New insights into factors affecting clot stability:A role for thrombin activatable fibrinolysis inhibitor (TAFI; Plasma procarboxypeptidase B, plasma procarboxypeptidase U, procarboxypeptidase R)

The thrombin-catalyzed conversion of plasma fibrinogen into fibrin and the development of an insoluble fibrin clot are the final steps in the coagulation cascade during hemostasis. The delicate balance between clot formation and fibrinolysis, which determines clot stability, is controlled by a complex interplay between fibrin and other molecular and cellular components of the hemostatic system, including thrombin activatable fibrinolysis inhibitor (TAFI). TAFI is activated by thrombin and has an important role in the stability of the fibrin clot, which is reviewed here. In particular, the role of TAFI in fibrinolysis and those characteristics of the protein that affect clot stability are described. In addition, the importance of TAFI in the coagulation process and how changes in its availability may contribute to bleeding or thrombotic disorders are discusse

Changes of hemostatic variables during oral contraceptive use

The use of oral contraceptives (OCs) has been known for many years to affect significantly almost all hemostatic parameters, but the challenge to relate these changes in a meaningful way to OC-induced increased venous thrombotic risk has not been met. New insights indicate that at least part of the answer can be found in the net effect of OC use on the efficacy with which the protein C pathway down-regulates thrombin formation. During OC use the (blood) plasma of a woman becomes resistant to the anticoagulant action of activated protein C (APC). The extent of this so-called acquired APC resistance as determined in a thrombin generation-based assay correlates remarkably well with the risk increases observed in clinical studies. Recent evidence indicates that the prothrombotic effect of the estrogen component ethinylestradiol in combined OC is counteracted by the progestagen component present in these preparations and that third-generation progestagens such as desogestrel or gestodene are less efficient with respect to this than the second-generation progestagen levonorgestre

Role of zinc ions in activation and inactivation of thrombin-activatable fibrinolysis inhibitor

Thrombin-activatable fibrinolysis inhibitor (TAFI) circulates as an inactive proenzyme of a carboxypeptidase B-like enzyme (TAFIa). It functions by removing C-terminal lysine residues from partially degraded fibrin that are important in tissue-type plasminogen activator mediated plasmin formation. TAFI was classified as a metallocarboxypeptidase, which contains a Zn(2+), since its amino acid sequence shows approximately 40% identity with pancreatic carboxypeptidases, the Zn(2+) pocket is conserved, and the Zn(2+) chelator o-phenanthroline inhibited TAFIa activity. In this study we showed that TAFI contained Zn(2+) in a 1:1 molar ratio. o-Phenanthroline inhibited TAFIa activity and increased the susceptibility of TAFI to trypsin digestion. TAFIa is spontaneously inactivated (TAFIai) by a temperature-dependent intrinsic mechanism. The lysine analogue epsilon-ACA, which stabilizes TAFIa, delayed the o-phenanthroline mediated inhibition of TAFIa. We investigated if inactivation of TAFIa involves the release of Zn(2+). However, the zinc ion was still incorporated in TAFIai, indicating that inactivation is not caused by Zn(2+) release. After TAFIa was converted to TAFIai, it was more susceptible to proteolytic degradation by thrombin, which cleaved TAFIai at Arg(302). Proteolysis may make the process of inactivation by a conformational change irreversible. Although epsilon-ACA stabilizes TAFIa, it was unable to reverse inactivation of TAFIa or R302Q-rTAFIa, in which Arg(302) was changed into a glutamine residue and could therefore not be inactivated by proteolysis, suggesting that conversion to TAFIai is irreversibl

High levels of coagulation factor XI as a risk factor for venous thrombosis.

Background: Factor XI, a component of the intrinsic pathway of coagulation, contributes to the generation of thrombin, which is involved in both the formation of fibrin and protection against fibrinolysis. A deficiency of factor XI is associated with bleeding, but a role of high factor XI levels in thrombosis has not been investigated. Methods: We determined factor XI antigen levels in the patients enrolled in the Leiden Thrombophilia Study, a large population-based, case-control study (with a total of 474 patients and 474 controls) designed to estimate the contributions of genetic and acquired factors to the risk of deep venous thrombosis. Odds ratios were calculated as a measure of relative risk. Results: The age- and sex-adjusted odds ratio for deep venous thrombosis in subjects who had factor XI levels above the 90th percentile, as compared with those who had factor XI levels at or below that value, was 2.2 (95 percent confidence interval, 1.5 to 3.2). There was a dose-response relation between the factor XI level and the risk of venous thrombosis. Adjustment of the odds ratios for other risk factors such as oral-contraceptive use, homocysteine, fibrinogen, factor VIII, female sex, and older age did not alter the result. Also, when we excluded subjects who had known genetic risk factors for thrombosis (e.g., protein C or S deficiency, antithrombin deficiency, the factor V Leiden mutation, or the prothrombin G20210A mutation), the odds ratio remained the same, indicating that the risk of venous thrombosis associated with elevated levels of factor XI was not the result of one of the known risk factors for thrombosis. Conclusions: High levels of factor XI are a risk factor for deep venous thrombosis, with a doubling of the risk at levels that are present in 10 percent of the population. (N Engl J Med 2000;342:696-701.) (C)2000, Massachusetts Medical Society

Protein C inhibitor (plasminogen activator inhibitor-3) and the risk of venous thrombosis

Protein C inhibitor (PCI), also known as plasminogen activator inhibitor-3, is a serine proteinase inhibitor that can inhibit enzymes in blood coagulation, fibrinolysis and fertility. The role of PCI in regulating the blood coagulation mechanism is not known, as it can inhibit both procoagulant (thrombin, factor Xa, factor XIa) and anticoagulant (activated protein C, thrombin-thrombomodulin, urokinase) enzymes. To determine the relevance of this inhibitor in thrombosis, PCI levels were assessed in the Leiden Thrombophilia Study, a case-control study of venous thrombosis in 473 patients with a first deep-vein thrombosis and 474 age- and sex-matched control subjects. PCI levels above the 95th percentile of the controls (136.1%) increased the risk 1.6-fold compared with PCI levels below the 95th percentile (95% confidence interval 0.9-2.8). There was a gradual increase in risk of thrombosis with further increasing levels of PCI. Adjustment for a number of possible confounders led to a reduction of the risk estimates associated with PCI. However, it is unclear whether adjustment for such factors in the risk models is justified. These results indicate that high levels of PCI may constitute a mild risk factor for venous thrombosi