:239-48. [PMID: 25744496 DOI: 10.1016/j.clim.2015.02.013] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Accepted: 02/20/2015] [Indexed: 11/28/2022]
Abstract
Sporadic and familiar forms of non-histaminergic angioedema and normal C1 inhibitor encompass a group of disorders possibly caused by bradikinin. We aimed to study the subgroups of hereditary angioedema with FXII mutation (FXII-HAE), unknown genetic defect (U-HAE) and idiopathic non-histaminergic acquired angioedema (InH-AAE). We screened the F12 locus in our cohort and delineated the clinical, laboratory and genetic features. Four families carried the p.Thr309Lys mutation in F12 gene. Haplotyping confirmed the hypothesis of a common founder. Six families were affected by U-HAE and 13 patients by sporadic InH-AAE. C4 levels were significantly lower in FXII-HAE than in InH-AAE. In the FXII-HAE group, none had attacks exclusively in high estrogenic states; acute attacks were treated with icatibant. Prophylaxis with tranexamic acid reduced the attack frequency in most patients. Our study provides new data on the diagnosis, clinical features and treatment of non-histaminergic angioedema, underlying the role of the screening for F12 mutations.
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Affiliation(s)
- Davide Firinu
- Department of Medical Sciences "M. Aresu", University of Cagliari, Italy.
| | - Valeria Bafunno
- Medical Genetics, Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | - Gennaro Vecchione
- Atherosclerosis and Thrombosis Unit, I.R.C.C.S. "Casa Sollievo della Sofferenza", S. Giovanni Rotondo, Foggia, Italy
| | - Maria Pina Barca
- Department of Medical Sciences "M. Aresu", University of Cagliari, Italy
| | | | - Rosa Santacroce
- Medical Genetics, Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | - Maurizio Margaglione
- Medical Genetics, Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
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Pour une révision de la nosologie des angio-œdèmes bradykiniques. Ann Dermatol Venereol 2015; 142:159-61. [DOI: 10.1016/j.annder.2014.09.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2014] [Accepted: 09/12/2014] [Indexed: 11/22/2022]
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[Hereditary angioedema]. Med Clin (Barc) 2015; 145:356-65. [PMID: 25726303 DOI: 10.1016/j.medcli.2014.12.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Revised: 12/08/2014] [Accepted: 12/11/2014] [Indexed: 11/22/2022]
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Dessart P, Defendi F, Humeau H, Nicolie B, Sarre ME, Charignon D, Ponard D, Cichon S, Drouet C, Martin L. Distinct conditions support a novel classification for bradykinin-mediated angio-oedema. Dermatology 2015; 230:324-31. [PMID: 25720836 DOI: 10.1159/000371814] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2014] [Accepted: 12/13/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Angio-oedema (AO) can be attributable to bradykinin (BK) accumulation, as is the case for prototypical hereditary AO (HAO) due to C1 inhibitor (C1-INH) deficiency. However, our clinical experience in a reference centre has shown that some patients display a clinical history suggestive of HAO, but exhibit normal C1-INH function, have no mutation in the causative genes associated with HAO (SERPING1, F12), and report no intake of drugs known to promote AO. OBJECTIVE We sought to determine the frequency and distribution of different AO subtypes suspected to be BK-mediated AO (BK-AO) and defined by clinical, history and biological criteria (enzyme activities implicated in BK formation and catabolism). METHODS The files of all patients referred to our centre for suspected BK-AO were retrospectively analysed. RESULTS The distribution of patients (n = 162) was 16 and 4% with a hereditary deficiency of C1-INH or a gain of factor XII function, respectively, 29% with iatrogenic BK-AO, 21% with non-iatrogenic defective kininase activity and 30% with idiopathic increased kinin formation. CONCLUSION BK-AO may be caused by multiple inherited or acquired factors triggering BK accumulation. Therefore, we propose a novel typology for BK-AO based on the imbalance of production/catabolism of BK.
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Affiliation(s)
- Panteha Dessart
- Department of Dermatology, Angers Hospital, L'UNAM University, Angers, France
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Defendi F, Charignon D, Ghannam A, Ponard D, Drouet C. [Biological investigation of kinin-mediated angioedema]. Ann Dermatol Venereol 2015; 142:163-9. [PMID: 25683013 DOI: 10.1016/j.annder.2015.01.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Revised: 11/21/2014] [Accepted: 01/06/2015] [Indexed: 11/15/2022]
Abstract
Kinin-mediated angioedema results from accumulation of kinins, vasoactive and vasopermeant peptides, on the vascular endothelium. The disease is characterized by sudden episodes of swelling in the subcutaneous and submucosal tissues; the edema may occur spontaneously or it may be precipitated by triggering factors such as physical or emotional stress, or certain medicines. The characterization of kinin formation and catabolism systems helps improve knowledge of the aetiopathogenic mechanisms involved and provides the basis for classification of kinin-mediated angioedema conditions; thus, we may distinguish between angioedema with C1 inhibitor deficiency, whether inherited or acquired, and angioedema with normal C1 inhibitor activity, associated with increased kinin-forming activity or deficiency in kinin catabolism enzymes. In support of the clinical diagnosis, the physician may request laboratory investigation for a functional and molecular definition of the disease. Laboratory diagnosis is based on the characterization of: (1) kinin production control by C1 inhibitor investigation (function, antigen levels and circulating species); (2) kinin production (kininogenase activity, kininogen cleavage species); and (3) kinin catabolism enzymes (aminopeptidase P, carboxypeptidase N, angiotensin-I converting enzyme and dipeptidyl peptidase IV). An abnormal biological phenotype is supported by examination of susceptibility genes (SERPING1, F12 and XPNPEP2) and mutation segregation in the families.
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Affiliation(s)
- F Defendi
- Exploration fonctionnelle de l'angiœdème, CHU Grenoble, CS 10217, 38043 Grenoble, France; Université Joseph Fourier, GREPI/AGIM CNRS FRE 3405, 38043 Grenoble cedex 9, France.
| | - D Charignon
- Exploration fonctionnelle de l'angiœdème, CHU Grenoble, CS 10217, 38043 Grenoble, France; Université Joseph Fourier, GREPI/AGIM CNRS FRE 3405, 38043 Grenoble cedex 9, France
| | - A Ghannam
- Exploration fonctionnelle de l'angiœdème, CHU Grenoble, CS 10217, 38043 Grenoble, France; Université Joseph Fourier, GREPI/AGIM CNRS FRE 3405, 38043 Grenoble cedex 9, France
| | - D Ponard
- Laboratoire d'immunologie, CHU Grenoble, CS 10217, 38043 Grenoble, France
| | - C Drouet
- Exploration fonctionnelle de l'angiœdème, CHU Grenoble, CS 10217, 38043 Grenoble, France; Université Joseph Fourier, GREPI/AGIM CNRS FRE 3405, 38043 Grenoble cedex 9, France
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Ponard D. [Hereditary angioedema biological diagnosis]. Presse Med 2014; 44:57-64. [PMID: 25511654 DOI: 10.1016/j.lpm.2014.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Revised: 05/16/2014] [Accepted: 06/02/2014] [Indexed: 11/24/2022] Open
Abstract
C1 inhibitor (C1 Inh) activity is an essential parameter for kinins angioedema (AE) diagnosis either hereditary or acquired or sporadic, it is analysed on plasma exclusively. Hereditary AE with C1 Inh functional deficiency is associated with alterations of the SERPING1 gene. Hereditary AE with normal C1 Inh (HAE nC1 Inh) is combined with F12 gene mutations, it is coding for Factor XII whose activity is controlled by C1 Inh, they are found in about 5% of HAE nC1 Inh cases. Every loss of C1 Inh activity must be taken as anormal by clinicians even for women with oral oestroprogestatives, it would be confirmed by the presence of cleaved C1 Inh. The kinins (primarily bradykinin) are the mediators responsible for local increase of vascular permeability. Bradykinin is released from high MW kininogen (HK) during the contact system activation. Plasma proteases mainly support this proteolytic activity controlled by C1 Inh. Family of a patient diagnosed with HAE must be studied, symptomatic as asymptomatic members indeed clinical symptoms regularly emerge very late in the life.
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Affiliation(s)
- Denise Ponard
- CHU de Grenoble, laboratoire d'immunologie, IBP, CS10217, boulevard de la Chantourne, 38043 Grenoble cedex 09, France.
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Charignon D, Ghannam A, Defendi F, Ponard D, Monnier N, López Trascasa M, Launay D, Caballero T, Djenouhat K, Fain O, Cichon S, Martin L, Drouet C. Hereditary angioedema with F12 mutation: factors modifying the clinical phenotype. Allergy 2014; 69:1659-65. [PMID: 25134986 DOI: 10.1111/all.12515] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/12/2014] [Indexed: 11/27/2022]
Abstract
BACKGROUND Hereditary angioedema (HAE) with normal C1 inhibitor (C1Inh) associated with the c.983C>A and c.983C>G mutations of the F12 gene (FXII-HAE) is a rare condition, and presents with highly variable clinical expression. On the basis of data gathered from a large carrier cohort, we assessed the modifiers affecting the clinical phenotype. METHODS We analyzed clinical and biological data recorded from 118 mutation carriers (80 symptomatic and 38 asymptomatic), 58 noncarrier relatives from 40 families, and 200 healthy donors. Disease severity was scored in relation to frequency and location of edema, as well as age at disease onset. To predict FXII-HAE disease severity, we analyzed the biological phenotype [C1Inh, C4, spontaneous amidase, angiotensin-I-converting enzyme (ACE), aminopeptidase P (APP), and carboxypeptidase N/M (CPN)] by means of logistic regression (Akaike information criterion) and odds ratio (OR). RESULTS Meaningful variables contributed to FXII-HAE, with the kinin catabolism enzymes ACE and CPN exhibiting a significant inverse relationship with disease severity (OR = 0.36, 95% CI 0.23-0.59, P < 0.001; OR = 0.58, 95% CI 0.36-0.91, P < 0.05, respectively). CPN activities were 37.5 (28.5-41.3) nmol/ml/min and 38.5 (32.8-45.6) for FXII-HAE asymptomatic and symptomatic carriers, respectively, and 37.9 (30.5-43.7) nmol/ml/min for noncarriers. Angiotensin-I-converting enzyme activities were 58 (44-76) and 49 (35-59) nmol/ml/min for FXII-HAE asymptomatic and symptomatic carriers, respectively, and 56 (49-66) nmol/ml/min for noncarriers. CONCLUSIONS The FXII-HAE is associated with modifiers, for example kinin catabolism enzymes, ACE and CPN, different from those recognized in HAE with C1Inh deficiency.
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Affiliation(s)
- D. Charignon
- CREAK; Centre de Référence des Angioedèmes; Grenoble France
- GREPI/AGIM CNRS FRE 3405; Université Joseph Fourier; Grenoble France
| | - A. Ghannam
- CREAK; Centre de Référence des Angioedèmes; Grenoble France
- GREPI/AGIM CNRS FRE 3405; Université Joseph Fourier; Grenoble France
| | - F. Defendi
- CREAK; Centre de Référence des Angioedèmes; Grenoble France
- GREPI/AGIM CNRS FRE 3405; Université Joseph Fourier; Grenoble France
| | - D. Ponard
- CREAK; Centre de Référence des Angioedèmes; Grenoble France
| | - N. Monnier
- CREAK; Centre de Référence des Angioedèmes; Grenoble France
| | - M. López Trascasa
- Institute for Health Research (IdiPaz); Hospital Universitario La Paz; Madrid Spain
- Biomedical Research Network on Rare Diseases-U754 (CIBERER); Madrid Spain
| | - D. Launay
- CREAK; Centre de Référence des Angioedèmes; Grenoble France
- Département de Médecine Interne; Université du Droit et de la Santé Lille 2; Lille France
| | - T. Caballero
- Institute for Health Research (IdiPaz); Hospital Universitario La Paz; Madrid Spain
- Biomedical Research Network on Rare Diseases-U754 (CIBERER); Madrid Spain
| | - K. Djenouhat
- Département d'Immunologie; Institut Pasteur; Alger Algeria
| | - O. Fain
- CREAK; Centre de Référence des Angioedèmes; Grenoble France
- Département de Médecine Interne; Université Paris XIII; Bondy France
| | - S. Cichon
- Institute für Humangenetics; Universität Bonn; Bonn Germany
- Departement Biomedizin; Universität Basel; Basel Switzerland
| | - L. Martin
- CREAK; Centre de Référence des Angioedèmes; Grenoble France
- Département de Dermatologie; L'UNAM Université; Hôpital d'Angers; Angers France
| | - C. Drouet
- CREAK; Centre de Référence des Angioedèmes; Grenoble France
- GREPI/AGIM CNRS FRE 3405; Université Joseph Fourier; Grenoble France
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Pedrosa M, Prieto-García A, Sala-Cunill A, Baeza ML, Cabañas R, Campos A, Cimbollek S, Gómez-Traseira C, González Quevedo T, Guilarte M, Jurado-Palomo J, Lobera T, López-Serrano MC, Marcos C, Piñero-Saavedra M, Prior N, Sáenz de San Pedro B, Ferrer M, Barceló JM, Daschner A, Echechipía M, Garcés M, Iriarte P, Jáuregui I, Lázaro M, Quiñones M, Veleiro B, Villareal O. Management of angioedema without urticaria in the emergency department. Ann Med 2014; 46:607-18. [PMID: 25580506 DOI: 10.3109/07853890.2014.949300] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Angioedema refers to a localized, transient swelling of the deep skin layers or the upper respiratory or gastrointestinal mucosa. It develops as a result of mainly two different vasoactive peptides, histamine or bradykinin. Pathophysiology, as well as treatment, is different in each case; nevertheless, the resulting signs and symptoms may be similar and difficult to distinguish. Angioedema may occur at any location. When the affected area involves the upper respiratory tract, both forms of angioedema can lead to an imminent upper airway obstruction and a life-threatening emergency. Emergency physicians must have a basic understanding of the pathophysiology underlying this process. Angioedema evaluation in the emergency department (ED) should aim to distinguish between histamine- and bradykinin-induced angioedema, in order to provide appropriate treatment to patients. However, diagnostic methods are not available at the ED setting, neither to confirm one mechanism or the other, nor to identify a cause. For this reason, the management of angioedema should rely on clinical data depending on the particular features of the episode and the patient in each case. The history-taking should be addressed to identify a possible etiology or triggering agent, recording complete information for an ulterior diagnostic study in the outpatient clinic. It is mandatory quickly to recognize and treat a potential life-threatening upper airway obstruction or anaphylaxis. This review focuses on the underlying mechanisms and management of histamine- and bradykinin-induced angioedema at the emergency department and provides an update on the currently available treatments.
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Affiliation(s)
- Maria Pedrosa
- Department of Allergy, Hospital La Paz Institute for Health Research (IdiPAZ), Madrid, Spain.
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Suffritti C, Zanichelli A, Maggioni L, Bonanni E, Cugno M, Cicardi M. High-molecular-weight kininogen cleavage correlates with disease states in the bradykinin-mediated angioedema due to hereditary C1-inhibitor deficiency. Clin Exp Allergy 2014; 44:1503-14. [DOI: 10.1111/cea.12293] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2013] [Revised: 01/31/2014] [Accepted: 02/10/2014] [Indexed: 11/29/2022]
Affiliation(s)
- C. Suffritti
- Department of Biomedical and Clinical Sciences Luigi Sacco; University of Milan, Ospedale Luigi Sacco; Milan Italy
| | - A. Zanichelli
- Department of Biomedical and Clinical Sciences Luigi Sacco; University of Milan, Ospedale Luigi Sacco; Milan Italy
| | - L. Maggioni
- Department of Biomedical and Clinical Sciences Luigi Sacco; University of Milan, Ospedale Luigi Sacco; Milan Italy
| | - E. Bonanni
- Department of Biomedical and Clinical Sciences Luigi Sacco; University of Milan, Ospedale Luigi Sacco; Milan Italy
| | - M. Cugno
- Department of Internal Medicine; IRCCS Fondazione Ospedale Maggiore Policlinico Mangiagalli Regina Elena; University of Milan; Milan Italy
| | - M. Cicardi
- Department of Biomedical and Clinical Sciences Luigi Sacco; University of Milan, Ospedale Luigi Sacco; Milan Italy
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Vincent D, Ponard D, Fiorella S, Drouet C. Benefits of hydroxychloroquine in the treatment of a patient with angioedema due to acquired C1 inhibitor deficiency. Ann Allergy Asthma Immunol 2014; 114:68-70. [PMID: 25457864 DOI: 10.1016/j.anai.2014.10.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Revised: 09/14/2014] [Accepted: 10/09/2014] [Indexed: 01/25/2023]
Affiliation(s)
- Denis Vincent
- Department of Internal Medicine, Service d'Asthmologie-Allergologie-Médecine Interne, CHU de Nîmes, Nîmes, France.
| | - Denise Ponard
- Service de Biochimie, CHU de Grenoble, Grenoble, France
| | - Sandrine Fiorella
- Service d'Asthmologie-Allergologie-Médecine Interne, CHU de Nîmes, Nîmes, France
| | - Christian Drouet
- Department of Biochemistry, Université Joseph Fourier, Centre de Référence des Angioedèmes & Immunogénétique HLA, CHU Grenoble, Grenoble, France
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47
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Ghannam A, Defendi F, Charignon D, Csopaki F, Favier B, Habib M, Cichon S, Drouet C. Contact System Activation in Patients with HAE and Normal C1 Inhibitor Function. Immunol Allergy Clin North Am 2013; 33:513-33. [PMID: 24176216 DOI: 10.1016/j.iac.2013.07.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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