Multimodal assessment of non-specific hemostatic agents for apixaban reversal

BACKGROUND

Non-specific hemostatic agents, namely activated prothrombin complex concentrate (aPCC), PCC and recombinant activated factor (F) VII (rFVIIa), can be used, off-label, to reverse the effects of FXa inhibitors in the rare cases of severe hemorrhages, as no approved specific antidote is available. We have evaluated the ability of aPCC, PCC and rFVIIa to reverse apixaban.

METHODS

Healthy volunteer whole blood was spiked with therapeutic or supra-therapeutic apixaban concentrations and two doses of aPCC, PCC or rFVIIa. Tests performed included a turbidimetry assay for fibrin polymerization kinetics analysis, scanning electron microscopy for fibrin network structure observation, thrombin generation assay (TGA), thromboelastometry, prothrombin time and activated partial thromboplastin time.

RESULTS

aPCC generated a dense clot constituting thin and branched fibers similar to those of a control without apixaban, increased fibrin polymerization velocity and improved quantitative (endogenous thrombin potential and peak height) as well as latency (clotting and lag times) parameters. Adding PCC also improved the fibrin and increased quantitative parameters, but fibrin polymerization kinetics and latency parameters were not corrected. Finally, rFVIIa improved latency parameters but failed to restore the fibrin network structure, fibrin polymerization velocity and quantitative parameters.

CONCLUSION

aPCC was more effective than PCC or rFVIIa in reversing in vitro the effects of apixaban. aPCC rapidly triggered the development of an apparently normal fibrin network and corrected latency and quantitative parameters, whereas PCC or rFVIIa had only a partial effect.

Implication of protein S thrombin-sensitive region with membrane binding via conformational changes in the gamma-carboxyglutamic acid-rich domain

In the vitamin K-dependent protein family, only protein S (PS) contains a thrombin-sensitive region (TSR), located between the domain containing the gamma-carboxyglutamic acid and the first epidermal growth factor-like domain. To better define the role of TSR in the PS molecule, we expressed a recombinant human PS (rHPS) and its analogue lacking TSR (rTSR-less), and prepared factor Xa- and thrombin-cleaved rHPS. A peptide reproducing TSR (TSR-peptide) was also synthesized in an attempt to obtain direct evidence of the domain involvement in PS anticoagulant activity. In a coagulation assay, both rTSR-less and factor Xa-cleaved PS were devoid of activated protein C cofactor activity. The TSR-peptide did not inhibit rHPS activity, showing that TSR must be embedded in the native protein to promote interaction with activated protein C. The binding of rHPS to activated platelets and to phospholipid vesicles was not modified after factor Xa- or thrombin-mediated TSR cleavage, whereas the binding of rTSR-less was markedly reduced. This suggested a role for TSR in conferring to PS a strong affinity for phospholipid membranes. TSR-peptide did not directly bind to activated platelets or compete with rHPS for phospholipid binding. The results of the present study show that TSR may not interact directly with membranes, but probably constrains the gamma-carboxyglutamic acid-rich domain in a conformation allowing optimal interaction with phospholipids.

Analysis of ligand-binding data without knowledge of bound or free ligand molar concentration

A method is proposed to set the parameters in a nonlinear regression procedure to determine the equilibrium dissociation constant (Kd) and the high affinity receptor concentration (Bmax) of systems consisting of one ligand, one high affinity receptor, and n low affinity binding sites. This method is suitable when neither bound or free ligand formal concentrations nor the maximum of the binding signal can be deduced from the experimental data. The method makes use of (i) the abscissa of the first inflection point of the plot of any signal proportional to the binding of ligand to receptors versus the logarithm of the total ligand concentration, and (ii) the initial slope of the saturation curve plotted in direct coordinates. We first demonstrate that when such an inflection point exists, its abscissa lies between Bmax/2 + Kd(1 + d) and Bmax + 2Kd(1 + d), where d is a parameter representative of the binding to the low affinity sites. Second, we demonstrate that the initial slopes of two saturation curves in direct coordinates, where Bmax varies by a known factor, allows an estimation of the Bmax/Kd ratio, within certain limits. From these two sets of data it is subsequently possible to define a precise window for the values of both Bmax and Kd. The performance of the method has been evaluated in representative cases using Monte Carlo studies. The results establish conditions for the existence of an inflection point as well as the influence of low affinity binding, whether or not proportional to Bmax.

Functional identification of t-PA in crude and purified systems

In the present study the activation of glu-plasminogen by fibrin-bound t-PA was determined by integrating spectrophotometric and computer analysis of the reaction. Our aim was to determine the parameters of the activation and to characterize the functional activity of t-PA. Our results indicate that the t-PA present in purified or crude sources such as plasma or culture supernatants, can be specifically identified using the methodology described in this report.

Measurement of glycated albumin in diabetic patients by biospecific affinity chromatography

The percentage of glycated plasma albumin was measured by a procedure involving ammonium sulphate precipitation and Affi-Gel-Blue and phenylboronate chromatographies. The value correlates well with the amount of ketoamine-bound sugars determined by colorimetric assay (r = 0.98, n = 39). The normal mean value is 3.9 +/- 0.3% (mean +/- S.D., coefficient of variation = 7.7%, n = 32) and varies from 3.9 to 21% in diabetics (n = 54). A good correlation is found with the mean blood glucose value of the preceding twenty days (r = 0.92, n = 57). Because of its relative ease of determination, glycated albumin constitutes a good short-term glycemic index and an alternative to glycated haemoglobin in some specific cases.

Production of monoclonal antibodies to the high fibrin-affinity, tissue-type plasminogen activator of human plasma. Demonstration of its endothelial origin by immunolocalization

Monoclonal antibodies (MAbs) to vascular plasminogen activator (vPA), the tissue-type plasminogen activator (tPA) in human plasma, were produced to be used as probes for immunochemical analysis. Human tissue sections and one of these MAbs were used to demonstrate the endothelial origin of plasma-tPA by immunohistochemistry. To produce MAbs, mice were immunized with semipurified vPA isolated from postocclusion human venous blood. Primed spleen cells were fused with the mouse myeloma cell line NS-1. Screening for MAb-producing hybridomas was performed with postocclusion euglobulins as a source of antigen by means of a solid-phase fibrin-vPA immunoassay. The selective and high-affinity binding of vPA for fibrin ensures the specificity and sensitivity of this test. Thus, eight hybridomas secreting MAbs to vPA were selected, cloned, and established as permanent hybridoma cell lines. Immunohistochemical analysis of cryostat sections of human tissues was performed with EA-delta 12D, a MAb having no inhibitory effect against vPA activity but binding to vPA with a high affinity. Thus, the only structures immunostained were endothelial cells of venules, capillaries, and arterioles. The EA-delta 12D monoclonal localization of plasma vPA in the endothelial lining of blood vessels provides evidence that tPA in plasma originates from the vascular wall and validates its designation as vascular plasminogen activator, ie, vPA. Also, our results are consistent with the fact that vPA in blood and tPA in tissues are immunologically identical and have a common endothelial origin.

Covalent structures of beta and gamma autolytic derivatives of human alpha-thrombin

Nonclotting beta- and gamma-thrombins have been prepared by autolysis of human alpha-thrombin at pH 8.6 in the presence of 0.4 M NaCl and purified on BioRex 70. Reduced and carbamidomethylated A and B chains fragments were separated by gel filtration and reverse phase high performance liquid chromatography. Structural characterization of these fragments demonstrated that alpha to beta conversion results from two cleavages at Arg 62 and Arg 73 in the B chain, releasing an intact 11-residue peptide. beta to gamma conversion corresponds to the additional loss of a fragment of the B chain stretching from Ile 124 to Lys 154. Autolysis is not accompanied by cleavages in the A chain. Loss of clotting activity is therefore related solely to the excision of residues 63 to 73 in the B chain. With the exception of cleavage at Arg 73, these results differ from a proposed model for alpha to gamma conversion of bovine thrombin.