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Giavina-Bianchi P, Vivolo Aun M, Giavina-Bianchi M, Ribeiro AJ, Camara Agondi R, Motta AA, Kalil J. Hereditary angioedema classification: Expanding knowledge by genotyping and endotyping. World Allergy Organ J 2024; 17:100906. [PMID: 38818086 PMCID: PMC11137532 DOI: 10.1016/j.waojou.2024.100906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 04/08/2024] [Accepted: 04/11/2024] [Indexed: 06/01/2024] Open
Abstract
Hereditary angioedema (HAE) encompasses a group of diseases characterized by recurrent, genetically mediated angioedema associated with increased vascular permeability primarily due to bradykinin. The disease poses diagnostic challenges, leading to underdiagnosis and delayed therapy. Severe manifestations include laryngeal and intestinal angioedema, contributing to significant morbidity and mortality. If left undiagnosed, the estimated mortality rate of the disease ranges from 25% to 40% due to asphyxiation caused by laryngeal angioedema. There is a pressing need to enhance awareness of hereditary angioedema and its warning signs. The acronym "H4AE" may facilitate the memorization of these signs. This study comprehensively reviews clinical, laboratory, and physiopathological features of documented HAE subtypes. The study advocates for an improved HAE classification based on endotypes, building on the knowledge of angioedema pathophysiology. The proposed endotype classification of HAE offers a clear and applicable framework, encouraging advancements in disease understanding and classification.
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Affiliation(s)
- Pedro Giavina-Bianchi
- Clinical Immunology and Allergy Division, University of São Paulo School of Medicine, Brazil
| | - Marcelo Vivolo Aun
- Clinical Immunology and Allergy Division, University of São Paulo School of Medicine, Brazil
- Faculdade Israelita de Ciências da Saúde Albert Einstein, Hospital Israelita Albert Einstein, Brazil
| | - Mara Giavina-Bianchi
- Clinical Immunology and Allergy Division, University of São Paulo School of Medicine, Brazil
- Hospital Israelita Albert Einstein, Brazil
| | - Ana Júlia Ribeiro
- Clinical Immunology and Allergy Division, University of São Paulo School of Medicine, Brazil
| | - Rosana Camara Agondi
- Clinical Immunology and Allergy Division, University of São Paulo School of Medicine, Brazil
| | - Antônio Abílio Motta
- Clinical Immunology and Allergy Division, University of São Paulo School of Medicine, Brazil
| | - Jorge Kalil
- Clinical Immunology and Allergy Division, University of São Paulo School of Medicine, Brazil
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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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Tachdjian R, Kaplan AP. A Comprehensive Management Approach in Pediatric and Adolescent Patients With Hereditary Angioedema. Clin Pediatr (Phila) 2023; 62:973-980. [PMID: 36908071 PMCID: PMC10478326 DOI: 10.1177/00099228231155703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
Abstract
Hereditary angioedema (HAE) is a rare autosomal-dominant disorder; most cases are characterized by low plasma levels of C1 esterase inhibitor (C1-INH). Clinical manifestations of HAE due to C1-INH deficiency include unpredictable, acute, recurrent episodes of nonpruritic swelling that can affect the face, trunk, limbs, and the respiratory, gastrointestinal, and genitourinary tracts. Attacks can be disfiguring, disabling, painful, and even life-threatening if laryngeal swelling occurs. Symptoms of HAE generally manifest in childhood. Effective medications are available and approved to treat HAE in children. However, evidence informing use of these medications in pediatric clinical practice is limited. Hereditary angioedema management plans are critical to optimize outcomes and should address on-demand treatment for acute attacks and plans to prevent potentially fatal laryngeal attacks. The plan should also comprise a holistic approach to address nonclinical aspects of HAE, including quality of life (QoL) and psychological issues. This article provides an overview of HAE management principles that health care providers can apply to treat pediatric patients to improve their QoL.
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Affiliation(s)
- Raffi Tachdjian
- UCLA School of Medicine, Los Angeles, CA, USA
- Division of Allergy and Immunology, Providence St. John Medical Center, Santa Monica, CA, USA
| | - Allen P. Kaplan
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Allergy and Clinical Immunology, Medical University of South Carolina, Charleston, SC, USA
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Shamanaev A, Dickeson SK, Ivanov I, Litvak M, Sun MF, Kumar S, Cheng Q, Srivastava P, He TZ, Gailani D. Mechanisms involved in hereditary angioedema with normal C1-inhibitor activity. Front Physiol 2023; 14:1146834. [PMID: 37288434 PMCID: PMC10242079 DOI: 10.3389/fphys.2023.1146834] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 05/12/2023] [Indexed: 06/09/2023] Open
Abstract
Patients with the inherited disorder hereditary angioedema (HAE) suffer from episodes of soft tissue swelling due to excessive bradykinin production. In most cases, dysregulation of the plasma kallikrein-kinin system due to deficiency of plasma C1 inhibitor is the underlying cause. However, at least 10% of HAE patients have normal plasma C1 inhibitor activity levels, indicating their syndrome is the result of other causes. Two mutations in plasma protease zymogens that appear causative for HAE with normal C1 inhibitor activity have been identified in multiple families. Both appear to alter protease activity in a gain-of-function manner. Lysine or arginine substitutions for threonine 309 in factor XII introduces a new protease cleavage site that results in formation of a truncated factor XII protein (Δ-factor XII) that accelerates kallikrein-kinin system activity. A glutamic acid substitution for lysine 311 in the fibrinolytic protein plasminogen creates a consensus binding site for lysine/arginine side chains. The plasmin form of the variant plasminogen cleaves plasma kininogens to release bradykinin directly, bypassing the kallikrein-kinin system. Here we review work on the mechanisms of action of the FXII-Lys/Arg309 and Plasminogen-Glu311 variants, and discuss the clinical implications of these mechanisms.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - David Gailani
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, United States
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Efficacy, pharmacokinetics, and safety of subcutaneous C1-esterase inhibitor as prophylaxis in Japanese patients with hereditary angioedema: Results of a Phase 3 study. Allergol Int 2023:S1323-8930(23)00006-0. [PMID: 36858856 DOI: 10.1016/j.alit.2023.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 12/21/2022] [Accepted: 01/10/2023] [Indexed: 03/03/2023] Open
Abstract
BACKGROUND Hereditary angioedema (HAE) is a rare and potentially life-threatening genetic disorder characterized by recurrent attacks of angioedema. HAE types I and II result from deficient or dysfunctional C1-esterase inhibitor (C1-INH). This Phase 3 study assessed the efficacy, pharmacokinetics (PK), and safety of subcutaneous (SC) C1-INH in Japanese patients with HAE. METHODS The prospective, open-label, multicenter, single-arm Phase 3 study recruited patients with HAE types I or II to an initial run-in period, followed by a 16-week treatment period where patients received 60 IU/kg C1-INH (SC) twice weekly. The two primary endpoints were the time-normalized number of HAE attacks per month and C1-INH functional activity at Week 16. RESULTS Nine patients entered the treatment period and completed the study. Treatment with C1-INH (SC) significantly reduced the mean monthly attack rate from 3.7 during the run-in period to 0.3 during treatment (exploratory p value of within-patient comparison = 0.004). After the last dose of C1-INH (SC) at Week 16, the mean trough concentration of C1-INH was 59.8%, and the mean area under the plasma concentration-time curve to the end of the dosing period and to the last sample were 5317.1 and 13,091.5 h•%, respectively. During the study, there were no deaths, serious adverse events, or adverse events leading to study discontinuation. CONCLUSIONS C1-INH (SC) (60 IU/kg twice weekly) was efficacious and well tolerated as a prophylaxis against HAE attacks in Japanese patients with HAE types I or II, which was supported by the increased and maintained C1-INH functional activity. EudraCT Number 2019-003921-99; JapicCTI-205273.
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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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Specific Targeting of Plasma Kallikrein for Treatment of Hereditary Angioedema: A Revolutionary Decade. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:716-722. [PMID: 34838707 DOI: 10.1016/j.jaip.2021.11.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 10/01/2021] [Accepted: 11/19/2021] [Indexed: 11/21/2022]
Abstract
Hereditary angioedema (HAE) is a rare, chronic, genetic disease that presents with nonpruritic angioedema of the face, extremities, airway (can be life-threatening), genitourinary system, and abdomen. These symptoms can significantly impair daily activities. Hereditary angioedema is classified into HAE owing to a deficiency of functional C1INH (HAE-C1INH) or HAE with normal C1INH (HAE-nl-C1INH). Both type I and II HAE-C1INH result from inherited or spontaneous mutations in the SERPING1 gene, which encodes for C1INH. These mutations result in C1INH dysfunction, leading to uncontrolled plasma kallikrein activity with excessive bradykinin production. Bradykinin receptor activation leads to vasodilation, increased vascular permeability, and smooth muscle contractions, resulting in submucosal angioedema through fluid extravasation. Hereditary angioedema nl-C1INH is caused by either a known or unknown genetic mutation. The underlying mechanism of HAE-nl-C1INH is less well understood but is thought to be related to bradykinin signaling. Plasma kallikrein inhibitors have been developed to inhibit the kallikrein-kinin pathway to prevent (prophylactic) and treat on-demand (acute) HAE attacks. Several of these medications are delivered through subcutaneous or intravenous injection, although new and emerging therapies include oral formulations. This article provides a historical review and describes the evolving landscape of available kallikrein inhibitors to treat HAE-C1INH.
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Luo S, Chen Y, Yang L, Gong X, Wu Z. The complement system in retinal detachment with choroidal detachment. Curr Eye Res 2022; 47:809-812. [PMID: 35176953 DOI: 10.1080/02713683.2022.2038634] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
PURPOSE This study aims to explore the differences in the levels of complement components and complement regulatory factors in the vitreous humor of patients with retinal detachment with choroidal detachment (RRDCD), patients with rhegmatogenous retinal detachment (RRD). METHODS A prospective case-control study design was used to recruit 20 patients with RRDCD and 20 patients with RRD in consecutive cases who underwent pars plana vitrectomy from March 2019 to January 2020. The control group comprised 15 patients with epiretinal membrane and 5 eyes from cadavers. The concentrations of complement C2, complement C4b, complement C5/C5a, complement C9, complement factor D (CFD), lectin, and complement factor I (CFI) were measured using Multiplex Luminex Assay, and the concentration of soluble decay acceleration factor (sDAF) was measured using ELISA. RESULTS As compared with the RRD and control groups, complement C2, complement C4b, complement C5/C5a, complement C9, CFD, lectin, CFI, and sDAF were significantly increased in the RRDCD group. Additionally, as compared with the control group, the concentrations of complement component C2 and CFD were significantly increased in the vitreous humor of the RRD group. CONCLUSION Components of all three complement pathways were elevated in eyes with RRDCD. Interestingly, while there was evidence of early complement activation in RRD, the final common pathway components were not elevated. In contrast, RRDCD eyes showed significant elevations of the MAC complex components, underscoring a potential pathophysiologic impact of complement activation in this condition.
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Affiliation(s)
- Shasha Luo
- Department of Ophthalmology, Nanjing Medical University Affiliated Wuxi Second Hospital, Wuxi, Jiangsu Province, People's Republic of China.,Department of Ophthalmology, Affiliated Wuxi Clinical College of Nantong University, Wuxi, Jiangsu Province, People's Republic of China
| | - Yanghao Chen
- Department of Ophthalmology, Anqing No.2 People's Hospital, Anqing, Anhui Province, People's Republic of China
| | - Lufei Yang
- Department of Ophthalmology, Nanjing Medical University Affiliated Wuxi Second Hospital, Wuxi, Jiangsu Province, People's Republic of China
| | - Xuechun Gong
- Department of Ophthalmology, Nanjing Medical University Affiliated Wuxi Second Hospital, Wuxi, Jiangsu Province, People's Republic of China
| | - Zhifeng Wu
- Department of Ophthalmology, Nanjing Medical University Affiliated Wuxi Second Hospital, Wuxi, Jiangsu Province, People's Republic of China.,Department of Ophthalmology, Affiliated Wuxi Clinical College of Nantong University, Wuxi, Jiangsu Province, People's Republic of China
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Gramstad OR, Kandanur SPS, Etscheid M, Nielsen EW, Kanse SM. Factor VII activating protease (FSAP) is not essential in the pathophysiology of angioedema in patients with C1 inhibitor deficiency. Mol Immunol 2021; 142:95-104. [PMID: 34973499 DOI: 10.1016/j.molimm.2021.11.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 11/20/2021] [Accepted: 11/30/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND Excessive bradykinin (BK) generation from high molecular weight kininogen (HK) by plasma kallikrein (PK) due to lack of protease inhibition is central to the pathophysiology of hereditary angioedema (HAE). Inadequate protease inhibition may contribute to HAE through a number of plasma proteases including factor VII activating protease (FSAP) that can also cleave HK. OBJECTIVE To investigate the interaction between FSAP and C1 inhibitor (C1Inh) and evaluate the potential role of FSAP in HAE with C1Inh deficiency. MATERIALS AND METHODS Plasma samples from 20 persons with HAE types 1 or 2 in remission were studied and compared to healthy controls. We measured and compared antigenic FSAP levels, spontaneous FSAP activity, FSAP generation potential, activation of plasma pre-kallikrein (PPK) by FSAP, and the formation of FSAP-C1Inh and FSAP-alpha2-antiplasmin (FSAP-α2AP) complexes. Furthermore, we measured HK cleavage and PK activation after activation of endogenous pro-FSAP and after addition of exogenous FSAP. RESULTS In plasma from HAE patients, there is increased basal FSAP activity compared to healthy volunteers. HAE plasma exhibits decreased formation of FSAP-C1Inh complexes and increased formation of FSAP-α2AP complexes in histone-activated plasma. Although exogenous FSAP can cleave HK in plasma, this was not seen when endogenous plasma pro-FSAP was activated with histones in either group. PK was also not activated by FSAP in plasma. CONCLUSION In this study, we established that FSAP activity is increased and the pattern of FSAP-inhibitor complexes is altered in HAE patients. However, we did not find evidence suggesting that FSAP contributes directly to HAE attacks.
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Affiliation(s)
- Olav Rogde Gramstad
- Department of Dermatology and Venerology, Oslo University Hospital, Oslo, Norway.
| | | | - Michael Etscheid
- Department of Haematology/Transfusion Medicine, Paul Ehrlich Institute, Langen, Germany
| | - Erik Waage Nielsen
- Department of Anesthesia and Intensive Care Medicine, Surgical Clinic, Nordland Hospital, Bodø, Norway; Faculty of Nursing and Health Sciences, Nord University, Bodø, Norway; Institute of Clinical Medicine, University of Tromsø, Tromsø, Norway; Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Norway
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Crosstalk between the renin-angiotensin, complement and kallikrein-kinin systems in inflammation. Nat Rev Immunol 2021; 22:411-428. [PMID: 34759348 PMCID: PMC8579187 DOI: 10.1038/s41577-021-00634-8] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/24/2021] [Indexed: 12/28/2022]
Abstract
During severe inflammatory and infectious diseases, various mediators modulate the equilibrium of vascular tone, inflammation, coagulation and thrombosis. This Review describes the interactive roles of the renin–angiotensin system, the complement system, and the closely linked kallikrein–kinin and contact systems in cell biological functions such as vascular tone and leakage, inflammation, chemotaxis, thrombosis and cell proliferation. Specific attention is given to the role of these systems in systemic inflammation in the vasculature and tissues during hereditary angioedema, cardiovascular and renal glomerular disease, vasculitides and COVID-19. Moreover, we discuss the therapeutic implications of these complex interactions, given that modulation of one system may affect the other systems, with beneficial or deleterious consequences. The renin–angiotensin, complement and kallikrein–kinin systems comprise a multitude of mediators that modulate physiological responses during inflammatory and infectious diseases. This Review investigates the complex interactions between these systems and how these are dysregulated in various conditions, including cardiovascular diseases and COVID-19, as well as their therapeutic implications.
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11
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Fandaros M, Joseph K, Kaplan AP, Rubenstein DA, Ghebrehiwet B, Yin W. gC1qR Antibody Can Modulate Endothelial Cell Permeability in Angioedema. Inflammation 2021; 45:116-128. [PMID: 34494203 DOI: 10.1007/s10753-021-01532-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 07/23/2021] [Accepted: 07/31/2021] [Indexed: 10/20/2022]
Abstract
Angioedema is characterized by swelling of the skin or mucous membranes. Overproduction of the vasodilator bradykinin (BK) is an important contributor to the disease pathology, which causes rapid increase in vascular permeability. BK formation on endothelial cells results from high molecular weight kininogen (HK) interacting with gC1qR, the receptor for the globular heads of C1q, the first component of the classical pathway of complement. Endothelial cells are sensitive to blood-flow-induced shear stress and it has been shown that shear stress can modulate gC1qR expression. This study aimed to determine the following: (1) how BK or angioedema patients' (HAE) plasma affected endothelial cell permeability and gC1qR expression under shear stress, and (2) if monoclonal antibody (mAb) 74.5.2, which recognizes the HK binding site on gC1qR, had an inhibitory effect in HK binding to endothelial cells. Human dermal microvascular endothelial cells (HDMECs) grown on Transwell inserts were exposed to shear stress in the presence of HAE patients' plasma. Endothelial cell permeability was measured using FITC-conjugated bovine serum albumin. gC1qR expression and HK binding to endothelial cell surface was measured using solid-phase ELISA. Cell morphology was quantified using immunofluorescence microscopy. The results demonstrated that BK at 1 µg/mL, but not HAE patients' plasma and/or shear stress, caused significant increases in HDMEC permeability. The mAb 74.5.2 could effectively inhibit HK binding to recombinant gC1qR, and reduce HAE patients' plasma-induced HDMEC permeability change. These results suggested that monoclonal antibody to gC1qR, i.e., 74.5.2, could be potentially used as an effective therapeutic reagent to prevent angioedema.
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Affiliation(s)
- Marina Fandaros
- Department of Biomedical Engineering, Stony Brook University, NY, Stony Brook, USA
| | - Kusumam Joseph
- Department of Medicine, Medical University of South Carolina, Charleston, SC, USA.,BioCryst Pharmaceuticals Inc., Durham, NC, 27703, USA
| | - Allen P Kaplan
- Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - David A Rubenstein
- Department of Biomedical Engineering, Stony Brook University, NY, Stony Brook, USA
| | | | - Wei Yin
- Department of Biomedical Engineering, Stony Brook University, NY, Stony Brook, USA.
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12
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Manning ME. Recognition and Management of Hereditary Angioedema: Best Practices for Dermatologists. Dermatol Ther (Heidelb) 2021; 11:1829-1838. [PMID: 34460082 PMCID: PMC8484417 DOI: 10.1007/s13555-021-00593-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 08/13/2021] [Indexed: 01/18/2023] Open
Abstract
Objective The goal of this article is to discuss the importance of differentiating hereditary angioedema (HAE) from other types of angioedema, describe advances in HAE management, especially long-term prophylaxis (LTP), and offer practical recommendations for dermatologists. Commentary While HAE is rare, dermatologists are likely to encounter patients with this condition at some point over the course of their clinical practice due to the fact that HAE episodes typically involve subcutaneous swelling and sometimes erythema marginatum. HAE is characterized by recurrent episodes of painful and/or disabling bradykinin-mediated angioedema. Unfortunately, HAE is commonly mistaken for other conditions such as allergic and other mast cell-mediated angioedema, but has very different treatment requirements. Delayed diagnosis of HAE can result in years of avoidable debilitating symptoms, inappropriate treatment, potentially unnecessary invasive intervention, and reduced quality of life, and can be life threatening. Thus, timely identification of HAE is essential to ensure appropriate clinical management. Patients with HAE have either deficiency or dysfunction of the C1 inhibitor (C1INH) protein that inhibits proteases in the contact, complement, and fibrinolytic systems. Pathway-specific HAE treatments include C1INH replacement, kallikrein inhibitors, and bradykinin receptor antagonists. Treatment options for managing acute attacks include C1INH replacement (plasma-derived or recombinant formulations), icatibant (kallikrein inhibitor), and ecallantide (bradykinin B2 receptor antagonist). In the past 5 years, several new options for LTP have been approved, including a subcutaneous plasma-derived C1INH formulation and two kallikrein inhibitors (lanadelumab; berotralstat). Optimal management of HAE entails the creation of a comprehensive management plan that addresses both acute and long-term patient needs and includes input from an HAE expert and the patient/caregivers.
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Affiliation(s)
- Michael E Manning
- Allergy, Asthma & Immunology Associates, Ltd., Internal Medicine, UA College of Medicine-Phoenix, 7514 E Monterey Way, Suite 1, Scottsdale, AZ, 85251, USA.
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Analysis of cold activation of the contact system in hereditary angioedema with normal C1 inhibitor. Mol Immunol 2021; 136:150-160. [PMID: 34153620 DOI: 10.1016/j.molimm.2021.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 06/01/2021] [Accepted: 06/14/2021] [Indexed: 11/20/2022]
Abstract
Hereditary angioedema (HAE) attacks are caused by excessive activation of the contact system. Understanding how the contact system is activated in HAE, especially in patients with normal C1 inhibitor (HAEnCI), is essential to effectively treat this disease. Contact system activation involves the cleavage of several proteins including Factor XII (FXII), high molecular weight kininogen (HK), prekallikrein, sgp120 (ITIH4) and C1 inhibitor (C1-INH) before the subsequent generation of bradykinin that mediates HAE. In this study, we evaluated the fragmentation and enzymatic activity of contact system proteins in HAEnCI plasma samples before and after contact system activation induced by incubation in the cold. Our results show that in contrast to normal plasma, cold activation induced contact system activation in the majority of the HAEnCI patient samples we tested, in which each contact system protein exhibited fragmentation, FXII and kallikrein enzymatic activity increased, and C1-INH functional activity decreased. HAEnCI samples with low FXII concentrations or functional activity were not affected by cold activation. One HAEnCI sample with a plasminogen gene mutation activated the fibrinolytic system, as shown by an increase in concentration of plasma D dimers. Our results suggest that cold activation seems to be initiated by the cleavage of prekallikrein, and that it needs FXII in order to occur. Reported to be susceptible to excessive contact system activation after incubation in the cold, we further applied this system of study to the evaluation of plasma from women undergoing estrogen treatment. Similar to plasma from HAEnCI patients, excessive contact system activation was demonstrated.
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Joseph K. Legends of Allergy and Immunology: Allen Kaplan. Allergy 2020; 75:3290-3292. [PMID: 32496627 DOI: 10.1111/all.14431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 05/08/2020] [Accepted: 05/19/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Kusumam Joseph
- Scientific Director, BioCryst Pharmaceuticals Inc, Durham, NC, USA
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15
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Burnham K, Reinert JP. Thromboembolic Risk of C1 Esterase Inhibitors: A Systematic Review on Current Evidence. Expert Rev Clin Pharmacol 2020; 13:779-786. [PMID: 32476505 DOI: 10.1080/17512433.2020.1776110] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION The exact risk of developing a thromboembolic event (TEE) while using complement 1 esterase inhibitors (C1-INHs) is currently undetermined for patients with hereditary angioedema (HAE). This systematic review aimed to define the potential risk of TEEs from these agents. AREAS COVERED This evaluation covers publications examining or mentioning the risk of TEEs in association with C1-INHs. A systematic literature search was conducted utilizing PubMed, Scopus, and ProQuest. This review utilized search results through January 2020 and followed the PRISMA recommendations for a systematic review. Articles not available in English and animal or in-vitro studies were excluded. For inclusion, studies had to be open-label, randomized-controlled, cross-sectional, or clinical observational studies. A total of 13 studies met inclusion criteria and yielded 1716 patients receiving at least one dose of C1-INH, though only 41 incidences of thrombosis were documented. EXPERT OPINION Significant heterogeneity exists in the available literature concerning both study design and the reporting of data; therefore, interpretation of thrombotic risk is difficult. TEEs are rarely reported in the literature, and they seem unlikely to occur in patients without underlying risk factors. Important risk factors include those found in the prescribing information of C1-INHs.
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Affiliation(s)
- Kevin Burnham
- Ben and Maytee Fisch College of Pharmacy, The University of Texas , Tyler, TX, USA
| | - Justin P Reinert
- Ben and Maytee Fisch College of Pharmacy, The University of Texas , Tyler, TX, USA
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16
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Bova M, Suffritti C, Bafunno V, Loffredo S, Cordisco G, Del Giacco S, De Pasquale TMA, Firinu D, Margaglione M, Montinaro V, Petraroli A, Radice A, Brussino L, Zanichelli A, Zoli A, Cicardi M. Impaired control of the contact system in hereditary angioedema with normal C1-inhibitor. Allergy 2020; 75:1394-1403. [PMID: 31860755 DOI: 10.1111/all.14160] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 11/11/2019] [Accepted: 11/21/2019] [Indexed: 01/23/2023]
Abstract
BACKGROUND Hereditary angioedema (HAE) comprises HAE with C1-inhibitor deficiency (C1-INH-HAE) and HAE with normal C1-INH activity (nl-C1-INH-HAE), due to mutations in factor XII (FXII-HAE), plasminogen (PLG-HAE), angiopoietin 1 (ANGPT1-HAE), kininogen 1 genes (KNG1-HAE), or angioedema of unknown origin (U-HAE). The Italian network for C1-INH-HAE (ITACA) created a registry including different forms of angioedema without wheals. OBJECTIVE We analyzed clinical and laboratory features of a cohort of Italian subjects with nl-C1-INH-HAE followed by ITACA to identify specific biomarkers. METHODS A total of 105 nl-C1-INH-HAE patients were studied. Plasma concentrations of cleaved high-molecular-weight kininogen (cHK), vascular endothelial growth factors (VEGFs), angiopoietins (Angs), and secreted phospholipase A2 enzymes (sPLA2 ) were evaluated. RESULTS We identified 43 FXII-HAE patients, 58 U-HAE, and 4 ANGPT1-HAE. We assessed a prevalence of 1:1.4 × 106 for FXII-HAE and 1:1.0 × 106 for U-HAE. cHK levels in U-HAE patients were similar to controls in plasma collected using protease inhibitors cocktail (PIC), but they significantly increased in the absence of PIC. In FXII-HAE patients, cHK levels, in the absence of PIC, were significantly higher than in controls. We found a significant increase of VEGF-A, VEGF-C, and Ang1 levels in U-HAE patients compared to controls. In FXII-HAE, only VEGF-C levels were increased. Ang2 concentrations and sPLA2 activity were not modified. The levels of these mediators in ANGPT1-HAE patients were not altered. CONCLUSIONS Our results suggest that pathogenesis of FXII-, ANGPT1-, and U-HAE moves through an unbalanced control of kallikrein activity, with bradykinin as most likely mediator. VEGFs and Ang1 participate in the pathophysiology of U-HAE increasing the basal vascular permeability.
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Affiliation(s)
- Maria Bova
- Department of Translational Medical Sciences and Center for Basic and Clinical Immunology Research University of Naples Federico II Naples Italy
| | - Chiara Suffritti
- Department of Biomedical and Clinical Sciences Luigi Sacco University of Milan Milan Italy
| | - Valeria Bafunno
- Medical Genetics Department of Clinical and Experimental Medicine University of Foggia Foggia Italy
| | - Stefania Loffredo
- Department of Translational Medical Sciences and Center for Basic and Clinical Immunology Research University of Naples Federico II Naples Italy
- Institute of Experimental Endocrinology and Oncology “G. Salvatore” National Research Council Naples Italy
| | - Giorgia Cordisco
- Medical Genetics Department of Clinical and Experimental Medicine University of Foggia Foggia Italy
| | | | | | - Davide Firinu
- Department of Medical Sciences University of Cagliari Cagliari Italy
| | - Maurizio Margaglione
- Medical Genetics Department of Clinical and Experimental Medicine University of Foggia Foggia Italy
| | | | - Angelica Petraroli
- Department of Translational Medical Sciences and Center for Basic and Clinical Immunology Research University of Naples Federico II Naples Italy
| | - Anna Radice
- Department of Allergy University of Florence Florence Italy
| | - Luisa Brussino
- Department of Medical Science University of Torino Turin Italy
| | | | - Alessandra Zoli
- Department of Clinical Immunology Ospedali Riuniti Ancona Italy
| | - Marco Cicardi
- Department of Biomedical and Clinical Sciences Luigi Sacco University of Milan Milan Italy
- IRCCS‐ICS Maugeri Milano Italy
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17
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Affiliation(s)
- Paula J Busse
- From the Division of Clinical Immunology and Allergy, Icahn School of Medicine at Mount Sinai, New York (P.J.B.); and the Department of Medicine, University of California, San Diego, San Diego (S.C.C.)
| | - Sandra C Christiansen
- From the Division of Clinical Immunology and Allergy, Icahn School of Medicine at Mount Sinai, New York (P.J.B.); and the Department of Medicine, University of California, San Diego, San Diego (S.C.C.)
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18
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Kaplan AP, Pawaskar D, Chiao J. C1 Inhibitor Activity and Angioedema Attacks in Patients with Hereditary Angioedema. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:892-900. [DOI: 10.1016/j.jaip.2019.10.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Revised: 10/14/2019] [Accepted: 10/15/2019] [Indexed: 11/28/2022]
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19
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Wu MA, Bova M, Berra S, Senter R, Parolin D, Caccia S, Cicardi M. The central role of endothelium in hereditary angioedema due to C1 inhibitor deficiency. Int Immunopharmacol 2020; 82:106304. [PMID: 32114411 DOI: 10.1016/j.intimp.2020.106304] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 02/10/2020] [Indexed: 12/31/2022]
Abstract
An impairment of the endothelial barrier function underlies a wide spectrum of pathological conditions. Hereditary angioedema due to C1-inhibitor deficiency (C1-INH-HAE) can be considered the "pathophysiological and clinical paradigm" of Paroxysmal Permeability Diseases (PPDs), conditions characterized by recurrent transient primitively functional alteration of the endothelial sieving properties, not due to inflammatory-ischemic-degenerative injury and completely reversible after the acute flare. It is a rare yet probably still underdiagnosed disease which presents with localized, non-pitting swelling of the skin and submucosal tissues of the upper respiratory and gastrointestinal tracts, without significant wheals or pruritus. The present review addresses the pathophysiology of C1-INH-HAE with a focus on the crucial role of the endothelium during contact and kallikrein/kinin system (CAS and KKS) activation, currently available and emerging biomarkers, methods applied to get new insights into the mechanisms underlying the disease (2D, 3D and in vivo systems), new promising investigation techniques (autonomic nervous system analysis, capillaroscopy, flow-mediated dilation method, non-invasive finger plethysmography). Hints are given to the binding of C1-INH to endothelial cells. Finally, crucial issues as the local vs systemic nature of CAS/KKS activation, the episodic nature of attacks vs constant C1-INH deficiency, pros and cons as well as future perspectives of available methodologies are briefly discussed.
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Affiliation(s)
- Maddalena Alessandra Wu
- Department of Biomedical and Clinical Sciences, ASST Fatebenefratelli Sacco, University of Milan, Milan, Italy.
| | - Maria Bova
- Department of Translational Medical Sciences and Interdepartmental Center for Research in Basic and Clinical Immunology Sciences, University of Naples Federico II, Naples, Italy
| | - Silvia Berra
- Department of Biomedical and Clinical Sciences, ASST Fatebenefratelli Sacco, University of Milan, Milan, Italy
| | | | - Debora Parolin
- Department of Biomedical and Clinical Sciences, ASST Fatebenefratelli Sacco, University of Milan, Milan, Italy
| | - Sonia Caccia
- Department of Biomedical and Clinical Sciences, ASST Fatebenefratelli Sacco, University of Milan, Milan, Italy
| | - Marco Cicardi
- Department of Biomedical and Clinical Sciences, ASST Fatebenefratelli Sacco, University of Milan, Milan, Italy; IRCCS-ICS Maugeri, Milan, Italy
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20
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Design and characterization of α1-antitrypsin variants for treatment of contact system-driven thromboinflammation. Blood 2020; 134:1658-1669. [PMID: 31366623 DOI: 10.1182/blood.2019000481] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 07/22/2019] [Indexed: 01/15/2023] Open
Abstract
The contact system produces the inflammatory peptide bradykinin and contributes to experimental thrombosis. C1 esterase-inhibitor (C1INH) deficiency or gain-of-function mutations in factor XII (FXII) cause hereditary angioedema, a life-threatening tissue swelling disease. C1INH is a relatively weak contact system enzyme inhibitor. Although α1-antitrypsin (α1AT) does not naturally inhibit contact system enzymes, a human mutation (M358R; α1AT-Pittsburgh) changes it into a powerful broad-spectrum enzyme inhibitor. It blocks the contact system, but also thrombin and activated protein C (APC), making it an unattractive candidate for therapeutic contact system blockade. We adapted the reactive center loop of α1AT-Pittsburgh (AIPR/S) to overcome these obstacles. Two α1AT variants (SMTR/S and SLLR/S) strongly inhibit plasma kallikrein, activated FXII, and plasmin. α1AT-SMTR/S no longer inhibits thrombin, but residually inhibits APC. In contrast, α1AT-SLLR/S residually inhibits thrombin, but no longer APC. Additional modification at the P1' position (S→V) eliminates residual inhibition of thrombin and APC for both variants, while retaining their properties as contact system inhibitors. Both α1AT-SMTR/V and -SLLR/V are superior to C1INH in reducing bradykinin production in plasma. Owing to their capacity to selectively block contact system-driven coagulation, both variants block vascular occlusion in an in vivo model for arterial thrombosis. Furthermore, both variants block acute carrageenan-induced tissue edema in mice. Finally, α1AT-SLLR/V, our most powerful candidate, suppresses epithelial leakage of the gut in a mouse model of colitis. Our findings confirm that redesign of α1AT strongly alters its inhibitory behavior and can be used for the treatment of contact system-mediated thrombosis and inflammation.
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21
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Germenis AE, Cicardi M. Driving towards Precision Medicine for angioedema without wheals. J Autoimmun 2019; 104:102312. [PMID: 31402201 DOI: 10.1016/j.jaut.2019.102312] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 07/24/2019] [Indexed: 01/09/2023]
Abstract
Evidence accumulated over the last two decades indicates that recurrent angioedema without wheals constitutes a diverse family of disorders with a much higher complexity than was previously regarded. Indicatively, during the last two years, novel variants of three genes other than SERPING1 and F12 have been identified in association with hereditary angioedema. Most interestingly, functional studies of at least one of these variants (the variant c.807G > T of ANGPT1 gene) imply the existence of a new disease endotype in which the altered bradykinin metabolism and function does not play a central role. Therefore, using conventional approaches, it seems that the complexity of this disease cannot be sufficiently elucidated and any attempt to interrelate its many diverse aspects seems unrealistic. Similar to other rare and chronic diseases, a Precision Medicine approach, discovering the right target and giving "the right drug, for the right patient, at the right time, every time" seems the optimal future practice. Herein, we review recent data challenging and dictating the need for a switch of angioedema research into high-throughput approaches and we present the expected advantages for better understanding of the disease and patients management.
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Affiliation(s)
- Anastasios E Germenis
- Department of Immunology & Histocompatibility, School of Medicine, University of Thessaly, Larissa, Greece.
| | - Marco Cicardi
- Dipartimento di Scienze Biomediche e Cliniche Luigi Sacco, Universita Degli Studi di Milano, IRCCS ICS Maugeri Milano via Camaldoli, Italy
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22
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Neutrophils Are Dysregulated in Patients with Hereditary Angioedema Types I and II in a Symptom-Free Period. Mediators Inflamm 2019; 2019:9515628. [PMID: 31236065 PMCID: PMC6545807 DOI: 10.1155/2019/9515628] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 03/06/2019] [Accepted: 03/18/2019] [Indexed: 12/23/2022] Open
Abstract
Neutrophils impact on processes preceding the formation of bradykinin, a major swelling mediator in hereditary angioedema (HAE), yet their potential role in HAE pathogenesis has not been sufficiently studied. We assessed the relative mRNA expression of 10 genes related to neutrophil activation using RNA extracted from the peripheral blood neutrophils of 23 HAE patients in a symptom-free period and 39 healthy donors. Increased relative mRNA expression levels of CD274, IL1B, IL1RN, IL8, MMP9, and TLR4, together with a lack in their mutual correlations detected in HAE patients compared to healthy controls, suggested a preactivated state and dysregulation of patients' neutrophils. Patients' neutrophil-alerted state was further supported by increased CD11b, decreased CD16 plasma membrane deposition, and increased relative CD274+ and CD87+ neutrophil counts, but not by increased neutrophil elastase or myeloperoxidase plasma levels. As CD274 mediates inhibitory signals to different immune cells, neutrophils were cocultured with T-cells/PBMC. The decrease in CD25+ and IFN-γ + T-cell/PBMC ratio in patients indicated the patients' neutrophil suppressive functions. In summary, the results showed neutrophils' alerted state and dysregulation at the transcript level in patients with HAE types I and II even in a symptom-free period, which might make them more susceptible to edema formation. Neutrophils' T-cell suppressive capacity in HAE patients needs to be further investigated.
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23
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Castellano G, Divella C, Sallustio F, Montinaro V, Curci C, Zanichelli A, Bonanni E, Suffritti C, Caccia S, Bossi F, Gallone A, Schena FP, Gesualdo L, Cicardi M. A transcriptomics study of hereditary angioedema attacks. J Allergy Clin Immunol 2018; 142:883-891. [DOI: 10.1016/j.jaci.2018.03.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Revised: 02/20/2018] [Accepted: 03/28/2018] [Indexed: 01/21/2023]
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24
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De Maat S, Hofman ZLM, Maas C. Hereditary angioedema: the plasma contact system out of control. J Thromb Haemost 2018; 16:1674-1685. [PMID: 29920929 DOI: 10.1111/jth.14209] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Accepted: 06/11/2018] [Indexed: 01/06/2023]
Abstract
The plasma contact system contributes to thrombosis in experimental models. Even though our standard blood coagulation tests are prolonged when plasma lacks contact factors, this enzyme system appears to have a minor (if any) role in hemostasis. In this review, we explore the clinical phenotype of C1 esterase inhibitor (C1-INH) deficiency. C1-INH is the key plasma inhibitor of the contact system enzymes, and its deficiency causes hereditary angioedema (HAE). This inflammatory disorder is characterized by recurrent aggressive attacks of tissue swelling that occur at unpredictable locations throughout the body. Bradykinin, which is considered to be a byproduct of the plasma contact system during in vitro coagulation, is the main disease mediator in HAE. Surprisingly, there is little evidence for thrombotic events in HAE patients, suggesting mechanistic uncoupling from the intrinsic pathway of coagulation. In addition, it is questionable whether a surface is responsible for contact system activation in HAE. In this review, we discuss the clinical phenotype, disease modifiers and diagnostic challenges of HAE. We subsequently describe the underlying biochemical mechanisms and contributing disease mediators. Furthermore, we review three types of HAE that are not caused by C1-INH inhibitor deficiency. Finally, we propose a central enzymatic axis that we hypothesize to be responsible for bradykinin production in health and disease.
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Affiliation(s)
- S De Maat
- Department of Clinical Chemistry and Haematology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Z L M Hofman
- Department of Clinical Chemistry and Haematology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - C Maas
- Department of Clinical Chemistry and Haematology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
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25
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Maurer M, Magerl M, Ansotegui I, Aygören-Pürsün E, Betschel S, Bork K, Bowen T, Balle Boysen H, Farkas H, Grumach AS, Hide M, Katelaris C, Lockey R, Longhurst H, Lumry WR, Martinez-Saguer I, Moldovan D, Nast A, Pawankar R, Potter P, Riedl M, Ritchie B, Rosenwasser L, Sánchez-Borges M, Zhi Y, Zuraw B, Craig T. The international WAO/EAACI guideline for the management of hereditary angioedema-The 2017 revision and update. Allergy 2018; 73:1575-1596. [PMID: 29318628 DOI: 10.1111/all.13384] [Citation(s) in RCA: 298] [Impact Index Per Article: 49.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/12/2017] [Indexed: 12/25/2022]
Abstract
Hereditary Angioedema (HAE) is a rare and disabling disease. Early diagnosis and appropriate therapy are essential. This update and revision of the global guideline for HAE provides up-to-date consensus recommendations for the management of HAE. In the development of this update and revision of the guideline, an international expert panel reviewed the existing evidence and developed 20 recommendations that were discussed, finalized and consented during the guideline consensus conference in June 2016 in Vienna. The final version of this update and revision of the guideline incorporates the contributions of a board of expert reviewers and the endorsing societies. The goal of this guideline update and revision is to provide clinicians and their patients with guidance that will assist them in making rational decisions in the management of HAE with deficient C1-inhibitor (type 1) and HAE with dysfunctional C1-inhibitor (type 2). The key clinical questions covered by these recommendations are: (1) How should HAE-1/2 be defined and classified?, (2) How should HAE-1/2 be diagnosed?, (3) Should HAE-1/2 patients receive prophylactic and/or on-demand treatment and what treatment options should be used?, (4) Should HAE-1/2 management be different for special HAE-1/2 patient groups such as pregnant/lactating women or children?, and (5) Should HAE-1/2 management incorporate self-administration of therapies and patient support measures?
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Affiliation(s)
- M. Maurer
- Department of Dermatology and Allergy; Charité-Universitätsmedizin Berlin; Berlin Germany
| | - M. Magerl
- Department of Dermatology and Allergy; Charité-Universitätsmedizin Berlin; Berlin Germany
| | - I. Ansotegui
- Department of Allergy and Immunology; Hospital Quironsalud Bizkaia; Bilbao Spain
| | - E. Aygören-Pürsün
- Center for Children and Adolescents; University Hospital Frankfurt; Frankfurt Germany
| | - S. Betschel
- Division of Clinical Immunology and Allergy; St. Michael's Hospital; University of Toronto; Toronto ON Canada
| | - K. Bork
- Department of Dermatology; Johannes Gutenberg University Mainz; Mainz Germany
| | - T. Bowen
- Department of Medicine and Pediatrics; University of Calgary; Calgary AB Canada
| | | | - H. Farkas
- Hungarian Angioedema Center; 3rd Department of Internal Medicine; Semmelweis University; Budapest Hungary
| | - A. S. Grumach
- Clinical Immunology; Faculdade de Medicina ABC; São Paulo Brazil
| | - M. Hide
- Department of Dermatology; Hiroshima University; Hiroshima Japan
| | - C. Katelaris
- Department of Medicine; Campbelltown Hospital and Western Sydney University; Sydney NSW Australia
| | - R. Lockey
- Department of Internal Medicine; University of South Florida Morsani College of Medicine; Tampa FL USA
| | - H. Longhurst
- Department of Clinical Biochemistry and Immunology; Addenbrooke's Hospital; Cambridge University Hospitals NHS Foundation Trust; UK
| | - W. R. Lumry
- Department of Internal Medicine; Allergy/Immunology Division; Southwestern Medical School; University of Texas; Dallas TX USA
| | | | - D. Moldovan
- University of Medicine and Pharmacy; Tîrgu Mures Romania
| | - A. Nast
- Berlin Institute of Health; Department of Dermatology, Venereology und Allergy; Division of Evidence based Medicine (dEBM); Corporate Member of Freie Universität Berlin; Humboldt-Universität zu Berlin; Charité-Universitätsmedizin Berlin; Berlin Germany
| | - R. Pawankar
- Department of Pediatrics; Nippon Medical School; Tokyo Japan
| | - P. Potter
- Department of Medicine; University of Cape Town; Cape Town South Africa
| | - M. Riedl
- Department of Medicine; University of California-San Diego; La Jolla CA USA
| | - B. Ritchie
- Division of Hematology; University of Alberta; Edmonton AB Canada
| | - L. Rosenwasser
- Allergy and Immunology Department; University of Missouri at Kansas City School of Medicine; Kansas City MO USA
| | - M. Sánchez-Borges
- Allergy and Clinical Immunology Department; Centro Medico Docente La Trinidad; Caracas Venezuela
| | - Y. Zhi
- Department of Allergy; Peking Union Medical College Hospital and Chinese Academy of Medical Sciences; Beijing China
| | - B. Zuraw
- Department of Medicine; University of California-San Diego; La Jolla CA USA
- San Diego VA Healthcare; San Diego CA USA
| | - T. Craig
- Department of Medicine and Pediatrics; Penn State University; Hershey PA USA
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Cicardi M, Zuraw BL. Angioedema Due to Bradykinin Dysregulation. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 6:1132-1141. [DOI: 10.1016/j.jaip.2018.04.022] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 04/25/2018] [Accepted: 04/25/2018] [Indexed: 01/08/2023]
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27
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Bafunno V, Firinu D, D'Apolito M, Cordisco G, Loffredo S, Leccese A, Bova M, Barca MP, Santacroce R, Cicardi M, Del Giacco S, Margaglione M. Mutation of the angiopoietin-1 gene (ANGPT1) associates with a new type of hereditary angioedema. J Allergy Clin Immunol 2018; 141:1009-1017. [PMID: 28601681 DOI: 10.1016/j.jaci.2017.05.020] [Citation(s) in RCA: 176] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Revised: 05/03/2017] [Accepted: 05/10/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Valeria Bafunno
- Medical Genetics, Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | - Davide Firinu
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Maria D'Apolito
- Medical Genetics, Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | - Giorgia Cordisco
- Medical Genetics, Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | - Stefania Loffredo
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Angelica Leccese
- Medical Genetics, Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | - Maria Bova
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Maria Pina Barca
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Rosa Santacroce
- Medical Genetics, Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | - Marco Cicardi
- Department of Biomedical and Clinical Sciences Luigi Sacco, University of Milan, Luigi Sacco Hospital Milan, Milan, Italy
| | - Stefano Del Giacco
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Maurizio Margaglione
- Medical Genetics, Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy.
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Schmaier AH. Plasma Prekallikrein: Its Role in Hereditary Angioedema and Health and Disease. Front Med (Lausanne) 2018; 5:3. [PMID: 29423395 PMCID: PMC5788901 DOI: 10.3389/fmed.2018.00003] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Accepted: 01/09/2018] [Indexed: 11/13/2022] Open
Abstract
Plasma prekallikrein (PK) has a critical role in acute attacks of hereditary angioedema (HAE). Unlike C1 inhibitor, its levels fall during HAE attacks with resultant cleaved high-molecular-weight kininogen. Cleavage of high-molecular-weight kininogen liberates bradykinin, the major biologic peptide that promotes the edema. How prekallikrein initially becomes activated in acute attacks of HAE is not known. PK itself is negatively associated with cardiovascular disease. High prekallikrein is associated with accelerated vascular disease in diabetes and polymorphisms of prekallikrein that reduce high-molecular-weight kininogen binding are associated with protection from cardiovascular events. Prekallikrein-deficient mice have reduced thrombosis risk and plasma kallikrein (PKa) inhibition is associated with reduced experimental gastroenterocolitis and arthritis in rodents. In sum, prekallikrein and its enzyme PKa are major targets in HAE providing much opportunity to improve the acute and chronic management of HAE. PKa inhibition also may be a target to ameliorate cardiovascular disease, thrombosis risk, and inflammation as in enterocolitis and arthritis.
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Affiliation(s)
- Alvin H Schmaier
- Hematology and Oncology Division, Department of Medicine, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH, United States
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Maurer M, Magerl M, Ansotegui I, Aygören-Pürsün E, Betschel S, Bork K, Bowen T, Boysen HB, Farkas H, Grumach AS, Hide M, Katelaris C, Lockey R, Longhurst H, Lumry WR, Martinez-Saguer I, Moldovan D, Nast A, Pawankar R, Potter P, Riedl M, Ritchie B, Rosenwasser L, Sánchez-Borges M, Zhi Y, Zuraw B, Craig T. The international WAO/EAACI guideline for the management of hereditary angioedema – the 2017 revision and update. World Allergy Organ J 2018. [DOI: 10.1186/s40413-017-0180-1] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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30
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Kaplan AP, Maas C. The Search for Biomarkers in Hereditary Angioedema. Front Med (Lausanne) 2017; 4:206. [PMID: 29214154 PMCID: PMC5702621 DOI: 10.3389/fmed.2017.00206] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Accepted: 11/06/2017] [Indexed: 11/16/2022] Open
Abstract
The unpredictable nature of attacks of tissue swelling in hereditary angioedema requires the identification of reliable biomarkers to monitor disease activity as well as response to therapy. At present, one can assess a C4 level (by ELISA) to assist in diagnosis but neither C4 nor C1 inhibitor levels reflect clinical course or prognosis. We will here review a collection of plasma proteins involved in blood coagulation, fibrinolysis, and innate immunity (Figure 1). A main focus is those proteins that are key to the formation of bradykinin (BK); namely, factor XII, plasma prekallikrein/kallikrein, high-molecular weight kininogen, and BK itself since overproduction of BK is key to the disease. Considerations include new approaches to measurement of active enzymes, ELISA methods that may supersede SDS gel analysis of bond cleavages, and examples of changes outside the BK cascade that may reflect when, where, and how an attack of swelling is initiated. We will discuss their usefulness as biomarker candidates, with pros and cons, and compare the analytical methods that are being developed to measure their levels or activity.
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Affiliation(s)
- Allen P. Kaplan
- Department of Medicine, Medical University of South Carolina, Charleston, SC, United States
| | - Coen Maas
- Department of Clinical Chemistry and Haematology, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
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31
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Chen IJ, Chuang CH, Hsieh YC, Lu YC, Lin WW, Huang CC, Cheng TC, Cheng YA, Cheng KW, Wang YT, Chen FM, Cheng TL, Tzou SC. Selective antibody activation through protease-activated pro-antibodies that mask binding sites with inhibitory domains. Sci Rep 2017; 7:11587. [PMID: 28912497 PMCID: PMC5599682 DOI: 10.1038/s41598-017-11886-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Accepted: 08/31/2017] [Indexed: 12/16/2022] Open
Abstract
Systemic injection of therapeutic antibodies may cause serious adverse effects due to on-target toxicity to the antigens expressed in normal tissues. To improve the targeting selectivity to the region of disease sites, we developed protease-activated pro-antibodies by masking the binding sites of antibodies with inhibitory domains that can be removed by proteases that are highly expressed at the disease sites. The latency-associated peptide (LAP), C2b or CBa of complement factor 2/B were linked, through a substrate peptide of matrix metalloproteinase-2 (MMP-2), to an anti-epidermal growth factor receptor (EGFR) antibody and an anti-tumor necrosis factor-α (TNF-α) antibody. Results showed that all the inhibitory domains could be removed by MMP-2 to restore the binding activities of the antibodies. LAP substantially reduced (53.8%) the binding activity of the anti-EGFR antibody on EGFR-expressing cells, whereas C2b and CBa were ineffective (21% and 9.3% reduction, respectively). Similarly, LAP also blocked 53.9% of the binding activity of the anti-TNF-α antibody. Finally, molecular dynamic simulation showed that the masking efficiency of LAP, C2b and CBa was 33.7%, 10.3% and −5.4%, respectively, over the binding sites of the antibodies. This strategy may aid in designing new protease-activated pro-antibodies that attain high therapeutic potency yet reduced systemic on-target toxicity.
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Affiliation(s)
- I-Ju Chen
- Graduate Institute of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chih-Hung Chuang
- Department of Medical Laboratory Science and Biotechnology, College of Health Sciences, Kaohsiung Medical University, Kaohsiung, Taiwan.,Center for Biomarkers and Biotech Drugs, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yuan-Chin Hsieh
- Graduate Institute of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yun-Chi Lu
- Graduate Institute of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Wen-Wei Lin
- Institute of Biomedical Sciences, National Sun Yat-Sen University, Kaohsiung, Taiwan
| | - Chien-Chiao Huang
- Center for Biomarkers and Biotech Drugs, Kaohsiung Medical University, Kaohsiung, Taiwan.,Graduate Institute of Clinical Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Biomedical Science and Environmental Biology, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ta-Chun Cheng
- Center for Biomarkers and Biotech Drugs, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yi-An Cheng
- Graduate Institute of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Kai-Wen Cheng
- Institute of Biomedical Sciences, National Sun Yat-Sen University, Kaohsiung, Taiwan
| | - Yeng-Tseng Wang
- Department of Biochemistry, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Fang-Ming Chen
- Department of Surgery, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Tian-Lu Cheng
- Graduate Institute of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan. .,Center for Biomarkers and Biotech Drugs, Kaohsiung Medical University, Kaohsiung, Taiwan. .,Institute of Biomedical Sciences, National Sun Yat-Sen University, Kaohsiung, Taiwan. .,Department of Biomedical Science and Environmental Biology, Kaohsiung Medical University, Kaohsiung, Taiwan. .,Department of Medical Research, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.
| | - Shey-Cherng Tzou
- Institute of Molecular Medicine and Bioengineering, Department of Biological Science and Technology, National Chiao Tung University, Hsin-Chu, Taiwan.
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Ghebrehiwet B, Kaplan AP, Joseph K, Peerschke EIB. The complement and contact activation systems: partnership in pathogenesis beyond angioedema. Immunol Rev 2017; 274:281-289. [PMID: 27782339 DOI: 10.1111/imr.12469] [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: 01/30/2023]
Abstract
The blood plasma contains four biologically important proteolytic cascades, which probably evolved from the same ancestral gene. This in part may explain why each cascade has very similar "initiating trigger" followed by sequential and cascade-like downstream enzymatic activation pattern. The four cascades are: the complement system, the blood clotting cascade, the fibrinolytic system, and the kallikrein-kinin system. Although much has been written about the interplay between all these enzymatic cascades, the cross-talk between the complement and the kinin generating systems has become particularly relevant as this interaction results in the generation of nascent molecules that have significant impact in various inflammatory diseases including angioedema and cancer. In this review, we will focus on the consequences of the interplay between the two systems by highlighting the role of a novel molecular link called gC1qR. Although this protein was first identified as a receptor for C1q, it is now recognized as a multiligand binding cellular protein, which serves not only as C1q receptor, but also as high affinity (KD ≤ 0.8 nM) binding site for both high molecular weight kininogen (HK) and factor XII (FXII). At inflammatory sites, where atherogenic factors such as immune complexes and/or pathogens can activate the endothelial cell into a procoagulant and proinflammatory surface, the two pathways are activated to generate vasoactive peptides that contribute in various ways to the inflammatory processes associated with numerous diseases. More importantly, since recent observations strongly suggest an important role for both pathways in cancer, we will focus on how a growing tumor cluster can employ the byproducts derived from the two activation systems to ensure not only its survival and growth, but also its escape into distal sites of colonization.
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Affiliation(s)
- Berhane Ghebrehiwet
- The Departments of Medicine and Pathology, Stony Brook University, Stony Brook, NY, USA.
| | - Allen P Kaplan
- Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Kusumam Joseph
- Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Ellinor I B Peerschke
- The Department of Laboratory Medicine, Memorial Sloan-Kettering Cancer Center (MSKCC), New York, NY, USA.,The Department of Pathology, Weill-Cornell Medical College, New York, NY, USA
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34
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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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35
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Csuka D, Veszeli N, Varga L, Prohászka Z, Farkas H. The role of the complement system in hereditary angioedema. Mol Immunol 2017; 89:59-68. [PMID: 28595743 DOI: 10.1016/j.molimm.2017.05.020] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Revised: 05/22/2017] [Accepted: 05/23/2017] [Indexed: 10/19/2022]
Abstract
Hereditary angioedema (HAE) is a rare, but potentially life-threatening disorder, characterized by acute, recurring, and self-limiting edematous episodes of the face, extremities, trunk, genitals, upper airways, or the gastrointestinal tract. HAE may be caused by the deficiency of C1-inhibitor (C1-INH-HAE) but another type of the disease, hereditary angioedema with normal C1-INH function (nC1-INH-HAE) was also described. The patient population is quite heterogeneous as regards the location, frequency, and severity of edematous attacks, presenting large intra- and inter-individual variation. Here, we review the role of the complement system in the pathomechanism of HAE and also present an overview on the complement parameters having an importance in the diagnosis or in predicting the severity of HAE.
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Affiliation(s)
- Dorottya Csuka
- 3rd Department of Internal Medicine, Semmelweis University, Budapest, Hungary.
| | - Nóra Veszeli
- 3rd Department of Internal Medicine, Semmelweis University, Budapest, Hungary
| | - Lilian Varga
- 3rd Department of Internal Medicine, Semmelweis University, Budapest, Hungary
| | - Zoltán Prohászka
- 3rd Department of Internal Medicine, Semmelweis University, Budapest, Hungary
| | - Henriette Farkas
- 3rd Department of Internal Medicine, Semmelweis University, Budapest, Hungary
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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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Hofman Z, de Maat S, Hack CE, Maas C. Bradykinin: Inflammatory Product of the Coagulation System. Clin Rev Allergy Immunol 2017; 51:152-61. [PMID: 27122021 PMCID: PMC5025506 DOI: 10.1007/s12016-016-8540-0] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Episodic and recurrent local cutaneous or mucosal swelling are key features of angioedema. The vasoactive agents histamine and bradykinin are highly implicated as mediators of these swelling attacks. It is challenging to assess the contribution of bradykinin to the clinical expression of angioedema, as accurate biomarkers for the generation of this vasoactive peptide are still lacking. In this review, we will describe the mechanisms that are responsible for bradykinin production in hereditary angioedema (HAE) and the central role that the coagulation factor XII (FXII) plays in it. Evidently, several plasma parameters of coagulation change during attacks of HAE and may prove valuable biomarkers for disease activity. We propose that these changes are secondary to vascular leakage, rather than a direct consequence of FXII activation. Furthermore, biomarkers for fibrinolytic system activation (i.e. plasminogen activation) also change during attacks of HAE. These changes may reflect triggering of the bradykinin-forming mechanisms by plasmin. Finally, multiple lines of evidence suggest that neutrophil activation and mast-cell activation are functionally linked to bradykinin production. We put forward the paradigm that FXII functions as a ‘sensor molecule’ to detect conditions that require bradykinin release via crosstalk with cell-derived enzymes. Understanding the mechanisms that drive bradykinin generation may help to identify angioedema patients that have bradykinin-mediated disease and could benefit from a targeted treatment.
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Affiliation(s)
- Zonne Hofman
- Laboratory of Clinical Chemistry and Hematology, University Medical Center Utrecht, Utrecht, The Netherlands.,Laboratory of Translational Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Steven de Maat
- Laboratory of Clinical Chemistry and Hematology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - C Erik Hack
- Laboratory of Translational Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Coen Maas
- Laboratory of Clinical Chemistry and Hematology, University Medical Center Utrecht, Utrecht, The Netherlands.
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38
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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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40
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Complement, Kinins, and Hereditary Angioedema: Mechanisms of Plasma Instability when C1 Inhibitor is Absent. Clin Rev Allergy Immunol 2016; 51:207-15. [PMID: 27273087 DOI: 10.1007/s12016-016-8555-6] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Plasma of patients with types I and II hereditary angioedema is unstable if incubated in a plastic (i.e., inert) vessel at 37 °C manifested by progressively increasing formation of bradykinin. There is also a persistent low level of C4 in 95 % of patients even when they are symptomatic. These phenomena are due to the properties of the C1r subcomponent of C1, factor XII, and the bimolecular complex of prekallikrein with high molecular weight kininogen (HK). Purified C1r auto-activates in physiologic buffers, activates C1s, which in turn depletes C4. This occurs when C1 inhibitor is deficient. The complex of prekallikrein-HK acquires an inducible active site not present in prekallikrein which in Tris-type buffers cleaves HK stoichiometrically to release bradykinin, or in phosphate buffer auto-activates to generate kallikrein and bradykinin. Thus immunologic depletion of C1 inhibitor from factor XII-deficient plasma (phosphate is the natural buffer) auto-activates on incubation to release bradykinin. Normal C1 inhibitor prevents this from occurring. During attacks of angioedema, if factor XII auto-activates on surfaces, the initial factor XIIa formed converts prekallikrein to kallikrein, and kallikrein cleaves HK to release bradykinin. Kallikrein also rapidly activates most remaining factor XII to factor XIIa. Additional cleavages convert factor XIIa to factor XIIf and factor XIIf activates C1r enzymatically so that C4 levels approach zero, and C2 is depleted. There is also a possibility that kallikrein is generated first as a result of activation of the prekallikrein-HK complex by heat shock protein 90 released from endothelial cells, followed by kallikrein activation of factor XII.
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41
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Prophylaxis of hereditary angioedema attacks: A randomized trial of oral plasma kallikrein inhibition with avoralstat. J Allergy Clin Immunol 2016; 138:934-936.e5. [PMID: 27302552 DOI: 10.1016/j.jaci.2016.03.043] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Revised: 02/29/2016] [Accepted: 03/15/2016] [Indexed: 11/24/2022]
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42
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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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43
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Leach JK, Spencer K, Mascelli M, McCauley TG. Pharmacokinetics of single and repeat doses of icatibant. Clin Pharmacol Drug Dev 2015; 4:105-11. [DOI: 10.1002/cpdd.138] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Accepted: 06/19/2014] [Indexed: 11/09/2022]
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44
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Caccia S, Suffritti C, Cicardi M. Pathophysiology of Hereditary Angioedema. PEDIATRIC ALLERGY, IMMUNOLOGY, AND PULMONOLOGY 2014; 27:159-163. [PMID: 25538858 PMCID: PMC4268578 DOI: 10.1089/ped.2014.0425] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2014] [Accepted: 10/10/2014] [Indexed: 02/05/2023]
Abstract
The genetic deficiency of the C1 inhibitor is responsible for hereditary angioedema (HAE), which is a disease transmitted as an autosomal dominant trait. More than 200 point mutations in the C1 inhibitor gene have been found to be associated with HAE. Patients with this disease suffer from recurrent angioedema, which is mediated by bradykinin derived from activation of the contact system. This system is physiologically controlled at several steps by the C1 inhibitor. In this review, we describe known mechanisms for the development of angioedema in patients with C1 inhibitor deficiency.
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Affiliation(s)
- Sonia Caccia
- Department of Biotechnologies and Translational Medicine, University of Milan, Milan, Italy
| | - Chiara Suffritti
- Department of Biomedical and Clinical Sciences L.Sacco, University of Milan, Milan, Italy
| | - Marco Cicardi
- Department of Biomedical and Clinical Sciences L.Sacco, University of Milan, Milan, Italy
- Department of Medicine, Luigi Sacco Hospital, Milan, Italy
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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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Cicardi M, Aberer W, Banerji A, Bas M, Bernstein JA, Bork K, Caballero T, Farkas H, Grumach A, Kaplan AP, Riedl MA, Triggiani M, Zanichelli A, Zuraw B. Classification, diagnosis, and approach to treatment for angioedema: consensus report from the Hereditary Angioedema International Working Group. Allergy 2014; 69:602-16. [PMID: 24673465 DOI: 10.1111/all.12380] [Citation(s) in RCA: 408] [Impact Index Per Article: 40.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/21/2014] [Indexed: 01/13/2023]
Abstract
Angioedema is defined as localized and self-limiting edema of the subcutaneous and submucosal tissue, due to a temporary increase in vascular permeability caused by the release of vasoactive mediator(s). When angioedema recurs without significant wheals, the patient should be diagnosed to have angioedema as a distinct disease. In the absence of accepted classification, different types of angioedema are not uniquely identified. For this reason, the European Academy of Allergy and Clinical Immunology gave its patronage to a consensus conference aimed at classifying angioedema. Four types of acquired and three types of hereditary angioedema were identified as separate forms from the analysis of the literature and were presented in detail at the meeting. Here, we summarize the analysis of the data and the resulting classification of angioedema.
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Affiliation(s)
- M. Cicardi
- Department of Biomedical and Clinical Sciences Luigi Sacco; University of Milan; Luigi Sacco Hospital Milan; Milan Italy
| | - W. Aberer
- Department of Dermatology; Medical University of Graz; Graz Austria
| | - A. Banerji
- Division of Rheumatology, Allergy and Immunology; Massachusetts General Hospital; Boston MA USA
| | - M. Bas
- Department of Otorhinolaryngology; Klinikum rechts der Isar; Technische Universität München; Munich Germany
| | - J. A. Bernstein
- Division of Immunology/Allergy Section; Department of Internal Medicine; University of Cincinnati College of Medicine; Cincinnati OH USA
| | - K. Bork
- Department of Dermatology; Johannes Gutenberg University; Mainz Germany
| | - T. Caballero
- Department of Allergy; Hospital La Paz Institute for Health Research (IdiPaz); Biomedical Research Network on Rare Diseases-U754 (CIBERER); Madrid Spain
| | - H. Farkas
- 3rd Department of Internal Medicine; National Angioedema Center; Semmelweis University; Budapest Hungary
| | - A. Grumach
- Department of Clinical Medicine; Faculty of Medicine ABC; Sao Paulo Brazil
| | - A. P. Kaplan
- Medical University of South Carolina; Charleston SC
| | - M. A. Riedl
- Division of Rheumatology, Allergy and Immunology; Department of Medicine; University of California - San Diego; La Jolla CA USA
| | - M. Triggiani
- Department of Medicine; University of Salerno; Salerno Italy
| | - A. Zanichelli
- Department of Biomedical and Clinical Sciences Luigi Sacco; University of Milan; Luigi Sacco Hospital Milan; Milan Italy
| | - B. Zuraw
- Division of Rheumatology, Allergy and Immunology; Department of Medicine; University of California - San Diego; La Jolla CA USA
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Hemperly SE, Agarwal NS, Xu YY, Zhi YX, Craig TJ. Recent advances in the management of hereditary angioedema. J Osteopath Med 2014; 113:546-55. [PMID: 23843378 DOI: 10.7556/jaoa.2013.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Hereditary angioedema (HAE) is a rare genetic condition that manifests as painful and potentially life-threatening episodic attacks of cutaneous and submucosal swelling. It results from functional deficiency of C1 inhibitor (C1 INH), which is a regulator of the complement, fibrinolytic, kinin (contact), and coagulation systems. In patients with HAE, the low plasma concentration of functional C1 INH leads to overactivation of the kinin cascade and local release of bradykinin. Bradykinin is responsible for the pain, vascular permeability changes, and edema associated with HAE. Until recently, therapeutic options for HAE have been very limited. Many new therapies have emerged, however, such as C1 INH replacement drugs and medications aimed at components of the contact system (eg, plasma kallikrein inhibitor and bradykinin B2 receptor antagonist). The authors review current and novel treatments for patients with HAE.
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Affiliation(s)
- Stephen E Hemperly
- Department of Medicine, Lehigh Valley Health Network, Allentown, Pennsylvania, USA
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Zuraw BL, Bernstein JA, Lang DM, Craig T, Dreyfus D, Hsieh F, Khan D, Sheikh J, Weldon D, Bernstein DI, Blessing-Moore J, Cox L, Nicklas RA, Oppenheimer J, Portnoy JM, Randolph CR, Schuller DE, Spector SL, Tilles SA, Wallace D. A focused parameter update: Hereditary angioedema, acquired C1 inhibitor deficiency, and angiotensin-converting enzyme inhibitor–associated angioedema. J Allergy Clin Immunol 2013; 131:1491-3. [DOI: 10.1016/j.jaci.2013.03.034] [Citation(s) in RCA: 127] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2012] [Revised: 03/11/2013] [Accepted: 03/14/2013] [Indexed: 11/26/2022]
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Joseph K, Tholanikunnel BG, Bygum A, Ghebrehiwet B, Kaplan AP. Factor XII-independent activation of the bradykinin-forming cascade: Implications for the pathogenesis of hereditary angioedema types I and II. J Allergy Clin Immunol 2013; 132:470-5. [PMID: 23672780 DOI: 10.1016/j.jaci.2013.03.026] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2013] [Revised: 03/04/2013] [Accepted: 03/14/2013] [Indexed: 11/19/2022]
Abstract
BACKGROUND We have previously reported that prekallikrein expresses an active site when it is bound to high-molecular-weight kininogen (HK) and can digest HK to produce bradykinin. The reaction is stoichiometric and inhibited by C1 inhibitor (C1-INH) or corn trypsin inhibitor. Addition of heat shock protein 90 leads to conversion of prekallikrein to kallikrein in a zinc-dependent reaction. OBJECTIVE Our goal was to determine whether these reactions are demonstrable in plasma and distinguish them from activation through factor XII. METHODS Plasma was incubated in polystyrene plates and assayed for kallikrein formation. C1-INH was removed from factor XII-deficient plasma by means of immunoadsorption. RESULTS We demonstrate that prekallikrein-HK will activate to kallikrein in phosphate-containing buffers and that the rate is further accelerated on addition of heat shock protein 90. Prolonged incubation of plasma deficient in both factor XII and C1-INH led to conversion of prekallikrein to kallikrein and cleavage of HK, as was seen in plasma from patients with hereditary angioedema but not plasma from healthy subjects. CONCLUSIONS These results indicate that C1-INH stabilizes the prekallikrein-HK complex to prevent HK cleavage either by prekallikrein or by prekallikrein-HK autoactivation to generate kallikrein. In patients with hereditary angioedema, kallikrein and bradykinin formation can occur without invoking factor XII activation, although the kallikrein formed can rapidly activate factor XII if it is surface bound.
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Affiliation(s)
- Kusumam Joseph
- Department of Biochemistry and Molecular Biology, Medical University of South Carolina, Charleston, SC 29425, USA.
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