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Yin Y, Wang L, Gao F, Liu L, Qi X. Anticoagulation Therapy for Splanchnic Vein Thrombosis Associated With Acute Pancreatitis: A Systematic Review and Meta-Analysis. Clin Appl Thromb Hemost 2023; 29:10760296231188718. [PMID: 37461391 DOI: 10.1177/10760296231188718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023] Open
Abstract
Splanchnic vein thrombosis (SVT) is not rare in patients with acute pancreatitis. It remains unclear about whether anticoagulation should be given for acute pancreatitis-associated SVT. The PubMed, EMBASE, and Cochrane Library databases were searched. Rates of SVT recanalization, any bleeding, death, intestinal ischemia, portal cavernoma, and gastroesophageal varices were pooled and compared between patients with acute pancreatitis-associated SVT who received and did not receive therapeutic anticoagulation. Pooled rates and risk ratios (RRs) with 95% confidence intervals (CIs) were calculated. Heterogeneity among studies was evaluated. Overall, 16 studies including 698 patients with acute pancreatitis-associated SVT were eligible. After therapeutic anticoagulation, the pooled rates of SVT recanalization, any bleeding, death, intestinal ischemia, portal cavernoma, and gastroesophageal varices were 44.3% (95%CI = 32.3%-56.6%), 10.7% (95%CI = 4.9%-18.5%), 13.3% (95%CI = 6.9%-21.4%), 16.8% (95%CI = 6.9%-29.9%), 21.2% (95%CI = 7.5%-39.5%), and 29.1% (95%CI = 16.1%-44.1%), respectively. Anticoagulation therapy significantly increased the rate of SVT recanalization (RR = 1.69; 95%CI = 1.29-2.19; P < .01), and marginally increased the risk of bleeding (RR = 1.98; 95%CI = 0.93-4.22; P = .07). The rates of death (RR = 1.42; 95%CI = 0.62-3.25; P = .40), intestinal ischemia (RR = 2.55; 95%CI = 0.23-28.16; P = .45), portal cavernoma (RR = 0.51; 95%CI = 0.21-1.22; P = .13), and gastroesophageal varices (RR = 0.71; 95%CI = 0.38-1.32; P = .28) were not significantly different between patients who received and did not receive anticoagulation therapy. Heterogeneity was statistically significant in the meta-analysis of intestinal ischemia, but not in those of SVT recanalization, any bleeding, death, portal cavernoma, or gastroesophageal varices. Anticoagulation may be effective for recanalization of acute pancreatitis-associated SVT, but cannot improve the survival. Randomized controlled trials are warranted to further investigate the clinical significance of anticoagulation therapy in such patients.
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Affiliation(s)
- Yuhang Yin
- Meta-Analysis Interest Group & Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
- Postgraduate College, China Medical University, Shenyang, China
| | - Le Wang
- Meta-Analysis Interest Group & Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
- Postgraduate College, China Medical University, Shenyang, China
| | - Fangbo Gao
- Meta-Analysis Interest Group & Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
- Department of Life Sciences and Biopharmaceutics, Shenyang Pharmaceutical University, Shenyang, China
| | - Lei Liu
- Department of Digestive Diseases, Daping Hospital, Army Medical University, Chongqing, China
| | - Xingshun Qi
- Meta-Analysis Interest Group & Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
- Postgraduate College, China Medical University, Shenyang, China
- Department of Life Sciences and Biopharmaceutics, Shenyang Pharmaceutical University, Shenyang, China
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Parmeshwar Ramesh J, Sanjay C, Udgirkar S, Sujit N, Prasanta D, Ammar M, Partha D, Shubham J, Thanage R, Pravin R, Qais C. Multiple extra-splanchnic venous thromboses - an unusual vascular complication of acute pancreatitis. Clin Pract 2020; 10:1226. [PMID: 33072246 PMCID: PMC7533600 DOI: 10.4081/cp.2020.1226] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Accepted: 09/11/2020] [Indexed: 11/23/2022] Open
Abstract
Acute pancreatitis (AP) is an acute inflammatory process of the pancreas with variable clinical presentations. Splanchnic venous thrombosis is a well-known vascular complication of AP and commonly present as thrombosis of the splanchnic venous system: splenic vein (SplV), portal vein (PV) and superior mesenteric vein (SMV), either separately or in combinations. Involvement of extra-splanchnic vessels is rare and associated with morbidity and mortality. Vascular complications are late phenomena and usually associated with local complications of AP, namely acute fluid collections, necrotizing pancreatitis and walled-off pancreatic necrosis. Pathogenesis of venous thrombosis is multifactorial in which pancreatic inflammation and systemic inflammatory response play a key role. At present, there are no consensus guidelines on treatment and use of anticoagulation for venous thrombosis in the setting of AP. Limited literature suggests the use of anticoagulation in presence of PV with or without SMV thrombosis and extrasplanchnic vessel involvement. Literature on extra-splanchnic vessels involvement in acute pancreatitis is sparse. Here we present two cases with multiple extra-splanchnic vessels involvement and their management.
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Affiliation(s)
- Junare Parmeshwar Ramesh
- Department of Gastroenterology, Topiwala National Medical College and B.Y.L. Nair Charitable Hospital, Mumbai, India
| | - Chandnani Sanjay
- Department of Gastroenterology, Topiwala National Medical College and B.Y.L. Nair Charitable Hospital, Mumbai, India
| | - Suhas Udgirkar
- Department of Gastroenterology, Topiwala National Medical College and B.Y.L. Nair Charitable Hospital, Mumbai, India
| | - Nair Sujit
- Department of Gastroenterology, Topiwala National Medical College and B.Y.L. Nair Charitable Hospital, Mumbai, India
| | - Debnath Prasanta
- Department of Gastroenterology, Topiwala National Medical College and B.Y.L. Nair Charitable Hospital, Mumbai, India
| | - Modi Ammar
- Department of Gastroenterology, Topiwala National Medical College and B.Y.L. Nair Charitable Hospital, Mumbai, India
| | - Debnath Partha
- Department of Gastroenterology, Topiwala National Medical College and B.Y.L. Nair Charitable Hospital, Mumbai, India
| | - Jain Shubham
- Department of Gastroenterology, Topiwala National Medical College and B.Y.L. Nair Charitable Hospital, Mumbai, India
| | - Ravi Thanage
- Department of Gastroenterology, Topiwala National Medical College and B.Y.L. Nair Charitable Hospital, Mumbai, India
| | - Rathi Pravin
- Department of Gastroenterology, Topiwala National Medical College and B.Y.L. Nair Charitable Hospital, Mumbai, India
| | - Contractor Qais
- Department of Gastroenterology, Topiwala National Medical College and B.Y.L. Nair Charitable Hospital, Mumbai, India
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Junare PR, Udgirkar S, Nair S, Debnath P, Jain S, Modi A, Rathi P, Rane S, Contractor Q. Splanchnic Venous Thrombosis in Acute Pancreatitis: Does Anticoagulation Affect Outcome? Gastroenterology Res 2020; 13:25-31. [PMID: 32095170 PMCID: PMC7011913 DOI: 10.14740/gr1223] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 11/05/2019] [Indexed: 12/20/2022] Open
Abstract
Background Splanchnic venous system thrombosis is a well recognized local vascular complication of acute pancreatitis (AP). It may involve thrombosis of splenic vein (SplV), portal vein (PV) and superior mesenteric vein (SMV), either separately or in combinations, and often detected incidentally, indeed some cases present with upper gastrointestinal bleed, bowel ischemia and hepatic decompensation. Incidence is variable depending on study subjects and diagnostic modalities. Pathogenesis is multifactorial centered on local and systemic inflammation. Management involves treatment of underlying AP and its complications. Universal use of anticoagulation may lead to increased risk of bleeding due to frequent need of interventions (radiologic/endoscopic/surgical). Literature on anticoagulation in setting of AP is sparse and at present there is no consensus guideline on it. Current article details our experience on splanchnic venous thrombosis (SVT) in AP in a well defined cohort of patients at a tertiary care center. Methods Hospitalized patients with AP from January 2018 to December 2018 were included in the study. Detailed information on demographic, clinical, laboratory, radiologic features, and indication of anticoagulation use were collected prospectively during the index admission. Outcome variables were analyzed at the end of 6 months. Results Twenty four out of 105 (22.85%) patients with AP develop SVT. Etiology of AP was alcohol use in 21/24 (87.5%) subjects. Most common vessel involved was isolated SplV in 11/24 (45.8%) patients followed by SplV along with PV and SMV 9/24 (37.50%, P < 0.001). Bowel ischemia 4/12 (33.3%), hepatic decompensation 3/12 (25%), triple vessel involvement 4/12 (33.3%) and pulmonary embolism 1/12 (8.3%) were reasons for anticoagulation. There was no statistical difference with respect to development of varices, collateral formation, recanalization, bleeding and mortality with use of anticoagulation (P > 0.05 with respect to all above variables). Conclusions SVT is commonly seen in alcohol-induced AP. Anticoagulation does not affect outcomes of SVT. Subset of patients may benefit with anticoagulation.
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Affiliation(s)
- Parmeshwar Ramesh Junare
- Department of Gastroenterology, Topiwala National Medical College and B.Y.L. Nair Charitable Hospital,Mumbai, India
| | - Suhas Udgirkar
- Department of Gastroenterology, Topiwala National Medical College and B.Y.L. Nair Charitable Hospital,Mumbai, India
| | - Sujit Nair
- Department of Gastroenterology, Topiwala National Medical College and B.Y.L. Nair Charitable Hospital,Mumbai, India
| | - Prasanta Debnath
- Department of Gastroenterology, Topiwala National Medical College and B.Y.L. Nair Charitable Hospital,Mumbai, India
| | - Shubham Jain
- Department of Gastroenterology, Topiwala National Medical College and B.Y.L. Nair Charitable Hospital,Mumbai, India
| | - Ammar Modi
- Department of Radio-Diagnosis, Topiwala National Medical College and B.Y.L. Nair Charitable Hospital,Mumbai, India
| | - Pravin Rathi
- Department of Gastroenterology, Topiwala National Medical College and B.Y.L. Nair Charitable Hospital,Mumbai, India
| | - Siddhesh Rane
- Department of Gastroenterology, Topiwala National Medical College and B.Y.L. Nair Charitable Hospital,Mumbai, India
| | - Qais Contractor
- Department of Gastroenterology, Topiwala National Medical College and B.Y.L. Nair Charitable Hospital,Mumbai, India
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Serum Concentrations of Angiopoietin-2 and Soluble fms-Like Tyrosine Kinase 1 (sFlt-1) Are Associated with Coagulopathy among Patients with Acute Pancreatitis. Int J Mol Sci 2017; 18:ijms18040753. [PMID: 28368336 PMCID: PMC5412338 DOI: 10.3390/ijms18040753] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Revised: 03/17/2017] [Accepted: 03/30/2017] [Indexed: 12/21/2022] Open
Abstract
In severe acute pancreatitis (SAP), systemic inflammation leads to endothelial dysfunction and activation of coagulation. Thrombotic disorders in acute pancreatitis (AP) include disseminated intravascular coagulation (DIC). Recently, angiopoietin-2 and soluble fms-like tyrosine kinase 1 (sFlt-1) were proposed as markers of endothelial dysfunction in acute states. Our aim was to assess the frequency of coagulation abnormalities in the early phase of AP and evaluate the relationships between serum angiopoietin-2 and sFlt-1 and severity of coagulopathy. Sixty-nine adult patients with AP were recruited: five with SAP, 15 with moderately severe AP (MSAP) and 49 with mild AP. Six patients were diagnosed with DIC according to International Society on Thrombosis and Haemostasis (ISTH) score. All patients had at least one abnormal result of routine tests of hemostasis (low platelet count, prolonged clotting times, decreased fibrinogen, and increased D-dimer). The severity of coagulopathy correlated with AP severity according to 2012 Atlanta criteria, bedside index of severity in AP and duration of hospital stay. D-dimers correlated independently with C-reactive protein and studied markers of endothelial dysfunction. Angiopoietin-2, D-dimer, and ISTH score were best predictors of SAP, while sFlt-1 was good predictor of MSAP plus SAP. In clinical practice, routine tests of hemostasis may assist prognosis of AP.
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Dumnicka P, Maduzia D, Ceranowicz P, Olszanecki R, Drożdż R, Kuśnierz-Cabala B. The Interplay between Inflammation, Coagulation and Endothelial Injury in the Early Phase of Acute Pancreatitis: Clinical Implications. Int J Mol Sci 2017; 18:E354. [PMID: 28208708 PMCID: PMC5343889 DOI: 10.3390/ijms18020354] [Citation(s) in RCA: 90] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Revised: 01/17/2017] [Accepted: 01/31/2017] [Indexed: 02/07/2023] Open
Abstract
Acute pancreatitis (AP) is an inflammatory disease with varied severity, ranging from mild local inflammation to severe systemic involvement resulting in substantial mortality. Early pathologic events in AP, both local and systemic, are associated with vascular derangements, including endothelial activation and injury, dysregulation of vasomotor tone, increased vascular permeability, increased leukocyte migration to tissues, and activation of coagulation. The purpose of the review was to summarize current evidence regarding the interplay between inflammation, coagulation and endothelial dysfunction in the early phase of AP. Practical aspects were emphasized: (1) we summarized available data on diagnostic usefulness of the markers of endothelial dysfunction and activated coagulation in early prediction of severe AP; (2) we reviewed in detail the results of experimental studies and clinical trials targeting coagulation-inflammation interactions in severe AP. Among laboratory tests, d-dimer and angiopoietin-2 measurements seem the most useful in early prediction of severe AP. Although most clinical trials evaluating anticoagulants in treatment of severe AP did not show benefits, they also did not show significantly increased bleeding risk. Promising results of human trials were published for low molecular weight heparin treatment. Several anticoagulants that proved beneficial in animal experiments are thus worth testing in patients.
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Affiliation(s)
- Paulina Dumnicka
- Department of Medical Diagnostics, Jagiellonian University Medical College, Medyczna 9, 30-688 Kraków, Poland.
| | - Dawid Maduzia
- Department of Anatomy, Jagiellonian University Medical College, Kopernika 12, 31-034 Kraków, Poland.
| | - Piotr Ceranowicz
- Department of Physiology, Jagiellonian University Medical College, Grzegórzecka 16, 31-531 Kraków, Poland.
| | - Rafał Olszanecki
- Department of Pharmacology, Jagiellonian University Medical College, Grzegórzecka 16, 31-531 Kraków, Poland.
| | - Ryszard Drożdż
- Department of Medical Diagnostics, Jagiellonian University Medical College, Medyczna 9, 30-688 Kraków, Poland.
| | - Beata Kuśnierz-Cabala
- Department of Diagnostics, Chair of Clinical Biochemistry, Jagiellonian University Medical College, Kopernika 15A, 31-501 Kraków, Poland.
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Zhou J, Ke L, Tong Z, Li G, Li W, Li N, Li J. Risk factors and outcome of splanchnic venous thrombosis in patients with necrotizing acute pancreatitis. Thromb Res 2014; 135:68-72. [PMID: 25466845 DOI: 10.1016/j.thromres.2014.10.021] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Revised: 09/24/2014] [Accepted: 10/27/2014] [Indexed: 12/18/2022]
Abstract
BACKGROUND Splanchnic venous thrombosis (SVT) is considered a rare but important complication in patients with acute pancreatitis (AP) and literatures regarding this topic were sparse. The aim of the present study was to investigate the risk factors of SVT in necrotizing acute pancreatitis (NAP) and assess the prognosis of these patients. METHODS Both univariate and multivariate logistic regression analyses were applied using 15 indices including age, gender, Acute Physiology and Chronic Health Evaluation II scores (APACHE II), CRP (C - reactive protein) levels, etc to explore potential risk factors for the development of SVT in NAP patients. Moreover, clinical outcome measures such as mortality, organ failure and length of hospital and ICU stay were also compared between NAP patients with or without SVT. RESULTS According to the statistical results, only intra-abdominal pressure (IAP) was proved to be an independent risk factor for SVT (OR, 1.283; 95% CI, 1.091-1.509,P=0.003). In addition, Balthazar's CT score and occurrence of IPN (infected pancreatic necrosis) also reached statistical significance (P=0.040 and 0.047, respectively), but the 95% confidence interval shown in the multivariate logistic regression suggested that the observed ORs are not significant (1.326;95% CI 0.984-1.787 and 2.61;95 CI 0.972-7.352, respectively), which indicates weaker association between the two parameters and SVT. Regarding the clinical outcomes, patients with SVT showed higher mortality, longer hospital and intensive care unit duration, higher rates of a variety of complications and more utilization of invasive interventions. CONCLUSIONS IAP is an independent risk factor for the development of SVT in patients with NAP, while Balthazar's CT score and occurrence of IPN are also associated with SVT, although not as strong as IAP. Moreover, occurrence of SVT relates with extremely poor prognosis in NAP patients, evidenced by increased mortality, morbidity and need for invasive interventions.
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Affiliation(s)
- Jing Zhou
- Department of General Surgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing 210002, People's Repubic of China
| | - Lu Ke
- Department of General Surgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing 210002, People's Repubic of China
| | - Zhihui Tong
- Department of General Surgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing 210002, People's Repubic of China
| | - Gang Li
- Department of General Surgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing 210002, People's Repubic of China
| | - Weiqin Li
- Department of General Surgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing 210002, People's Repubic of China.
| | - Ning Li
- Department of General Surgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing 210002, People's Repubic of China
| | - Jieshou Li
- Department of General Surgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing 210002, People's Repubic of China
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Abstract
OBJECTIVES This study aimed to estimate outcomes of splanchnic vein thrombosis (SVT) in hospitalized patients with acute pancreatitis (AP). METHODS This was a retrospective study (January 1996 to December 2006) via chart review. RESULTS Over 10 years, 1.8% (45/2454) of patients with AP with a mean (SD) age of 58 (15) years were diagnosed with SVT. Splenic vein thrombosis was the most common form of SVT (30/45 patients, 67%). Seventeen patients were anticoagulated with heparin, when the SVT was diagnosed in the acute stage followed by oral anticoagulation (AC). The thrombosis that was most commonly anticoagulated was portal vein thrombosis in 11 (65%) of 17 patients. Of 17 patients in the AC group, 2 (12%) showed recanalization as compared with 3 (11%) of 28 patients in the non-AC group (P > 0.05). The mortality was 3 (7%) of 45 (2 from the AC group versus 1 in the non-AC group, P > 0.05). Two of these died of multiorgan failure, and the other, from septic shock. None of the deaths were due to bleeding complications. CONCLUSIONS Splanchnic vein thrombosis occurred in 1.8% patients of AP. The use of AC was reasonably safe with no fatal bleeding complications. However, there was no significant difference in the recanalization rates in those with and without AC.
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Abstract
Pancreatitis is an inflammatory process with local and systemic manifestations. One such local manifestation is thrombosis in splanchnic venous circulation, predominantly of the splenic vein. The literature on this important complication is very sparse. This review offers an overview of mechanism of thrombosis, its pathophysiology, diagnosis, and management in the setting of acute as well as chronic pancreatitis.
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The clinical course of acute pancreatitis and the inflammatory mediators that drive it. Int J Inflam 2012; 2012:360685. [PMID: 23304633 PMCID: PMC3530799 DOI: 10.1155/2012/360685] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2012] [Revised: 11/09/2012] [Accepted: 11/15/2012] [Indexed: 02/06/2023] Open
Abstract
Acute pancreatitis (AP) is a common emergency condition. In the majority of cases, it presents in a mild and self-limited form. However, about 20% of patients develop severe disease with local pancreatic complications (including necrosis, abscess, or pseudocysts), systemic organ dysfunction, or both. A modern classification of AP severity has recently been proposed based on the factors that are causally associated with severity of AP. These factors are both local (peripancreatic necrosis) and systemic (organ failure). In AP, inflammation is initiated by intracellular activation of pancreatic proenzymes and/or nuclear factor-κB. Activated leukocytes infiltrate into and around the pancreas and play a central role in determining AP severity. Inflammatory reaction is first local, but may amplify leading to systemic overwhelming production of inflammatory mediators and early organ failure. Concomitantly, anti-inflammatory cytokines and specific cytokine inhibitors are produced. This anti-inflammatory reaction may overcompensate and inhibit the immune response, rendering the host at risk for systemic infection. Currently, there is no specific treatment for AP. However, there are several early supportive treatments and interventions which are beneficial. Also, increasing the understanding of the pathogenesis of systemic inflammation and the development of organ dysfunction may provide us with future treatment modalities.
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Sayilir A, Beyazit Y, Yesil Y, Albayrak M, Ekiz F, Celik T, Suvak B, Torun S, Ibiş M. Plasma thrombin-activatable fibrinolysis inhibitor as an indicator of inflammation and disease severity in acute pancreatitis. Clin Res Hepatol Gastroenterol 2012; 36:498-504. [PMID: 22230218 DOI: 10.1016/j.clinre.2011.12.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2011] [Revised: 11/28/2011] [Accepted: 12/05/2011] [Indexed: 02/04/2023]
Abstract
AIM In addition to suppressing fibrinolysis, thrombin activatable fibrinolysis inhibitor (TAFI) was suggested to be involved in inflammation. To date, no study has been published that reports the role of TAFI in acute pancreatitis (AP). Therefore, the objective of the present study was to investigate the role of plasma TAFI as an indicator of inflammation in AP, and its association with disease severity. METHODS Plasma TAFI antigen levels quantitatively determined by using ELISA kits in 21 AP patients at onset and remission and 17 healthy controls. Associations of TAFI with inflammatory markers to determine AP and disease severity were assessed. To predict the severity of AP, modified Glasgow prognostic score (mGPS) and computerized tomography severity index (CTSI) were used for each subject. RESULTS Plasma TAFI levels was higher in AP patients at onset of the disease compared with healthy controls. The disease severity according to mGPS was significantly correlated with TAFI levels. Overall, accuracy of TAFI in determining AP was 83.3% with a sensitivity, specificity, NPV and PPV of 80.9%, 85.7%, 81.8%, and 85% respectively (AUC: 0.915). CONCLUSIONS The present study for the first time demonstrated that TAFI is elevated in AP. The appraisal of TAFI levels in patients with AP in conjunction with other markers of inflammation may provide additional information in estimating AP severity.
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Affiliation(s)
- Abdurrahim Sayilir
- Department of Gastroenterology, Turkiye Yuksek İhtisas Teaching and Research Hospital, Kızılay Sk. No: 2, 06100, Sıhhiye Ankara, Turkey.
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Lindström OK, Tukiainen EM, Kylänpää ML, Mentula PJ, Puolakkainen PA, Wartiovaara-Kautto UMK, Repo H, Petäjä JM. Thrombin generation in vitro and in vivo, and disturbed tissue factor regulation in patients with acute pancreatitis. Pancreatology 2011; 11:557-66. [PMID: 22213026 DOI: 10.1159/000333481] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2011] [Accepted: 09/23/2011] [Indexed: 12/11/2022]
Abstract
BACKGROUND Being a central link between inflammation and coagulation, tissue factor (TF) and its inhibitor (TFPI) might be associated with the severity of acute pancreatitis (AP) and the development of organ failure (OF). METHODS The study comprises 9 severe AP patients with OF and 24 reference patients (11 mild AP and 13 severe AP without OF). Plasma samples were collected on admission. TF-induced thrombin generation in plasma samples was studied using the thrombogram method. In vivo thrombin generation was estimated by prothrombin fragment F1+2. Free and total TFPI levels were measured. To evaluate coagulation status the activated partial thromboplastin time, prothrombin time, platelet count, D-dimer, fibrinogen, antithrombin (AT) 3 and protein C (PC) were determined. RESULTS There was no significant difference in F1+2 levels between the patient groups. Patients with severe AP tended to show low platelet counts, PC and AT3 levels, and high D-dimer levels. In 11 patients the standard TF stimulation did not trigger thrombin generation in the thrombogram. All deaths occurred in these patients. Free TFPI levels and free/total TFPI ratios were significantly higher in these patients and in non-survivors. CONCLUSION Failure of TF-initiated thrombin generation in the thrombogram assay explained by high levels of circulating free TFPI may be associated with OF and mortality in AP. and IAP.
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Affiliation(s)
- Outi K Lindström
- Department of Surgery, Helsinki University Central Hospital, Helsinki, Finland.
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12
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Plasma tissue factor pathway inhibitor levels in patients with acute pancreatitis. J Gastroenterol 2009; 44:1071-9. [PMID: 19565179 DOI: 10.1007/s00535-009-0096-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2009] [Accepted: 06/03/2009] [Indexed: 02/04/2023]
Abstract
BACKGROUND In acute pancreatitis (AP), disorders of the coagulation-fibrinolysis system are closely related to the severity of the AP and to organ dysfunctions. We previously reported that plasma tissue factor (TF) levels were elevated in patients with AP, particularly in cases of alcoholic AP with pancreatic necrosis. Tissue factor pathway inhibitor (TFPI) is a key regulator of the extrinsic coagulation pathway, but plasma TFPI levels in AP have not yet been determined. METHODS Plasma TFPI concentrations were measured by enzyme-linked immunosorbent assay in 44 patients with AP on admission. The relationships between AP severity, pancreatic necrosis, organ dysfunction, infection, and prognosis were analyzed. RESULTS Plasma TFPI levels were increased in AP patients compared with healthy volunteers. Plasma TFPI levels in severe AP were greater than those in mild AP. Plasma TFPI levels significantly correlated with Ranson score, APACHE II score, and Japanese severity score. Plasma TFPI levels in patients with pancreatic necrosis were greater than those in patients without pancreatic necrosis. Plasma TFPI levels in patients with organ dysfunction were greater than those in patients without organ dysfunction. In patients with pancreatic necrosis, the TF/TFPI ratios in non-survivors were lower than those in survivors. Moreover, the mortality rates in patients with TF/TFPI ratios > or = 2.0 were lower than those in patients with TF/TFPI ratios < 2.0. CONCLUSIONS Plasma TFPI levels were significantly increased in patients with AP, and the elevation was markedly related to the severity, pancreatic necrosis and organ dysfunctions. The imbalance of TF and TFPI may influence the disease state and thereby the prognosis in AP.
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Okita Y, Okahisa T, Sogabe M, Suzuki M, Ohnishi Y, Ito S. Low-Volume Continuous Hemodiafiltration With Nafamostat Mesilate Increases Trypsin Clearance Without Decreasing Plasma Trypsin Concentration in Severe Acute Pancreatitis. ASAIO J 2007; 53:207-12. [PMID: 17413562 DOI: 10.1097/mat.0b013e3180310473] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Continuous hemodiafiltration (CHDF) has recently been used for treatment of severe acute pancreatitis. CHDF is capable of eliminating small molecules from blood, but whether trypsin can be eliminated by CHDF is not clear. In this study, elimination of trypsin-like enzyme activity (TLE) and cationic trypsin-like immunoreactivity (TLI) using low-volume CHDF was examined at the first CHDF session in eight patients with severe acute pancreatitis. CHDF was performed with a polysulfone hemofilter (membrane area, 0.7 m2) and nafamostat mesilate, a protease inhibitor and anticoagulant, at a blood flow rate of 100 ml/min and a filtration and dialysis flow rate of 10 ml/min each. Before beginning CHDF, plasma TLE was 3.41 +/- 2.86 nmol/(ml.min), and TLI was 5,900 +/- 9,008 ng/ml. The average plasma clearances of TLE and TLI achieved by the circuit during the 12-hour therapy were 56.7 +/- 4.9 ml/min and 8.0 +/- 7.2 ml/min, respectively. The average plasma clearance of TLI into the waste fluid was 2.4 +/- 1.6 ml/min whereas TLE was below the measurable sensitivity. The plasma concentration of TLE and TLI remained unchanged. These results indicate that low-volume CHDF using nafamostat mesilate as an anticoagulant can increase trypsin plasma clearance. However, low-volume CHDF is not effective to eliminate the plasma trypsin concentration.
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Affiliation(s)
- Yoshio Okita
- Department of Digestive and Cardiovascular Medicine, Institute of Health Biosciences, University of Tokushima Graduate School, Tokushima, Japan
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Lugea A, Nan L, French SW, Bezerra JA, Gukovskaya AS, Pandol SJ. Pancreas recovery following cerulein-induced pancreatitis is impaired in plasminogen-deficient mice. Gastroenterology 2006; 131:885-99. [PMID: 16952557 PMCID: PMC1636452 DOI: 10.1053/j.gastro.2006.06.023] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2005] [Accepted: 06/08/2006] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS The plasminogen (plg) system participates in tissue repair in several organs, but its role in pancreas repair remains poorly characterized. To understand better the role of plg in pancreas recovery following injury, we examined the course of cerulein-induced pancreatitis in plg-deficient and -sufficient mice. METHODS Pancreatitis was induced by cerulein administration (50 microg/kg, 7 intraperitoneal injections). Mice were killed either at the acute phase (7 hours after the first cerulein injection) or during recovery (at 2, 4, and 7 days). In pancreatic sections, we examined pancreatic morphology, trypsin activation, inflammatory cell infiltration, acinar cell death, cell proliferation, extracellular matrix deposition, activation of stellate cells (PSCs), and components of the plg and metalloproteinase systems. RESULTS In plg-sufficient mice, pancreatic plg levels and plasmin activity increased during the acute phase and remained elevated during recovery. Pancreatitis resolved in plg-sufficient mice within 7 days. Pancreas recovery involved reorganization of the parenchyma structure, removal of necrotic debris, cell proliferation, transient activation of PSCs, and moderate deposition of extracellular matrix proteins. Acute pancreatitis (7 hours) was indistinguishable between plg-deficient and -sufficient mice. In contrast, pancreas recovery was impaired in plg-deficient mice. Plg deficiency led to disorganized parenchyma, extensive acinar cell loss, poor removal of necrotic debris, reduced cell proliferation, and fibrosis. Fibrosis was characterized by deposition of collagens and fibronectin, persistent activation of PSCs, and up-regulation of pancreatic transforming growth factor beta1. CONCLUSIONS Plg/plasmin deficiency leads to features similar to those found in chronic pancreatitis such as parenchymal atrophy and fibrosis.
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Affiliation(s)
- Aurelia Lugea
- USC-UCLA Research Center for Alcoholic Liver and Pancreatic Diseases, Veterans Affairs Greater Los Angeles Healthcare System and University of California, Los Angeles, California 90073, USA.
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Maeda K, Hirota M, Ichihara A, Ohmuraya M, Hashimoto D, Sugita H, Takamori H, Kanemitsu K, Baba H. Applicability of disseminated intravascular coagulation parameters in the assessment of the severity of acute pancreatitis. Pancreas 2006; 32:87-92. [PMID: 16340749 DOI: 10.1097/01.mpa.0000186248.89081.44] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES To evaluate the clinical applicability of the determination of disseminated intravascular coagulation (DIC) parameters in acute pancreatitis. METHODS The subjects for this study were 139 consecutive patients with acute pancreatitis. DIC parameters were assessed at the initial observation of these patients. RESULTS The levels of the DIC parameters at admission were significantly associated with the severity and the prognosis of acute pancreatitis. Antithrombin III (AT-III), fibrin/fibrinogen degradation products-E, platelet count, D-dimer, and thrombin-AT-III complex at admission showed better area under the receiver operating characteristics curve values compared with C-reactive protein. An AT-III value of 69% at admission was the best cut-off value to predict fatal outcome (sensitivity, 81%; specificity, 86%). CONCLUSIONS The aggravated coagulation parameters predict a fatal outcome in patients with acute pancreatitis. AT-III level (<69%) was the most accurate marker for poor outcome of acute pancreatitis at admission.
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Affiliation(s)
- Keisuke Maeda
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto City, Kumamoto, Japan
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Radenković D, Bajec D, Karamarkovic A, Stefanovic B, Milic N, Ignjatović S, Gregoric P, Milicevic M. Disorders of hemostasis during the surgical management of severe necrotizing pancreatitis. Pancreas 2004; 29:152-6. [PMID: 15257107 DOI: 10.1097/00006676-200408000-00010] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Several clinical studies of severe necrotizing pancreatitis (SNP) suggest profound activation of coagulation as well as activation of the fibrinolytic system. The aim of this study was to evaluate the hemostatic derangements in patients who were managed for SNP. METHODS Forty-one operated-on patients with SNP were analyzed regarding clinical outcome and activation of the coagulation systems. Serial measurement of coagulation, anticoagulation, and fibrinolysis parameters: prothrombin time (PT), activated partial thromboplastin time (APTT), fibrinogen, antithrombin III (AT III), protein C, plasminogen activator inhibitor-1 (PAI-1), d-dimer, alpha2-antiplasmin, and plasminogen were performed on days 1, 3, 5, 7, 10, and 14 after the initial operation. According to treatment outcome at the end of study, groups of 26 survivors and 15 nonsurvivors were compared. RESULTS Nonsurvivors had significantly lower levels of activity of protein C and AT III, and higher concentrations of d-dimer and PAI-1 than survivors. The other measured parameters did not show significant differences between the compared groups of patients. CONCLUSIONS Changes in protein C, AT III, d-dimer and PAI-1 levels indicate exhaustion of fibrinolysis and coagulation inhibitors in patients with poor outcome during the course of SNP.
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Affiliation(s)
- Dejan Radenković
- Center of Emergency Surgery, Clinical Center of Serbia and School of Medicine, University of Belgrade, Belgrade, Serbia and Montenegro.
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Nobar SM, Guy-Crotte O, Rabaud M, Bieth JG. Inhibition of human pancreatic proteinases by human plasma α2-antiplasmin and antithrombin. Biol Chem 2004; 385:423-7. [PMID: 15196003 DOI: 10.1515/bc.2004.048] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Human plasma alpha1-antitrypsin inhibits human pancreatic trypsin, chymotrypsin and elastase, which are massively released into the blood stream during acute pancreatitis. To examine whether the plasma proteins of individuals with genetic deficiency of alpha1-antitrypsin are protected against the deleterious action of these enzymes by other inhibitors, we have tested their inhibition by alpha2-antiplasmin and antithrombin. We have determined the inhibition rate constants kass and calculated d(t), the in vivo inhibition time. Surprisingly, trypsin is inhibited faster by alpha2-antiplasmin [kass=2.5 x 10(6) M(-1)S(-1), d(t)=2.3 s] and antithrombin [kass=1.7 x 10(5) M(-1)s(-1), d(t)=5.8 s] than by alpha1-antitrypsin [d(t)=17 s or 116 s in alpha1-antitrypsin-sufficient or alpha1-antitrypsin-deficient individuals, respectively]. Low molecular weight heparin accelerates the inhibition of trypsin by antithrombin by a factor of 16 [d(t)=0.36 s]. Antithrombin and alpha2-antiplasmin are not physiological inhibitors of chymotrypsin and elastase. These enzymes are, however, physiologically inhibited by alpha1-antitrypsin and alpha1-antichymotrypsin even in alpha1-antitrypsin-deficient individuals. We conclude that (i) low molecular weight heparin may be helpful in the management of acute pancreatitis, and (ii) genetically determined alpha1-antitrypsin deficiency probably does not lead to a significantly increased risk of plasma protein degradation during this disease.
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Affiliation(s)
- Shila M Nobar
- Laboratoire d'Enzymologie, INSERM U392, Université Louis Pasteur de Strasbourg, F-67400 Illkirch, France
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Salomone T, Tosi P, Palareti G, Tomassetti P, Migliori M, Guariento A, Saieva C, Raiti C, Romboli M, Gullo L. Coagulative disorders in human acute pancreatitis: role for the D-dimer. Pancreas 2003; 26:111-6. [PMID: 12604906 DOI: 10.1097/00006676-200303000-00003] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
INTRODUCTION AND AIMS We investigated coagulative disorders, particularly the role of the D-dimer, in acute pancreatitis where coagulation abnormalities related to disease severity are known to occur. METHODOLOGY D-dimer levels in 30 patients with acute pancreatitis were evaluated; pancreatitis was mild and uncomplicated in 11 patients, accompanied by complications in 15, and severe in 4. We attempted to find a relationship between the D-dimer level and the antithrombin III level, prothrombin time, partial thromboplastin time, the C-reactive protein level, and results of routine laboratory tests. RESULTS In the 11 patients with uncomplicated pancreatitis, the D-dimer level increased about 1.5 times over the limit, while in the 15 patients with complications and the four patients with severe pancreatitis, the D-dimer level increased about seven times above the normal limit; this difference was highly significant (p < 0.0001). The rise in the D-dimer level was inversely related to albumin and calcium levels (p = 0.0001) and directly related to the C-reactive protein level, fibrinogen level and leukocyte count (p = 0.0001), prothrombin time (p = 0.006), partial thromboplastin time (p = 0.03), and acute abdominal collections and lung involvement (p = 0.0001). The increase appeared early on, lasting for the entire study and peaking on days 3-6. CONCLUSIONS The D-dimer is the expression of pancreatitis and the extension of systemic involvement; it may be considered a prominent link in the chain of events leading to severe disease.
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Larvin M, Alexander DJ, Switala SF, McMahon MJ. Impaired mononuclear phagocyte function in patients with severe acute pancreatitis: evidence from studies of plasma clearance of trypsin and monocyte phagocytosis. Dig Dis Sci 1993; 38:18-27. [PMID: 8420754 DOI: 10.1007/bf01296768] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Activated proteases in plasma are complexed by alpha 2-macroglobulin. Although the complexes retain peptidase activity, they are usually eliminated promptly by mononuclear phagocytes. In severe acute pancreatitis, almost 30% of plasma alpha 2-macroglobulin becomes complexed, suggesting impaired clearance. In the present study, plasma [methyl-14C]trypsin clearance and monocyte phagocytosis were investigated. Attacks complicated by major organ-system failure, pancreatic pseudocyst, abscess, or necrosis were graded severe (median Ranson score 5.5). Plasma [methyl-14C]trypsin half-life was significantly increased in severe attacks (N = 7, median 21.1 min), compared to mild attacks (N = 14, median 15.4 min, P < 0.05) and healthy controls (N = 4, median 10.8 min, P < 0.02). Monocyte phagocytosis was significantly lower in severe attacks (N = 9, median 3.6%) compared to mild attacks (N = 20, median 20.8%, P < 0.01) and healthy controls (N = 8, median 26.9%, P < 0.01). Plasma [methyl-14C]trypsin half-life and monocyte phagocytosis were significantly inversely correlated (r = -0.51, P < 0.01). Impaired clearance of circulating trypsin in acute pancreatitis is potentially deleterious but may be reversed by stimulating mononuclear phagocytes.
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Affiliation(s)
- M Larvin
- University Department of Surgery, General Infirmary, Leeds, UK
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Etoh Y, Sumi H, Tsushima H, Maruyama M, Mihara H. Fibrinolytic enzymes in ascites during experimental acute pancreatitis in rats. INTERNATIONAL JOURNAL OF PANCREATOLOGY : OFFICIAL JOURNAL OF THE INTERNATIONAL ASSOCIATION OF PANCREATOLOGY 1992; 12:127-37. [PMID: 1460327 DOI: 10.1007/bf02924636] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The ascites accumulating during acute pancreatitis contain proteases that play a role in the progression of this disease. The proteases of the fibrinolytic system in the ascites were therefore studied in experimental acute pancreatitis induced in rats. Synthetic substrate assay and the fibrin plate method revealed high activities of proteases, including plasminogen activator, in the ascites. The plasminogen activator had a mol wt of about 50,000 by zymography. The plasminogen activator adsorbed on Lys-sepharose from the ascites was observed at the 100,000 mol wt position and in the 50,000-100,000 mol wt range on zymography and appeared at the 50,000 mol wt position after treatment by concentration. Its activity was enhanced by trypsin treatment. In other experiments, when incubated homogenate of normal pancreas lacking in zymographic activity was injected intraperitoneally into healthy rats, the recovered fluid displayed lytic zones between the 100,00 and 50,000 mol wt positions. These findings suggest that the ascites contained plasminogen activator, part of which was released by intrapancreatic substances and was present in the precursor form.
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Affiliation(s)
- Y Etoh
- Department of Physiology, Miyazaki Medical College, Japan
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Laurent P, Bieth JG. Kinetics of the inhibition of free and elastin-bound human pancreatic elastase by alpha 1-proteinase inhibitor and alpha 2-macroglobulin. BIOCHIMICA ET BIOPHYSICA ACTA 1989; 994:285-8. [PMID: 2465784 DOI: 10.1016/0167-4838(89)90306-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
At pH 8.0 and 25 degrees C alpha 1-proteinase inhibitor and alpha 2-macroglobulin bind human pancreatic elastase with rate constants of 4.7.10(5) M-1.s-1 and 6.4.10(6) M-1.s-1, respectively. The corresponding delay times of elastase inhibition in plasma are 0.4 s and 0.2 s, respectively, indicating that both inhibitors may act as physiological antielastases. Elastin impairs the elastase inhibitory capacity of alpha 1-proteinase inhibitor and alpha 2-macroglobulin. In presence of human elastin, the former behaves like a slow-binding elastase inhibitor, with a rate constant of about 260 M-1.s-1. In contrast, alpha 2-macroglobulin is a fast-binding inhibitor of elastin-bound elastase, but only one of its two sites is functioning in presence of elastin.
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Affiliation(s)
- P Laurent
- Laboratoire d'Enzymologie, INSERM Unité 237, Université Louis Pasteur de Strasbourg, Illkirch, France
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