Ongoing Contact Activation in Patients with Hereditary Angioedema

Abstract

Hereditary angioedema (HAE) is predominantly caused by a deficiency in C1 esterase inhibitor (C1INH) (HAE-C1INH). C1INH inhibits activated factor XII (FXIIa), activated factor XI (FXIa), and kallikrein. In HAE-C1INH patients the thrombotic risk is not increased even though activation of the contact system is poorly regulated. Therefore, we hypothesized that contact activation preferentially leads to kallikrein formation and less to activation of the coagulation cascade in HAE-C1INH patients. We measured the levels of C1INH in complex with activated contact factors in plasma samples of HAE-C1INH patients (N=30, 17 during remission and 13 during acute attack) and healthy controls (N=10). We did not detect differences in enzyme-inhibitor complexes between samples of controls, patients during remission and patients during an acute attack. Reconstitution with C1INH did not change this result. Next, we determined the potential to form enzyme-inhibitory complexes after complete in vitro activation of the plasma samples with a FXII trigger. In all samples, enzyme-C1INH levels increased after activation even in patients during an acute attack. However, the levels of FXIIa-C1INH, FXIa-C1INH and kallikrein-C1INH were at least 52% lower in samples taken during remission and 70% lower in samples taken during attack compared to samples from controls (p<0.05). Addition of C1INH after activation led to an increase in levels of FXIIa-C1INH and FXIa-C1INH (p<0.05), which were still lower than in controls (p<0.05), while the levels of kallikrein-C1INH did not change. These results are consistent with constitutive activation and attenuated depletion of the contact system and show that the ongoing activation of the contact system, which is present in HAE-C1INH patients both during remission and during acute attacks, is not associated with preferential generation of kallikrein over FXIa.

Pharmacology of Heparin and Related Drugs

“…C1inh deficiency leads to hereditary angioedema through continuous overactivity of the contact system (Konings et al, 2013). The properties of C1inh are not limited to the complement and contact systems (Zeerleder, 2011).…”

Elevated D‐dimers in attacks of hereditary angioedema are not associated with increased thrombotic risk

“…In addition, endothelial cell activation has been shown to be associated with elevated FXII-dependent fibrinolytic activity ( 6 ) and plasminogen activation is triggered by bradykinin-stimulated release of tPA from the surface of endothelial cells ( 7 ). Indeed, high levels of procoagulant and fibrinolytic activity have been demonstrated in patients with C1-INH-HAE during acute attacks and remissions ( 8 – 11 ). In clinical practice, elevated plasma D-dimers are considered biomarkers of extensive thrombosis but are also elevated in certain nonpathologic conditions ( 12 ).…”

Examination of Laboratory for Monitoring Heparin Anticoagulant Therapy

“…The effects of c1inh are not limited to complement and contact systems. Heparin potentiates the activity of the c1inh, and the crystal structure of the c1inh indicates Examination of Laboratory for Monitoring Heparin Anticoagulant Therapy DOI: http://dx.doi.org/10.5772/intechopen.88401 a different model of activity against different protease and heparin-binding sites against AT [22].…”