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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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Casanova JL, Abel L. Lethal Infectious Diseases as Inborn Errors of Immunity: Toward a Synthesis of the Germ and Genetic Theories. ANNUAL REVIEW OF PATHOLOGY 2021; 16:23-50. [PMID: 32289233 PMCID: PMC7923385 DOI: 10.1146/annurev-pathol-031920-101429] [Citation(s) in RCA: 67] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
It was first demonstrated in the late nineteenth century that human deaths from fever were typically due to infections. As the germ theory gained ground, it replaced the old, unproven theory that deaths from fever reflected a weak personal or even familial constitution. A new enigma emerged at the turn of the twentieth century, when it became apparent that only a small proportion of infected individuals die from primary infections with almost any given microbe. Classical genetics studies gradually revealed that severe infectious diseases could be driven by human genetic predisposition. This idea gained ground with the support of molecular genetics, in three successive, overlapping steps. First, many rare inborn errors of immunity were shown, from 1985 onward, to underlie multiple, recurrent infections with Mendelian inheritance. Second, a handful of rare and familial infections, also segregating as Mendelian traits but striking humans resistant to other infections, were deciphered molecularly beginning in 1996. Third, from 2007 onward, a growing number of rare or common sporadicinfections were shown to result from monogenic, but not Mendelian, inborn errors. A synthesis of the hitherto mutually exclusive germ and genetic theories is now in view.
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Affiliation(s)
- Jean-Laurent Casanova
- St. Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller Branch, The Rockefeller University, New York, NY 10065, USA;
- Howard Hughes Medical Institute, New York, NY 10065, USA
- Laboratory of Human Genetics of Infectious Diseases, Necker Branch, INSERM U1163, Necker Hospital for Sick Children, 75015 Paris, France
- Paris University, Imagine Institute, 75015 Paris, France
- Pediatric Hematology-Immunology Unit, Necker Hospital for Sick Children, 75015 Paris, France
| | - Laurent Abel
- St. Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller Branch, The Rockefeller University, New York, NY 10065, USA;
- Laboratory of Human Genetics of Infectious Diseases, Necker Branch, INSERM U1163, Necker Hospital for Sick Children, 75015 Paris, France
- Paris University, Imagine Institute, 75015 Paris, France
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Willems E, Lorés-Motta L, Zanichelli A, Suffritti C, van der Flier M, van der Molen RG, Langereis JD, van Drongelen J, van den Heuvel LP, Volokhina E, van de Kar NC, Keizer-Garritsen J, Levin M, Herberg JA, Martinon-Torres F, Wessels HJ, de Breuk A, Fauser S, Hoyng CB, den Hollander AI, de Groot R, van Gool AJ, Gloerich J, de Jonge MI. Quantitative multiplex profiling of the complement system to diagnose complement-mediated diseases. Clin Transl Immunology 2020; 9:e1225. [PMID: 33318796 PMCID: PMC7724921 DOI: 10.1002/cti2.1225] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 11/16/2020] [Accepted: 11/16/2020] [Indexed: 02/06/2023] Open
Abstract
Objectives Complement deficiencies are difficult to diagnose because of the variability of symptoms and the complexity of the diagnostic process. Here, we applied a novel ‘complementomics’ approach to study the impact of various complement deficiencies on circulating complement levels. Methods Using a quantitative multiplex mass spectrometry assay, we analysed 44 peptides to profile 34 complement proteins simultaneously in 40 healthy controls and 83 individuals with a diagnosed deficiency or a potential pathogenic variant in 14 different complement proteins. Results Apart from confirming near or total absence of the respective protein in plasma of complement‐deficient patients, this mass spectrometry‐based profiling method led to the identification of additional deficiencies. In many cases, partial depletion of the pathway up‐ and/or downstream of the absent protein was measured. This was especially found in patients deficient for complement inhibitors, such as angioedema patients with a C1‐inhibitor deficiency. The added value of complementomics was shown in three patients with poorly defined complement deficiencies. Conclusion Our study shows the potential clinical utility of profiling circulating complement proteins as a comprehensive read‐out of various complement deficiencies. Particularly, our approach provides insight into the intricate interplay between complement proteins due to functional coupling, which contributes to the better understanding of the various disease phenotypes and improvement of care for patients with complement‐mediated diseases.
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Affiliation(s)
- Esther Willems
- Laboratory of Medical Immunology Department of Laboratory Medicine Radboud Institute for Molecular Life Sciences Radboud University Medical Center Nijmegen The Netherlands.,Radboud Center for Infectious Diseases Radboud University Medical Center Nijmegen The Netherlands.,Translational Metabolic Laboratory Department of Laboratory Medicine Radboud Institute for Molecular Life Sciences Radboud University Medical Center Nijmegen The Netherlands
| | - Laura Lorés-Motta
- Department of Ophthalmology Donders Institute for Brain Cognition and Behaviour Radboud University Medical Center Nijmegen The Netherlands
| | - Andrea Zanichelli
- Department of Biomedical and Clinical Sciences Luigi Sacco ASST Fatebenefratelli Sacco University of Milan Milan Italy
| | - Chiara Suffritti
- Department of Biomedical and Clinical Sciences Luigi Sacco ASST Fatebenefratelli Sacco University of Milan Milan Italy
| | - Michiel van der Flier
- Laboratory of Medical Immunology Department of Laboratory Medicine Radboud Institute for Molecular Life Sciences Radboud University Medical Center Nijmegen The Netherlands.,Radboud Center for Infectious Diseases Radboud University Medical Center Nijmegen The Netherlands.,Department of Pediatrics University Medical Center Utrecht Utrecht The Netherlands.,Amalia Children's Hospital Radboud University Medical Center Nijmegen The Netherlands
| | - Renate G van der Molen
- Laboratory of Medical Immunology Department of Laboratory Medicine Radboud Institute for Molecular Life Sciences Radboud University Medical Center Nijmegen The Netherlands
| | - Jeroen D Langereis
- Laboratory of Medical Immunology Department of Laboratory Medicine Radboud Institute for Molecular Life Sciences Radboud University Medical Center Nijmegen The Netherlands
| | - Joris van Drongelen
- Department of Obstetrics and Gynecology Radboud University Medical Center Nijmegen The Netherlands
| | - Lambert P van den Heuvel
- Translational Metabolic Laboratory Department of Laboratory Medicine Radboud Institute for Molecular Life Sciences Radboud University Medical Center Nijmegen The Netherlands.,Amalia Children's Hospital Radboud University Medical Center Nijmegen The Netherlands
| | - Elena Volokhina
- Translational Metabolic Laboratory Department of Laboratory Medicine Radboud Institute for Molecular Life Sciences Radboud University Medical Center Nijmegen The Netherlands.,Amalia Children's Hospital Radboud University Medical Center Nijmegen The Netherlands
| | - Nicole Caj van de Kar
- Amalia Children's Hospital Radboud University Medical Center Nijmegen The Netherlands
| | - Jenneke Keizer-Garritsen
- Translational Metabolic Laboratory Department of Laboratory Medicine Radboud Institute for Molecular Life Sciences Radboud University Medical Center Nijmegen The Netherlands
| | - Michael Levin
- Department of Medicine Section for Paediatrics Imperial College London London UK
| | - Jethro A Herberg
- Department of Medicine Section for Paediatrics Imperial College London London UK
| | - Federico Martinon-Torres
- Translational Pediatrics and Infectious Diseases Instituto de Investigación Sanitaria de Santiago Hospital Clínico Universitario de Santiago Santiago de Compostela Spain
| | - Hans Jtc Wessels
- Translational Metabolic Laboratory Department of Laboratory Medicine Radboud Institute for Molecular Life Sciences Radboud University Medical Center Nijmegen The Netherlands
| | - Anita de Breuk
- Department of Ophthalmology Donders Institute for Brain Cognition and Behaviour Radboud University Medical Center Nijmegen The Netherlands
| | - Sascha Fauser
- Department of Ophthalmology University Hospital Cologne Koln Germany.,F. Hoffmann - La Roche AG Basel Switzerland
| | - Carel B Hoyng
- Department of Ophthalmology Donders Institute for Brain Cognition and Behaviour Radboud University Medical Center Nijmegen The Netherlands
| | - Anneke I den Hollander
- Department of Ophthalmology Donders Institute for Brain Cognition and Behaviour Radboud University Medical Center Nijmegen The Netherlands
| | - Ronald de Groot
- Laboratory of Medical Immunology Department of Laboratory Medicine Radboud Institute for Molecular Life Sciences Radboud University Medical Center Nijmegen The Netherlands.,Radboud Center for Infectious Diseases Radboud University Medical Center Nijmegen The Netherlands
| | - Alain J van Gool
- Translational Metabolic Laboratory Department of Laboratory Medicine Radboud Institute for Molecular Life Sciences Radboud University Medical Center Nijmegen The Netherlands
| | - Jolein Gloerich
- Translational Metabolic Laboratory Department of Laboratory Medicine Radboud Institute for Molecular Life Sciences Radboud University Medical Center Nijmegen The Netherlands
| | - Marien I de Jonge
- Laboratory of Medical Immunology Department of Laboratory Medicine Radboud Institute for Molecular Life Sciences Radboud University Medical Center Nijmegen The Netherlands.,Radboud Center for Infectious Diseases Radboud University Medical Center Nijmegen The Netherlands
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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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Joseph K, Bains S, Tholanikunnel BG, Bygum A, Aabom A, Koch C, Farkas H, Varga L, Ghebrehiwet B, Kaplan AP. A novel assay to diagnose hereditary angioedema utilizing inhibition of bradykinin-forming enzymes. Allergy 2015; 70:115-9. [PMID: 25186184 DOI: 10.1111/all.12520] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/28/2014] [Indexed: 12/01/2022]
Abstract
BACKGROUND Hereditary angioedema types I and II are caused by a functional deficiency of C1 inhibitor (C1-INH), leading to overproduction of bradykinin. The current functional diagnostic assays employ inhibition of activated C1s; however, an alternative, more physiologic method is desirable. METHODS ELISAs were developed using biotinylated activated factor XII (factor XIIa) or biotinylated kallikrein bound to avidin-coated plates. Incubation with plasma was followed by detection of bound C1-INH. RESULTS After standard curves were developed for quantification of C1-INH, serial dilutions of normal plasma were employed to validate the ability to detect known concentration of C1-INH in the plasma as a percent of normal. Hereditary angioedema (HAE) types I and II were then tested. The level of functional C1-INH in all HAE types I and II plasma tested was less than 40% of our normal control. This was evident regardless of whether we measured factor XIIa-C1-INH or kallikrein-C1-INH complexes, and the two assays were in close agreement. By contrast, testing the same samples utilizing the commercial method (complex ELISA, Quidel Corp.) revealed the levels of C1-INH between 0 and 57% of normal (mean, 38%), and 42 samples were considered equivocal (four controls and 38 patients). CONCLUSIONS Diagnosis of HAE types I and II can be ascertained by inhibition of enzymes of the bradykinin-forming cascade, namely factor XIIa and kallikrein. Either method yields functional C1-INH levels in patients with HAE (types I and II) that are clearly abnormal with less variance or uncertainty than the commercial method.
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Affiliation(s)
- K. Joseph
- Medical university of South Carolina; Charleston SC USA
| | - S. Bains
- Medical university of South Carolina; Charleston SC USA
| | | | - A. Bygum
- University of Southern Denmark and OPEN Odense Patient data Explorative Network; Odense University Hospital; Odense Denmark
| | - A. Aabom
- University of Southern Denmark and OPEN Odense Patient data Explorative Network; Odense University Hospital; Odense Denmark
| | - C. Koch
- University of Southern Denmark and OPEN Odense Patient data Explorative Network; Odense University Hospital; Odense Denmark
| | - H. Farkas
- 3rd Department of Internal Medicine; National Angioedema Center; Semmelweis University; Budapest Hungary
| | - L. Varga
- 3rd Department of Internal Medicine; National Angioedema Center; Semmelweis University; Budapest Hungary
| | | | - A. P. Kaplan
- Medical university of South Carolina; Charleston SC USA
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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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Bhardwaj N, Craig TJ. Treatment of hereditary angioedema: a review (CME). Transfusion 2014; 54:2989-96; quiz 2988. [PMID: 24735226 DOI: 10.1111/trf.12674] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2014] [Revised: 02/28/2014] [Accepted: 03/03/2014] [Indexed: 01/25/2023]
Abstract
Hereditary angioedema (HAE) is a rare autosomal dominant disorder characterized by recurrent attacks of self-limiting tissue swelling. The management of HAE has transformed dramatically with recently approved therapies in the United States. However, there is lack of awareness among physicians about these new modalities. The aim of this review is to update the practicing physician about various therapeutic options available for HAE patients. An exhaustive literature search of PubMed and OVID was performed to develop this article. Management of HAE is traditionally classified into treatment of acute attacks or on-demand therapy, short-term (preprocedural) prophylaxis, and long-term prophylaxis. Newer therapies include C1 esterase inhibitor (C1-INH) and contact system modulators, namely, ecallantide and icatibant. Recombinant C1-INH, which is available in Europe, is awaiting approval in the United States. C1-INH concentrate is approved for prophylaxis as well as on-demand therapy while ecallantide and icatibant are approved for acute treatment only. Effective HAE management further includes patient education, reliable access to specific medications, and regular follow-up to monitor therapeutic response and safety.
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Affiliation(s)
- Neeti Bhardwaj
- Division of Pediatric Allergy and Immunology, Department of Pediatrics, Pennsylvania State University, Milton S. Hershey Medical Center, Hershey, Pennsylvania
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Joseph K, Tuscano TB, Kaplan AP. Studies of the mechanisms of bradykinin generation in hereditary angioedema plasma. Ann Allergy Asthma Immunol 2008; 101:279-86. [DOI: 10.1016/s1081-1206(10)60493-0] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
I have spent my entire professional life at Harvard Medical School, beginning as a medical student. I have enjoyed each day of a diverse career in four medical subspecialties while following the same triad of preclinical areas of investigation—cysteinyl leukotrienes, mast cells, and complement—with occasional translational opportunities. I did not envision a career with a predominant preclinical component. Such a path simply evolved because I chose instinctively at multiple junctures to follow what proved to be propitious opportunities. My commentary notes some of the highlights for each area of interest and the mentors, collaborators, and trainees whose counsel has been immensely important at particular intervals or over an extended period.
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Affiliation(s)
- K Frank Austen
- Department of Medicine, Harvard Medical School, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, Massachusetts 02115, USA.
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Davis AE. Mechanism of angioedema in first complement component inhibitor deficiency. Immunol Allergy Clin North Am 2007; 26:633-51. [PMID: 17085282 DOI: 10.1016/j.iac.2006.08.003] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Since shortly after the discovery that hereditary angioedema resulted from deficiency of first complement component (C1) inhibitor, the characterization of the mediator of angioedema has been a major goal. However, because C1 inhibitor regulates activation of both the contract and complement systems, identification of the mediator was not immediately accomplished. For a number of years, some studies appeared to indicate involvement of one system, whereas other studies suggested involvement of the other. However, the vast majority of the evidence accumulated over the past years indicates quite clearly that the major mediator is bradykinin. Therefore, unregulated contact system activation is the defect that leads directly to the development of angioedema.
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Affiliation(s)
- Alvin E Davis
- CBR Institute for Biomedical Research, Harvard Medical School, Boston, MA 02115, USA.
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Austen KF, Russell PS. DETECTION OF RENAL ALLOGRAFT REJECTION IN MAN BY DEMONSTRATION OF A REDUCTION IN THE SERUM CONCENTRATION OF THE SECOND COMPONENT OF COMPLEMENT*. Ann N Y Acad Sci 2006. [DOI: 10.1111/j.1749-6632.1966.tb12886.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Ueno A, Oh-ishi S. Roles for the kallikrein-kinin system in inflammatory exudation and pain: lessons from studies on kininogen-deficient rats. J Pharmacol Sci 2004; 93:1-20. [PMID: 14501145 DOI: 10.1254/jphs.93.1] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
Roles for the kallikrein-kinin system in inflammation have been investigated extensively, and many reviews on this topic have been published during the 50 years since the discovery of bradykinin in 1949. Recent progress in the field has been remarkable with the help of experiments using gene-targetted transgenic or knockout mice, which have added further valuable information in addition to previous results obtained from pharmacological and biochemical studies using purified and isolated components of the system. Furthermore, much knowledge has been accumulated as a result of the development of various bradykinin agonists and antagonists. In this review, we focused on the data obtained from the kininogen-deficient rat, which is a natural mutant, and discuss the results in comparison with those from bradykinin receptor knockout mice. These data have clarified that endogenous bradykinin exerts a most important role in inflammatory exudation along with prostanoids, preferentially to histamine, serotonin, or neuropeptides. In inflammatory pain perception also, bradykinin produced in the local perivascular spaces stimulates polymodal pain receptors in conjunction with co-helpers such as prostanoids, vanilloids, and neuropeptides. These important roles are concluded based on consistent results obtained from experiments using several antagonists of bradykinin, kininogen-deficient rats, and bradykinin receptor knockout mice.
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Affiliation(s)
- Akinori Ueno
- Department of Pharmacology, School of Pharmaceutical Sciences, Kitasato University, Tokyo, Japan
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Kaplan AP, Joseph K, Silverberg M. Pathways for bradykinin formation and inflammatory disease. J Allergy Clin Immunol 2002; 109:195-209. [PMID: 11842287 DOI: 10.1067/mai.2002.121316] [Citation(s) in RCA: 207] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Bradykinin is formed by the interaction of factor XII, prekallikrein, and high-molecular-weight kininogen on negatively charged inorganic surfaces (silicates, urate, and pyrophosphate) or macromolecular organic surfaces (heparin, other mucopolysaccharides, and sulfatides) or on assembly along the surface of cells. Catalysis along the cell surface requires zinc-dependent binding of factor XII and high-molecular-weight kininogen to proteins, such as the receptor for the globular heads of the C1q subcomponent of complement, cytokeratin 1, and urokinase plasminogen activator receptor. These 3 proteins complex together within the cell membrane, and initiation depends on autoactivation of factor XII on binding to gC1qR (the receptor for the globular heads of the C1q subcomponent of complement). There is also a factor XII-independent bypass mechanism requiring a cell-derived cofactor or protease that activates prekallikrein. Bradykinin is degraded by carboxypeptidase N and angiotensin-converting enzyme. Angioedema that is bradykinin dependent results from hereditary or acquired C1 inhibitor deficiencies or use of angiotensin-converting enzyme inhibitors to treat hypertension, heart failure, diabetes, or scleroderma. The role for bradykinin in allergic rhinitis, asthma, and anaphylaxis is to contribute to tissue hyperresponsiveness, local inflammation, and hypotension. Activation of the plasma cascade occurs as a result of heparin release and endothelial-cell activation and as a secondary event caused by other pathways of inflammation.
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Affiliation(s)
- Allen P Kaplan
- Department of Medicine, Medical University of South Carolina, 29425, USA
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Choi-Miura NH, Saito K, Takahashi K, Yoda M, Tomita M. Regulation mechanism of the serine protease activity of plasma hyaluronan binding protein. Biol Pharm Bull 2001; 24:221-5. [PMID: 11256474 DOI: 10.1248/bpb.24.221] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The inhibitor for the serine protease activity of plasma hyaluronan binding protein (PHBP) was purified from human plasma by polyethylene glycol (PEG) fractionation, diethylaminoethyl (DEAE)-Sephacel ion-exchange chromatography, Phenyl Toyopearl 650M hydrophobic chromatography, Bio Gel A-0.5 m gel-filtration and hydroxyapatite chromatography. The serine protease activity of PHBP was measured with Boc-Phe-Ser-Arg-methylcoumarine amide (MCA) as the synthetic substrate of PHBP. The results of the amino acid sequence analyses of the purified PHBP inhibitor indicated that it was C1 inhibitor of the serpin family. C1 inhibitor formed a complex with PHBP, suggesting that it is the actual inhibitor of PHBP in human plasma. On the other hand, dextran sulfate and phosphatidylethanolamine enhanced the auto-fragmentation and the serine protease activity of pro-PHBP, but kaolin did not. These results suggested that the serine protease activity of PHBP was regulated in a similar manner to that of factor XII of the coagulation system.
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Affiliation(s)
- N H Choi-Miura
- Department of Physiological Chemistry, School ol Pharmaceutical Sciences, Showa University, Tokyo, Japan.
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Abstract
BACKGROUND Hereditary angioedema results from a congenital deficiency of functional C1 inhibitor and is characterized by episodic bouts of edema, which may be life-threatening when they involve the larynx. We evaluated the effectiveness of a C1 inhibitor concentrate in the prevention and treatment of attacks of hereditary angioedema. The concentrate was vapor-heated to inactivate hepatitis and human immunodeficiency viruses. METHODS We conducted two double-blind, placebo-controlled studies. The first was a crossover study consisting of two 17-day trials in which prophylactic infusions of either C1 inhibitor (25 plasma units per kilogram of body weight) or placebo were given intravenously every third day to six patients with hereditary angioedema. The second study was conducted in patients with acute attacks of hereditary angioedema and assessed the length of time to a clinical response after infusions of either 25 plasma units of C1 inhibitor per kilogram (55 infusions in 11 patients) or placebo (49 infusions in 11 patients). RESULTS The infusions of C1 inhibitor concentrate resulted in close to normal functional levels of C1 inhibitor and C4. As compared with placebo, prophylactic infusions of C1 inhibitor resulted in significantly lower daily symptom scores for the severity of edema of the extremities (P<0.01), larynx (P<0.05), abdomen (P<0.05), and genitourinary tract (P<0.05). Likewise, during the treatment study the time from the start of an infusion to the beginning of improvement in symptoms was shorter for the C1 inhibitor infusions than the placebo infusions (55 vs. 563 minutes, P<0.001). There was no evidence of toxicity. CONCLUSIONS Infusions of a vapor-heated C1 inhibitor concentrate are a safe and effective means of both preventing attacks of hereditary angioedema and treating acute attacks.
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Affiliation(s)
- A T Waytes
- Laboratory of Clinical Investigation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md, USA
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Zuraw BL. Cl INHIBITOR DEFICIENCY AND AUTOIMMUNITY. Immunol Allergy Clin North Am 1993. [DOI: 10.1016/s0889-8561(22)00169-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
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Review. Clin Chem Lab Med 1992. [DOI: 10.1515/cclm.1992.30.12.793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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23
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Patston PA, Roodi N, Schifferli JA, Bischoff R, Courtney M, Schapira M. Reactivity of alpha 1-antitrypsin mutants against proteolytic enzymes of the kallikrein-kinin, complement, and fibrinolytic systems. J Biol Chem 1990. [DOI: 10.1016/s0021-9258(18)87016-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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24
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Cugno M, Nuijens J, Hack E, Eerenberg A, Frangi D, Agostoni A, Cicardi M. Plasma levels of C1- inhibitor complexes and cleaved C1- inhibitor in patients with hereditary angioneurotic edema. J Clin Invest 1990; 85:1215-20. [PMID: 2318974 PMCID: PMC296554 DOI: 10.1172/jci114555] [Citation(s) in RCA: 50] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
C1- inhibitor (C1(-)-Inh) catabolism in plasma of patients with hereditary angioneurotic edema (HANE) was assessed by measuring the complexes formed by C1(-)-Inh with its target proteases (C1-s, Factor XIIa, and kallikrein) and a modified (cleaved) inactive form of C1(-)-Inh (iC1(-)-Inh). This study was performed in plasma from 18 healthy subjects and 30 patients with HANE in remission: 20 with low antigen concentration (type I) and 10 (from 5 different kindreds) with dysfunctional protein (type II). Both type-I and type-II patients had increased C1(-)-C1(-)-Inh complexes (P less than 0.0001), which in type I inversely correlated with the levels of C1(-)-Inh (P less than 0.001). iC1(-)-Inh was normal in all type-I patients and in type-II patients from three families with increased C1(-)-Inh antigen, whereas iC1(-)-Inh was higher than 20 times the normal values in patients from the remaining two families with C1(-)-Inh antigen in the normal range. None of the subjects had an increase of either Factor XIIa-C1(-)-Inh or kallikrein-C1(-)-Inh complexes. This study shows that the hypercatabolism of C1(-)-Inh in HANE patients at least in part occurs via the formation of complexes with C1- and that genetically determined differences in catabolism of dysfunctional C1(-)-Inh proteins are present in type-II patients.
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Affiliation(s)
- M Cugno
- Cattedra di Clinica Medica Università di Milano, Ospedale S. Paolo, Italy
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Skriver K, Radziejewska E, Silbermann JA, Donaldson VH, Bock SC. CpG Mutations in the Reactive Site of Human C1¯ Inhibitor. J Biol Chem 1989. [DOI: 10.1016/s0021-9258(18)94031-7] [Citation(s) in RCA: 61] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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26
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Strang CJ, Cholin S, Spragg J, Davis AE, Schneeberger EE, Donaldson VH, Rosen FS. Angioedema induced by a peptide derived from complement component C2. J Exp Med 1988; 168:1685-98. [PMID: 2972793 PMCID: PMC2189099 DOI: 10.1084/jem.168.5.1685] [Citation(s) in RCA: 51] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Synthetic peptides that correspond to the COOH-terminal portion of C2b enhance vascular permeability in human and guinea pig skin. In human studies, 1 nmol of the most active peptide of 25-amino acid residues produced substantial local edema. A pentapeptide and a heptapeptide corresponding to the COOH-terminal sequence of C2b each induced contraction of estrous rat uterus in the micromole range; a peptide of 25 amino acids from this region induced a like contraction of rat uterus at a concentration 20-fold lower than the smaller peptides. The vascular permeability of guinea pig skin was enhanced by doses of these synthetic peptides in a similar fashion as that observed for the concentration of rat uterus. The induction of localized edema by intradermal injection in both the guinea pig and the human proceeds in the presence of antihistaminic drugs, suggesting that there is a histamine-independent component to the observed increase in vascular permeability. Cleavage of C2 with the enzymic subcomponent of C1, C1s, yields only C2a and C2b, and no small peptides, whereas cleavage of C2 with C1s and plasmin yields a set of small peptides. These plasmin-cleaved peptides are derived from the COOH terminus of C2b, and they induce the contraction of estrous rat uterus.
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Affiliation(s)
- C J Strang
- Children's Hospital, Boston, Massachusetts
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27
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Schapira M, Silver LD, Scott CF, Schmaier AH, Prograis LJ, Curd JG, Colman RW. Prekallikrein activation and high-molecular-weight kininogen consumption in hereditary angioedema. N Engl J Med 1983; 308:1050-3. [PMID: 6601240 DOI: 10.1056/nejm198305053081802] [Citation(s) in RCA: 152] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Patients with hereditary angioedema lack C-1 inhibitor, a plasma alpha 2-glycoprotein that inhibits both the proteolytic action of C1, the activated first component of the complement system, and the activity of components of the contact phase of coagulation: kallikrein, factor XIa, and factor XIIa. Such patients have been shown to have low levels of C4 and C2, the natural substrates for C-1, but the levels were not correlated with the presence of symptoms. We studied three patients with angioedema for evidence of activation of the contact system and found that during a symptomatic period they had decreased levels of prekallikrein, a substrate for the activated forms of factor XII, and reductions in high-molecular-weight kininogen, a substrate for plasma kallikrein. These observations suggest that zymogens of the contact system are activated during attacks of hereditary angioedema and that some of the clinical manifestations may be mediated through products of this pathway, such as kinins.
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Ghebrehiwet B, Randazzo BP, Dunn JT, Silverberg M, Kaplan AP. Mechanisms of activation of the classical pathway of complement by Hageman factor fragment. J Clin Invest 1983; 71:1450-6. [PMID: 6304147 PMCID: PMC437009 DOI: 10.1172/jci110898] [Citation(s) in RCA: 162] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
The mechanism by which a fragment of activated Hageman factor (HFf) activates the classical pathway of complement in serum or platelet-poor plasma has been further delineated. When serum or platelet-poor plasma was incubated with various concentrations of HFf, the total complement hemolytic activity was reduced in a dose-dependent manner. This activation appears to be due to the direct interaction of HFf with macromolecular C1, since incubation of purified C1 with HFf resulted in dissociation of the subunits with concomitant reduction of C1r antigenicity that is indicative of C1 activation. HFf-dependent activation was prevented by prior treatment of HFf with the active site-directed inhibitor, H-D-proline-phenylalanine-arginine chloromethyl ketone or with a specific inhibitor of activated HF derived from corn. Incubation of HFf with highly purified C1r also resulted in activation of C1r as assessed directly using a synthetic substrate or indirectly by activation of C1s and consumption of C2. However, incubation of HFf with highly purified C1s resulted in formation of activated C1s (C1s-) but this was less efficient than HFf activation of C1r. We therefore conclude that activation of C1 in macromolecular C1 is the result of HFf conversion of C1r to C1r; activation of C1s then occurs primarily by C-1r and to a lesser degree by the direct action of HFf.
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29
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Massa MC, Connolly SM. An association between C1 esterase inhibitor deficiency and lupus erythematosus: report of two cases and review of the literature. J Am Acad Dermatol 1982; 7:255-64. [PMID: 7130485 DOI: 10.1016/s0190-9622(82)70115-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Two patients who had lupus erythematosus and C1 esterase inhibitor deficiency are described. The data on eleven previously reported cases are reviewed and summarized with those from our own cases. Early complement component depletion secondary to C1 esterase inhibitor deficiency may predispose to the development of lupuslike syndromes by impairing the ability of the organism to handle foreign antigen. Further study of this unique group of patients may provide insight into the pathogenesis of immune complex disease.
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Laurent J, Branellec A, Heslan JM, Lagrue G. Basophil count, a guideline to the treatment of hereditary angioneurotic edema. Lancet 1982; 2:157. [PMID: 6123866 DOI: 10.1016/s0140-6736(82)91122-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Epstein PA, Kidd KK. Dermo-distortive urticaria: an autosomal dominant dermatologic disorder. AMERICAN JOURNAL OF MEDICAL GENETICS 1981; 9:307-15. [PMID: 7294069 DOI: 10.1002/ajmg.1320090407] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
A new hereditary physical urticaria, dermo-distortive urticaria (DDU), is described in a Christian Lebanese family. DDU is characterized by the appearance of pruritic, erythematosus, edematous, cutaneous swelling confined to the stimulated area in response to stimuli that vibrate or stretch the skin in a repetitive manner. The lesions appear within several minutes after stimulation and disappear within an hour. Extensive stimulation causes not only local urticaria but also a systemic response of faintness, headache, and facial erythema. Other than these annoying reactions, no other morbidity is associated with this disorder. While this disorder is certainly uncommon and its manifestations are more annoying than life threatening, it may be an important example of a heritable defect of inflammation control mechanisms. Although the mediator for the urticaria and systemic response was not isolated, a likely candidate is histamine. Computer analysis of the phenotype of 219 relatives in 6 generations shows that DDU is transmitted as an autosomal dominant trait with high penetrance. DDU is clinically distinct from hereditary angioneurotic edema, pressure urticaria, and dermographia. It is similar to vibratory angioedema (VA), but sufficient evidence to prove that DDU and VA are identical is not available.
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Epstein PA, Kidd KK, Sparkes RS. Genetic linkage analysis of dermo-distortive urticaria. AMERICAN JOURNAL OF MEDICAL GENETICS 1981; 9:317-21. [PMID: 6945804 DOI: 10.1002/ajmg.1320090408] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
We have described a new hereditary physical urticaria, dermo-distortive urticaria (DDU) [1]. In an attempt to man the locus of this autosomal-dominant disorder and to further characterize it, a linkage analysis with 18 genetic markers was done. Close linkage of DDU with TCII, GALT, Gc, Fy, Kell, and Se was excluded. The most significant positive lod score was for the MNSs blood antigen system, which has a maximum lod score of 1.09 at theta = 0.24 for all 28 family members who were typed. Although close linkage with DDU is not demonstrated at any marker, this study illustrates how linkage analysis may prove to be of value in the characterization of newly discovered heritable disorders.
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Curd JG, Prograis LJ, Cochrane CG. Detection of active kallikrein in induced blister fluids of hereditary angioedema patients. J Exp Med 1980; 152:742-7. [PMID: 6902743 PMCID: PMC2185921 DOI: 10.1084/jem.152.3.742] [Citation(s) in RCA: 103] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Six suction-induced blister fluids obtained from five patients with hereditary angioedema (HAE) contained active kallikrein, whereas only two blister fluids obtained from eight normal volunteers contained small amounts of this activity. Kallikrein was present in large amounts of HAE blister fluids as assessed by its ability to liberate smooth-muscle-contracting activity from purified high molecular weight kininogen. It was inhibited by purified antibodies specific for plasma prekallikrein and also by purified C1 inhibitor, but not by antibodies specific for C1s. These observations suggest that activation of the Hageman-factor-dependent pathways occurs in the tissues of HAE patients, and once generated, active kallikrein persists in these tissues.
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Ziccardi RJ, Cooper NR. Development of an immunochemical test to assess C1 inactivator function in human serum and its use for the diagnosis of hereditary angioedema. CLINICAL IMMUNOLOGY AND IMMUNOPATHOLOGY 1980; 15:465-71. [PMID: 6768480 DOI: 10.1016/0090-1229(80)90058-6] [Citation(s) in RCA: 37] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Sheffer AL, Fearon DT, Austen KF, Rosen FS. Tranexamic acid: preoperative prophylactic therapy for patients with hereditary angioneurotic edema. J Allergy Clin Immunol 1977; 60:38-40. [PMID: 874207 DOI: 10.1016/0091-6749(77)90080-x] [Citation(s) in RCA: 40] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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38
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Rissin L. Hereditary angioneurotic edema: report of case. J Am Dent Assoc 1977; 94:723-5. [PMID: 265334 DOI: 10.14219/jada.archive.1977.0330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Willms K, Rosen FS, Donaldson VH. Observations on the ultrastructure of lesions induced in human and guinea pig skin by C 1 esterase and polypeptide from hereditary angioneurotic edema (HANE) plasma. CLINICAL IMMUNOLOGY AND IMMUNOPATHOLOGY 1975; 4:174-88. [PMID: 1139801 DOI: 10.1016/0090-1229(75)90053-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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40
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Kohler PF, Percy J, Campion WM, Smyth CJ. Hereditary angioedema and "familial" lupus erythematosus in identical twin boys. Am J Med 1974; 56:406-11. [PMID: 4544343 DOI: 10.1016/0002-9343(74)90623-8] [Citation(s) in RCA: 85] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Logue GL, Rosse WF, Adams JP. Mechanisms of immune lysis of red blood cells in vitro. I. Paroxysmal nocturnal hemoglobinuria cells. J Clin Invest 1973; 52:1129-37. [PMID: 4700488 PMCID: PMC302368 DOI: 10.1172/jci107279] [Citation(s) in RCA: 62] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
The effect of five different reactions which activate complement (antibody activation, reduction in ionic strength, acidification, cobra venom factor (CoF) activation, and inulin activation) upon normal and PNH cells was investigated, using normal serum and serum devoid of the fourth component of complement (C4) activity from patients with hereditary angioneurotic edema (HANE) as a source of complement. Both normal and HANE serum lysed paroxysmal nocturnal hemoglobinuria (PNH) cells when complement was activated by acidification, CoF and inulin, indicating that the terminal steps of complement were activated in the absence of C4, presumably by the alternate or properdin pathway. Normal but not HANE serum lysed cells coated with anti-I, indicating that complement was activated by the C1-dependent classic pathway. HANE serum partially supported lysis by serum at reduced ionic strength, indicating that the activation of terminal complement components had occurred through both of the pathways of activation. The amount of the third component of human complement (C3) which was bound to the membrane of lysed and unlysed cells by these procedures was determined by anti-C3 absorption and was found to differ for each method of complement activation. In general, more C3 was bound to lysed cells than to unlysed cells. For given conditions, more was bound to PNH cells than to normal cells. However, very much less bound C3 was required for lysis of the PNH cells than for lysis of normal cells. These two phenomena, especially the latter, account for the marked lysis of PNH cells when complement is activated. Normal cells treated with AET (aminoethylisothiouronium bromide) did not bind more C3 than untreated cells and the lysed cells had less bound C3 than lysed PNH cells.
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Kueppers F, Schulz KH. Hereditary angioedema. A report of three families. HUMANGENETIK 1972; 16:201-8. [PMID: 5082101 DOI: 10.1007/bf00273465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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46
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Hadjiyannaki K, Lachmann PJ. Hereditary angio-oedema: a review with particular reference to pathogenesis and treatment. CLINICAL ALLERGY 1971; 1:221-33. [PMID: 4274092 DOI: 10.1111/j.1365-2222.1971.tb03021.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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48
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49
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Abstract
Two patients with hereditary angioneurotic oedema, a condition characterized by repeated episodes of abdominal pain and oedema, and by an absence of complement-1 esterase inhibitor activity in the plasma are presented in detail. Both underwent multiple surgical procedures before the diagnosis was established. Abdominal pain is often the presenting complaint, and although a complete history will usually lead to the proper diagnosis, cases in which the family history is not clear can present a diagnostic dilemma. Characteristic radiological demonstration of localized intestinal oedema will only be obtained if studies are performed early during the acute attack.
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