Plasma factor XIII and some other haemostasis parameters in patients with diabetic angiopathy

Diabetes and atherothrombosis: The circadian rhythm and role of melatonin in vascular protection

Obesity-related euglycaemic insulin resistance clusters with cardiometabolic risk factors, contributing to the development of both type 2 diabetes and cardiovascular disease. An increased thrombotic tendency in diabetes stems from platelet hyperactivity, enhanced activity of prothrombotic coagulation factors and impaired fibrinolysis. Furthermore, a low-grade inflammatory response and increased oxidative stress accelerate the atherosclerotic process and, together with an enhanced thrombotic environment, result in premature and more severe cardiovascular disease. The disruption of circadian cycles in man secondary to chronic obesity and loss of circadian cues is implicated in the increased risk of developing diabetes and cardiovascular disease. Levels of melatonin, the endogenous synchronizer of circadian rhythm, are reduced in individuals with vascular disease and those with deranged glucose metabolism. The anti-inflammatory, antihypertensive, antioxidative and antithrombotic activities of melatonin make it a potential therapeutic agent to reduce the risk of vascular occlusive disease in diabetes. The mechanisms behind melatonin-associated reduction in procoagulant response are not fully known. Current evidence suggests that melatonin inhibits platelet aggregation and might affect the coagulation cascade, altering fibrin clot structure and/or resistance to fibrinolysis. Large-scale clinical trials are warranted to investigate the effects of modulating the circadian clock on insulin resistance, glycaemia and cardiovascular outcome.

Tocilizumab Effects on Coagulation Factor XIII in Patients with Rheumatoid Arthritis

Introduction

Rheumatoid arthritis (RA) is a chronic systemic auto-immune disease associated with a prothrombotic state. Tocilizumab, an interleukin-6 receptor inhibitor, is highly effective in controlling disease activity and thrombotic risk. Factor XIII (FXIII), involved in thrombotic complications, has been reported to be reduced in RA patients during maintenance treatment with tocilizumab, but no data are available before and after the drug administration. Thus, we investigated the effects of tocilizumab on FXIII, thrombin generation and inflammation in patients with RA naïve for the drug.

Methods

We studied 15 consecutive adult patients with RA at baseline and 4 weeks after the onset of parenteral administration of tocilizumab, measuring disease activity and plasma levels of C-reactive protein (CRP), FXIII, and prothrombin fragments F1+2 by immunoenzymatic methods. Fifteen healthy subjects, sex-and age-matched with patients, served as normal controls for laboratory measurements.

Results

At baseline, patients with established RA had a median DAS28 of 4.8 (3.2–8.3) and, compared to healthy controls, had higher plasma levels of CRP (p < 0.0001), FXIII (p = 0.017) and F1+2 (p < 0.0001). Four weeks after starting treatment with tocilizumab, based on the EULAR response criteria, eight patients were classifiable as responders and seven as non-responders. In responders, we observed a statistically significant reduction not only of the values of DAS28 and CRP (p = 0.012 for both), ut also of plasma levels of FXIII (p = 0.05) and F1+2 (p = 0.025). In non-responders, all the studied parameters were unchanged.

Conclusion

The decrease of FXIII and F1+2 levels after tocilizumab treatment observed only in those patients who responded to the drug indicates that the effect of tocilizumab on the prothrombotic state is linked to the control of inflammation and disease activity and not to a direct effect of the drug, thus contributing to the reduction of the cardiovascular risk.

Combined measurement of factor XIII and D-dimer is helpful for differential diagnosis in patients with suspected pulmonary embolism

BACKGROUND

D-dimer has been used to rule out pulmonary embolism (PE). Based on previous reports of decreased concentrations of coagulation factor XIII (FXIII) in venous thromboembolism, and no change in FXIII concentration in patients with acute cardiovascular disease, we evaluated the benefit of simultaneously measuring D-dimer and FXIII concentrations for diagnosing PE.

METHODS

In this prospective single-center study, we enrolled 209 patients initially suspected of having PE, and measured their D-dimer and FXIII concentrations. Forty-one patients were diagnosed with PE and 168 with other final diagnoses, including acute coronary syndrome (ACS); aortic dissection (AD); spontaneous pneumothorax (SP); other respiratory, heart, digestive and nervous diseases; and uncertain diagnoses.

RESULTS

Patients with PE had significantly higher D-dimer and lower FXIII concentrations than did patients without PE. Combined D-dimer and FXIII measurements provided a higher positive predictive value (76.6%) for PE than single tests, especially in patients with Wells score >4.0 (89.3%). Specifically, patients with AD or ACS showed higher FXIII concentrations and mean platelet volumes than did patients with PE or SP, and patients with PE and AD had higher D-dimer concentrations than did other patients. At the thresholds of 69.0% for FXIII and 1.10 μg/mL for D-dimer, 123/151 patients (81.5%) with serious diseases (PE, AD, ACS and SP) were correctly distinguished.

CONCLUSIONS

Combined measurement of D-dimer and FXIII helps distinguish PE from serious diseases with similar symptoms and appears to relate to increased FXIII release from active platelets in cardiovascular disease.

Increased fibrin formation and impaired fibrinolytic capacity in severe chronic kidney disease

Chronic kidney disease (CKD) is associated with a concurrent increased risk of thrombosis and bleeding. We aimed to investigate whether CKD is associated with increased fibrin formation, impaired fibrin degradation, or both. Twenty-one patients with CKD stage 4 (CKD 4), 15 haemodialysis patients, and 13 controls (C) without kidney disease were studied. We used a global assay to determine fibrin formation and degradation in plasma. Fibrin turbidity was measured over time to obtain a value of the coagulation activation profile (Cp) and the fibrinolysis activation profile (Fp), and the amount of fibrin formed, termed fibrin optical density sum (fibrin OD-sum). We used scanning electron microscopy (SEM) to visualize the fibrin network. Plasminogen activator inhibitor type-1 antigen, thrombin-activatable fibrinolysis inhibitor activity, fibrinogen, von Willebrand factor, antithrombin, albumin, and C-reactive protein were measured in plasma. Fibrin OD-sum was significantly elevated in haemodialysis patients [312 a.u.; 278-435 (median; interquartile range); P < 0.0013] and in CKD 4 (293 a.u.; 169-434; P = 0.0119) compared with controls (115 a.u.; 82-234). SEM showed a tight fibrin network in haemodialysis and CKD 4 patients. Fp was lower in the haemodialysis group than in controls (P = 0.030). Plasminogen activator inhibitor type-1 was lower in haemodialysis patients (P = 0.034). Thrombin-activatable fibrinolysis inhibitor activity, Cp, antithrombin, and C-reactive protein did not differ between groups. Fibrinogen was significantly elevated and albumin decreased in both haemodialysis and CKD 4 patients compared with controls. Von Willebrand factor was elevated in haemodialysis patients compared with controls (P = 0.010). The prothrombotic state in severe CKD is characterized by impaired fibrinolysis in association with increased fibrin formation despite normal levels of endogenous fibrinolysis inhibitors.

Factor XIII assays

Factor XIII (FXIII) deficiency is a rare cause of bleeding and pregnancy loss that is easily treated with plasma products. Reliable assays for FXIII are necessary not only for the diagnosis of deficiency state but also to guide prophylaxis and replacement therapy in patients during times of increased risk. Diagnostic tests for FXIII activity whilst not technically demanding have a number of pitfalls including limited sensitivity and overestimation of activity at the lower end. Despite these shortcomings the performance of these assays is adequate for the diagnosis and management of the majority of patients with clinically significant deficiency.

Time-Dependent Plasma Protein Changes in Streptozotocin-Induced Diabetic Rats before and after Fungal Polysaccharide Treatments

Previous studies about protein modulation with chemically induced models of diabetes in animals have yielded conflicting results, in that many investigators have reported different regulation patterns for the same proteins. Therefore, it is reasonable to determine biomarkers for prognosis and diagnosis of diabetes with time profiling for the candidate proteins. In this regard, we examined the influence of hypoglycemic fungal polysaccharides (EPS) on the time-dependent plasma protein alterations in streptozotocin-induced diabetic rats. The 2-DE analysis of rat plasma demonstrated that about 50 proteins from about 900 visualized spots were found to be differentially regulated, of which 20 spots were identified as principal diabetes-associated proteins. The results of time profiling revealed that most of the identified proteins showed significant alterations in a time-dependent manner during 14 days, with notable trends. Nine out of the twenty proteins displayed very similar time profiles between normal healthy and EPS-treated diabetic rats. Interestingly, the altered profiles of several proteins by diabetes induction almost returned to control levels after EPS treatments. In particular, we found a clear distinction in differential expression of oxidative stress proteins (ceruloplasmin and transferrin) and lipid metabolism related proteins (Apo A-I, Apo A-IV, and Apo E) in the STZ-induced diabetic rats. The data presented here have identified and characterized the time-dependent changes in plasma proteins associated with EPS treatment in STZ-induced diabetic rats, thereby leading to the discovery of early-response and late-response biomarkers in diabetic and EPS-treated states.

Effect of fungal polysaccharides on the modulation of plasma proteins in streptozotocin-induced diabetic rats

To search out novel biomarkers for monitoring diabetes prognosis, we examined the effect of hypoglycemic fungal exopolysaccharides (EPS) on the differential levels of plasma proteins in streptozotocin-induced diabetic rats. The orally administrated EPS exhibited an excellent hypoglycemic effect, lowering the average plasma glucose level, and increasing insulin secretion in diabetic rats. The 2-DE analysis of rat plasma demonstrated that about 500 visualized spots were differentially regulated, of which 20 spots were identified as principal diabetes-associated proteins. The distinct effect of diabetes induction on the pattern of rat plasma proteins includes the down-regulation of albumin, apolipoprotein E (Apo E), alpha1-inhibitor-3, fetuin beta, Gc-globulin, hemopexin, vitronectin, and transthyretin (TTR) monomer, and the up-regulation of Apo A-I, Apo A-IV, ceruloplasmin, alpha1-antitrypsin, serine protease inhibitor III, and transferrin. Those protein levels were interestingly restored to those of healthy rats by EPS treatment, although the order of magnitude of the changes differed widely. Two proteins of interest showed distinct differential expression with opposite trends: TTR tetramer was significantly down-regulated and immunoglobulin (Ig) kappa light chain was significantly up-regulated upon diabetes induction, both of which were also normalized to those of healthy groups after EPS treatment.

Fibrin stabilization (factor XIII), fibrin structure and thrombosis

Factor XIII (FXIII) is a zymogen that is converted into an active transglutaminase (FXIIIa) by the concerted action of thrombin and Ca2+. Its main task is to crosslink alpha-, and gamma-chains of fibrin and alpha2-plasmin inhibitor to fibrin. By this way FXIIIa strengthens fibrin and protects it from the prompt elimination by fibrinolytic system.The changes of FXIII level in thrombotic diseases are hardly explored and there are contradictory results concerning the protective effect of Val34Leu polymorphism against arterial or venous thrombosis. The results suggest that the thrombo-protective effect of Leu34 allele prevails only in certain genetic and/or environmental constellations.

A Modified, Optimized Kinetic Photometric Assay for the Determination of Blood Coagulation Factor XIII Activity in Plasma

Background: Blood coagulation factor XIII (FXIII) is a zymogen that is transformed into an active transglutaminase by thrombin and Ca2+. FXIII plays an essential role in fibrin stabilization and in the protection of fibrin from proteolytic degradation. No convenient method has been available for the measurement of FXIII activity in plasma. The aim of the present study was to improve and optimize a kinetic photometric FXIII assay originally developed in our laboratory.

Methods: In the assay, FXIII was activated by thrombin and Ca2+. Fibrin polymerization was prevented by an inhibitory tetrapeptide. Glycine-ethyl ester and a glutamine residue of a synthetic dodecapeptide served as acyl acceptor and acyl donor transglutaminase substrates, respectively. The amount of ammonia released during the reaction was monitored using glutamate dehydrogenase and NADPH.

Results: The use of a new glutamine substrate and optimization of activator and substrate concentrations increased sensitivity. Substitution of NADPH for NADH and introduction of an appropriate blank eliminated systemic overestimation of FXIII activity. The recovery of FXIII was 96%, the assay was linear up to 470 U/L, the detection limit was 1 U/L, and the imprecision (CV) was &lt;8% even at very low FXIII activities. A reference interval of 108–224 U/L (69–143%) was established. The results correlated well with results obtained by an immunoassay specific for plasma FXIII.

Conclusions: The optimized FXIII assay is a simple, rapid method for the diagnosis of inherited or acquired FXIII deficiencies and increased FXIII concentrations. It can be easily adapted to clinical chemistry analyzers.

Subunit antigen and activity levels of blood coagulation factor XIII in healthy individuals. Relation to sex, age, smoking, and hypertension

Factor (F) XIII covalently cross-links and stabilizes the fibrin-clot. Recent evidence suggests a role for FXIII in atherothrombotic diseases, but no information is available regarding the association of FXIII with common risk factors. The aim of this study was to investigate the relationship of FXIII with age, sex, smoking, and hypertension. Plasma levels of FXIII A-subunit antigen, FXIII B-subunit antigen, and FXIII cross-linking activity were measured in 612 healthy individuals (250 men and 362 women). FXIII A- and B-subunit levels were correlated significantly with age in both men (r=0.21, P=0.001, and r=0.17, P=0.008, respectively) and women (r=0.20, P<0.0005, and r=0.13, P=0.011, respectively). FXIII B-subunit levels and activity were correlated significantly with FXIII A-subunit levels (r=0.60, P<0.0005, and r=0.14, P<0.0005, respectively) and fibrinogen (r=0.26, P<0.0005, and r=0.14, P=0.001, respectively). Women had higher levels of FXIII A-subunit (111.8% versus 105.2%, P<0.01) and B-subunit (109.5% versus 103.8%, P<0.01) than did men. FXIII A-subunit was significantly increased in smokers (117.0% versus 104.6%, P<0.0005) and in subjects with hypertension (114.9% versus 107.8%, P<0.05). In a multiple regression model, FXIII A-subunit was significantly increased by female sex (+6.4%, P<0.007), smoking (+12.3%, P<0.0005), and increasing age (+3.7% per 10 years, P<0.0005). FXIII B-subunit was significantly related to female sex and fibrinogen, and FXIII activity was significantly related to fibrinogen levels. In conclusion, the FXIII A-subunit level increases significantly with female sex, age, and smoking, whereas FXIII B-subunit and FXIII activity are associated with FXIII A-subunit level and fibrinogen. Although evidence for a causal relationship between FXIII A-subunit and vascular disease is not available, these results might suggest a role for elevated FXIII A-subunit levels in the pathogenesis of vascular disease.

Specific activity of alpha1proteinase inhibitor and alpha2macroglobulin in human serum: application to insulin-dependent diabetes mellitus

The shifting balance between proteinases and proteinase inhibitors in blood, a function of their relative affinities and concentrations, has long been hypothesized to influence immune competency. The identification of proteinase-activated receptor responses in cells of the mononuclear phagocyte system suggests a potential explanation. The major serum proteinase inhibitor, alpha1proteinase inhibitor (alpha1PI, alpha1-antitrypsin), has been reported to increase in concentration during inflammation. Quantitative determination of serum alpha1PI has traditionally been performed nephelometrically; however, antigenically quantitated levels may not be representative of functional capacity. It has previously been observed that alpha1PI in serum exhibits bimodal behavior as the result of various concentrations of proteinase inhibitors, specifically alpha2macroglobulin (alpha2M) and inter-alpha-trypsin inhibitor, which compete in binding to a panel of serine proteinases. Consequently, it has not previously been possible to assign a numerical value for the specific activity of these competing proteinase inhibitors in serum. By applying known constants representing the association of proteinase inhibitors with porcine pancreatic elastase (PPE), the theoretical relationship between the functional and antigenic values for alpha1PI and alpha2M has been empirically derived allowing, for the first time, the calculation of their specific activities in serum. As predicted, the serum concentration of alpha1PI was found to be highly correlated with residual uninhibited PPE catalytic activity in healthy individuals, but not in individuals exhibiting fragmented or complexed alpha1PI. Using these techniques, both the antigenic and functional levels of alpha1PI were determined in sera from subjects with insulin-dependent diabetes mellitus (IDDM) who had been clinically diagnosed as having either periodontal disease or gingival health. Determination of quantitative levels by antigen-capture suggests that the IDDM subjects with periodontitis manifest dramatically increased levels of fragmented serum alpha1PI compared with their orally healthy counterparts or normal controls. In contrast, functional analysis of serum alpha1PI revealed no differences between the three subject populations. The elevated levels of antigenically determined serum alpha1PI reflect the inflammatory status of periodontal disease. These results support the importance of and provide methodology for determining the functionally active levels of alpha1PI allowing reexamination of changes detected during the acute phase of inflammation, replacement therapy, and longitudinal studies in relevant disease processes including malignancy and diabetes.

Coagulation factor XIII in pregnant smokers and non-smokers

Human blood coagulation factor XIII is a transglutaminase zymogen. Two forms exist, an extracellular or plasma factor XIII and an intracellular form. Factor XIII occurs in platelets, blood, monocytes, megakaryocytes, the liver, the placenta, and the uterus. In obstetrics, factor XIII deficiency has been associated with fetal wastage. The interaction of smoking and the quantity of coagulation factor XIII during normal pregnancy was examined in 75 non-smoking and 118 smoking (> or = 20 cigarettes/day) women. A group of subjectively healthy, non-smoking, age-matched females served as a control group (n = 30). Smokers had a higher plasma concentration of factor XIII than non-smokers. Factor XIII declined during normal gestation. During the second half of gestation the plasma concentration of factor XIII was significantly higher in smokers than in non-smokers. In smokers the decline of factor XIII was less, possibly due to platelet activation and a relative polycythemia. The later decline of factor XIII in pregnant smokers remains unexplained. More extensive research with larger patient numbers is needed to address this matter.

Three-dimensional structure of a transglutaminase: human blood coagulation factor XIII

Mechanical stability in many biological materials is provided by the crosslinking of large structural proteins with gamma-glutamyl-epsilon-lysyl amide bonds. The three-dimensional structure of human recombinant factor XIII (EC 2.3.2.13 zymogen; protein-glutamine:amine gamma-glutamyltransferase a chain), a transglutaminase zymogen, has been solved at 2.8-A resolution by x-ray crystallography. This structure shows that each chain of the homodimeric protein is folded into four sequential domains. A catalytic triad reminiscent of that observed in cysteine proteases has been identified in the core domain. The amino-terminal activation peptide of each subunit crosses the dimer interface and partially occludes the opening of the catalytic cavity in the second subunit, preventing substrate binding to the zymogen. A proposal for the mechanism of activation by thrombin and calcium is made that details the structural events leading to active factor XIIIa'.

Plasma free N-terminal fibronectin 30-kDa domain as a marker of endothelial dysfunction in type 1 diabetes mellitus

The plasma free N-terminal fibronectin 30-kDa domain was measured in 44 type 1 diabetic patients and in 20 healthy subjects. A significantly raised mean concentration of a free N-terminal fibronectin 30-kDa domain was found in plasma of diabetic patients with proliferative retinopathy as compared with healthy persons (P less than 0.001). A positive correlation was observed between free N-terminal fibronectin 30-kDa domain and von Willebrand factor in plasma of all examined subjects (r = 0.62, P less than 0.01). A similar correlation was present between 30-kDa domain and albuminuria (r = 0.56, P less than 0.01). However, no relationship was found between fibronectin 30-kDa domain and control of diabetes as assessed by fructosamine concentration. The free N-terminal fibronectin 30-kDa domain may be used as a marker of actual endothelial cell dysfunction in diabetes.

Alterations of haemostasis parameters with special reference to fibrin stabilization, factor XIII and fibronectin in patients with obliterative atherosclerosis

Intravascular and endoparietal fibrin deposition are thought to be involved in atherosclerotic process, especially when fibrin is stabilized by factor XIII of coagulation system. The study carried out on a group of 50 patients with obliterative atherosclerosis of the lower limbs revealed an increased plasma fibrin stabilizing activity apparently due to an increased F.XIII level. Furthermore, alterations in coagulation and fibrinolysis indicating hypercoagulable tendency were found. It is concluded, that the observed changes may contribute to the development of atherosclerotic process.