Post-translational carboxylation of preprothrombin

A clinically suspected case of Anaphylactoid reaction to vitamin K injection in a child - a case report and review of literature

Vitamin K is commonly indicated in pediatric patients with coagulopathies. Its commercial preparations are available in the market since long. Minor complications are very well-known, but life-threatening events are rarely reported in children. We present a case of 8-year-old child who developed life-threatening event following intravenous Vitamin K injection. She was survived after cardiopulmonary resuscitation. The reaction was most probably due to anaphylactoid reaction to Vitamin K.

Comparison of Two Different Ecarin Clotting Time Methods

BACKGROUND

Ecarin Clotting Time (ECT) assay specifically determines the inhibition of meizothrombin by direct thrombin inhibitors (DTI). Blood coagulation factor levels lowered by vitamin K antagonists (VKA) may prolong ECT. Concomitant treatment of VKA with DTI may influence differently the two published ECT methods.

METHODS

Lepirudin (100-3,000 ng/ml), argatroban (300--3,000 ng/ml) and melagatran (30--1000 ng/ml) were added to normal plasma (NP; n=12) samples and to plasma of patients on stable vitamin K antagonist therapy with warfarin (VKAP; n=12). ECT assays were performed according to [5] (method 1) and according to [6] (method 2). Data were subjected to multifactorial variance analysis.

RESULTS

Normal ranges were 35.5+/-2.8 s in NP versus 31.8+/-1.2 s in VKAP with method 1 (p< 0.001) and 44.3+/-3.9 s in NP vs. 51.4+/-8.3 s in VKAP with method 2 (p< 0.004). Besides the inhibitors (p<0.0001), the method used (p<0.0001) and the group (NP vs. VKAP, p=0.003) had an influence on the ECT. Inhibitors (p< 0.02) or method used (p< 0.03) and the group (NP vs. VKAP, p=0.0001) influenced also the ECT ratio.

DISCUSSION

Both ECT methods are suitable for monitoring different DTIs over a large linear range with both methods during concomitant treatments with vitamin K antagonists. The ECT ratio improves but not abolishes the differences between the methods. Additive effects of vitamin K antagonists on ECT methods have to be taken into consideration in clinical routine.

Effects of vitamin K antagonist phenprocoumon on activated partial thromboplastin time measurement of direct thrombin inhibitors

The activated partial thromboplastin time (aPTT) is currently the most common test used to measure the anticoagulation intensity of heparins and direct thrombin inhibitors (DTIs). Vitamin K antagonists variably affect aPTT reagents. Interactions between heparin and DTIs occur during concurrent therapy. Three DTIs (lepirudin, argatroban, melagatran) and one unfractionated heparin (liquemin) were added to normal plasma (NP) samples (n = 23) and to vitamin K antagonist plasma (VKAP) samples (n = 23) of patients treated with phenprocoumon. Lepirudin and argatroban were added at concentrations from 300 to 3000 ng/ml, melagatran from 30 to 1000 ng/ml, and unfractionated heparin from 0.016 to 0.48 IU/ml. Wave parameters of clotting time and aPTT ratio curves were evaluated by multivariate analysis for inhibitors, aPTT reagents and NP and VKAP samples. Normal ranges resulting from NP samples were 34.5 +/- 1.0 s with Pathromtin SL and 33.9 +/- 0.8 s with Platelin LS. Normal ranges using VKAP were 52.8 +/- 2.6 s (Pathromtin SL) and 44.2 +/- 1.1 s (Platelin LS) (P < 0.0001). Variance analysis showed that inhibitors, plasmas (NP versus VKAP) and reagents influenced the wave characteristics of aPTT (s) (P < 0.0001) and aPTT ratios (P < 0.0001). Distinct statistical differences between aPTT reagents on one hand and normal versus vitamin K antagonist plasma on the other hand make a comparison of reported aPTT results difficult, especially during overlapping therapy with vitamin K antagonists.

Effects of lepirudin, argatroban and melagatran and additional influence of phenprocoumon on ecarin clotting time

INTRODUCTION

Direct thrombin inhibitors (DTI) prolong the ecarin clotting time (ECT). Oral anticoagulants (OA) decrease prothrombin levels and thus interact with actions of DTIs on the ECT method during concomitant therapy.

MATERIALS AND METHODS

Actions of lepirudin, argatroban and melagatran on ECT were investigated in normal plasma (NP) and in plasma of patients (n=23 each) on stable therapy with phenprocoumon (OACP). Individual line characteristics were tested statistically.

RESULTS

Control ECT in OACP was prolonged compared to NP (50.1+/-0.9 vs. 45.7+/-0.8 s; p<0.001). Lepirudin prolonged the ECT linearly. Argatroban and melagatran delivered biphasic dose-response curves. OA showed additive effects on the ECT of lepirudin but not of argatroban and melagatran. Both in NP and OACP, the first and second slopes of melagatran were steeper compared to argatroban (primary analysis; p<0.001). When using the same drug, slopes in OACP were steeper than in NP (secondary analysis; p<0.001). At similar molar concentrations, the crossing points of both slopes were significantly higher with melagatran (323.1+/-11.0 s in NP and 333.2+/-8.2 s in OACP) than with argatroban (219.6+/-14.7 and 248.4+/-15.2 s) corresponding to ratios of 7.1+/-0.2 and 6.7+/-0.2 (melagatran) vs. 4.8+/-0.3 and 4.9+/-03 with argatroban (p<0.0001).

DISCUSSION

The patterns of interactions between vitamin K antagonists and DTI effects are different for bivalent (increase of slope without affecting linearity) and monovalent inhibitors (slight increase or alteration of nonlinear slopes), but there are also differences between the two monovalent inhibitors on thrombin inhibition as determined by ECT.

Vitamin K modulates cardiac action potential by blocking sodium and potassium ion channels

BACKGROUND

Cardiovascular collapses, syncopes, and sudden deaths have been observed following the rapid administration of intravenous vitamin K. Our objectives were to characterize the effects of vitamin K on cardiac action potentials and to evaluate effects of vitamin K on sodium and potassium currents, namely I(Na), I(Kr), and I(Ks).

METHODS AND RESULTS

Guinea pig hearts (n = 21) were paced at a cycle length of 250 msec and exposed to vitamin K at 1.15-4.6 micromol/L (2.5-10 mg/L). Monophasic action potential duration measured at 90% repolarization (MAPD(90)) was not significantly reduced (-1.6 +/- 0.3 msec; P >.05; N.S.) at 1.15 micromol/L, but increased by 6.5 +/- 0.4 msec (P <.05) at 2.3 micromol/L. MAPD(90) was not measurable at 4.6 micromol/L, as a result of inexcitability. Patch-clamp experiments in ventricular myocytes demonstrated a approximately 50% reduction in I(Na) by 10 micromol/L vitamin K and a concentration-dependent reduction of the K(+) current elicited by short depolarizations (250 msec; I(K250)). Estimated IC(50) for I(K250), mostly representing I(Kr), was 2.3 micromol/L. Vitamin K was less potent to block the K(+) current elicited by long depolarizations (5,000 msec; I(K5000)), mostly representing I(Ks), with an estimated IC(50) over 100 micromol/L.

CONCLUSIONS

Therapeutic concentrations ( approximately 1.5 micromol/L) of intravenous vitamin K modulate cardiac action potential by blocking ionic currents involved in cardiac depolarization and repolarization.

Vitamin K-induced cardiovascular collapse

A patient underwent a partial right hepatic lobectomy for adenocarcinoma of the colon metastatic to the liver. He was admitted to the surgical intensive care unit in stable condition. Six hours after surgery, the patient experienced sudden and sever hypotension, bradycardia, and systole. Differential diagnoses included acute myocardial infarction, hemorrhage from the surgical site, and pulmonary embolism. However, these complications were ruled out. We believe that an allergic reaction to vitamin K and its potential side effects are discussed.

The vitamin K dependent reaction

The vitamin K's are 2-methyl-1,4-naphthoquinones. The vitamin is required for the post-translational gamma-carboxylation of glutamyl residues in precursor polypeptides. The vitamin K step in this carboxylation, however, requires not the quinone but the hydroquinone plus oxygen. Thus, the vitamin K-dependent step is a "mixed function" oxidation requiring a reducing compound plus molecular oxygen to provide a form of oxidant (e.g., a free radical, a hydroperoxide) capable of abstracting a particular, slightly labile hydrogen from a glutamyl residue, leaving this position free to accept a carbon dioxide molecule. This oxidation appears similar to that of other mixed function oxidants such as cytochrome P450 plus oxygen, ascorbic acid (with traces of ferrous iron) plus oxygen, ferrous iron plus oxygen, and a number of other systems which function in a wide variety of oxidation. Inhibition by spin-trapping agents suggests a free radical step in the vitamin K hydroquinone-dependent reaction, similar to other mixed function oxidations.

The interaction of vitamin K1 with phospholipid vesicles

Vitamin K1 is a component of the electron transport chain in chloroplasts and also an activator of carboxylases present in microsomes of different tissues. In order to understand its mechanism of action it is necessary to know its interactions, localization and organization in the phospholipid bilayer. We have studied this question using reconstituted systems of vitamin K1 incorporated in DPPC multibilayer vesicles, using DSC, DPH anisotropy and FT-IR spectroscopy. DSC shows that the pretransition is modified and disappears as the concentration of vitamin K1 in the bilayer increases. The main transition is also affected, with a decrease of Tm and delta H with increasing concentrations of vitamin K1. Furthermore, a second peak appears at high concentrations of vitamin K1, which is indicative of a lateral phase separation of a phase rich in vitamin K1. Fluorescence measurements using DPH show, in agreement with the calorimetric measurements, that the phase transition is shifted to lower temperatures and the anisotropy is increased above Tm but, interestingly, not below Tm. FT-IR spectroscopic measurements are also in good agreement with the calorimetric and fluorescence results, indicating that vitamin K1 induced a broadening and a shift to lower temperatures in the phase transition. It is deduced from the variation of the frequency parameter of the CH2 stretching vibration band with temperature that vitamin K1 perturbs the average number of gauche and all-trans conformers of DPPC, only during the phase transition interval but neither at temperatures above nor below the phase transition. However, the bandwidth parameter of this vibration indicated a perturbation above, but not below, the phase transition. The possible relationship between these observations and those coming from fluorescence depolarization of DPH are discussed. Finally, it is concluded from the observation of the C=O stretching mode that vitamin K1 does not produce a very strong perturbation of the interfacial region of the membrane of the type given by, for example, cholesterol.

Vitamin K dependent carboxylation: study of diastereoisomeric gamma-methylglutamic acid containing peptidic substrates

Two pentapeptides Phe-Leu-X-Glu-Val where X is either the L-threo-gamma-methylglutamic acid or the L-erythro isomer have been synthesized and tested as substrates in the vitamin K dependent carboxylation. The gamma-methylglutamic residue is not carboxylated and both peptides are inhibitors of the carboxylation of the reference peptide Phe-Leu-Glu-Glu-Val. The threo containing isomer has a much better affinity than the reference and is the best inhibitor of this reaction described so far.