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Gailani D, Gruber A. Targeting factor XI and factor XIa to prevent thrombosis. Blood 2024; 143:1465-1475. [PMID: 38142404 PMCID: PMC11033593 DOI: 10.1182/blood.2023020722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 11/22/2023] [Accepted: 12/07/2023] [Indexed: 12/26/2023] Open
Abstract
ABSTRACT Direct oral anticoagulants (DOACs) that inhibit the coagulation proteases thrombin or factor Xa (FXa) have replaced warfarin and other vitamin K antagonists (VKAs) for most indications requiring long-term anticoagulation. In many clinical situations, DOACs are as effective as VKAs, cause less bleeding, and do not require laboratory monitoring. However, because DOACs target proteases that are required for hemostasis, their use increases the risk of serious bleeding. Concerns over therapy-related bleeding undoubtedly contribute to undertreatment of many patients who would benefit from anticoagulation therapy. There is considerable interest in the plasma zymogen factor XI (FXI) and its protease form factor XIa (FXIa) as drug targets for treating and preventing thrombosis. Laboratory and epidemiologic studies support the conclusion that FXI contributes to venous and arterial thrombosis. Based on 70 years of clinical observations of patients lacking FXI, it is anticipated that drugs targeting this protein will cause less severe bleeding than warfarin or DOACs. In phase 2 studies, drugs that inhibit FXI or FXIa prevent venous thromboembolism after total knee arthroplasty as well as, or better than, low molecular weight heparin. Patients with heart disease on FXI or FXIa inhibitors experienced less bleeding than patients taking DOACs. Based on these early results, phase 3 trials have been initiated that compare drugs targeting FXI and FXIa to standard treatments or placebo. Here, we review the contributions of FXI to normal and abnormal coagulation and discuss results from preclinical, nonclinical, and clinical studies of FXI and FXIa inhibitors.
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Affiliation(s)
- David Gailani
- The Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN
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2
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Dickeson SK, Kumar S, Sun MF, Litvak M, He TZ, Phillips DR, Roberts ET, Feener EP, Law RHP, Gailani D. A mechanism for hereditary angioedema caused by a methionine-379-to-lysine substitution in kininogens. Blood 2024; 143:641-650. [PMID: 37992228 PMCID: PMC10873535 DOI: 10.1182/blood.2023022254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 10/20/2023] [Accepted: 11/13/2023] [Indexed: 11/24/2023] Open
Abstract
ABSTRACT Hereditary angioedema (HAE) is associated with episodic kinin-induced swelling of the skin and mucosal membranes. Most patients with HAE have low plasma C1-inhibitor activity, leading to increased generation of the protease plasma kallikrein (PKa) and excessive release of the nanopeptide bradykinin from high-molecular-weight kininogen (HK). However, disease-causing mutations in at least 10% of patients with HAE appear to involve genes for proteins other than C1-inhibitor. A point mutation in the Kng1 gene encoding HK and low-molecular weight kininogen (LK) was identified recently in a family with HAE. The mutation changes a methionine (Met379) to lysine (Lys379) in both proteins. Met379 is adjacent to the Lys380-Arg381 cleavage site at the N-terminus of the bradykinin peptide. Recombinant wild-type (Met379) and variant (Lys379) versions of HK and LK were expressed in HEK293 cells. PKa-catalyzed kinin release from HK and LK was not affected by the Lys379 substitutions. However, kinin release from HK-Lys379 and LK-Lys379 catalyzed by the fibrinolytic protease plasmin was substantially greater than from wild-type HK-Met379 and LK-Met379. Increased kinin release was evident when fibrinolysis was induced in plasma containing HK-Lys379 or LK-Lys379 compared with plasma containing wild-type HK or LK. Mass spectrometry revealed that the kinin released from wild-type and variant kininogens by PKa is bradykinin. Plasmin also released bradykinin from wild-type kininogens but cleaved HK-Lys379 and LK-Lys379 after Lys379 rather than Lys380, releasing the decapeptide Lys-bradykinin (kallidin). The Met379Lys substitutions make HK and LK better plasmin substrates, reinforcing the relationship between fibrinolysis and kinin generation.
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Affiliation(s)
- S. Kent Dickeson
- Department of Pathology, Microbiology and Immunology, Vanderbilt University, Nashville, TN
| | - Sunil Kumar
- Department of Pathology, Microbiology and Immunology, Vanderbilt University, Nashville, TN
| | - Mao-fu Sun
- Department of Pathology, Microbiology and Immunology, Vanderbilt University, Nashville, TN
| | - Maxim Litvak
- Department of Pathology, Microbiology and Immunology, Vanderbilt University, Nashville, TN
| | - Tracey Z. He
- Department of Pathology, Microbiology and Immunology, Vanderbilt University, Nashville, TN
| | | | | | | | - Ruby H. P. Law
- Department of Biochemistry and Molecular Biology, Monash University, Clayton, VIC, Australia
| | - David Gailani
- Department of Pathology, Microbiology and Immunology, Vanderbilt University, Nashville, TN
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Mohammed BM, Sun MF, Cheng Q, Litvak M, McCrae KR, Emsley J, McCarty OJT, Gailani D. High molecular weight kininogen interactions with the homologs prekallikrein and factor XI: importance to surface-induced coagulation. J Thromb Haemost 2024; 22:225-237. [PMID: 37813198 PMCID: PMC10841474 DOI: 10.1016/j.jtha.2023.09.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 09/22/2023] [Accepted: 09/27/2023] [Indexed: 10/11/2023]
Abstract
BACKGROUND In plasma, high molecular weight kininogen (HK) is either free or bound to prekallikrein (PK) or factor (F) XI (FXI). During contact activation, HK is thought to anchor PK and FXI to surfaces, facilitating their conversion to the proteases plasma kallikrein and FXIa. Mice lacking HK have normal hemostasis but are resistant to injury-induced arterial thrombosis. OBJECTIVES To identify amino acids on the HK-D6 domain involved in PK and FXI binding and study the importance of the HK-PK and HK-FXI interactions to coagulation. METHODS Twenty-four HK variants with alanine replacements spanning residues 542-613 were tested in PK/FXI binding and activated partial thromboplastin time clotting assays. Surface-induced FXI and PK activation in plasma were studied in the presence or absence of HK. Kng1-/- mice lacking HK were supplemented with human or murine HK and tested in an arterial thrombosis model. RESULTS Overlapping binding sites for PK and FXI were identified in the HK-D6 domain. HK variants with defects only in FXI binding corrected the activated partial thromboplastin time of HK-deficient plasma poorly compared to a variant defective only in PK-binding. In plasma, HK deficiency appeared to have a greater deleterious effect on FXI activation than PK activation. Human HK corrected the defect in arterial thrombus formation in HK-deficient mice poorly due to a specific defect in binding to mouse FXI. CONCLUSION Clinical observations indicate FXI is required for hemostasis, while HK is not. Yet, the HK-FXI interaction is required for contact activation-induced clotting in vitro and in vivo suggesting an important role in thrombosis and perhaps other FXI-related activities.
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Affiliation(s)
- Bassem M Mohammed
- Edward A. Doisy Research Center, Department of Biochemistry and Molecular Biology, St. Louis University School of Medicine, St. Louis, Missouri, USA.
| | - Mao-Fu Sun
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Qiufang Cheng
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Maxim Litvak
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Keith R McCrae
- Department of Hematology and Oncology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jonas Emsley
- Biodiscovery Institute, School of Pharmacy, University of Nottingham, Nottingham, UK
| | - Owen J T McCarty
- Department of Biomedical Engineering, Division of Hematology/Medical Oncology, School of Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - David Gailani
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
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Sharma M, Molina CA, Toyoda K, Bereczki D, Bangdiwala SI, Kasner SE, Lutsep HL, Tsivgoulis G, Ntaios G, Czlonkowska A, Shuaib A, Amarenco P, Endres M, Yoon BW, Tanne D, Toni D, Yperzeele L, von Weitzel-Mudersbach P, Sampaio Silva G, Avezum A, Dawson J, Strbian D, Tatlisumak T, Eckstein J, Ameriso SF, Weber JR, Sandset EC, Goar Pogosova N, Lavados PM, Arauz A, Gailani D, Diener HC, Bernstein RA, Cordonnier C, Kahl A, Abelian G, Donovan M, Pachai C, Li D, Hankey GJ. Safety and efficacy of factor XIa inhibition with milvexian for secondary stroke prevention (AXIOMATIC-SSP): a phase 2, international, randomised, double-blind, placebo-controlled, dose-finding trial. Lancet Neurol 2024; 23:46-59. [PMID: 38101902 PMCID: PMC10822143 DOI: 10.1016/s1474-4422(23)00403-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 10/02/2023] [Accepted: 10/06/2023] [Indexed: 12/17/2023]
Abstract
BACKGROUND People with factor XI deficiency have lower rates of ischaemic stroke than the general population and infrequent spontaneous bleeding, suggesting that factor XI has a more important role in thrombosis than in haemostasis. Milvexian, an oral small-molecule inhibitor of activated factor XI, added to standard antiplatelet therapy, might reduce the risk of non-cardioembolic ischaemic stroke without increasing the risk of bleeding. We aimed to estimate the dose-response of milvexian for recurrent ischaemic cerebral events and major bleeding in patients with recent ischaemic stroke or transient ischaemic attack (TIA). METHODS AXIOMATIC-SSP was a phase 2, randomised, double-blind, placebo-controlled, dose-finding trial done at 367 hospitals in 27 countries. Eligible participants aged 40 years or older, with acute (<48 h) ischaemic stroke or high-risk TIA, were randomly assigned by a web-based interactive response system in a 1:1:1:1:1:2 ratio to receive one of five doses of milvexian (25 mg once daily, 25 mg twice daily, 50 mg twice daily, 100 mg twice daily, or 200 mg twice daily) or matching placebo twice daily for 90 days. All participants received clopidogrel 75 mg daily for the first 21 days and aspirin 100 mg daily for the first 90 days. Investigators, site staff, and participants were masked to treatment assignment. The primary efficacy endpoint was the composite of ischaemic stroke or incident covert brain infarct on MRI at 90 days, assessed in all participants allocated to treatment who completed a follow-up MRI brain scan, and the primary analysis assessed the dose-response relationship with Multiple Comparison Procedure-Modelling (MCP-MOD). The main safety outcome was major bleeding at 90 days, assessed in all participants who received at least one dose of the study drug. This trial is registered with ClinicalTrials.gov (NCT03766581) and the EU Clinical Trials Register (2017-005029-19). FINDINGS Between Jan 27, 2019, and Dec 24, 2021, 2366 participants were randomly allocated to placebo (n=691); milvexian 25 mg once daily (n=328); or twice-daily doses of milvexian 25 mg (n=318), 50 mg (n=328), 100 mg (n=310), or 200 mg (n=351). The median age of participants was 71 (IQR 62-77) years and 859 (36%) were female. At 90 days, the estimates of the percentage of participants with either symptomatic ischaemic stroke or covert brain infarcts were 16·8 (90·2% CI 14·5-19·1) for placebo, 16·7 (14·8-18·6) for 25 mg milvexian once daily, 16·6 (14·8-18·3) for 25 mg twice daily, 15·6 (13·9-17·5) for 50 mg twice daily, 15·4 (13·4-17·6) for 100 mg twice daily, and 15·3 (12·8-19·7) for 200 mg twice daily. No significant dose-response was observed among the five milvexian doses for the primary composite efficacy outcome. Model-based estimates of the relative risk with milvexian compared with placebo were 0·99 (90·2% CI 0·91-1·05) for 25 mg once daily, 0·99 (0·87-1·11) for 25 mg twice daily, 0·93 (0·78-1·11) for 50 mg twice daily, 0·92 (0·75-1·13) for 100 mg twice daily, and 0·91 (0·72-1·26) for 200 mg twice daily. No apparent dose-response was observed for major bleeding (four [1%] of 682 participants with placebo, two [1%] of 325 with milvexian 25 mg once daily, two [1%] of 313 with 25 mg twice daily, five [2%] of 325 with 50 mg twice daily, five [2%] of 306 with 100 mg twice daily, and five [1%] of 344 with 200 mg twice daily). Five treatment-emergent deaths occurred, four of which were considered unrelated to the study drug by the investigator. INTERPRETATION Factor XIa inhibition with milvexian, added to dual antiplatelet therapy, did not substantially reduce the composite outcome of symptomatic ischaemic stroke or covert brain infarction and did not meaningfully increase the risk of major bleeding. Findings from our study have informed the design of a phase 3 trial of milvexian for the prevention of ischaemic stroke in patients with acute ischaemic stroke or TIA. FUNDING Bristol Myers Squibb and Janssen Research & Development.
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Affiliation(s)
- Mukul Sharma
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada.
| | | | - Kazunori Toyoda
- National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | | | - Shrikant I Bangdiwala
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Scott E Kasner
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, USA
| | - Helmi L Lutsep
- Department of Neurology, Oregon Health & Science University, Portland, OR, USA
| | - Georgios Tsivgoulis
- Second Department of Neurology, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | - George Ntaios
- Department of Internal Medicine, University of Thessaly, Larissa, Greece
| | - Anna Czlonkowska
- 2nd Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland
| | - Ashfaq Shuaib
- Division of Neurology, Department of Medicine, University of Alberta Hospital, Edmonton, AB, Canada
| | - Pierre Amarenco
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada; Department of Neurology and Stroke Center, University of Paris, Bichat Hospital, Paris, France
| | - Matthias Endres
- Department of Neurology and Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Byung-Woo Yoon
- Uijeongbu Eulji Medical Center, Eulji University, Gyeonggi-do, South Korea
| | - David Tanne
- Stroke and Cognition Institute, Rambam Health Care Campus, Haifa, Technion, Israel
| | - Danilo Toni
- Emergency Department Stroke Unit, Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
| | - Laetitia Yperzeele
- Stroke Unit and Neurovascular Center Antwerp, Department of Neurology, Antwerp University Hospital, Antwerp (Edegem), Belgium
| | | | - Gisele Sampaio Silva
- Universidade Federal de São Paulo/UNIFESP and Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Alvaro Avezum
- Centro Internacional de Pesquisa, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | - Jesse Dawson
- School of Cardiovascular and Metabolic Health, College of Medical, Veterinary & Life Sciences, Queen Elizabeth University Hospital, Glasgow, UK
| | - Daniel Strbian
- Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland
| | - Turgut Tatlisumak
- Department of Clinical Neuroscience/Neurology, Institute of Neuroscience and Physiology, Sahlgrenska Academy at the University of Gothenburg and Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Jens Eckstein
- Department of Internal Medicine and Department of Digitalization & ICT, University Hospital Basel, Basel, Switzerland
| | - Sebastián F Ameriso
- Servicio de Neurología Vascular, Departamento de Neurología, FLENI, Buenos Aires, Argentina
| | - Joerg R Weber
- Department of Neurology, Klinikum Klagenfurt, Austria
| | - Else Charlotte Sandset
- Department of Neurology, Oslo University Hospital and The Norwegian Air Ambulance Foundation, Oslo, Norway
| | - Nana Goar Pogosova
- National Medical Research Center of Cardiology after E Chazov, Moscow, Russia
| | - Pablo M Lavados
- Departamento de Neurología y Psiquiatría, Unidad de Investigación y Ensayos Clínicos, Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
| | - Antonio Arauz
- Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, México City, México
| | - David Gailani
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Hans-Christoph Diener
- Department of Neuroepidemiology, Institute for Medical Informatics, Biometry and Epidemiology (IMIBE), University Duisburg-Essen, Essen, Germany
| | - Richard A Bernstein
- Davee Department of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Charlotte Cordonnier
- University of Lille, Lille, Inserm, CHU Lille, U1172 - LiINCog - Lille Neuroscience & Cognition, F-59000, Lille, France
| | - Anja Kahl
- Bristol Myers Squibb, Princeton, NJ, USA
| | | | | | | | - Danshi Li
- Bristol Myers Squibb, Princeton, NJ, USA
| | - Graeme J Hankey
- Medical School, Centre for Neuromuscular and Neurological Disorders, The University of Western Australia, Perth, WA, Australia; Perron Institute for Neurological and Translational Science, Perth, Australia
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5
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Pfeffer MA, Kohs TC, Vu HH, Jordan KR, Wang JSH, Lorentz CU, Tucker EI, Puy C, Olson SR, DeLoughery TG, Hinds MT, Keshari RS, Gailani D, Lupu F, McCarty OJ, Shatzel JJ. Factor XI Inhibition for the Prevention of Catheter-Associated Thrombosis in Patients With Cancer Undergoing Central Line Placement: A Phase 2 Clinical Trial. Arterioscler Thromb Vasc Biol 2024; 44:290-299. [PMID: 37970718 PMCID: PMC10877270 DOI: 10.1161/atvbaha.123.319692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 10/24/2023] [Indexed: 11/17/2023]
Abstract
BACKGROUND Despite the ubiquitous utilization of central venous catheters in clinical practice, their use commonly provokes thromboembolism. No prophylactic strategy has shown sufficient efficacy to justify routine use. Coagulation factors FXI (factor XI) and FXII (factor XII) represent novel targets for device-associated thrombosis, which may mitigate bleeding risk. Our objective was to evaluate the safety and efficacy of an anti-FXI mAb (monoclonal antibody), gruticibart (AB023), in a prospective, single-arm study of patients with cancer receiving central line placement. METHODS We enrolled ambulatory cancer patients undergoing central line placement to receive a single dose of gruticibart (2 mg/kg) administered through the venous catheter within 24 hours of placement and a follow-up surveillance ultrasound at day 14 for evaluation of catheter thrombosis. A parallel, noninterventional study was used as a comparator. RESULTS In total, 22 subjects (n=11 per study) were enrolled. The overall incidence of catheter-associated thrombosis was 12.5% in the interventional study and 40.0% in the control study. The anti-FXI mAb, gruticibart, significantly prolonged the activated partial thromboplastin time in all subjects on day 14 compared with baseline (P<0.001). Gruticibart was well tolerated and without infusion reactions, drug-related adverse events, or clinically relevant bleeding. Platelet flow cytometry demonstrated no difference in platelet activation following administration of gruticibart. T (thrombin)-AT (antithrombin) and activated FXI-AT complexes increased following central line placement in the control study, which was not demonstrated in our intervention study. CRP (C-reactive protein) did not significantly increase on day 14 in those who received gruticibart, but it did significantly increase in the noninterventional study. CONCLUSIONS FXI inhibition with gruticibart was well tolerated without any significant adverse or bleeding-related events and resulted in a lower incidence of catheter-associated thrombosis on surveillance ultrasound compared with the published literature and our internal control study. These findings suggest that targeting FXI could represent a safe intervention to prevent catheter thrombosis. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT04465760.
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Affiliation(s)
- Michael A. Pfeffer
- Division of Hematology and Medical Oncology, Oregon Health
& Science University, Portland, OR
| | - Tia C.L. Kohs
- Department of Biomedical Engineering, Oregon Health &
Science University, Portland, OR
| | - Helen H. Vu
- Department of Biomedical Engineering, Oregon Health &
Science University, Portland, OR
| | - Kelley R. Jordan
- Department of Biomedical Engineering, Oregon Health &
Science University, Portland, OR
| | - Jenny Si Han Wang
- Department of Biomedical Engineering, Oregon Health &
Science University, Portland, OR
| | - Christina U. Lorentz
- Department of Biomedical Engineering, Oregon Health &
Science University, Portland, OR
- Aronora, Inc., Portland, OR
| | - Erik I. Tucker
- Department of Biomedical Engineering, Oregon Health &
Science University, Portland, OR
- Aronora, Inc., Portland, OR
| | - Cristina Puy
- Department of Biomedical Engineering, Oregon Health &
Science University, Portland, OR
| | - Sven R. Olson
- Division of Hematology and Medical Oncology, Oregon Health
& Science University, Portland, OR
| | - Thomas G. DeLoughery
- Division of Hematology and Medical Oncology, Oregon Health
& Science University, Portland, OR
| | - Monica T. Hinds
- Department of Biomedical Engineering, Oregon Health &
Science University, Portland, OR
| | - Ravi S. Keshari
- Cardiovascular Biology Research Program, Oklahoma Medical
Research Foundation, Oklahoma City, OK
| | - David Gailani
- Department of Pathology, Microbiology and Immunology,
Vanderbilt University Medical Center, Nashville, TN
| | - Florea Lupu
- Cardiovascular Biology Research Program, Oklahoma Medical
Research Foundation, Oklahoma City, OK
| | - Owen J.T. McCarty
- Department of Biomedical Engineering, Oregon Health &
Science University, Portland, OR
| | - Joseph J. Shatzel
- Division of Hematology and Medical Oncology, Oregon Health
& Science University, Portland, OR
- Department of Biomedical Engineering, Oregon Health &
Science University, Portland, OR
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Kohs TC, Vu HH, Jordan KR, Parra-Izquierdo I, Hinds MT, Shatzel JJ, Kievit P, Morgan TK, Yunga ST, Ngo TT, Aslan JE, Wallisch M, Lorentz CU, Tucker EI, Gailani D, Lindner JR, Puy C, McCarty OJ. Activation of coagulation FXI promotes endothelial inflammation and amplifies platelet activation in a nonhuman primate model of hyperlipidemia. Res Pract Thromb Haemost 2024; 8:102276. [PMID: 38226339 PMCID: PMC10788631 DOI: 10.1016/j.rpth.2023.102276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 09/16/2023] [Accepted: 09/19/2023] [Indexed: 01/17/2024] Open
Abstract
Background Hyperlipidemia is associated with chronic inflammation and thromboinflammation. This is an underlying cause of several cardiovascular diseases, including atherosclerosis. In diseased blood vessels, rampant thrombin generation results in the initiation of the coagulation cascade, activation of platelets, and endothelial cell dysfunction. Coagulation factor (F) XI represents a promising therapeutic target to reduce thromboinflammation, as it is uniquely positioned at an intersection between inflammation and thrombin generation. Objectives This study aimed to investigate the role of FXI in promoting platelet and endothelial cell activation in a model of hyperlipidemia. Methods Nonhuman primates (NHPs) were fed a standard chow diet (lean, n = 6) or a high-fat diet (obese, n = 8) to establish a model of hyperlipidemia. Obese NHPs were intravenously administered a FXI blocking antibody (2 mg/kg) and studied at baseline and at 1, 7, 14, 21, and 28 days after drug administration. Platelet activation and inflammatory markers were measured using fluorescence-activated cell sorting or enzyme-linked immunosorbent assay. Molecular imaging was used to quantify vascular cell adhesion molecule 1 (VCAM-1) expression at the carotid bifurcation. Results Obese NHPs demonstrated increased sensitivity for platelet P-selectin expression and phosphatidylserine exposure in response to platelet GPVI or PAR agonists compared with lean NHPs. Obese NHPs exhibited elevated levels of C-reactive protein, cathepsin D, and myeloperoxidase compared with lean NHPs. Following pharmacological inhibition of FIX activation by FXIa, platelet priming for activation by GPVI or PAR agonists, C-reactive protein levels, and endothelial VCAM-1 levels were reduced in obese NHPs. Conclusion FXI activation promotes the proinflammatory phenotype of hyperlipidemia by priming platelet activation and inciting endothelial cell dysfunction.
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Affiliation(s)
- Tia C.L. Kohs
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, Oregon, USA
| | - Helen H. Vu
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, Oregon, USA
| | - Kelley R. Jordan
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, Oregon, USA
| | - Iván Parra-Izquierdo
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, Oregon, USA
| | - Monica T. Hinds
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, Oregon, USA
| | - Joseph J. Shatzel
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, Oregon, USA
- Division of Hematology and Oncology, Oregon Health & Science University, Portland, Oregon, USA
| | - Paul Kievit
- Division of Cardiometabolic Health, Oregon National Primate Research Center, Oregon Health & Science University, Beaverton, Oregon, USA
| | - Terry K. Morgan
- Department of Pathology and Laboratory Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Samuel Tassi Yunga
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, Oregon, USA
- Cancer Early Detection Advanced Research Center, Knight Cancer Institute, Oregon Health & Science University, Portland, Oregon, USA
| | - Thuy T.M. Ngo
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, Oregon, USA
- Cancer Early Detection Advanced Research Center, Knight Cancer Institute, Oregon Health & Science University, Portland, Oregon, USA
- Department of Molecular and Medical Genetics, Oregon Health & Science University, Portland, Oregon, USA
| | - Joseph E. Aslan
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, Oregon, USA
- Knight Cardiovascular Institute, School of Medicine, Oregon Health & Science University, Portland, Oregon, USA
- Department of Chemical Physiology and Biochemistry, Oregon Health & Science University, Portland, Oregon, USA
| | - Michael Wallisch
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, Oregon, USA
- Aronora, Inc, Portland, Oregon, USA
| | - Christina U. Lorentz
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, Oregon, USA
- Aronora, Inc, Portland, Oregon, USA
| | - Erik I. Tucker
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, Oregon, USA
- Aronora, Inc, Portland, Oregon, USA
| | - David Gailani
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jonathan R. Lindner
- Division of Cardiovascular Medicine and Robert M. Berne Cardiovascular Research Institute, University of Virginia, Charlottesville, Virginia, USA
| | - Cristina Puy
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, Oregon, USA
| | - Owen J.T. McCarty
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, Oregon, USA
- Division of Hematology and Oncology, Oregon Health & Science University, Portland, Oregon, USA
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7
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Clermont AC, Murugesan N, Edwards HJ, Lee DK, Bayliss NP, Duckworth EJ, Pethen SJ, Hampton SL, Gailani D, Feener EP. Oral FXIIa inhibitor KV998086 suppresses FXIIa and single chain FXII mediated kallikrein kinin system activation. Front Pharmacol 2023; 14:1287487. [PMID: 38178859 PMCID: PMC10766353 DOI: 10.3389/fphar.2023.1287487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 12/04/2023] [Indexed: 01/06/2024] Open
Abstract
Background: The kallikrein kinin system (KKS) is an established pharmacological target for the treatment and prevention of attacks in hereditary angioedema (HAE). Proteolytic activities of FXIIa and single-chain Factor XII (FXII) zymogen contribute to KKS activation and thereby may play roles in both initiating and propagating HAE attacks. In this report, we investigated the effects of potent small molecule FXIIa inhibitors on FXIIa and single chain FXII enzymatic activities, KKS activation, and angioedema in mice. Methods: We examined the effects of 29 structurally distinct FXIIa inhibitors on enzymatic activities of FXIIa and a mutant single chain FXII with R334A, R343A and R353A substitutions (rFXII-T), that does not undergo zymogen conversion to FXIIa, using kinetic fluorogenic substrate assays. We examined the effects of a representative FXIIa inhibitor, KV998086, on KKS activation and both carrageenan- and captopril-induced angioedema in mice. Results: FXIIa inhibitors designed to target its catalytic domain also potently inhibited the enzymatic activity of rFXII-T and the pIC50s of these compounds linearly correlated for rFXIIa and rFXII-T (R 2 = 0.93). KV998086, a potent oral FXIIa inhibitor (IC50 = 7.2 nM) inhibited dextran sulfate (DXS)-stimulated generation of plasma kallikrein and FXIIa, and the cleavage of high molecular weight kininogen (HK) in human plasma. KV998086 also inhibited rFXII-T mediated HK cleavage (p < 0.005) in plasma from FXII knockout mice supplemented with rFXII-T and stimulated with polyphosphate or DXS. Orally administered KV998086 protected mice from 1) captopril-induced Evans blue leakage in colon and laryngotracheal tissues and 2) blocked carrageenan-induced plasma HK consumption and paw edema. Conclusion: These findings show that small molecule FXIIa inhibitors, designed to target its active site, also inhibit the enzymatic activity of FXII zymogen. Combined inhibition of FXII zymogen and FXIIa may thereby suppress both the initiation and amplification of KKS activation that contribute to hereditary angioedema attacks and other FXII-mediated diseases.
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Affiliation(s)
| | | | | | | | | | | | | | | | - David Gailani
- Hematology/Oncology Division, Vanderbilt University, Nashville, TN, United States
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8
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Meyer AD, Thorpe CR, Fraker T, Cancio T, Rocha J, Willis RP, Cap AP, Gailani D, Shatzel JJ, Tucker EI, McCarty OJ. Factor XI Inhibition With Heparin Reduces Clot Formation in Simulated Pediatric Extracorporeal Membrane Oxygenation. ASAIO J 2023; 69:1074-1082. [PMID: 37801726 PMCID: PMC10841048 DOI: 10.1097/mat.0000000000002048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/08/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) supplies circulatory support and gas exchange to critically ill patients. Despite the use of systemic anticoagulation, blood exposure to ECMO surfaces causes thromboembolism complications. Inhibition of biomaterial surface-mediated activation of coagulation factor XI (FXI) may prevent device-associated thrombosis. Blood was collected from healthy volunteers (n = 13) following the U.S. Army Institute of Surgical Research standard operating procedure for testing in an ex vivo ECMO circuit. A roller-pump circuit circulated either 0.5 U/ml of unfractionated heparin alone or in combination with the anti-FXI immunoglobulin G (IgG) (AB023) for 6 hours or until clot formation caused device failure. Coagulation factor activity, platelet counts, time to thrombin generation, peak thrombin, and endogenous thrombin potential were quantified. AB023 in addition to heparin sustained circuit patency in all tested circuits (5/5) after 6 hours, while 60% of circuits treated with heparin alone occluded (3/8), log-rank p < 0.03. AB023 significantly prolonged the time to clot formation as compared to heparin alone (15.5 vs . 3.3 minutes; p < 0.01) at the 3-hour time point. AB023 plus heparin significantly reduced peak thrombin compared to heparin alone (123 vs . 217 nM; p < 0.01). Inhibition of contact pathway activation of FXI may be an effective adjunct to anticoagulation in extracorporeal life support.
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Affiliation(s)
- Andrew D. Meyer
- Division of Pediatric Critical Care, Department of Pediatrics, University of Texas Health Science Center, San Antonio, TX
- Organ Support & Automation Technologies, U.S. Army Institute of Surgical Research (USAISR), Ft. Sam Houston, TX
| | | | - Tamara Fraker
- The Geneva Foundation, San Antonio Military Medical Center, Ft. Sam Houston, TX
| | | | | | | | - Andrew P. Cap
- Organ Support & Automation Technologies, U.S. Army Institute of Surgical Research (USAISR), Ft. Sam Houston, TX
| | - David Gailani
- Department of Pathology, Microbiology and Immunology, Vanderbilt University School of Medicine, Nashville, TN
| | - Joseph J. Shatzel
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR
- Division of Hematology & Medical Oncology, Oregon Health & Science University, Portland, OR
| | - Erik I. Tucker
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR
- Aronora, Inc., Portland, OR
| | - Owen J.T. McCarty
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR
- Aronora, Inc., Portland, OR
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9
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Raghavendran P, Tillman BF, Wheeler AP, Gailani D. Chromogenic and Clot-Based Bivalirudin Assays for Monitoring Anticoagulation. J Appl Lab Med 2023; 8:1074-1083. [PMID: 37811688 PMCID: PMC10842487 DOI: 10.1093/jalm/jfad072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 08/28/2023] [Indexed: 10/10/2023]
Abstract
BACKGROUND Direct thrombin inhibitors (DTIs) are usually monitored with the activated partial thromboplastin time (aPTT) or activated clotting time (ACT). Both are complex assays with multiple enzymatic steps, and performance may be influenced by physiologic and pathologic factors unrelated to the DTI. Simpler systems, such as clot-based dilute thrombin time (dTT) and chromogenic anti-factor IIa assays, have been developed for monitoring DTIs, but there is limited data on their performance in clinical settings. METHODS Medical records of patients who received bivalirudin between March 2020 and April 2022 at a single institution were reviewed for demographic data and adverse outcomes. Plasma samples drawn for aPTT testing were analyzed with chromogenic anti-IIa and dTT bivalirudin assays. Results were compared to bivalirudin dosing. RESULTS Results of aPTT assays from 32 patients were compared with the chromogenic (n = 136) and dTT (n = 120) bivalirudin assays. Correlations between the aPTT and the chromogenic and dTT assays were poor (Spearman coefficients 0.55 and 0.62, respectively). There was a stronger correlation when results of the chromogenic and dTT assays were compared to each other (Spearman coefficient 0.92). When assay results were compared to bivalirudin dose, there were stronger correlations with the chromogenic and dTT assays than with the aPTT (Spearman coefficients 0.51, 0.63 and 0.22, respectively). CONCLUSIONS There was considerable variation between results of specific bivalirudin assays and the aPTT. While bivalirudin assay results correlated better with administered drug dose, suggesting improving reliability, more studies are needed to determine if there is correlation between testing and clinical outcomes.
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Affiliation(s)
- Prashant Raghavendran
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Benjamin F. Tillman
- Division of Hematology and Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Allison P. Wheeler
- Department of Pathology, Microbiology and Immunology, Vanderbilt University, Nashville, TN, United States
| | - David Gailani
- Department of Pathology, Microbiology and Immunology, Vanderbilt University, Nashville, TN, United States
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10
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Kohs TCL, Fallon ME, Oseas EC, Healy LD, Tucker EI, Gailani D, McCarty OJT, Vandenbark AA, Offner H, Verbout NG. Pharmacological targeting of coagulation factor XI attenuates experimental autoimmune encephalomyelitis in mice. Metab Brain Dis 2023; 38:2383-2391. [PMID: 37341855 PMCID: PMC10530106 DOI: 10.1007/s11011-023-01251-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 06/05/2023] [Indexed: 06/22/2023]
Abstract
Multiple sclerosis (MS) is the most common causes of non-traumatic disability in young adults worldwide. MS pathophysiologies include the formation of inflammatory lesions, axonal damage and demyelination, and blood brain barrier (BBB) disruption. Coagulation proteins, including factor (F)XII, can serve as important mediators of the adaptive immune response during neuroinflammation. Indeed, plasma FXII levels are increased during relapse in relapsing-remitting MS patients, and previous studies showed that reducing FXII levels was protective in a murine model of MS, experimental autoimmune encephalomyelitis (EAE). Our objective was to determine if pharmacological targeting of FXI, a major substrate of activated FXII (FXIIa), improves neurological function and attenuates CNS damage in the setting of EAE. EAE was induced in male mice using murine myelin oligodendrocyte glycoprotein peptides combined with heat-inactivated Mycobacterium tuberculosis and pertussis toxin. Upon onset of symptoms, mice were treated every other day intravenously with anti-FXI antibody, 14E11, or saline. Disease scores were recorded daily until euthanasia for ex vivo analyses of inflammation. Compared to the vehicle control, 14E11 treatment reduced the clinical severity of EAE and total mononuclear cells, including CD11b+CD45high macrophage/microglia and CD4+ T cell numbers in brain. Following pharmacological targeting of FXI, BBB disruption was reduced, as measured by decreased axonal damage and fibrin(ogen) accumulation in the spinal cord. These data demonstrate that pharmacological inhibition of FXI reduces disease severity, immune cell migration, axonal damage, and BBB disruption in mice with EAE. Thus, therapeutic agents targeting FXI and FXII may provide a useful approach for treating autoimmune and neurologic disorders.
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Affiliation(s)
- Tia C L Kohs
- Department of Biomedical Engineering, Oregon Health & Science University, 3303 S. Bond Avenue, Portland, OR, 97239, USA.
| | - Meghan E Fallon
- Department of Biomedical Engineering, Oregon Health & Science University, 3303 S. Bond Avenue, Portland, OR, 97239, USA
| | - Ethan C Oseas
- Department of Biomedical Engineering, Oregon Health & Science University, 3303 S. Bond Avenue, Portland, OR, 97239, USA
| | - Laura D Healy
- Department of Biomedical Engineering, Oregon Health & Science University, 3303 S. Bond Avenue, Portland, OR, 97239, USA
| | - Erik I Tucker
- Department of Biomedical Engineering, Oregon Health & Science University, 3303 S. Bond Avenue, Portland, OR, 97239, USA
- Aronora, Inc., Portland, OR, USA
| | - David Gailani
- Department of Pathology and Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Owen J T McCarty
- Department of Biomedical Engineering, Oregon Health & Science University, 3303 S. Bond Avenue, Portland, OR, 97239, USA
| | - Arthur A Vandenbark
- Department of Neurology, Oregon Health & Science University, Portland, OR, USA
- Department of Molecular Microbiology & Immunology, Oregon Health & Science University, Portland, OR, USA
- Veterans Affairs Portland Health Care System, Portland, OR, USA
- Department of Anesthesiology & Perioperative Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Halina Offner
- Department of Neurology, Oregon Health & Science University, Portland, OR, USA
| | - Norah G Verbout
- Department of Biomedical Engineering, Oregon Health & Science University, 3303 S. Bond Avenue, Portland, OR, 97239, USA
- Aronora, Inc., Portland, OR, USA
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11
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Mohammed BM, Gailani D. Kininogen debuts on apple (domain) disks. J Thromb Haemost 2023; 21:2370-2372. [PMID: 37597897 PMCID: PMC10616902 DOI: 10.1016/j.jtha.2023.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 05/11/2023] [Indexed: 08/21/2023]
Affiliation(s)
- Bassem M Mohammed
- Department of Biochemistry and Molecular Biology, Edward A. Doisy Research Center, St. Louis University School of Medicine, St. Louis, Missouri, USA
| | - David Gailani
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
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12
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Shamanaev A, Litvak M, Ivanov I, Srivastava P, Sun MF, Dickeson SK, Kumar S, He TZ, Gailani D. Factor XII Structure-Function Relationships. Semin Thromb Hemost 2023:10.1055/s-0043-1769509. [PMID: 37276883 PMCID: PMC10696136 DOI: 10.1055/s-0043-1769509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Factor XII (FXII), the zymogen of the protease FXIIa, contributes to pathologic processes such as bradykinin-dependent angioedema and thrombosis through its capacity to convert the homologs prekallikrein and factor XI to the proteases plasma kallikrein and factor XIa. FXII activation and FXIIa activity are enhanced when the protein binds to a surface. Here, we review recent work on the structure and enzymology of FXII with an emphasis on how they relate to pathology. FXII is a homolog of pro-hepatocyte growth factor activator (pro-HGFA). We prepared a panel of FXII molecules in which individual domains were replaced with corresponding pro-HGFA domains and tested them in FXII activation and activity assays. When in fluid phase (not surface bound), FXII and prekallikrein undergo reciprocal activation. The FXII heavy chain restricts reciprocal activation, setting limits on the rate of this process. Pro-HGFA replacements for the FXII fibronectin type 2 or kringle domains markedly accelerate reciprocal activation, indicating disruption of the normal regulatory function of the heavy chain. Surface binding also enhances FXII activation and activity. This effect is lost if the FXII first epidermal growth factor (EGF1) domain is replaced with pro-HGFA EGF1. These results suggest that FXII circulates in blood in a "closed" form that is resistant to activation. Intramolecular interactions involving the fibronectin type 2 and kringle domains maintain the closed form. FXII binding to a surface through the EGF1 domain disrupts these interactions, resulting in an open conformation that facilitates FXII activation. These observations have implications for understanding FXII contributions to diseases such as hereditary angioedema and surface-triggered thrombosis, and for developing treatments for thrombo-inflammatory disorders.
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Affiliation(s)
- Aleksandr Shamanaev
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Maxim Litvak
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ivan Ivanov
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Priyanka Srivastava
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mao-Fu Sun
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - S. Kent Dickeson
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sunil Kumar
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Tracey Z. He
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - David Gailani
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee
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13
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Shamanaev A, Dickeson SK, Ivanov I, Litvak M, Sun MF, Kumar S, Cheng Q, Srivastava P, He TZ, Gailani D. Mechanisms involved in hereditary angioedema with normal C1-inhibitor activity. Front Physiol 2023; 14:1146834. [PMID: 37288434 PMCID: PMC10242079 DOI: 10.3389/fphys.2023.1146834] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 05/12/2023] [Indexed: 06/09/2023] Open
Abstract
Patients with the inherited disorder hereditary angioedema (HAE) suffer from episodes of soft tissue swelling due to excessive bradykinin production. In most cases, dysregulation of the plasma kallikrein-kinin system due to deficiency of plasma C1 inhibitor is the underlying cause. However, at least 10% of HAE patients have normal plasma C1 inhibitor activity levels, indicating their syndrome is the result of other causes. Two mutations in plasma protease zymogens that appear causative for HAE with normal C1 inhibitor activity have been identified in multiple families. Both appear to alter protease activity in a gain-of-function manner. Lysine or arginine substitutions for threonine 309 in factor XII introduces a new protease cleavage site that results in formation of a truncated factor XII protein (Δ-factor XII) that accelerates kallikrein-kinin system activity. A glutamic acid substitution for lysine 311 in the fibrinolytic protein plasminogen creates a consensus binding site for lysine/arginine side chains. The plasmin form of the variant plasminogen cleaves plasma kininogens to release bradykinin directly, bypassing the kallikrein-kinin system. Here we review work on the mechanisms of action of the FXII-Lys/Arg309 and Plasminogen-Glu311 variants, and discuss the clinical implications of these mechanisms.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - David Gailani
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, United States
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14
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Gailani D. Hereditary angioedema and thrombosis. Blood 2023; 141:2295-2297. [PMID: 37166925 PMCID: PMC10273157 DOI: 10.1182/blood.2023019861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2023] Open
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15
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Barnes GD, Ageno W, Castellucci LA, Chiasakul T, Eslick R, Ferreiro JL, Gailani D, Gorog DA, Lip GYH, Raffini L, Rezende SM, Weitz JI, Cuker A. Recommendation on the nomenclature for anticoagulants: updated communication from the International Society on Thrombosis and Haemostasis Scientific and Standardization Commitee on the Control of Anticoagulation. J Thromb Haemost 2023; 21:1381-1384. [PMID: 36796485 PMCID: PMC10629847 DOI: 10.1016/j.jtha.2023.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 02/06/2023] [Accepted: 02/06/2023] [Indexed: 02/16/2023]
Abstract
Oral anticoagulation therapy has evolved beyond vitamin K antagonists to include oral direct thrombin inhibitors and factor Xa inhibitors. Collectively known as "direct oral anticoagulants," this class of medications represents the current standard of care for the prevention and treatment of common thrombotic disorders, including atrial fibrillation and venous thromboembolism. Medications that target factors XI/XIa and XII/XIIa are currently under investigation for several thrombotic and nonthrombotic conditions. Given that these emerging medications will likely have distinct risk-benefit profiles to the current direct oral anticoagulants, may have different routes of administration, and could be used for unique clinical conditions (e.g., hereditary angioedema), the International Society on Thrombosis and Haemostasis Subcommittee on Control of Anticoagulation assembled a writing group to make recommendations on the nomenclature of anticoagulant medications. With input from the broader thrombosis community, the writing group recommends that anticoagulant medications be described by the route of administration and specific targets (e.g., oral factor XIa inhibitor).
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Affiliation(s)
- Geoffrey D Barnes
- Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan, USA.
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Lana A Castellucci
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada. https://twitter.com/LanaCastellucci
| | - Thita Chiasakul
- Department of Medicine, Research Unit in Translational Hematology, Division of Hematology, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand. https://twitter.com/JoyThitaC
| | - Renee Eslick
- Department of Haematology, Canberra Health Services, Garran, Australia. https://twitter.com/Renee_Eslick
| | - José L Ferreiro
- Department of Cardiology, Bellvitge University Hospital, and Bio-Heart Cardiovascular Diseases Research Group, Bellvitge Biomedical Research Institute (IDIBELL), CIBERCV, L'Hospitalet de Llobregat, Spain
| | - David Gailani
- Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Diana A Gorog
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Leslie Raffini
- Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Suely M Rezende
- Department of Internal Medicine, Faculty of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | | | - Adam Cuker
- Department of Medicine and Department of Pathology & Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA. https://twitter.com/CukerMD
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16
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Litvak M, Shamanaev A, Zalawadiya S, Matafonov A, Kobrin A, Feener EP, Wallisch M, Tucker EI, McCarty OJT, Gailani D. Titanium is a potent inducer of contact activation: implications for intravascular devices. J Thromb Haemost 2023; 21:1200-1213. [PMID: 36696212 PMCID: PMC10621279 DOI: 10.1016/j.jtha.2022.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 12/07/2022] [Accepted: 12/15/2022] [Indexed: 01/09/2023]
Abstract
BACKGROUND Titanium (Ti) and its alloys are widely used in manufacturing medical devices because of their strength and resistance to corrosion. Although Ti compounds are considered compatible with blood, they appear to support plasma contact activation and may be thrombogenic. OBJECTIVES The objective of this study was to compare Ti and titanium nitride (TiN) with known activators of contact activation (kaolin and silica) in plasma-clotting assays and to assess binding and activation of factor XII, (FXII), factor XI (FXI), prekallikrein, and high-molecular-weight kininogen (HK) with Ti/TiN. METHODS Ti-based nanospheres and foils were compared with kaolin, silica, and aluminum in plasma-clotting assays. Binding and activation of FXII, prekallikrein, HK, and FXI to surfaces was assessed with western blots and chromogenic assays. RESULTS Using equivalent surface amounts, Ti and TiN were comparable with kaolin and superior to silica, for inducing coagulation and FXII autoactivation. Similar to many inducers of contact activation, Ti and TiN are negatively charged; however, their effects on FXII are not neutralized by the polycation polybrene. Antibodies to FXII, prekallikrein, or FXI or coating Ti with poly-L-arginine blocked Ti-induced coagulation. An antibody to FXII reduced FXII and PK binding to Ti, kallikrein generation, and HK cleavage. CONCLUSION Titanium compounds induce contact activation with a potency comparable with that of kaolin. Binding of FXII with Ti shares some features with FXII binding to soluble polyanions but may have unique features. Inhibitors targeting FXII or FXI may be useful in mitigating Ti-induced contact activation in patients with titanium-based implants that are exposed to blood.
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Affiliation(s)
- Maxim Litvak
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Aleksandr Shamanaev
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sandip Zalawadiya
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Anton Matafonov
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Anton Kobrin
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Edward P Feener
- KalVista Pharmaceuticals, Inc., Cambridge, Massachusetts, USA
| | - Michael Wallisch
- Aronora, Inc., Portland, Oregon, USA; Department of Biomedical Engineering, Oregon Health & Science University, Oregon, USA
| | - Erik I Tucker
- Aronora, Inc., Portland, Oregon, USA; Department of Biomedical Engineering, Oregon Health & Science University, Oregon, USA
| | - Owen J T McCarty
- Department of Biomedical Engineering, Oregon Health & Science University, Oregon, USA
| | - David Gailani
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
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17
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Sparkenbaugh EM, Henderson MW, Miller-Awe M, Abrams C, Ilich A, Trebak F, Ramadas N, Vital S, Bohinc D, Bane KL, Chen C, Patel M, Wallisch M, Renné T, Gruber A, Cooley B, Gailani D, Kasztan M, Vercellotti GM, Belcher JD, Gavins FE, Stavrou EX, Key NS, Pawlinski R. Factor XII contributes to thrombotic complications and vaso-occlusion in sickle cell disease. Blood 2023; 141:1871-1883. [PMID: 36706361 PMCID: PMC10122107 DOI: 10.1182/blood.2022017074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 01/03/2023] [Accepted: 01/05/2023] [Indexed: 01/28/2023] Open
Abstract
A hypercoagulable state, chronic inflammation, and increased risk of venous thrombosis and stroke are prominent features in patients with sickle cell disease (SCD). Coagulation factor XII (FXII) triggers activation of the contact system that is known to be involved in both thrombosis and inflammation, but not in physiological hemostasis. Therefore, we investigated whether FXII contributes to the prothrombotic and inflammatory complications associated with SCD. We found that when compared with healthy controls, patients with SCD exhibit increased circulating biomarkers of FXII activation that are associated with increased activation of the contact pathway. We also found that FXII, but not tissue factor, contributes to enhanced thrombin generation and systemic inflammation observed in sickle cell mice challenged with tumor necrosis factor α. In addition, FXII inhibition significantly reduced experimental venous thrombosis, congestion, and microvascular stasis in a mouse model of SCD. Moreover, inhibition of FXII attenuated brain damage and reduced neutrophil adhesion to the brain vasculature of sickle cell mice after ischemia/reperfusion induced by transient middle cerebral artery occlusion. Finally, we found higher FXII, urokinase plasminogen activator receptor, and αMβ2 integrin expression in neutrophils of patients with SCD compared with healthy controls. Our data indicate that targeting FXII effectively reduces experimental thromboinflammation and vascular complications in a mouse model of SCD, suggesting that FXII inhibition may provide a safe approach for interference with inflammation, thrombotic complications, and vaso-occlusion in patients with SCD.
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Affiliation(s)
- Erica M. Sparkenbaugh
- Division of Hematology and Blood Research Center, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Michael W. Henderson
- Division of Hematology and Blood Research Center, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Megan Miller-Awe
- Division of Hematology and Blood Research Center, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Christina Abrams
- Division of Hematology and Blood Research Center, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Anton Ilich
- Division of Hematology and Blood Research Center, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Fatima Trebak
- Division of Hematology and Blood Research Center, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Nirupama Ramadas
- Division of Hematology and Blood Research Center, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Shantel Vital
- Louisiana State University Health Sciences Center, Shreveport, LA
| | - Dillon Bohinc
- Hematology and Oncology Division, Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Kara L. Bane
- Hematology and Oncology Division, Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Chunsheng Chen
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN
| | - Margi Patel
- Division of Hematology-Oncology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL
| | | | - Thomas Renné
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Center for Thrombosis and Hemostasis, Johannes Gutenberg University Medical Center, Mainz, Germany
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | | | - Brian Cooley
- Division of Hematology and Blood Research Center, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | - Malgorzata Kasztan
- Division of Hematology-Oncology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL
| | - Gregory M. Vercellotti
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN
| | - John D. Belcher
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN
| | - Felicity E. Gavins
- Department of Life Sciences, Centre for Inflammation Research and Translational Medicine, Brunel University London, London, United Kingdom
| | - Evi X. Stavrou
- Hematology and Oncology Division, Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH
- Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, OH
- Department of Medicine, Section of Hematology-Oncology, Louis Stokes Veterans Administration Medical Center, Cleveland, OH
| | - Nigel S. Key
- Division of Hematology and Blood Research Center, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Rafal Pawlinski
- Division of Hematology and Blood Research Center, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
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18
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Shamanaev A, Litvak M, Cheng Q, Ponczek M, Dickeson SK, Smith SA, Morrissey JH, Gailani D. A site on factor XII required for productive interactions with polyphosphate. J Thromb Haemost 2023; 21:1567-1579. [PMID: 36863563 DOI: 10.1016/j.jtha.2023.02.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 02/07/2023] [Accepted: 02/22/2023] [Indexed: 03/04/2023]
Abstract
BACKGROUND During plasma contact activation, factor XII (FXII) binds to surfaces through its heavy chain and undergoes conversion to the protease FXIIa. FXIIa activates prekallikrein and factor XI (FXI). Recently, we showed that the FXII first epidermal growth factor-1 (EGF1) domain is required for normal activity when polyphosphate is used as a surface. OBJECTIVES The aim of this study was to identify amino acids in the FXII EGF1 domain required for polyphosphate-dependent FXII functions. METHODS FXII with alanine substitutions for basic residues in the EGF1 domain were expressed in HEK293 fibroblasts. Wild-type FXII (FXII-WT) and FXII containing the EGF1 domain from the related protein Pro-HGFA (FXII-EGF1) were positive and negative controls. Proteins were tested for their capacity to be activated, and to activate prekallikrein and FXI, with or without polyphosphate, and to replace FXII-WT in plasma clotting assays and a mouse thrombosis model. RESULTS FXII and all FXII variants were activated similarly by kallikrein in the absence of polyphosphate. However, FXII with alanine replacing Lys73, Lys74, and Lys76 (FXII-Ala73,74,76) or Lys76, His78, and Lys81 (FXII-Ala76,78,81) were activated poorly in the presence of polyphosphate. Both have <5% of normal FXII activity in silica-triggered plasma clotting assays and have reduced binding affinity for polyphosphate. Activated FXIIa-Ala73,74,76 displayed profound defects in surface-dependent FXI activation in purified and plasma systems. FXIIa-Ala73,74,76 reconstituted FXII-deficient mice poorly in an arterial thrombosis model. CONCLUSION FXII Lys73, Lys74, Lys76, and Lys81 form a binding site for polyanionic substances such as polyphosphate that is required for surface-dependent FXII function.
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Affiliation(s)
- Aleksandr Shamanaev
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA. https://twitter.com/Aleksan18944927
| | - Maxim Litvak
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Qiufang Cheng
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Michal Ponczek
- Department of General Biochemistry, Faculty of Biology and Environmental Protection, University of Lodz, Lodz, Poland
| | - S Kent Dickeson
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Stephanie A Smith
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - James H Morrissey
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - David Gailani
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA.
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19
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Mohammed BM, Cheng Q, Gailani D. A demonstration of factor XI contributing to hemostasis in the absence of factor XII. Res Pract Thromb Haemost 2022; 6:e12841. [PMID: 36426234 PMCID: PMC9679972 DOI: 10.1002/rth2.12841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 09/26/2022] [Accepted: 10/11/2022] [Indexed: 11/23/2022] Open
Affiliation(s)
- Bassem M. Mohammed
- Department of BiochemistrySt. Louis UniversityMissouriSt. LouisUSA
- Department of Pathology, Microbiology and ImmunologyVanderbilt University Medical CenterTennesseeNashvilleUSA
| | - Qiufang Cheng
- Department of Pathology, Microbiology and ImmunologyVanderbilt University Medical CenterTennesseeNashvilleUSA
| | - David Gailani
- Department of Pathology, Microbiology and ImmunologyVanderbilt University Medical CenterTennesseeNashvilleUSA
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20
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Jordan KR, Wyatt CR, Fallon ME, Woltjer R, Neuwelt EA, Cheng Q, Gailani D, Lorentz C, Tucker EI, McCarty OJ, Hinds MT, Nguyen KP. Pharmacological reduction of coagulation factor XI reduces macrophage accumulation and accelerates deep vein thrombosis resolution in a mouse model of venous thrombosis. J Thromb Haemost 2022; 20:2035-2045. [PMID: 35638310 PMCID: PMC9580566 DOI: 10.1111/jth.15777] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 05/10/2022] [Accepted: 05/25/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Deep vein thrombosis (DVT) and post-thrombotic syndrome (PTS) remain highly prevalent despite modern medical therapy. Contact activation is a promising target for safe antithrombotic anticoagulation. The anti-factor XI (FXI) monoclonal antibody 14E11 reduces circulating levels of FXI without compromising hemostasis. The human recombinant analog, AB023, is in clinical development. The role of FXI in mediation of inflammation during DVT resolution is unknown. OBJECTIVES Investigate the effects of pharmacological targeting of FXI with 14E11 in an experimental model of venous thrombosis. METHODS Adult wild-type CD1 mice were treated with subcutaneous anti-FXI antibody (14E11, 5 mg/kg) versus saline prior to undergoing surgical constriction of the inferior vena cava (IVC). Mice were evaluated at various time points to assess thrombus weight and volume, as well as histology analysis, ferumoxytol enhanced magnetic resonance imaging (Fe-MRI), and whole blood flow cytometry. RESULTS 14E11-treated mice had reduced thrombus weights and volumes after IVC constriction on day 7 compared to saline-treated mice. 14E11 treatment reduced circulating monocytes by flow cytometry and macrophage content within thrombi as evaluated by histologic staining and Fe-MRI. Collagen deposition was increased at day 3 while CD31 and smooth muscle cell actin expression was increased at day 7 in the thrombi of 14E11-treated mice compared to saline-treated mice. CONCLUSION Pharmacologic targeting of FXI enhances the early stages of experimental venous thrombus resolution in wild-type CD1 mice, and may be of interest for future clinical evaluation of the antibody in DVT and PTS.
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Affiliation(s)
- Kelley R. Jordan
- Department of Biomedical Engineering, School of Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Cory R. Wyatt
- Advanced Imaging Research Center, Oregon Health & Science University, Portland, Oregon, USA
| | - Meghan E. Fallon
- Department of Biomedical Engineering, School of Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Randy Woltjer
- Department of Pathology, Oregon Health & Science University, Portland, Oregon, USA
| | - Edward A. Neuwelt
- Department of Neurology, Oregon Health & Science University, Portland, Oregon, USA
| | - Quifang Cheng
- Department of Medicine, Vanderbilt University, Nashville, TN, USA
- Department of Pathology, Microbiology and Immunology, Vanderbilt University, Nashville, TN, USA
| | - David Gailani
- Department of Medicine, Vanderbilt University, Nashville, TN, USA
- Department of Pathology, Microbiology and Immunology, Vanderbilt University, Nashville, TN, USA
| | - Christina Lorentz
- Department of Biomedical Engineering, School of Medicine, Oregon Health & Science University, Portland, Oregon, USA
- Aronora Inc., Portland, OR, USA
| | - Erik I. Tucker
- Department of Biomedical Engineering, School of Medicine, Oregon Health & Science University, Portland, Oregon, USA
- Aronora Inc., Portland, OR, USA
| | - Owen J.T. McCarty
- Department of Biomedical Engineering, School of Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Monica T. Hinds
- Department of Biomedical Engineering, School of Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Khanh P. Nguyen
- Department of Biomedical Engineering, School of Medicine, Oregon Health & Science University, Portland, Oregon, USA
- VA Portland Health Care System, Portland, Oregon, USA
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21
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Abstract
PURPOSE OF REVIEW Factor XII (FXII), the precursor of the protease FXIIa, contributes to pathologic processes including angioedema and thrombosis. Here, we review recent work on structure-function relationships for FXII based on studies using recombinant FXII variants. RECENT FINDINGS FXII is a homolog of pro-hepatocyte growth factor activator (Pro-HGFA). We prepared FXII in which domains are replaced by corresponding parts of Pro-HGA, and tested them in FXII activation and activity assays. In solution, FXII and prekallikrein undergo reciprocal activation to FXIIa and kallikrein. The rate of this process is restricted by the FXII fibronectin type-2 and kringle domains. Pro-HGA replacements for these domains accelerate FXII and prekallikrein activation. When FXII and prekallikrein bind to negatively charged surfaces, reciprocal activation is enhanced. The FXII EGF1 domain is required for surface binding. SUMMARY We propose a model in which FXII is normally maintained in a closed conformation resistant to activation by intramolecular interactions involving the fibronectin type-2 and kringle domains. These interactions are disrupted when FXII binds to a surface through EGF1, enhancing FXII activation and prekallikrein activation by FXIIa. These observations have important implications for understanding the contributions of FXII to disease, and for developing therapies to treat thrombo-inflammatory disorders.
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Affiliation(s)
- Aleksandr Shamanaev
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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22
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Sharma M, Molina CA, Toyoda K, Bereczki D, Kasner SE, Lutsep HL, Tsivgoulis G, Ntaios G, Czlonkowska A, Shuaib A, Amarenco P, Endres M, Diener HC, Gailani D, Kahl A, Donovan M, Perera V, Li D, Hankey GJ. Rationale and design of the AXIOMATIC-SSP phase II trial: Antithrombotic treatment with factor XIa inhibition to Optimize Management of Acute Thromboembolic events for Secondary Stroke Prevention. J Stroke Cerebrovasc Dis 2022; 31:106742. [PMID: 36037679 PMCID: PMC9619293 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106742] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 08/12/2022] [Accepted: 08/17/2022] [Indexed: 10/15/2022] Open
Abstract
BACKGROUND Individuals with ischemic stroke or transient ischemic attack (TIA) have a high early risk of ischemic stroke despite dual antiplatelet therapy. The risk of ischemic stroke, and associated disability, represents a significant unmet clinical need. Genetic variants resulting in reduced factor XI levels are associated with reduced risk for ischemic stroke but are not associated with increased intracranial bleeding. Milvexian is an oral small-molecule inhibitor of FXIa that binds activated factor XI with high affinity and selectivity and may reduce the risk of stroke when added to antiplatelet drugs without significant bleeding. We aimed to evaluate the dose-response relationship of milvexian in participants treated with dual antiplatelets. METHODS We began a phase II, double-blinded, randomized, placebo-controlled trial at 367 sites in 2019. Participants (N = 2366) with ischemic stroke (National Institutes of Health Stroke Scale score ≤7) or high-risk TIA (ABCD2 score ≥6) were randomized to 1 of 5 doses of milvexian or placebo for 90 days. Participants also received clopidogrel 75 mg daily for the first 21 days and aspirin 100 mg for 90 days. The efficacy endpoint was the composite of ischemic stroke or incident infarct on magnetic resonance imaging. Major bleeding, defined as type 3 or 5 bleeding according to the Bleeding Academic Research Consortium, was the safety endpoint. Participant follow-up will end in 2022. CONCLUSION The AXIOMATIC-SSP trial will evaluate the dose-response of milvexian for ischemic stroke occurrence in participants with ischemic stroke or TIA.
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Affiliation(s)
- Mukul Sharma
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada.
| | | | | | | | - Scott E Kasner
- Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | | | - Georgios Tsivgoulis
- National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | | | | | - Ashfaq Shuaib
- University of Alberta Hospital, Edmonton, Alberta, Canada
| | | | - Matthias Endres
- Department Neurology and Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | | | - David Gailani
- Vanderbilt University Medical Center, Nashville, TN, USA
| | - Anja Kahl
- Bristol Myers Squibb, Princeton, NJ, USA
| | | | | | - Danshi Li
- Bristol Myers Squibb, Princeton, NJ, USA
| | - Graeme J Hankey
- The University of Western Australia, Perth, Australia; Perron Institute for Neurological and Translational Science, Perth, Australia
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23
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Lakshmanan HHS, Estonilo A, Reitsma SE, Melrose AR, Subramanian J, Zheng TJ, Maddala J, Tucker EI, Gailani D, McCarty OJT, Jurney PL, Puy C. Revised model of the tissue factor pathway of thrombin generation: Role of the feedback activation of FXI. J Thromb Haemost 2022; 20:1350-1363. [PMID: 35352494 PMCID: PMC9590754 DOI: 10.1111/jth.15716] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 02/26/2022] [Accepted: 03/16/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Biochemical reaction networks are self-regulated in part due to feedback activation mechanisms. The tissue factor (TF) pathway of blood coagulation is a complex reaction network controlled by multiple feedback loops that coalesce around the serine protease thrombin. OBJECTIVES Our goal was to evaluate the relative contribution of the feedback activation of coagulation factor XI (FXI) in TF-mediated thrombin generation using a comprehensive systems-based analysis. MATERIALS AND METHODS We developed a systems biology model that improves the existing Hockin-Mann (HM) model through an integrative approach of mathematical modeling and in vitro experiments. Thrombin generation measured using in vitro assays revealed that the feedback activation of FXI contributes to the propagation of thrombin generation based on the initial concentrations of TF or activated coagulation factor X (FXa). We utilized experimental data to improve the robustness of the HM model to capture thrombin generation kinetics without a role for FXI before including the feedback activation of FXI by thrombin to construct the extended (ext.) HM model. RESULTS AND CONCLUSIONS Using the ext.HM model, we predicted that the contribution of positive feedback of FXI activation by thrombin can be abolished by selectively eliminating the inhibitory function of tissue factor pathway inhibitor (TFPI), a serine protease inhibitor of FXa and TF-activated factor VII (FVIIa) complex. This prediction from the ext.HM model was experimentally validated using thrombin generation assays with function blocking antibodies against TFPI and plasmas depleted of FXI. Together, our results demonstrate the applications of combining experimental and modeling techniques in predicting complex biochemical reaction systems.
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Affiliation(s)
| | - Aldrich Estonilo
- Department of Biomedical Engineering, San Jose State University, San Jose, California, USA
| | - Stéphanie E. Reitsma
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, Oregon, USA
| | - Alexander R. Melrose
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, Oregon, USA
| | | | - Tony J. Zheng
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, Oregon, USA
| | - Jeevan Maddala
- Department of Chemical and Biomedical Engineering, West Virginia University, Morgantown, West Virginia, USA
| | - Erik I. Tucker
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, Oregon, USA
- Aronora, Inc., Portland, Oregon, USA
| | - David Gailani
- Department of Pathology, Microbiology and Immunology, Vanderbilt University, Nashville, Tennessee, USA
| | - Owen J. T. McCarty
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, Oregon, USA
| | - Patrick L. Jurney
- Department of Biomedical Engineering, San Jose State University, San Jose, California, USA
| | - Cristina Puy
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, Oregon, USA
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24
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Dickeson SK, Kumar S, Sun MF, Mohammed BM, Phillips DR, Whisstock JC, Quek AJ, Feener EP, Law RHP, Gailani D. A mechanism for hereditary angioedema caused by a lysine 311-to-glutamic acid substitution in plasminogen. Blood 2022; 139:2816-2829. [PMID: 35100351 PMCID: PMC9074402 DOI: 10.1182/blood.2021012945] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 01/18/2022] [Indexed: 11/20/2022] Open
Abstract
Patients with hereditary angioedema (HAE) experience episodes of bradykinin (BK)-induced swelling of skin and mucosal membranes. The most common cause is reduced plasma activity of C1 inhibitor, the main regulator of the proteases plasma kallikrein (PKa) and factor XIIa (FXIIa). Recently, patients with HAE were described with a Lys311 to glutamic acid substitution in plasminogen (Plg), the zymogen of the protease plasmin (Plm). Adding tissue plasminogen activator to plasma containing Plg-Glu311 vs plasma containing wild-type Plg (Plg-Lys311) results in greater BK generation. Similar results were obtained in plasma lacking prekallikrein or FXII (the zymogens of PKa and FXIIa) and in normal plasma treated with a PKa inhibitor, indicating Plg-Glu311 induces BK generation independently of PKa and FXIIa. Plm-Glu311 cleaves high and low molecular weight kininogens (HK and LK, respectively), releasing BK more efficiently than Plm-Lys311. Based on the plasma concentrations of HK and LK, the latter may be the source of most of the BK generated by Plm-Glu311. The lysine analog ε-aminocaproic acid blocks Plm-catalyzed BK generation. The Glu311 substitution introduces a lysine-binding site into the Plg kringle 3 domain, perhaps altering binding to kininogens. Plg residue 311 is glutamic acid in most mammals. Glu311 in patients with HAE, therefore, represents reversion to the ancestral condition. Substantial BK generation occurs during Plm-Glu311 cleavage of human HK, but not mouse HK. Furthermore, mouse Plm, which has Glu311, did not liberate BK from human kininogens more rapidly than human Plg-Lys311. This indicates Glu311 is pathogenic in the context of human Plm when human kininogens are the substrates.
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Affiliation(s)
- S Kent Dickeson
- Department of Pathology, Microbiology and Immunology, Vanderbilt University, Nashville, TN
| | - Sunil Kumar
- Department of Pathology, Microbiology and Immunology, Vanderbilt University, Nashville, TN
| | - Mao-Fu Sun
- Department of Pathology, Microbiology and Immunology, Vanderbilt University, Nashville, TN
| | - Bassem M Mohammed
- Department of Pathology, Microbiology and Immunology, Vanderbilt University, Nashville, TN
| | | | - James C Whisstock
- Department of Biochemistry and Molecular Biology, Monash University, Clayton, VIC, Australia; and
| | - Adam J Quek
- Department of Biochemistry and Molecular Biology, Monash University, Clayton, VIC, Australia; and
| | | | - Ruby H P Law
- Department of Biochemistry and Molecular Biology, Monash University, Clayton, VIC, Australia; and
| | - David Gailani
- Department of Pathology, Microbiology and Immunology, Vanderbilt University, Nashville, TN
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25
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Puy C, Jordan KR, Nguyen N, Lorentz CU, Tucker EI, Gailani D, McCarty OJT. Abstract 133: Coagulation FXI Regulates Endothelial Cell Barrier Function By Inducing VE-cadherin Proteolysis In An ADAM10-dependent Manner. Arterioscler Thromb Vasc Biol 2022. [DOI: 10.1161/atvb.42.suppl_1.133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Introduction:
Proteolysis of vascular endothelial (VE)-cadherin is a biomarker for disruption of endothelial cell (EC) barrier function, with elevated levels of soluble VE-cadherin associated with atherosclerosis and sepsis. Factor XI (FXI), known for its role in the coagulation cascade, also plays a regulatory role in inflammation. While a relationship between FXI activity, VE-cadherin expression levels, and endothelial barrier function has been observed, the mechanisms by which this process is mediated are unknown.
Hypothesis:
Activated FXI (FXIa) regulates EC barrier function by inducing VE-cadherin proteolysis.
Methods:
Human umbilical vein endothelial cells were stimulated with FXIa (30 and 5 nM) for six hours. VE-cadherin proteolysis and expression levels were analyzed by Western blot and immunofluorescence. ECs permeability was quantified by measuring the flux of Evans blue-albumin across the ECs. Immunoprecipitation and Western blot analysis were used to study FXIa-PAI-1 or -very low density lipoprotein receptor (VLDLR) interactions.
Results:
FXIa (5 nM) generated a VE-cadherin C-terminal fragment and decreased VE-cadherin expression on ECs; this process was reversed by the serine protease inhibitor, PPACK. Thrombin, kallikrein, or FXIIa did not induce VE-cadherin proteolysis. FXIa increased ECs permeability, yet did not induce the expression of VCAM-1. In contrast, while VCAM-1 expression was upregulated by tumor necrosis factor alpha or vascular endothelial growth factor, neither of these induced VE-cadherin proteolysis. A pharmacological inhibitor of a disintegrin and metalloproteinase 10 (ADAM10) abrogated the effects of FXIa on ECs, including proteolysis of VE-cadherin. Similarly, the low density lipoprotein antagonist, receptor-associated protein (RAP), inhibited FXIa-induced VE-cadherin proteolysis by preventing FXIa complex formation with PAI-1 and VLDLR on ECs.
Conclusion:
These results suggest that FXIa disrupts VE-cadherin-mediated EC permeability by increasing ADAM10 activity through complex formation and internalization by PAI-1 and VLDLR. It remains to be seen whether this pathway represents a druggable target to protect EC barrier function in inflammatory diseases by inhibiting FXIa.
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Affiliation(s)
| | | | - Nhu Nguyen
- Oregon Health & Science Univ, Portland, OR
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26
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Kuder H, Dickeson SK, Brooks MB, Kehl A, Müller E, Gailani D, Giger U. A Common Missense Variant Causing Factor XI Deficiency and Increased Bleeding Tendency in Maine Coon Cats. Genes (Basel) 2022; 13:792. [PMID: 35627175 PMCID: PMC9140718 DOI: 10.3390/genes13050792] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 04/22/2022] [Accepted: 04/26/2022] [Indexed: 02/05/2023] Open
Abstract
Hereditary factor XI (FXI) deficiency is characterized as an autosomal mild to moderate coagulopathy in humans and domestic animals. Coagulation testing revealed FXI deficiency in a core family of Maine Coon cats (MCCs) in the United States. Factor XI-deficient MCCs were homozygous for a guanine to adenine transition resulting in a methionine substitution for the highly conserved valine-516 in the FXI catalytic domain. Immunoblots detected FXI of normal size and quantity in plasmas of MCCs homozygous for V516M. Some FXI-deficient MCCs experienced excessive post-operative/traumatic bleeding. Screening of 263 MCCs in Europe revealed a mutant allele frequency of 0.232 (23.2%). However, V516M was not found among 100 cats of other breeds. Recombinant feline FXI-M516 (fFXI-M516) expressed ~4% of the activity of wild-type fFXI-V516 in plasma clotting assays. Furthermore, fFXIa-M516 cleaved the chromogenic substrate S-2366 with ~4.3-fold lower catalytic efficacy (kcat/Km) than fFXIa-V516, supporting a conformational alteration of the protease active site. The rate of FIX activation by fFXIa-M516 was reduced >3-fold compared with fFXIa-V516. The common missense variant FXI-V516M causes a cross-reactive material positive FXI deficiency in MCCs that is associated with mild-moderate bleeding tendencies. Given the prevalence of the variant in MCCs, genotyping is recommended prior to invasive procedures or breeding.
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Affiliation(s)
- Henrike Kuder
- Vetsuisse Faculty, University of Zürich, Winterthurerstrasse 260, CH-8057 Zurich, Switzerland;
- Laboklin GmbH & Co. KG (Labogen), Steubenstrasse 4, D-97688 Bad Kissingen, Germany; (A.K.); (E.M.)
| | - S. Kent Dickeson
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, 1301 Medical Center Dr, Nashville, TN 37232, USA; (S.K.D.); (D.G.)
| | - Marjory B. Brooks
- Comparative Coagulation Laboratory, Cornell University, 240 Farrier Road, Ithaca, NY 14853, USA;
| | - Alexandra Kehl
- Laboklin GmbH & Co. KG (Labogen), Steubenstrasse 4, D-97688 Bad Kissingen, Germany; (A.K.); (E.M.)
| | - Elisabeth Müller
- Laboklin GmbH & Co. KG (Labogen), Steubenstrasse 4, D-97688 Bad Kissingen, Germany; (A.K.); (E.M.)
| | - David Gailani
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, 1301 Medical Center Dr, Nashville, TN 37232, USA; (S.K.D.); (D.G.)
| | - Urs Giger
- Vetsuisse Faculty, University of Zürich, Winterthurerstrasse 260, CH-8057 Zurich, Switzerland;
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27
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Affiliation(s)
- David Gailani
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN 37232, USA.
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28
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Affiliation(s)
- David Gailani
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Morla S, Deguchi H, Zilberman-Rudenko J, Gruber A, McCarty OJT, Srivastava P, Gailani D, Griffin JH. Skeletal muscle myosin promotes coagulation by binding factor XI via its A3 domain and enhancing thrombin-induced factor XI activation. J Biol Chem 2022; 298:101567. [PMID: 35007530 PMCID: PMC8856988 DOI: 10.1016/j.jbc.2022.101567] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Revised: 12/30/2021] [Accepted: 01/02/2022] [Indexed: 12/01/2022] Open
Abstract
Skeletal muscle myosin (SkM) has been shown to possess procoagulant activity; however, the mechanisms of this coagulation-enhancing activity involving plasma coagulation pathways and factors are incompletely understood. Here, we discovered direct interactions between immobilized SkM and coagulation factor XI (FXI) using biolayer interferometry (Kd = 0.2 nM). In contrast, we show that prekallikrein, a FXI homolog, did not bind to SkM, reflecting the specificity of SkM for FXI binding. We also found that the anti-FXI monoclonal antibody, mAb 1A6, which recognizes the Apple (A) 3 domain of FXI, potently inhibited binding of FXI to immobilized SkM, implying that SkM binds FXI A3 domain. In addition, we show that SkM enhanced FXI activation by thrombin in a concentration-dependent manner. We further used recombinant FXI chimeric proteins in which each of the four A domains of the heavy chain (designated A1 through A4) was individually replaced with the corresponding A domain from prekallikrein to investigate SkM-mediated enhancement of thrombin-induced FXI activation. These results indicated that activation of two FXI chimeras with substitutions of either the A3 domains or A4 domains was not enhanced by SkM, whereas substitution of the A2 domain did not reduce the thrombin-induced activation compared with wildtype FXI. These data strongly suggest that functional interaction sites on FXI for SkM involve the A3 and A4 domains. Thus, this study is the first to reveal and support the novel intrinsic blood coagulation pathway concept that the procoagulant mechanisms of SkM include FXI binding and enhancement of FXI activation by thrombin.
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Affiliation(s)
- Shravan Morla
- Department of Molecular Medicine, The Scripps Research Institute, La Jolla, California, USA
| | - Hiroshi Deguchi
- Department of Molecular Medicine, The Scripps Research Institute, La Jolla, California, USA
| | - Jevgenia Zilberman-Rudenko
- Department of Molecular Medicine, The Scripps Research Institute, La Jolla, California, USA; Departments of Biomedical Engineering and Medicine, School of Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - András Gruber
- Departments of Biomedical Engineering and Medicine, School of Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Owen J T McCarty
- Departments of Biomedical Engineering and Medicine, School of Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Priyanka Srivastava
- Departments of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - David Gailani
- Departments of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - John H Griffin
- Department of Molecular Medicine, The Scripps Research Institute, La Jolla, California, USA; Department of Medicine, University of California, San Diego, California, USA.
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Mast AE, Wolberg AS, Gailani D, Garvin MR, Alvarez C, Miller JI, Jones P, Aronow B, Jacobson D. Response to comment on 'SARS-CoV-2 suppresses anticoagulant and fibrinolytic gene expression in the lung'. eLife 2022; 11:e74951. [PMID: 35014952 PMCID: PMC8752086 DOI: 10.7554/elife.74951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 11/24/2021] [Indexed: 11/16/2022] Open
Abstract
Early in the SARS-CoV-2 pandemic, we compared transcriptome data from hospitalized COVID-19 patients and control patients without COVID-19. We found changes in procoagulant and fibrinolytic gene expression in the lungs of COVID-19 patients (Mast et al., 2021). These findings have been challenged based on issues with the samples (Fitzgerald and Jamieson, 2022). We have revisited our previous analyses in the light of this challenge and find that these new analyses support our original conclusions.
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Affiliation(s)
- Alan E Mast
- Versiti Blood Research Institute, Department of Cell Biology Neurobiology and Anatomy Medical College of WisconsinMilwaukeeUnited States
| | - Alisa S Wolberg
- Department of Pathology and Laboratory Medicine and UNC Blood Research CenterChapel HillUnited States
| | - David Gailani
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical CenterNashvilleUnited States
| | - Michael R Garvin
- Oak Ridge National Laboratory, Biosciences DivisionOak RidgeUnited States
| | - Christiane Alvarez
- Oak Ridge National Laboratory, Biosciences DivisionOak RidgeUnited States
| | - J Izaak Miller
- Oak Ridge National Laboratory, Biosciences DivisionOak RidgeUnited States
| | - Piet Jones
- University of Tennessee Knoxville, The Bredesen Center for Interdisciplinary Research and Graduate EducationKnoxvilleUnited States
| | - Bruce Aronow
- Biomedical Informatics, Cincinnati Children’s Hospital Research Foundation, University of CincinnatiCincinnatiUnited States
| | - Daniel Jacobson
- Oak Ridge National Laboratory, Biosciences DivisionOak RidgeUnited States
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Abstract
Evaluating prospective anticoagulant therapies in animal thrombosis and bleeding models are standard pre-clinical approaches. Mice are frequently used for initial evaluations because a variety of models have been developed in this well-characterized species, and mice are relatively inexpensive to maintain. Because mice seem to be resistant to forming "spontaneous" thrombosis, vessel injury is used to induce intravascular clot formation. For the purpose of testing heparin-based drugs, we adapted a well-established model in which thrombus formation in the carotid artery is induced by exposing the vessel to ferric chloride. For studying anticoagulant effects on venous thrombosis, we use a model in which the inferior vena cava is ligated and the size of the resulting clots are measured. The most common adverse effect of anticoagulation therapy is bleeding. We describe a simple tail bleeding time that has been used for many years to study the effects of anticoagulants on hemostasis. We also describe a more reproducible, but more technically challenging, saphenous vein bleeding model that is also used for this purpose.
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Affiliation(s)
- Bassem M Mohammed
- Department of Biochemistry and Molecular Biology, Saint Louis University School of Medicine, Doisy Research Center, St. Louis, MO, USA
| | - Qiufang Cheng
- Department of Pathology, Microbiology and Immunology, Vanderbilt University, Nashville, TN, USA
| | - Ivan S Ivanov
- Department of Pathology, Microbiology and Immunology, Vanderbilt University, Nashville, TN, USA
| | - David Gailani
- Department of Pathology, Microbiology and Immunology, Vanderbilt University, Nashville, TN, USA.
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32
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Salomon O, Gailani D. A proposal for managing bleeding in patients on therapeutic factor XI(a) inhibitors. J Thromb Haemost 2022; 20:32-38. [PMID: 34735741 PMCID: PMC9540351 DOI: 10.1111/jth.15579] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 10/27/2021] [Accepted: 11/01/2021] [Indexed: 12/16/2022]
Abstract
Several drugs that reduce functional levels of the plasma protease zymogen factor XI (FXI), or that inhibit its activated form (FXIa), are being evaluated as treatments to prevent thrombosis. Based on the observation that individuals with inherited FXI deficiency have a relatively mild bleeding disorder, it is anticipated that therapeutic FXI(a) inhibitors will have a smaller impact on hemostasis than anticoagulants targeting thrombin or factor Xa. However, even if FXI(a) inhibitors are determined to be safer than currently used anticoagulants, some patients on these drugs will experience abnormal bleeding or require emergent surgery. Strategies for dealing with such situations are required. Treatment with antifibrinolytic agents and low doses of recombinant factor VIIa effectively prevent abnormal bleeding in FXI-deficient patients with alloantibody inhibitors to FXI who undergo surgery. We propose that a similar strategy can be used for patients on therapeutic FXI(a) inhibitors who are bleeding or require invasive procedures.
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Affiliation(s)
- Ophira Salomon
- Thrombosis Unit Sheba Medical Center, Tel Hashomer, Israel
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - David Gailani
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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33
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Weitz JI, Strony J, Ageno W, Gailani D, Hylek EM, Lassen MR, Mahaffey KW, Notani RS, Roberts R, Segers A, Raskob GE. Milvexian for the Prevention of Venous Thromboembolism. N Engl J Med 2021; 385:2161-2172. [PMID: 34780683 PMCID: PMC9540352 DOI: 10.1056/nejmoa2113194] [Citation(s) in RCA: 111] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Factor XIa inhibitors for the prevention and treatment of venous and arterial thromboembolism may be more effective and result in less bleeding than conventional anticoagulants. Additional data are needed regarding the efficacy and safety of milvexian, an oral factor XIa inhibitor. METHODS In this parallel-group, phase 2 trial, we randomly assigned 1242 patients undergoing knee arthroplasty to receive one of seven postoperative regimens of milvexian (25 mg, 50 mg, 100 mg, or 200 mg twice daily or 25 mg, 50 mg, or 200 mg once daily) or enoxaparin (40 mg once daily). The primary efficacy outcome was venous thromboembolism (which was a composite of asymptomatic deep-vein thrombosis, confirmed symptomatic venous thromboembolism, or death from any cause). The principal safety outcome was bleeding. RESULTS Among the patients receiving milvexian twice daily, venous thromboembolism developed in 27 of 129 (21%) taking 25 mg, in 14 of 124 (11%) taking 50 mg, in 12 of 134 (9%) taking 100 mg, and in 10 of 131 (8%) taking 200 mg. Among those receiving milvexian once daily, venous thromboembolism developed in 7 of 28 (25%) taking 25 mg, in 30 of 127 (24%) taking 50 mg, and in 8 of 123 (7%) taking 200 mg, as compared with 54 of 252 patients (21%) taking enoxaparin. The dose-response relationship with twice-daily milvexian was significant (one-sided P<0.001), and the 12% incidence of venous thromboembolism with twice-daily milvexian was significantly lower than the prespecified benchmark of 30% (one-sided P<0.001). Bleeding of any severity occurred in 38 of 923 patients (4%) taking milvexian and in 12 of 296 patients (4%) taking enoxaparin; major or clinically relevant nonmajor bleeding occurred in 1% and 2%, respectively; and serious adverse events were reported in 2% and 4%, respectively. CONCLUSIONS Postoperative factor XIa inhibition with oral milvexian in patients undergoing knee arthroplasty was effective for the prevention of venous thromboembolism and was associated with a low risk of bleeding. (Funded by Bristol Myers Squibb and Janssen Research and Development; AXIOMATIC-TKR ClinicalTrials.gov number, NCT03891524.).
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Affiliation(s)
- Jeffrey I Weitz
- From the Thrombosis and Atherosclerosis Research Institute and McMaster University (J.I.W., R.R.) - both in Hamilton, ON, Canada; Janssen Research and Development, Raritan, NJ (J.S., R.S.N.); the University of Insubria, Varese, Italy (W.A.); Vanderbilt University Medical Center, Nashville (D.G.); Boston University School of Medicine, Boston (E.M.H.); Gildhøj Private Hospital, Copenhagen (M.R.L.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Stanford, CA (K.W.M.); International Trial Expertise Advisory and Services, Amsterdam (A.S.); and Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City (G.E.R.)
| | - John Strony
- From the Thrombosis and Atherosclerosis Research Institute and McMaster University (J.I.W., R.R.) - both in Hamilton, ON, Canada; Janssen Research and Development, Raritan, NJ (J.S., R.S.N.); the University of Insubria, Varese, Italy (W.A.); Vanderbilt University Medical Center, Nashville (D.G.); Boston University School of Medicine, Boston (E.M.H.); Gildhøj Private Hospital, Copenhagen (M.R.L.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Stanford, CA (K.W.M.); International Trial Expertise Advisory and Services, Amsterdam (A.S.); and Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City (G.E.R.)
| | - Walter Ageno
- From the Thrombosis and Atherosclerosis Research Institute and McMaster University (J.I.W., R.R.) - both in Hamilton, ON, Canada; Janssen Research and Development, Raritan, NJ (J.S., R.S.N.); the University of Insubria, Varese, Italy (W.A.); Vanderbilt University Medical Center, Nashville (D.G.); Boston University School of Medicine, Boston (E.M.H.); Gildhøj Private Hospital, Copenhagen (M.R.L.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Stanford, CA (K.W.M.); International Trial Expertise Advisory and Services, Amsterdam (A.S.); and Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City (G.E.R.)
| | - David Gailani
- From the Thrombosis and Atherosclerosis Research Institute and McMaster University (J.I.W., R.R.) - both in Hamilton, ON, Canada; Janssen Research and Development, Raritan, NJ (J.S., R.S.N.); the University of Insubria, Varese, Italy (W.A.); Vanderbilt University Medical Center, Nashville (D.G.); Boston University School of Medicine, Boston (E.M.H.); Gildhøj Private Hospital, Copenhagen (M.R.L.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Stanford, CA (K.W.M.); International Trial Expertise Advisory and Services, Amsterdam (A.S.); and Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City (G.E.R.)
| | - Elaine M Hylek
- From the Thrombosis and Atherosclerosis Research Institute and McMaster University (J.I.W., R.R.) - both in Hamilton, ON, Canada; Janssen Research and Development, Raritan, NJ (J.S., R.S.N.); the University of Insubria, Varese, Italy (W.A.); Vanderbilt University Medical Center, Nashville (D.G.); Boston University School of Medicine, Boston (E.M.H.); Gildhøj Private Hospital, Copenhagen (M.R.L.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Stanford, CA (K.W.M.); International Trial Expertise Advisory and Services, Amsterdam (A.S.); and Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City (G.E.R.)
| | - Michael R Lassen
- From the Thrombosis and Atherosclerosis Research Institute and McMaster University (J.I.W., R.R.) - both in Hamilton, ON, Canada; Janssen Research and Development, Raritan, NJ (J.S., R.S.N.); the University of Insubria, Varese, Italy (W.A.); Vanderbilt University Medical Center, Nashville (D.G.); Boston University School of Medicine, Boston (E.M.H.); Gildhøj Private Hospital, Copenhagen (M.R.L.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Stanford, CA (K.W.M.); International Trial Expertise Advisory and Services, Amsterdam (A.S.); and Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City (G.E.R.)
| | - Kenneth W Mahaffey
- From the Thrombosis and Atherosclerosis Research Institute and McMaster University (J.I.W., R.R.) - both in Hamilton, ON, Canada; Janssen Research and Development, Raritan, NJ (J.S., R.S.N.); the University of Insubria, Varese, Italy (W.A.); Vanderbilt University Medical Center, Nashville (D.G.); Boston University School of Medicine, Boston (E.M.H.); Gildhøj Private Hospital, Copenhagen (M.R.L.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Stanford, CA (K.W.M.); International Trial Expertise Advisory and Services, Amsterdam (A.S.); and Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City (G.E.R.)
| | - Ravi S Notani
- From the Thrombosis and Atherosclerosis Research Institute and McMaster University (J.I.W., R.R.) - both in Hamilton, ON, Canada; Janssen Research and Development, Raritan, NJ (J.S., R.S.N.); the University of Insubria, Varese, Italy (W.A.); Vanderbilt University Medical Center, Nashville (D.G.); Boston University School of Medicine, Boston (E.M.H.); Gildhøj Private Hospital, Copenhagen (M.R.L.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Stanford, CA (K.W.M.); International Trial Expertise Advisory and Services, Amsterdam (A.S.); and Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City (G.E.R.)
| | - Robin Roberts
- From the Thrombosis and Atherosclerosis Research Institute and McMaster University (J.I.W., R.R.) - both in Hamilton, ON, Canada; Janssen Research and Development, Raritan, NJ (J.S., R.S.N.); the University of Insubria, Varese, Italy (W.A.); Vanderbilt University Medical Center, Nashville (D.G.); Boston University School of Medicine, Boston (E.M.H.); Gildhøj Private Hospital, Copenhagen (M.R.L.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Stanford, CA (K.W.M.); International Trial Expertise Advisory and Services, Amsterdam (A.S.); and Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City (G.E.R.)
| | - Annelise Segers
- From the Thrombosis and Atherosclerosis Research Institute and McMaster University (J.I.W., R.R.) - both in Hamilton, ON, Canada; Janssen Research and Development, Raritan, NJ (J.S., R.S.N.); the University of Insubria, Varese, Italy (W.A.); Vanderbilt University Medical Center, Nashville (D.G.); Boston University School of Medicine, Boston (E.M.H.); Gildhøj Private Hospital, Copenhagen (M.R.L.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Stanford, CA (K.W.M.); International Trial Expertise Advisory and Services, Amsterdam (A.S.); and Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City (G.E.R.)
| | - Gary E Raskob
- From the Thrombosis and Atherosclerosis Research Institute and McMaster University (J.I.W., R.R.) - both in Hamilton, ON, Canada; Janssen Research and Development, Raritan, NJ (J.S., R.S.N.); the University of Insubria, Varese, Italy (W.A.); Vanderbilt University Medical Center, Nashville (D.G.); Boston University School of Medicine, Boston (E.M.H.); Gildhøj Private Hospital, Copenhagen (M.R.L.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Stanford, CA (K.W.M.); International Trial Expertise Advisory and Services, Amsterdam (A.S.); and Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City (G.E.R.)
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34
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Puy C, Pang J, Reitsma SE, Lorentz CU, Tucker EI, Gailani D, Gruber A, Lupu F, McCarty OJT. Cross-Talk between the Complement Pathway and the Contact Activation System of Coagulation: Activated Factor XI Neutralizes Complement Factor H. J Immunol 2021; 206:1784-1792. [PMID: 33811105 DOI: 10.4049/jimmunol.2000398] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 02/11/2021] [Indexed: 12/17/2022]
Abstract
Complement factor H (CFH) is the major inhibitor of the alternative pathway of the complement system and is structurally related to beta2-glycoprotein I, which itself is known to bind to ligands, including coagulation factor XI (FXI). We observed reduced complement activation when FXI activation was inhibited in a baboon model of lethal systemic inflammation, suggesting cross-talk between FXI and the complement cascade. It is unknown whether FXI or its activated form, activated FXI (FXIa), directly interacts with the complement system. We explored whether FXI could interact with and inhibit the activity of CFH. We found that FXIa neutralized CFH by cleavage of the R341/R342 bonds. FXIa reduced the capacity of CFH to enhance the cleavage of C3b by factor I and the decay of C3bBb. The binding of CFH to human endothelial cells was also reduced after incubating CFH with FXIa. The addition of either short- or long-chain polyphosphate enhanced the capacity of FXIa to cleave CFH. FXIa also cleaved CFH that was present on endothelial cells and in the secretome from blood platelets. The generation of FXIa in plasma induced the cleavage of CFH. Moreover, FXIa reduced the cleavage of C3b by factor I in serum. Conversely, we observed that CFH inhibited FXI activation by either thrombin or FXIIa. Our study provides, to our knowledge, a novel molecular link between the contact pathway of coagulation and the complement system. These results suggest that FXIa generation enhances the activity of the complement system and thus may potentiate the immune response.
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Affiliation(s)
- Cristina Puy
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR 97239; .,Division of Hematology and Medical Oncology, School of Medicine, Oregon Health & Science University, Portland, OR 97239
| | - Jiaqing Pang
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR 97239
| | - Stéphanie E Reitsma
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR 97239
| | - Christina U Lorentz
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR 97239.,Aronora, Inc., Portland, OR 97239
| | - Erik I Tucker
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR 97239.,Aronora, Inc., Portland, OR 97239
| | - David Gailani
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN 37232; and
| | - András Gruber
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR 97239.,Division of Hematology and Medical Oncology, School of Medicine, Oregon Health & Science University, Portland, OR 97239.,Aronora, Inc., Portland, OR 97239
| | - Florea Lupu
- Cardiovascular Biology Research Program, Oklahoma Medical Research Foundation, Oklahoma City, OK 73104
| | - Owen J T McCarty
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR 97239.,Division of Hematology and Medical Oncology, School of Medicine, Oregon Health & Science University, Portland, OR 97239
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35
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Hsu C, Hutt E, Bloomfield DM, Gailani D, Weitz JI. Factor XI Inhibition to Uncouple Thrombosis From Hemostasis: JACC Review Topic of the Week. J Am Coll Cardiol 2021; 78:625-631. [PMID: 34353538 DOI: 10.1016/j.jacc.2021.06.010] [Citation(s) in RCA: 62] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 06/07/2021] [Accepted: 06/08/2021] [Indexed: 11/29/2022]
Abstract
Hemostasis and thrombosis are believed to be so intricately linked that any strategies that reduce thrombosis will have an inevitable impact on hemostasis. Consequently, bleeding is viewed as an unavoidable side effect of anticoagulant therapy. Emerging evidence suggests that factor XI is important for thrombosis but has a minor role in hemostasis. This information raises the possibility that anticoagulants that target factor XI will be safer than currently available agents. The authors provide a visual representation of the coagulation pathways that distinguishes between the steps involved in thrombosis and hemostasis to explain why factor XI inhibitors may serve as hemostasis-sparing anticoagulants. A safer class of anticoagulants would provide opportunities for treatment of a wider range of patients, including those at high risk for bleeding. Ongoing clinical studies will determine the extent to which factor XI inhibitors attenuate thrombosis without disruption of hemostasis.
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Affiliation(s)
- Charles Hsu
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | | | | | - David Gailani
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jeffrey I Weitz
- Departments of Medicine and Biochemistry and Biomedical Sciences, McMaster University, Hamilton, Ontario, Canada; Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada.
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36
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Silasi R, Keshari RS, Regmi G, Lupu C, Georgescu C, Simmons JH, Wallisch M, Kohs TCL, Shatzel JJ, Olson SR, Lorentz CU, Puy C, Tucker EI, Gailani D, Strickland S, Gruber A, McCarty OJT, Lupu F. Factor XII plays a pathogenic role in organ failure and death in baboons challenged with Staphylococcus aureus. Blood 2021; 138:178-189. [PMID: 33598692 PMCID: PMC8288658 DOI: 10.1182/blood.2020009345] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 01/26/2021] [Indexed: 12/29/2022] Open
Abstract
Activation of coagulation factor (F) XI promotes multiorgan failure in rodent models of sepsis and in a baboon model of lethal systemic inflammation induced by infusion of heat-inactivated Staphylococcus aureus. Here we used the anticoagulant FXII-neutralizing antibody 5C12 to verify the mechanistic role of FXII in this baboon model. Compared with untreated control animals, repeated 5C12 administration before and at 8 and 24 hours after bacterial challenge prevented the dramatic increase in circulating complexes of contact system enzymes FXIIa, FXIa, and kallikrein with antithrombin or C1 inhibitor, and prevented cleavage and consumption of high-molecular-weight kininogen. Activation of several coagulation factors and fibrinolytic enzymes was also prevented. D-dimer levels exhibited a profound increase in the untreated animals but not in the treated animals. The antibody also blocked the increase in plasma biomarkers of inflammation and cell damage, including tumor necrosis factor, interleukin (IL)-1β, IL-6, IL-8, IL-10, granulocyte-macrophage colony-stimulating factor, nucleosomes, and myeloperoxidase. Based on clinical presentation and circulating biomarkers, inhibition of FXII prevented fever, terminal hypotension, respiratory distress, and multiorgan failure. All animals receiving 5C12 had milder and transient clinical symptoms and were asymptomatic at day 7, whereas untreated control animals suffered irreversible multiorgan failure and had to be euthanized within 2 days after the bacterial challenge. This study confirms and extends our previous finding that at least 2 enzymes of the contact activation complex, FXIa and FXIIa, play critical roles in the development of an acute and terminal inflammatory response in baboons challenged with heat-inactivated S aureus.
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Affiliation(s)
- Robert Silasi
- Cardiovascular Biology Research Program, Oklahoma Medical Research Foundation, Oklahoma City, OK
| | - Ravi S Keshari
- Cardiovascular Biology Research Program, Oklahoma Medical Research Foundation, Oklahoma City, OK
| | - Girija Regmi
- Cardiovascular Biology Research Program, Oklahoma Medical Research Foundation, Oklahoma City, OK
| | - Cristina Lupu
- Cardiovascular Biology Research Program, Oklahoma Medical Research Foundation, Oklahoma City, OK
| | - Constantin Georgescu
- Cardiovascular Biology Research Program, Oklahoma Medical Research Foundation, Oklahoma City, OK
| | - Joe H Simmons
- Michale E. Keeling Center for Comparative Medicine and Research, University of Texas MD Anderson Cancer Center, Bastrop, TX
| | - Michael Wallisch
- Department of Biomedical Engineering, School of Medicine, Oregon Health & Science University, Portland, OR
- Aronora, Inc, Portland, OR
| | - Tia C L Kohs
- Department of Biomedical Engineering, School of Medicine, Oregon Health & Science University, Portland, OR
| | - Joseph J Shatzel
- Department of Biomedical Engineering, School of Medicine, Oregon Health & Science University, Portland, OR
- Division of Hematology & Medical Oncology, School of Medicine, Oregon Health & Science University, Portland, OR
| | - Sven R Olson
- Department of Biomedical Engineering, School of Medicine, Oregon Health & Science University, Portland, OR
- Division of Hematology & Medical Oncology, School of Medicine, Oregon Health & Science University, Portland, OR
| | - Christina U Lorentz
- Department of Biomedical Engineering, School of Medicine, Oregon Health & Science University, Portland, OR
- Aronora, Inc, Portland, OR
| | - Cristina Puy
- Department of Biomedical Engineering, School of Medicine, Oregon Health & Science University, Portland, OR
| | - Erik I Tucker
- Department of Biomedical Engineering, School of Medicine, Oregon Health & Science University, Portland, OR
- Aronora, Inc, Portland, OR
| | - David Gailani
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN
| | - Sidney Strickland
- Patricia and John Rosenwald Laboratory of Neurobiology and Genetics, The Rockefeller University, New York, NY; and
| | - András Gruber
- Department of Biomedical Engineering, School of Medicine, Oregon Health & Science University, Portland, OR
- Aronora, Inc, Portland, OR
- Division of Hematology & Medical Oncology, School of Medicine, Oregon Health & Science University, Portland, OR
| | - Owen J T McCarty
- Department of Biomedical Engineering, School of Medicine, Oregon Health & Science University, Portland, OR
- Division of Hematology & Medical Oncology, School of Medicine, Oregon Health & Science University, Portland, OR
| | - Florea Lupu
- Cardiovascular Biology Research Program, Oklahoma Medical Research Foundation, Oklahoma City, OK
- Department of Cell Biology
- Department of Pathology, and
- Department of Internal Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK
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37
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Ngo ATP, Jordan KR, Mueller PA, Hagen MW, Reitsma SE, Puy C, Revenko AS, Lorentz CU, Tucker EI, Cheng Q, Hinds MT, Fazio S, Monia BP, Gailani D, Gruber A, Tavori H, McCarty OJT. Pharmacological targeting of coagulation factor XI mitigates the development of experimental atherosclerosis in low-density lipoprotein receptor-deficient mice. J Thromb Haemost 2021; 19:1001-1017. [PMID: 33421301 PMCID: PMC8549080 DOI: 10.1111/jth.15236] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 12/21/2020] [Accepted: 01/04/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND Human coagulation factor (F) XI deficiency, a defect of the contact activation system, protects against venous thrombosis, stroke, and heart attack, whereas FXII, plasma prekallikrein, or kininogen deficiencies are asymptomatic. FXI deficiency, inhibition of FXI production, activated FXI (FXIa) inhibitors, and antibodies to FXI that interfere with FXI/FXII interactions reduce experimental thrombosis and inflammation. FXI inhibitors are antithrombotic in patients, and FXI and FXII deficiencies are atheroprotective in apolipoprotein E-deficient mice. OBJECTIVES Investigate the effects of pharmacological targeting of FXI in experimental models of atherogenesis and established atherosclerosis. METHODS AND RESULTS Low-density lipoprotein receptor-knockout (Ldlr-/- ) mice were administered high-fat diet (HFD) for 8 weeks; concomitantly, FXI was targeted with anti-FXI antibody (14E11) or FXI antisense oligonucleotide (ASO). 14E11 and FXI-ASO reduced atherosclerotic lesion area in proximal aortas when compared with controls, and 14E11 also reduced aortic sinus lesions. In an established disease model, in which therapy was given after atherosclerosis had developed, Ldlr-/- mice were fed HFD for 8 weeks and then administered 14E11 or FXI-ASO weekly until 16 weeks on HFD. In this established disease model, 14E11 and FXI-ASO reduced atherosclerotic lesion area in proximal aortas, but not in aortic sinus. In cultures of human endothelium, FXIa exposure disrupted VE-Cadherin expression and increased endothelial lipoprotein permeability. Strikingly, we found that 14E11 prevented the disruption of VE-Cadherin expression in aortic sinus lesions observed in the atherogenesis mouse model. CONCLUSION Pharmacological targeting of FXI reduced atherogenesis in Ldlr-/- mice. Interference with the contact activation system may safely reduce development or progression of atherosclerosis.
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Affiliation(s)
- Anh T. P. Ngo
- Department of Biomedical Engineering, School of Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Kelley R. Jordan
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, OR, USA
| | - Paul A. Mueller
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, OR, USA
| | - Matthew W. Hagen
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, OR, USA
| | - Stéphanie E. Reitsma
- Department of Biomedical Engineering, School of Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Cristina Puy
- Department of Biomedical Engineering, School of Medicine, Oregon Health and Science University, Portland, OR, USA
| | | | - Christina U. Lorentz
- Department of Biomedical Engineering, School of Medicine, Oregon Health and Science University, Portland, OR, USA
- Aronora Inc, Portland, OR, USA
| | - Erik I. Tucker
- Department of Biomedical Engineering, School of Medicine, Oregon Health and Science University, Portland, OR, USA
- Aronora Inc, Portland, OR, USA
| | - Quifang Cheng
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University, Nashville, TN, USA
| | - Monica T. Hinds
- Department of Biomedical Engineering, School of Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Sergio Fazio
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, OR, USA
| | | | - David Gailani
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University, Nashville, TN, USA
| | - András Gruber
- Department of Biomedical Engineering, School of Medicine, Oregon Health and Science University, Portland, OR, USA
- Aronora Inc, Portland, OR, USA
| | - Hagai Tavori
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, OR, USA
| | - Owen J. T. McCarty
- Department of Biomedical Engineering, School of Medicine, Oregon Health and Science University, Portland, OR, USA
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Mast AE, Wolberg AS, Gailani D, Garvin MR, Alvarez C, Miller JI, Aronow B, Jacobson D. SARS-CoV-2 suppresses anticoagulant and fibrinolytic gene expression in the lung. eLife 2021; 10:e64330. [PMID: 33683204 PMCID: PMC8049742 DOI: 10.7554/elife.64330] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 03/06/2021] [Indexed: 12/13/2022] Open
Abstract
Extensive fibrin deposition in the lungs and altered levels of circulating blood coagulation proteins in COVID-19 patients imply local derangement of pathways that limit fibrin formation and/or promote its clearance. We examined transcriptional profiles of bronchoalveolar lavage fluid (BALF) samples to identify molecular mechanisms underlying these coagulopathies. mRNA levels for regulators of the kallikrein-kinin (C1-inhibitor), coagulation (thrombomodulin, endothelial protein C receptor), and fibrinolytic (urokinase and urokinase receptor) pathways were significantly reduced in COVID-19 patients. While transcripts for several coagulation proteins were increased, those encoding tissue factor, the protein that initiates coagulation and whose expression is frequently increased in inflammatory disorders, were not increased in BALF from COVID-19 patients. Our analysis implicates enhanced propagation of coagulation and decreased fibrinolysis as drivers of the coagulopathy in the lungs of COVID-19 patients.
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Affiliation(s)
- Alan E Mast
- Versiti Blood Research Institute, Department of Cell Biology Neurobiology and Anatomy Medical College of WisconsinMilwaukeeUnited States
| | - Alisa S Wolberg
- Department of Pathology and Laboratory Medicine and UNC Blood Research CenterChapel HillUnited States
| | - David Gailani
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical CenterNashvilleUnited States
| | - Michael R Garvin
- Oak Ridge National Laboratory, Biosciences DivisionOak RidgeUnited States
| | - Christiane Alvarez
- Oak Ridge National Laboratory, Biosciences DivisionOak RidgeUnited States
| | - J Izaak Miller
- Oak Ridge National Laboratory, Biosciences DivisionOak RidgeUnited States
| | - Bruce Aronow
- University of Tennessee Knoxville, The Bredesen Center for Interdisciplinary Research and Graduate EducationKnoxvilleUnited States
- Biomedical Informatics, Cincinnati Children’s Hospital Research FoundationCincinnatiUnited States
- University of CincinnatiCincinnatiUnited States
| | - Daniel Jacobson
- Oak Ridge National Laboratory, Biosciences DivisionOak RidgeUnited States
- University of Tennessee Knoxville, The Bredesen Center for Interdisciplinary Research and Graduate EducationKnoxvilleUnited States
- University of Tennessee Knoxville, Department of PsychologyKnoxvilleUnited States
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Shamanaev A, Emsley J, Gailani D. Proteolytic activity of contact factor zymogens. J Thromb Haemost 2021; 19:330-341. [PMID: 33107140 PMCID: PMC8552315 DOI: 10.1111/jth.15149] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 10/16/2020] [Accepted: 10/22/2020] [Indexed: 02/06/2023]
Abstract
Contact activation is triggered when blood is exposed to compounds or "surfaces" that promote conversion of the plasma zymogens factor XII (FXII) and prekallikrein to the active proteases FXIIa and kallikrein. FXIIa promotes blood coagulation by converting zymogen factor XI (FXI) to the protease FXIa. Contact activation appears to represent an enhancement of the propensity for FXII and prekallikrein to reciprocally activate each other by surface-independent limited proteolysis. The nature of the activities that perpetuate this process, and that trigger contact activation, are debated. FXII and prekallikrein, like most members of the chymotrypsin/trypsin protease family, are synthesized as single polypeptides that are presumed to be in an inactive state. Internal cleavage leads to conformational changes in the protease domain that convert the enzyme active site from a closed conformation to an open conformation accessible to substrates. We observed that FXII expresses a low level of activity as a single-chain zymogen that catalyzes prekallikrein activation in solution, as well as surface-dependent activation of prekallikrein, FXI, and FXII (autoactivation). Prekallikrein also expresses activity that promotes cleavage of kininogen to release bradykinin, and surface-dependent FXII activation. Modeling suggests that a glutamine residue at position 156 in the FXII and prekallikrein protease domains stabilizes an open active site conformation by forming hydrogen bonds with Asp194. The activity inherent in FXII and prekallikrein suggests a mechanism for sustaining reciprocal activation of the proteins and for initiating contact activation, and supports the premise that zymogens of some trypsin-like enzymes are active proteases.
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Affiliation(s)
- Aleksandr Shamanaev
- Department of Pathology, Microbiology and Immunology, Vanderbilt University, Nashville, TN, USA
| | - Jonas Emsley
- Biodiscovery Institute, Centre for Biomedical Science, University of Nottingham, Nottingham, UK
| | - David Gailani
- Department of Pathology, Microbiology and Immunology, Vanderbilt University, Nashville, TN, USA
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Reitsma SE, Pang J, Raghunathan V, Shatzel JJ, Lorentz CU, Tucker EI, Gruber A, Gailani D, McCarty OJT, Puy C. Role of platelets in regulating activated coagulation factor XI activity. Am J Physiol Cell Physiol 2021; 320:C365-C374. [PMID: 33471623 DOI: 10.1152/ajpcell.00056.2020] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Factor XI (FXI) has been shown to bind platelets, but the functional significance of this observation remains unknown. Platelets are essential for hemostasis and play a critical role in thrombosis, whereas FXI is not essential for hemostasis but promotes thrombosis. An apparent functional contradiction, platelets are known to support thrombin generation, yet platelet granules release protease inhibitors, including those of activated FXI (FXIa). We aim to investigate the secretory and binding mechanisms by which platelets could support or inhibit FXIa activity. The presence of platelets enhanced FXIa activity in a purified system and increased coagulation Factor IX (FIX) activation by FXIa and fibrin generation in human plasma. In contrast, platelets reduced the activation of FXI by activated coagulation factor XII (FXIIa) and the activation of FXII by kallikrein (PKa). Incubation of FXIa with the platelet secretome, which contains FXIa inhibitors, such as protease nexin-II, abolished FXIa activity, yet in the presence of activated platelets, the secretome was not able to block the activity of FXIa. FXIa variants lacking the anion-binding sites did not alter the effect of platelets on FXIa activity or interaction. Western blot analysis of bound FXIa [by FXIa-platelet membrane immunoprecipitation] showed that the interaction with platelets is zinc dependent and, unlike FXI binding to platelets, not dependent on glycoprotein Ib. FXIa binding to the platelet membrane increases its capacity to activate FIX in plasma likely by protecting it from inhibition by inhibitors secreted by activated platelets. Our findings suggest that an interaction of FXIa with the platelet surface may induce an allosteric modulation of FXIa.
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Affiliation(s)
- Stéphanie E Reitsma
- Department of Biomedical Engineering, School of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Jiaqing Pang
- Department of Biomedical Engineering, School of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Vikram Raghunathan
- Division of Hematology-Medical Oncology, Knight Cancer Institute, Oregon Health & Science University, Portland, Oregon
| | - Joseph J Shatzel
- Department of Biomedical Engineering, School of Medicine, Oregon Health & Science University, Portland, Oregon.,Division of Hematology-Medical Oncology, Knight Cancer Institute, Oregon Health & Science University, Portland, Oregon
| | | | | | - András Gruber
- Department of Biomedical Engineering, School of Medicine, Oregon Health & Science University, Portland, Oregon.,Aronora, Inc, Portland, Oregon
| | - David Gailani
- Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Owen J T McCarty
- Department of Biomedical Engineering, School of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Cristina Puy
- Department of Biomedical Engineering, School of Medicine, Oregon Health & Science University, Portland, Oregon
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Ponczek MB, Shamanaev A, LaPlace A, Dickeson SK, Srivastava P, Sun MF, Gruber A, Kastrup C, Emsley J, Gailani D. The evolution of factor XI and the kallikrein-kinin system. Blood Adv 2020; 4:6135-6147. [PMID: 33351111 PMCID: PMC7757006 DOI: 10.1182/bloodadvances.2020002456] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 10/19/2020] [Indexed: 12/16/2022] Open
Abstract
Factor XI (FXI) is the zymogen of a plasma protease (FXIa) that contributes to hemostasis by activating factor IX (FIX). In the original cascade model of coagulation, FXI is converted to FXIa by factor XIIa (FXIIa), a component, along with prekallikrein and high-molecular-weight kininogen (HK), of the plasma kallikrein-kinin system (KKS). More recent coagulation models emphasize thrombin as a FXI activator, bypassing the need for FXIIa and the KKS. We took an evolutionary approach to better understand the relationship of FXI to the KKS and thrombin generation. BLAST searches were conducted for FXI, FXII, prekallikrein, and HK using genomes for multiple vertebrate species. The analysis shows the KKS appeared in lobe-finned fish, the ancestors of all land vertebrates. FXI arose later from a duplication of the prekallikrein gene early in mammalian evolution. Features of FXI that facilitate efficient FIX activation are present in all living mammals, including primitive egg-laying monotremes, and may represent enhancement of FIX-activating activity inherent in prekallikrein. FXI activation by thrombin is a more recent acquisition, appearing in placental mammals. These findings suggest FXI activation by FXIIa may be more important to hemostasis in primitive mammals than in placental mammals. FXI activation by thrombin places FXI partially under control of the vitamin K-dependent coagulation mechanism, reducing the importance of the KKS in blood coagulation. This would explain why humans with FXI deficiency have a bleeding abnormality, whereas those lacking components of the KKS do not.
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Affiliation(s)
- Michał B Ponczek
- Department of General Biochemistry, Faculty of Biology and Environmental Protection, University of Lodz, Lodz, Poland
| | - Aleksandr Shamanaev
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN
| | - Alec LaPlace
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN
| | - S Kent Dickeson
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN
| | - Priyanka Srivastava
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN
| | - Mao-Fu Sun
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN
| | - Andras Gruber
- Department of Biomedical Engineering and
- Division of Hematology and Medical Oncology, School of Medicine, Oregon Health and Sciences University, Portland, OR
- Aronora, Inc., Portland, OR
| | - Christian Kastrup
- Michael Smith Laboratories and Department of Biochemistry and Molecular Biology, University of British Columbia, Vancouver, BC, Canada; and
| | - Jonas Emsley
- Biodiscovery Institute, School of Pharmacy, University of Nottingham, Nottingham, United Kingdom
| | - David Gailani
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN
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42
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Kohs TCL, Lorentz CU, Johnson J, Puy C, Olson SR, Shatzel JJ, Gailani D, Hinds MT, Tucker EI, Gruber A, McCarty OJT, Wallisch M. Development of Coagulation Factor XII Antibodies for Inhibiting Vascular Device-Related Thrombosis. Cell Mol Bioeng 2020; 14:161-175. [PMID: 33868498 DOI: 10.1007/s12195-020-00657-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Accepted: 09/26/2020] [Indexed: 11/26/2022] Open
Abstract
Introduction Vascular devices such as stents, hemodialyzers, and membrane oxygenators can activate blood coagulation and often require the use of systemic anticoagulants to selectively prevent intravascular thrombotic/embolic events or extracorporeal device failure. Coagulation factor (F)XII of the contact activation system has been shown to play an important role in initiating vascular device surface-initiated thrombus formation. As FXII is dispensable for hemostasis, targeting the contact activation system holds promise as a significantly safer strategy than traditional antithrombotics for preventing vascular device-associated thrombosis. Objective Generate and characterize anti-FXII monoclonal antibodies that inhibit FXII activation or activity. Methods Monoclonal antibodies against FXII were generated in FXII-deficient mice and evaluated for their binding and anticoagulant properties in purified and plasma systems, in whole blood flow-based assays, and in an in vivo non-human primate model of vascular device-initiated thrombus formation. Results A FXII antibody screen identified over 400 candidates, which were evaluated in binding studies and clotting assays. One non-inhibitor and six inhibitor antibodies were selected for characterization in functional assays. The most potent inhibitory antibody, 1B2, was found to prolong clotting times, inhibit fibrin generation on collagen under shear, and inhibit platelet deposition and fibrin formation in an extracorporeal membrane oxygenator deployed in a non-human primate. Conclusion Selective contact activation inhibitors hold potential as useful tools for research applications as well as safe and effective inhibitors of vascular device-related thrombosis.
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Affiliation(s)
- T C L Kohs
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR 97239 USA
| | - C U Lorentz
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR 97239 USA
- Aronora Inc., Portland, OR USA
| | - J Johnson
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR 97239 USA
| | - C Puy
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR 97239 USA
| | - S R Olson
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR 97239 USA
- Division of Hematology& Medical Oncology, Department of Medicine, Oregon Health & Science University, Portland, OR USA
| | - J J Shatzel
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR 97239 USA
- Division of Hematology& Medical Oncology, Department of Medicine, Oregon Health & Science University, Portland, OR USA
| | - D Gailani
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University School of Medicine, Nashville, TN USA
| | - M T Hinds
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR 97239 USA
| | - E I Tucker
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR 97239 USA
- Aronora Inc., Portland, OR USA
| | - A Gruber
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR 97239 USA
- Aronora Inc., Portland, OR USA
- Division of Hematology& Medical Oncology, Department of Medicine, Oregon Health & Science University, Portland, OR USA
| | - O J T McCarty
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR 97239 USA
- Division of Hematology& Medical Oncology, Department of Medicine, Oregon Health & Science University, Portland, OR USA
| | - M Wallisch
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR 97239 USA
- Aronora Inc., Portland, OR USA
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Ariens R, Becattini C, Bender M, Bergmeier W, Castoldi E, Devreese K, Ellis M, Gailani D, Ignjatovic V, James PD, Kerrigan S, Lambert M, Lee LH, Levi M, Maugeri N, Meijers J, Melero-Martin J, Michelson AD, Mingozzi F, Neeves K, Ni H, Olsson AK, Prohászka Z, Ranson M, Riva N, Senis Y, van Ommen CH, Vaughan DE, Weisel J. Illustrated State-of-the-Art Capsules of the ISTH 2020 Congress. Res Pract Thromb Haemost 2020; 4:680-713. [PMID: 32685876 PMCID: PMC7354406 DOI: 10.1002/rth2.12368] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 03/25/2020] [Accepted: 05/08/2020] [Indexed: 01/19/2023] Open
Abstract
The 2020 Congress of the International Society of Thrombosis and Haemostasis (ISTH) was held virtually July 12-15, 2019, due to the coronavirus disease 2019 pandemic. The congress convenes annually to discuss clinical and basic topics in hemostasis and thrombosis. Each year, the program includes State of Art (SOA) lectures given by prominent scientists. Presenters are asked to create Illustrated Capsules of their talks, which are concise illustrations with minimal explanatory text. Capsules cover major themes of the presentation, and these undergo formal peer review for inclusion in this article. Owing to the shift to a virtual congress this year, organizers reduced the program size. There were 39 SOA lectures virtually presented, and 29 capsules (9 from talks omitted from the virtual congress) were both submitted and successful in peer review, and are included in this article. Topics include the roles of the hemostatic system in inflammation, infection, immunity, and cancer, platelet function and signaling, platelet function disorders, megakaryocyte biology, hemophilia including gene therapy, phenotype tests in hemostasis, von Willebrand factor, anticoagulant factor V, computational driven discovery, endothelium, clinical and basic aspects of thrombotic microangiopathies, fibrinolysis and thrombolysis, antithrombotics in pediatrics, direct oral anticoagulant management, and thrombosis and hemostasis in pregnancy. Capsule authors invite virtual congress attendees to refer to these capsules during the live presentations and participate on Twitter in discussion. Research and Practice in Haemostasis and Thrombosis will release 2 tweets from @RPTHJournal during each presentation, using #IllustratedReview, #CoagCapsule and #ISTH2020. Readers are also welcome to utilize capsules for teaching and ongoing education.
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Affiliation(s)
- Robert Ariens
- Discovery and Translational Science Department Leeds Institute of Cardiovascular and Metabolic Medicine University of Leeds Leeds UK
| | - Cecilia Becattini
- Internal and Cardiovascular Medicine - Stroke Unit University of Perugia Perugia Italy
| | - Markus Bender
- Institute of Experimental Biomedicine - Chair I University Hospital and Rudolf Virchow Center Würzburg Germany
| | - Wolfgang Bergmeier
- Department of Biochemistry and Biophysics UNC Blood Research Center University of North Carolina at Chapel Hill Chapel Hill NC USA
| | - Elisabetta Castoldi
- Cardiovascular Research Institute Maastricht (CARIM) Maastricht University Maastricht The Netherlands
| | - Katrien Devreese
- Coagulation Laboratory Department of Laboratory Medicine Ghent University Hospital Ghent University Ghent Belgium
- Coagulation Laboratory Department of Diagnostic Sciences Ghent University Hospital Ghent University Ghent Belgium
| | - Martin Ellis
- Hematology Institute and Blood Bank Meir Medical Center and Sackler School of Medicine Tel Aviv University Tel Aviv Israel
| | - David Gailani
- Department of Pathology, Microbiology and Immunology Vanderbilt University Medical Center Nashville TN USA
| | - Vera Ignjatovic
- Haematology Research Team Murdoch Children's Research Institute Department of Paediatrics The University of Melbourne Parkville Vic. Australia
| | | | - Steven Kerrigan
- Royal College of Surgeons in Ireland School of Pharmacy and Biomolecular Sciences Irish Centre for Vascular Biology Dublin Ireland
| | - Michele Lambert
- Department of Pediatrics Perelman School of Medicine at the University of Pennsylvania Philadelphia PA USA
| | - Lai Heng Lee
- Department of Haematology Singapore General Hospital SingHealth Singapore City Singapore
| | - Marcel Levi
- University College London Hospitals London UK
| | - Norma Maugeri
- San Raffaele Scientific Institute and Vita-Salute San Raffaele University Milano Italy
| | - Joost Meijers
- Department of Experimental Vascular Medicine Amsterdam University Medical Centers University of Amsterdam Amsterdam The Netherlands
- Department of Molecular and Cellular Hemostasis Sanquin Research Amsterdam The Netherlands
| | | | - Alan D Michelson
- Boston Children's Hospital and Harvard Medical School Boston MA USA
| | | | - Keith Neeves
- Department of Chemical and Biological Engineering Colorado School of Mines Golden CO USA
| | - Heyu Ni
- Department of Laboratory Medicine and Keenan Research Centre for Biomedical Science of St. Michael's Hospital University of Toronto Toronto ON Canada
| | - Anna-Karin Olsson
- Department of Medical Biochemistry and Microbiology Uppsala University Uppsala Sweden
| | - Zoltán Prohászka
- Research Laboratory 3rd Department of Internal Medicine MTA-SE Research Group of Immunology and Hematology Hungarian Academy of Sciences and Semmelweis University Budapest Hungary
| | - Marie Ranson
- School of Chemistry and Molecular Bioscience University of Wollongong Wollongong NSW Australia
| | - Nicoletta Riva
- Department of Pathology Faculty of Medicine and Surgery University of Malta Msida Malta
| | - Yotis Senis
- Directeur de Recherche Etablissement Français du Sang Grand Est Inserm UMR-S1255 Université de Strasbourg Strasbourg France
| | - Cornelia H van Ommen
- Department of Pediatric Hematology Oncology Erasmus MC Sophia Children's Hospital Rotterdam The Netherlands
| | | | - John Weisel
- Department of Cell and Developmental Biology Perelman School of Medicine University of Pennsylvania Philadelphia PA USA
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Abstract
INTRODUCTION Factor XI (FXI) deficiency is associated with highly variable bleeding, including excessive gynecologic and obstetrical bleeding. Since approximately 20% of FXI-deficient women will experience pregnancy-related bleeding, careful planning and knowledge of appropriate hemostatic management is pivotal for their care. AREAS COVERED In this manuscript, authors present our current understanding of the role of FXI in hemostasis, the nature of the bleeding phenotype caused by its deficiency, and the impact of deficiency on obstetrical care. The authors searched PubMed with the terms, 'factor XI', 'factor XI deficiency', 'women', 'pregnancy', and 'obstetrics' to identify literature on these topics. Expectations of pregnancy-related complications in women with FXI deficiency, including antepartum, abortion-related, and postpartum bleeding, as well as bleeding associated with regional anesthesia are discussed. Recommendations for the care of these women are considered, including guidance for management of prophylactic care and acute bleeding. EXPERT COMMENTARY FXI deficiency results in a bleeding diathesis in some, but not all, patients, making treatment decisions and clinical management challenging. Currently available laboratory assays are not particularly useful for distinguishing patients with FXI deficiency who are prone to bleeding from those who are not. There is a need for alternative testing strategies to address this limitation.
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Affiliation(s)
- Allison P Wheeler
- Department of Pathology, Microbiology and Immunology, Vanderbilt University , Nashville, TN, USA.,Department of Pediatrics, Vanderbilt University , Nashville, TN, USA
| | - Celeste Hemingway
- Department of Obstetrics and Gynecology, Vanderbilt University , Nashville, TN, USA
| | - David Gailani
- Department of Pathology, Microbiology and Immunology, Vanderbilt University , Nashville, TN, USA
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Shatzel JJ, DeLoughery EP, Lorentz CU, Tucker EI, Aslan JE, Hinds MT, Gailani D, Weitz JI, McCarty OJT, Gruber A. The contact activation system as a potential therapeutic target in patients with COVID-19. Res Pract Thromb Haemost 2020; 4:500-505. [PMID: 32542210 PMCID: PMC7264624 DOI: 10.1002/rth2.12349] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 04/10/2020] [Accepted: 04/14/2020] [Indexed: 12/21/2022] Open
Abstract
Coronavirus disease 2019 (COVID-19) is predicted to overwhelm health care capacity in the United States and worldwide, and, as such, interventions that could prevent clinical decompensation and respiratory compromise in infected patients are desperately needed. Excessive cytokine release and activation of coagulation appear to be key drivers of COVID-19 pneumonia and associated mortality. Contact activation has been linked to pathologic upregulation of both inflammatory mediators and coagulation, and accumulating preclinical and clinical data suggest it to be a rational therapeutic target in patients with COVID-19. Pharmacologic inhibition of the interaction between coagulation factors XI and XII has been shown to prevent consumptive coagulopathy, pathologic systemic inflammatory response, and mortality in at least 2 types of experimental sepsis. Importantly, inhibition of contact activation also prevented death from Staphylococcus aureus-induced lethal systemic inflammatory response syndrome in nonhuman primates. The contact system is likely dispensable for hemostasis and may not be needed for host immunity, suggesting it to be a reasonably safe target that will not result in immunosuppression or bleeding. As a few drugs targeting contact activation are already in clinical development, immediate clinical trials for their use in patients with COVID-19 are potentially feasible for the prevention or treatment of respiratory distress.
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Affiliation(s)
- Joseph J. Shatzel
- Division of Hematology and OncologyOregon Health & Science UniversityPortlandORUSA
- Department of Biomedical EngineeringOregon Health & Science UniversityPortlandORUSA
| | | | - Christina U. Lorentz
- Department of Biomedical EngineeringOregon Health & Science UniversityPortlandORUSA
- Aronora, Inc.PortlandORUSA
| | - Erik I. Tucker
- Department of Biomedical EngineeringOregon Health & Science UniversityPortlandORUSA
- Aronora, Inc.PortlandORUSA
| | - Joseph E. Aslan
- Knight Cardiovascular InstituteOregon Health & Science UniversityPortlandORUSA
| | - Monica T. Hinds
- Department of Biomedical EngineeringOregon Health & Science UniversityPortlandORUSA
| | | | - Jeffrey I. Weitz
- The Thrombosis and Atherosclerosis Research Institute and McMaster UniversityHamiltonONCanada
| | - Owen J. T. McCarty
- Division of Hematology and OncologyOregon Health & Science UniversityPortlandORUSA
- Department of Biomedical EngineeringOregon Health & Science UniversityPortlandORUSA
| | - Andras Gruber
- Division of Hematology and OncologyOregon Health & Science UniversityPortlandORUSA
- Department of Biomedical EngineeringOregon Health & Science UniversityPortlandORUSA
- Aronora, Inc.PortlandORUSA
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Ivanov I, Verhamme IM, Sun MF, Mohammed B, Cheng Q, Matafonov A, Dickeson SK, Joseph K, Kaplan AP, Gailani D. Protease activity in single-chain prekallikrein. Blood 2020; 135:558-567. [PMID: 31800958 PMCID: PMC7033373 DOI: 10.1182/blood.2019002224] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 11/19/2019] [Indexed: 12/23/2022] Open
Abstract
Prekallikrein (PK) is the precursor of the trypsin-like plasma protease kallikrein (PKa), which cleaves kininogens to release bradykinin and converts the protease precursor factor XII (FXII) to the enzyme FXIIa. PK and FXII undergo reciprocal conversion to their active forms (PKa and FXIIa) by a process that is accelerated by a variety of biological and artificial surfaces. The surface-mediated process is referred to as contact activation. Previously, we showed that FXII expresses a low level of proteolytic activity (independently of FXIIa) that may initiate reciprocal activation with PK. The current study was undertaken to determine whether PK expresses similar activity. Recombinant PK that cannot be converted to PKa was prepared by replacing Arg371 with alanine at the activation cleavage site (PK-R371A, or single-chain PK). Despite being constrained to the single-chain precursor form, PK-R371A cleaves high-molecular-weight kininogen (HK) to release bradykinin with a catalytic efficiency ∼1500-fold lower than that of kallikrein cleavage of HK. In the presence of a surface, PK-R371A converts FXII to FXIIa with a specific activity ∼4 orders of magnitude lower than for PKa cleavage of FXII. These results support the notion that activity intrinsic to PK and FXII can initiate reciprocal activation of FXII and PK in solution or on a surface. The findings are consistent with the hypothesis that the putative zymogens of many trypsin-like proteases are actually active proteases, explaining their capacity to undergo processes such as autoactivation and to initiate enzyme cascades.
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Affiliation(s)
- Ivan Ivanov
- Department of Pathology, Microbiology and Immunology, Vanderbilt University, Nashville, TN
| | - Ingrid M Verhamme
- Department of Pathology, Microbiology and Immunology, Vanderbilt University, Nashville, TN
| | - Mao-Fu Sun
- Department of Pathology, Microbiology and Immunology, Vanderbilt University, Nashville, TN
| | - Bassem Mohammed
- Department of Pathology, Microbiology and Immunology, Vanderbilt University, Nashville, TN
| | - Qiufang Cheng
- Department of Pathology, Microbiology and Immunology, Vanderbilt University, Nashville, TN
| | - Anton Matafonov
- Department of Pathology, Microbiology and Immunology, Vanderbilt University, Nashville, TN
| | - S Kent Dickeson
- Department of Pathology, Microbiology and Immunology, Vanderbilt University, Nashville, TN
| | | | - Allen P Kaplan
- Department of Medicine, Medical University of South Carolina, Charleston, SC
| | - David Gailani
- Department of Pathology, Microbiology and Immunology, Vanderbilt University, Nashville, TN
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Halliday SJ, Matthews DT, Talati MH, Austin ED, Su YR, Absi TS, Fortune NL, Gailani D, Matafonov A, West JD, Hemnes AR. A multifaceted investigation into molecular associations of chronic thromboembolic pulmonary hypertension pathogenesis. JRSM Cardiovasc Dis 2020; 9:2048004020906994. [PMID: 32110389 PMCID: PMC7019411 DOI: 10.1177/2048004020906994] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 01/08/2020] [Accepted: 01/10/2020] [Indexed: 12/03/2022] Open
Abstract
Purpose Chronic thromboembolic pulmonary hypertension is characterized by incomplete
thrombus resolution following acute pulmonary embolism, leading to pulmonary
hypertension and right ventricular dysfunction. Conditions such as
thrombophilias, dysfibrinogenemias, and inflammatory states have been
associated with chronic thromboembolic pulmonary hypertension, but molecular
mechanisms underlying this disease are poorly understood. We sought to
characterize the molecular and functional features associated with chronic
thromboembolic pulmonary hypertension using a multifaceted approach. Methods We utilized functional assays to compare clot lysis times between chronic
thromboembolic pulmonary hypertension patients and multiple controls. We
then performed immunohistochemical characterization of tissue from chronic
thromboembolic pulmonary hypertension, pulmonary arterial hypertension, and
healthy controls, and examined RNA expression patterns of cultured
lymphocytes and pulmonary arterial specimens. We then confirmed RNA
expression changes using immunohistochemistry, immunofluorescence, and
Western blotting in pulmonary arterial tissue. Results Clot lysis times in chronic thromboembolic pulmonary hypertension patients
are similar to multiple controls. Chronic thromboembolic pulmonary
hypertension endarterectomized tissue has reduced expression of both smooth
muscle and endothelial cell markers. RNA expression profiles in pulmonary
arteries and peripheral blood lymphocytes identified differences in RNA
transcript levels related to inflammation and growth factor signaling, which
we confirmed using immunohistochemistry. Gene expression data also suggested
significant alterations in metabolic pathways, and immunofluorescence and
Western blot experiments confirmed that unglycosylated CD36 and adiponectin
expression were increased in chronic thromboembolic pulmonary hypertension
versus controls. Conclusions Our data do not support impaired clot lysis underlying chronic thromboembolic
pulmonary hypertension, but did demonstrate distinct molecular patterns
present both in peripheral blood and in pathologic specimens of chronic
thromboembolic pulmonary hypertension patients suggesting that altered
metabolism may play a role in chronic thromboembolic pulmonary hypertension
pathogenesis.
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Affiliation(s)
- Stephen J Halliday
- Division of Allergy, Pulmonary and Critical Care Medicine, University of Wisconsin Madison, Madison, USA
| | - Daniel T Matthews
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, USA
| | - Megha H Talati
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, USA
| | - Eric D Austin
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, USA
| | - Yan R Su
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, USA
| | - Tarek S Absi
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, USA
| | - Niki L Fortune
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, USA
| | - David Gailani
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, USA
| | - Anton Matafonov
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, USA
| | - James D West
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, USA
| | - Anna R Hemnes
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, USA
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48
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Wallisch M, Lorentz CU, Lakshmanan HHS, Johnson J, Carris MR, Puy C, Gailani D, Hinds MT, McCarty OJT, Gruber A, Tucker EI. Antibody inhibition of contact factor XII reduces platelet deposition in a model of extracorporeal membrane oxygenator perfusion in nonhuman primates. Res Pract Thromb Haemost 2020; 4:205-216. [PMID: 32110750 PMCID: PMC7040549 DOI: 10.1002/rth2.12309] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 12/20/2019] [Accepted: 12/27/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND The contact factor XII (FXII) activates upon contact with a variety of charged surfaces. Activated FXII (FXIIa) activates factor XI, which activates factor IX, resulting in thrombin generation, platelet activation, and fibrin formation. In both in vitro and in vivo rabbit models, components of medical devices, including extracorporeal oxygenators, are known to incite fibrin formation in a FXII-dependent manner. Since FXII has no known role in hemostasis and its inhibition is therefore likely a safe antithrombotic approach, we investigated whether FXII inhibition also reduces accumulation of platelets in extracorporeal oxygenators. OBJECTIVES We aimed to determine the effect of FXII inhibition on platelet deposition in perfused extracorporeal membrane oxygenators in nonhuman primates. METHODS A potent FXII neutralizing monoclonal antibody, 5C12, was administered intravenously to block contact activation in baboons. Extracorporeal membrane oxygenators were temporarily deployed into chronic arteriovenous access shunts. Radiolabeled platelet deposition in oxygenators was quantified in real time using gamma camera imaging. Biochemical assays were performed to characterize the method of action of 5C12. RESULTS The anti-FXII monoclonal antibody 5C12 recognized both the alpha and beta forms of human and baboon FXII by binding to the protease-containing domain, and inhibited FXIIa activity. Administration of 5C12 to baboons reduced platelet deposition and fibrin formation in the extracorporeal membrane oxygenators, in both the presence and absence of systemic low-dose unfractionated heparin. The antiplatelet dose of 5C12 did not cause measurable increases in template bleeding times in baboons. CONCLUSIONS FXII represents a possible therapeutic and safe target for reducing platelet deposition and fibrin formation during medical interventions including extracorporeal membrane oxygenation.
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Affiliation(s)
- Michael Wallisch
- Department of Biomedical EngineeringOregon Health & Science UniversityPortlandORUSA
- Aronora, Inc.PortlandORUSA
| | - Christina U. Lorentz
- Department of Biomedical EngineeringOregon Health & Science UniversityPortlandORUSA
- Aronora, Inc.PortlandORUSA
| | | | - Jennifer Johnson
- Department of Biomedical EngineeringOregon Health & Science UniversityPortlandORUSA
| | - Marschelle R. Carris
- Department of Biomedical EngineeringOregon Health & Science UniversityPortlandORUSA
- Aronora, Inc.PortlandORUSA
| | - Cristina Puy
- Department of Biomedical EngineeringOregon Health & Science UniversityPortlandORUSA
| | - David Gailani
- Department of Pathology, Microbiology, and ImmunologyVanderbilt University School of MedicineNashvilleTNUSA
| | - Monica T. Hinds
- Department of Biomedical EngineeringOregon Health & Science UniversityPortlandORUSA
| | - Owen J. T. McCarty
- Department of Biomedical EngineeringOregon Health & Science UniversityPortlandORUSA
- Division of Hematology & Medical OncologyDepartment of MedicineOregon Health & Science UniversityPortlandORUSA
| | - András Gruber
- Department of Biomedical EngineeringOregon Health & Science UniversityPortlandORUSA
- Aronora, Inc.PortlandORUSA
- Division of Hematology & Medical OncologyDepartment of MedicineOregon Health & Science UniversityPortlandORUSA
| | - Erik I. Tucker
- Department of Biomedical EngineeringOregon Health & Science UniversityPortlandORUSA
- Aronora, Inc.PortlandORUSA
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49
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Abstract
Hemostasis is the normal process that produces a blood clot at a site of vascular injury. Mice are widely used to study hemostasis and abnormalities of blood coagulation because their hemostatic system is similar in most respects to that of humans, and their genomes can be easily manipulated to create models of inherited human coagulation disorders. Two of the most widely used techniques for assessing hemostasis in mice are the tail bleeding time (TBT) and saphenous vein bleeding (SVB) models. Here we discuss the use of these methods in the evaluation of hemostasis, and the advantages and limits of using mice as surrogates for studying hemostasis in humans.
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Affiliation(s)
- Bassem M Mohammed
- Department of Pathology, Microbiology and Immunology, Vanderbilt University , Nashville, TN, USA.,Department of Pathology and Immunology, Washington University , St. Louis, MO, USA
| | - Dougald M Monroe
- UNC Blood Research Center and Hematology/Oncology, University of North Carolina , Chapel Hill, NC, USA
| | - David Gailani
- Department of Pathology, Microbiology and Immunology, Vanderbilt University , Nashville, TN, USA
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50
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Lorentz CU, Verbout NG, Wallisch M, Hagen MW, Shatzel JJ, Olson SR, Puy C, Hinds MT, McCarty OJT, Gailani D, Gruber A, Tucker EI. Contact Activation Inhibitor and Factor XI Antibody, AB023, Produces Safe, Dose-Dependent Anticoagulation in a Phase 1 First-In-Human Trial. Arterioscler Thromb Vasc Biol 2020; 39:799-809. [PMID: 30700130 DOI: 10.1161/atvbaha.118.312328] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Objective- Factor XI (FXI) contributes to thrombotic disease while playing a limited role in normal hemostasis. We generated a unique, humanized anti-FXI antibody, AB023, which blocks factor XIIa-mediated FXI activation without inhibiting FXI activation by thrombin or the procoagulant function of FXIa. We sought to confirm the antithrombotic activity of AB023 in a baboon thrombosis model and to evaluate the safety, tolerability, pharmacokinetics, and pharmacodynamics in healthy adult subjects. Approach and Results- In a primate model of acute vascular graft thrombosis, AB023 reduced platelet and fibrin accumulation within the grafts by >75%. To evaluate the safety of AB023, we performed a first-in-human study in healthy adult volunteers without any serious adverse events. Overall, 10 of 21 (48%) subjects experienced 20 treatment-emergent adverse events, with 7 of 16 (44%) subjects following active treatment and 3 of 5 (60%) subjects following placebo. AB023 did not increase bleeding or prothrombin times. Anticoagulation was verified by a saturable ≈2-fold prolongation of the partial thromboplastin time for over 1 month after the highest dose. Conclusions- AB023, which inhibits contact activation-initiated blood coagulation in vitro and experimental thrombus formation in primates, produced a dose-dependent duration of limited anticoagulation without drug-related adverse effects in a phase 1 trial. When put in context with earlier observations suggesting that FXI contributes to venous thromboembolism and cardiovascular disease, although contributing minimally to hemostasis, our data further justify clinical evaluation of AB023 in conditions where contact-initiated FXI activation is suspected to have a pathogenic role. Clinical Trial Registration- URL: http://www.clinicaltrials.gov . Unique identifier: NCT03097341.
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Affiliation(s)
- Christina U Lorentz
- From Aronora, Inc, Portland, OR (C.U.L., N.G.V., M.W., A.G., E.I.T.).,Department of Biomedical Engineering (C.U.L., N.G.V., M.W., M.W.H., J.J.S., S.R.O., C.P., M.T.H., O.J.T.M., A.G., E.I.T.), Oregon Health & Science University, Portland
| | - Norah G Verbout
- From Aronora, Inc, Portland, OR (C.U.L., N.G.V., M.W., A.G., E.I.T.).,Department of Biomedical Engineering (C.U.L., N.G.V., M.W., M.W.H., J.J.S., S.R.O., C.P., M.T.H., O.J.T.M., A.G., E.I.T.), Oregon Health & Science University, Portland
| | - Michael Wallisch
- From Aronora, Inc, Portland, OR (C.U.L., N.G.V., M.W., A.G., E.I.T.).,Department of Biomedical Engineering (C.U.L., N.G.V., M.W., M.W.H., J.J.S., S.R.O., C.P., M.T.H., O.J.T.M., A.G., E.I.T.), Oregon Health & Science University, Portland
| | - Matthew W Hagen
- Department of Biomedical Engineering (C.U.L., N.G.V., M.W., M.W.H., J.J.S., S.R.O., C.P., M.T.H., O.J.T.M., A.G., E.I.T.), Oregon Health & Science University, Portland
| | - Joseph J Shatzel
- Department of Biomedical Engineering (C.U.L., N.G.V., M.W., M.W.H., J.J.S., S.R.O., C.P., M.T.H., O.J.T.M., A.G., E.I.T.), Oregon Health & Science University, Portland.,Division of Hematology and Medical Oncology (J.J.S., S.R.O., O.J.T.M., A.G.), Oregon Health & Science University, Portland
| | - Sven R Olson
- Department of Biomedical Engineering (C.U.L., N.G.V., M.W., M.W.H., J.J.S., S.R.O., C.P., M.T.H., O.J.T.M., A.G., E.I.T.), Oregon Health & Science University, Portland.,Division of Hematology and Medical Oncology (J.J.S., S.R.O., O.J.T.M., A.G.), Oregon Health & Science University, Portland
| | - Cristina Puy
- Department of Biomedical Engineering (C.U.L., N.G.V., M.W., M.W.H., J.J.S., S.R.O., C.P., M.T.H., O.J.T.M., A.G., E.I.T.), Oregon Health & Science University, Portland
| | - Monica T Hinds
- Department of Biomedical Engineering (C.U.L., N.G.V., M.W., M.W.H., J.J.S., S.R.O., C.P., M.T.H., O.J.T.M., A.G., E.I.T.), Oregon Health & Science University, Portland
| | - Owen J T McCarty
- Department of Biomedical Engineering (C.U.L., N.G.V., M.W., M.W.H., J.J.S., S.R.O., C.P., M.T.H., O.J.T.M., A.G., E.I.T.), Oregon Health & Science University, Portland.,Division of Hematology and Medical Oncology (J.J.S., S.R.O., O.J.T.M., A.G.), Oregon Health & Science University, Portland
| | - David Gailani
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN (D.G.)
| | - András Gruber
- From Aronora, Inc, Portland, OR (C.U.L., N.G.V., M.W., A.G., E.I.T.).,Department of Biomedical Engineering (C.U.L., N.G.V., M.W., M.W.H., J.J.S., S.R.O., C.P., M.T.H., O.J.T.M., A.G., E.I.T.), Oregon Health & Science University, Portland.,Division of Hematology and Medical Oncology (J.J.S., S.R.O., O.J.T.M., A.G.), Oregon Health & Science University, Portland
| | - Erik I Tucker
- From Aronora, Inc, Portland, OR (C.U.L., N.G.V., M.W., A.G., E.I.T.).,Department of Biomedical Engineering (C.U.L., N.G.V., M.W., M.W.H., J.J.S., S.R.O., C.P., M.T.H., O.J.T.M., A.G., E.I.T.), Oregon Health & Science University, Portland
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