Hageman factor, high molecular weight kininogen, and prekallikrein in chronic liver disease

Serum acute phase reactants hallmark healthy individuals at risk for acetaminophen-induced liver injury

Background

Acetaminophen (APAP) is a commonly used analgesic. However, its use is associated with drug-induced liver injury (DILI). It is a prominent cause of acute liver failure, with APAP hepatotoxicity far exceeding other causes of acute liver failure in the United States. In order to improve its safe use this study aimed to identify individuals at risk for DILI prior to drug treatment by searching for non-genetic serum markers in healthy subjects susceptible to APAP-induced liver injury (AILI).

Methods

Healthy volunteers (n = 36) received either placebo or acetaminophen at the maximum daily dose of 4 g for 7 days. Blood samples were taken prior to and after APAP treatment. Serum proteomic profiling was done by 2D SDS-PAGE and matrix-assisted laser desorption/ionization-time of flight-mass spectrometry. Additionally, the proteins C-reactive protein, haptoglobin and hemopexin were studied by quantitative immunoassays.

Results

One-third of study subjects presented more than four-fold increased alanine transaminase activity to evidence liver injury, while serum proteomics informed on 20 proteins as significantly regulated. These function primarily in acute phase and immune response. Pre-treatment associations included C-reactive protein, haptoglobin isoforms and retinol binding protein being up to six-fold higher in AILI susceptible individuals, whereas alpha1-antitrypsin, serum amyloid A, kininogen and transtyretin were regulated by nearly five-fold in AILI responders. When compared with published findings for steatohepatitis and cases of hepatocellular, cholestatic and mixed DILI, 10 proteins were identified as uniquely associated with risk for AILI, including plasminogen. Notably, this zymogen facilitates macrophage chemotactic migration and inflammatory response as reported for plasminogen-deficient mice shown to be resistant to APAP hepatotoxicity. Finally, analysis of a publicly available database of gene expression profiles of cultures of human hepatocytes treated with drugs labeled as no- (n = 8), low- (n = 45) or most-DILI-concern (n = 39) confirmed regulation of the identified biomarkers to demonstrate utility in predicting risk for liver injury.

Conclusions

The significant regulation of acute phase reactants points to an important link between AILI and the immune system. Monitoring of serum acute phase reactants prior to drug treatment may contribute to prevention and management of AILI, and may also be of utility for other drugs with known liver liabilities.

Plasma prekallikrein levels in patients with hepatocellular carcinoma and liver cirrhosis: a pilot study

The concentration of plasma prekallikrein (PK) in five patients with hepatocellular carcinoma (HCC) has been measured and related to levels in 18 patients with liver cirrhosis (LC) and 30 healthy subjects. It was found that the mean PK level was significantly increased in patients with HCC, while patients with LC demonstrated lower concentrations, as compared with healthy subjects. The results indicate that PK might be useful in screening cirrhotic patients for HCC. Longitudinal studies of PK in a larger group of patients at risk of developing HCC are therefore recommended.

Plasma prekallikrein as a prognostic indicator in chronic liver insufficiency

The prognostic value of plasma prekallikrein activity, prothrombin time, and serum albumin with regard to survival in chronic liver insufficiency was evaluated in 21 consecutive patients. Twenty patients had liver cirrhosis, and one patient had malignant liver disease (hepatocellular carcinoma). Eight patients died between 4 and 43 days after the time of blood sampling. These patients had a prekallikrein value less than 0.42. There were no overlapping prekallikrein values between patients who died and patients who survived (overlap index 0; p less than 0.001). Overlap index for prothrombin time was 0.35 (p less than 0.02), and for serum albumin 0.34 (p less than 0.02). In conclusion, plasma prekallikrein seems to indicate whether death is imminent in patients with liver insufficiency due to cirrhosis. Longitudinal studies of prekallikrein activity in different subgroups of patients with chronic and acute liver disease are recommended.

Interrelation between factor VII, prekallikrein, and hyperfibrinolysis in advanced cirrhosis

Factor VII and prekallikrein activities were studied in 37 patients with liver cirrhosis who were in a decompensated state. Sixteen of them died 30-70 days after admission; 21 survived and were discharged after 30-80 days. Seven who died and six survivors had signs of hyperfibrinolysis: factor VII activity differentiated the two groups independently of the presence of hyperfibrinolysis. The presence of hyperfibrinolysis significantly reduced prekallikrein activity, which did not differentiate clearly survivors from non-survivors. Long term follow up of survivors showed a good correlation between factor VII and prekallikrein activities with long term survival. Hyperfibrinolysis seemed to influence the clinical course of patients: 87% of patients with hyperfibrinolysis who died had fatal haemorrhagic episodes. Low factor VII activity may be a precursor of terminal liver insufficiency.

Postnatal development of prekallikrein (Fletcher factor) in man

The aim of the present study was to determine the concentration of plasma prekallikrein in healthy infants during the first year of life. Prekallikrein levels evaluated by a chromogenic substrate assay were low in the first 15 days of life and increased progressively from the third week of life, reaching normal adult values after the third month of life. The low levels of prekallikrein during the neonatal age reflect the impaired ability of liver cells to synthesize proteins.