Dyga, Wojciech

Natorska, Joanna

Obtułowicz, Krystyna

Undas, Anetta

Ząbczyk, Michał

Polish Archives of Internal Medicine

English

Jagiellonian Univeristy Repository

POLISH ARCHIVES OF INTERNAL MEDICINE 2019; 129 (12)936The ethics committee of Jagiellonian University in Kraków approved the study and patients signed a written informed consent form. The study was carried out in accordance with the Declaration of Helsinki and its amendments.Laboratory investigations Blood samples (vol/vol, 9:1 of 3.2% trisodium citrate) were spun at 2000 g for 10 minutes, and the supernatants were al‑iquoted and stored at a temperature of –80ºC. Plasma levels of the C1INH antigen (aC1INH) were measured using nephelometry (Siemens Healthcare Diagnostics GmbH, Marburg, Ger‑many). The functional activity of C1INH was de‑termined using the functional chromogenic assay Berichrom C1INH (Siemens Healthcare Diagnos‑tics). All patients had reduced serum C1INH levels (mean, 0.07 g/l; reference range, 0.21–0.39 g/l) and functional activity of C1INH (mean func‑tional activity of C1INH, 26.0%; reference range, 70%–130%). Plasma levels of factor VIII (FVIII; based on activated partial thromboplastin time) were evaluated using the Behring Coagulation System (Siemens Healthcare Diagnostics). ELI‑SA test kits were used to measure thrombin–an‑tithrombin complexes (TAT; Enzygnost TAT mi‑cro, Siemens Healthcare Diagnostics).Fibrin clot analysis Plasma fibrin clot permea‑bility was determined as described previously.7 The permeation coefficient (Ks), which indicates the average size of pores formed in the fibrin net‑work (with low values indicating a tightly packed fibrin structure), was calculated from the equa‑tion: Ks = Q × L × η/t × A × Δp, where Q is the flow rate in time, L is the length of a fibrin gel, η is the viscosity of liquid (in poise), t is percolating time, A is the cross ‑sectional area (in cm2), and Δp is a differential pressure (in dyne/cm2).Introduction Hereditary angioedema (HAE) is a rare autosomal dominant disease caused by the deficiency of C1 inhibitor (C1INH). This HAE due to C1 inhibitor deficiency (C1INH ‑HAE) man‑ifests as subcutaneous and submucosal angioede‑ma, which can affect any part of the body.1The deficiency of C1INH1,2 disturbs the comple‑ment cascade, coagulation, kinins, and fibrinolysis and results in an uncontrolled release of bradyki‑nin, the main mediator in C1INH ‑HAE.3 Previous studies supported the involvement of blood co‑agulation and fibrinolysis in the pathophysiology of C1INH ‑HAE despite the absence of clinically relevant thrombosis and hemostatic disorders.4,5 To our knowledge, there have been no reports on the properties of plasma fibrin clot in relation to thrombin formation in this disease despite evi‑dence on their role in several pathologies.6We sought to evaluate thrombin generation and fibrinolytic potential along with factor VIII and fibrin clot density in patients with C1INH‑‑HAE during remission and acute angioedema attack.Patients and methods Patients The study includ‑ed 15 adult patients with C1INH ‑HAE in remis‑sion and during angioedema attacks. The control group included 15 healthy individuals matched for age, sex, and body mass index. The diagnosis of C1INH ‑HAE was established on the basis of the patient and family history, on the examina‑tion during attacks of angioedema, and reduced C1INH antigen as well as C1INH activity below 50% of the reference values.1 The study was per‑formed during remission (no attacks for at least 2 weeks) and in the first 3 to 5 hours of acute an‑gioedema attack. Patients with comorbidities and those receiving any long ‑term medication (includ‑ing tranexamic acid or danazol) were ineligible.RESEARCH LETTERElevated thrombin generation and factor VIII activity during angioedema attack in patients with hereditary C1 inhibitor deficiencyKrystyna Obtułowicz1, Wojciech Dyga1, Joanna Natorska2,3, Michał Ząbczyk2,3, Anetta Undas2,31  Department of Clinical and Environmental Allergology, Jagiellonian University Medical College, Kraków, Poland2  Institute of Cardiology, Jagiellonian University Medical College, Kraków, Poland3  John Paul II Hospital, Kraków, PolandCorrespondence to:Wojciech Dyga, PhD, Department of Clinical and Environmental Allergology, Jagiellonian University Medical College, ul. Śniadeckich 10, 31-531 Kraków, Poland, phone: +48 12 423 11 22, email: wojciech.dyga@uj.edu.plReceived: December 6, 2019.Revision accepted: December 9, 2019.Published online: December 9, 2019.Pol Arch Intern Med. 2019; 129 (12): 936-938doi:10.20452/pamw.15096Copyright by Medycyna Praktyczna, Kraków 2019RESEARCH LETTER Elevated thrombin and factor VIII activity in hereditary angioedema 937In remission, patients with C1INH ‑HAE had similar fibrinogen and TAT levels as con‑trols (median [interquartile range (IQR)], 240 [223–296] mg/dl vs 235 [215–287] mg/dl and 3.68 [2.61–8.71] µg/l vs 3.03 [2.39–4.09] µg/l, respectively). Patients with C1INH ‑HAE were characterized by 35% higher FVIII levels (median [IQR], 139% [129%–149%] vs 103% [92%–107%]; P <0.05), 66.4% higher endogenous thrombin potential (median [IQR], 1994 [1719–2203] nM×min vs 1198 [989–1298] nM×min; P <0.05), and 106% higher peak thrombin compared with controls (median [IQR], 305 [280–341] nM vs 148 [117–182] nM; P <0.05). In remission, Ks was lower by 19% (median [IQR], 6.05 [4.81–7.92] × 10–9 cm2 vs 7.47 [6.62–9.01] × 10–9 cm2; P <0.05), while clot lysis time did not differ from the controls (medi‑an [IQR], 95 [90–112] min vs 95 [85–105] min; P >0.05). There were no associations of throm‑bin generation or fibrin clot properties with age, body mass index, or C1INH levels and activity in C1INH ‑HAE patients during remission.Patients with C1INH ‑HAE during the attack compared with remission had 91.7% higher fi‑brinogen levels, 325.8% higher TAT levels, and 11.5% increased FVIII activity (TABLE 1). During the attack, FVIII levels were associated with peak thrombin (r = 0.55, P = 0.04), while a similar as‑sociation in remission tended to be significant in remission (r = 0.5, P = 0.069). No other associa‑tions were observed for FVIII activity and fibrin clot properties.Of note, we have not found differences in TAT levels between patients with C1INH ‑HAE and with erythema marginatum (n [%], 8 [53.3]) and those without erythema (n [%], 7 [46.7]) regardless of whether the patients were in re‑mission (median [IQR], 6.00 [2.91–11.52] vs 3.68 [2.46–7.27] µg/l; P = 0.39) or during the at‑tack (median [IQR], 39.74 [15.24–90.09] vs 7.82 [4.14–47.33] µg/l; P = 0.12).Discussion Our study is the first to show elevated FVIII activity and increased thrombin generation reflected by TAT and in vitro thrombin generation potential in patients with C1INH‑HAE. Howev‑er, our results are based on a small group of pa‑tients and should be confirmed in a larger study that would also assess coagulation factors (espe‑cially von Willebrand factor) and their relation‑ship with the duration and severity of an edema attack. Recently, increased thrombin generation assessed by CAT has been shown in patients with a chronic urticaria and a history of angioedema compared with patients with urticaria alone.10An association between increased thrombin peak, elevated TAT, and FVIII levels may explain high D ‑dimer levels in patients with edema at‑tacks, which are considered a biomarker of blood coagulation activation and fibrinolysis.5 Interest‑ingly, increased FVIII activity in patients with C1INH ‑HAE during an angioedema attack and in remission is a novel observation. Recent studies have suggested the possible active involvement of Clot lysis time was measured using the as‑say by Pieters et al.8 It was defined as the time from the midpoint of the clear ‑to ‑maximum‑‑turbid transition, which represents clot forma‑tion, to the midpoint of the maximum ‑turbid ‑to‑‑clear transition.Calibrated automated thrombogram Thrombin gen‑eration kinetics were measured with a calibrated automated thrombogram (CAT; Thrombinoscope BV, Maastricht, the Netherlands) according to the manufacturer’s instructions.9 Each plasma sample was analyzed in duplicate. The maximum concentration of thrombin formed during the re‑cording time was described as the thrombin peak and the area under the curve represented endog‑enous thrombin potential.Statistical analysis Categorical variables were analyzed by the Pearson χ2 test. Continuous vari‑ables were expressed as median and interquartile range. Normality of the data was assessed using the Shapiro–Wilk test. The groups were compared using the t test for normally distributed continu‑ous variables. For nonnormally distributed con‑tinuous variables, the Mann–Whitney test and the Wilcoxon rank test were used. Associations between variables were assessed by the Spear‑man rank correlation analysis. P values of less than 0.05 were considered significant.Results Patients with C1INH ‑HAE did not dif‑fer from age‑, sex‑, and body mass index–matched controls (all P >0.05). Eight patients (53.3%) had a positive family history of C1INH ‑HAE. The mean age of HAE onset was 9.9 years (range, 3–22 years). In 8 patients, angioedema attacks were preceded by erythema marginatum.TABLE 1 Characteristics of patients with hereditary angioedema due to C1 inhibitor deficiency during remission and attackVariable Patients (n = 15)In remission During attackAge, y 36 (29.5–56.5)Female sex, n (%) 11 (73.3)Body mass index, kg/m2 24.6 (20.3–28.6)Fibrinogen, mg/dl 240 (223–296) 460 (380–570)aFactor VIII, % 139 (129–149) 155 (145–173)aFibrin clot permeability (Ks), ×10–9 cm26.05 (4.81–7.92) 5.94 (4.79–7.15)Clot lysis time, min 95.0 (89.5–111.7) 91.4 (83.0–110.2)Lag time, min 2.94 (2.78–3.61) 2.94 (2.47–3.43)Endogenous thrombin potential, nM×min1994 (1719–2203) 1940 (1624–2444)Peak thrombin, nM 305 (280–341) 312 (271–394)Time to peak thrombin, min 6.95 (6.29–7.5) 5.94 (5.33–6.62)Thrombin–antithrombin complex, μg/l 3.68 (2.61–8.71) 5.67 (8.35–87.35)aData are presented as median (interquartile range) unless otherwise indicated.a P <0.05 compared with patients in remissionPOLISH ARCHIVES OF INTERNAL MEDICINE 2019; 129 (12)938REFERENCES1 Cicardi M, Aberer W, Banerji A, et al. Classification, diagnosis, and ap-proach to treatment for angioedema: consensus report from the Hereditary Angioedema International Working Group. Allergy. 2014; 69: 602-616. 2 Levi M, Cohn DM, Zeerleder S. Hereditary angioedema: linking com-plement regulation to the coagulation system. Res Pract Thromb Haemost. 2019; 3: 38-43. 3 Obtułowicz K. Bradykinin ‑mediated angioedema. Pol Arch Med Wewn. 2016; 126: 76-85. 4 Firinu D, Bassareo PP, Zedda AM, et al. Impaired endothelial function in hereditary angioedema during the symptom -free period. Front Physiol. 2018; 9: 523. 5 Deroux A, Dumestre -Perard C, Khalil -Mgharbel A, et al. BIOBRAD study: the search for biomarkers of bradykinin -mediated angio -oedema attacks. Int Arch Allergy Immunol. 2016; 170: 108-114. 6 Ząbczyk M, Undas A. Plasma fibrin clot structure and thromboembolism: clinical implications. Pol Arch Intern Med. 2017; 127: 873-881. 7 Cieslik J, Mrozinska S, Broniatowska E, Undas A. Altered plasma clot properties increase the risk of recurrent deep vein thrombosis: a cohort study. Blood. 2018; 131: 797-807. 8 Pieters M, Philippou H, Undas A, et al. An international study on the fea-sibility of a standardized combined plasma clot turbidity and lysis assay: communication from the SSC of the ISTH. J Thromb Haemost. 2018; 16: 1007-1012. 9 Hemker HC. Thrombin generation in a reconstituted relatives of pa-tients with premature coronary artery disease. Circulation. 2002; 106: 1938-1942. 10 Fernández ‑Pardo Á, Oto J, Ibañez E, et al. Increased parameters of thrombin generation in patients with chronic urticaria that associate angio-edema. Res Pract Thromb Haemost. 2019; 3 (suppl. 1): 96.11 Dong R, Chen W, Feng W, et al. Exogenous bradykinin inhibits tissue factor induction and deep vein thrombosis via activating the eNOS/phos-phoinositide 3 -kinase/Akt signaling pathway. Cell Physiol Biochem. 2015; 37: 1592-1606. 12 Kajdácsi E, Jani PK, Csuka D, et al. Endothelial cell activation during edematous attacks of hereditary angioedema types I and II. J Allergy Clin Immunol. 2014; 133: 1686-1691. some blood clotting factors such as FXII and tis‑sue factor–FVIIa complex2,11 in the pathomech‑anism of C1INH ‑HAE.We observed no difference in plasma fibrino‑lytic potential and fibrin clot density between pa‑tients with C1INH ‑HAE (regardless of remission or attack) and controls, despite elevated thrombin formation markers in the former group. This could explain, at least in part, the absence of thrombot‑ic manifestations despite very high D ‑dimer lev‑els found in patients with severe HAE attacks.5 In most cases, efficient fibrinolysis seems to pro‑tect against thrombosis. However, high thrombin formation might suggest clinical benefits from thromboprophylaxis in some patients with high D ‑dimer levels during a severe attack.During attack, contact system activation re‑sults in increased F1+F2 prothrombin fragment levels and shortening of activated partial throm‑boplastin time,2 which indicates enhanced throm‑bin generation due to FXII activation. Some au‑thors2,11 reported that during attack, FVIIa lev‑els are increased, suggesting that self ‑limiting thrombin generation may be due to the activa‑tion of the tissue factor pathway. This phenom‑enon under bradykinin control as suggested by Dong et al11 deserves further research. Throm‑bin generation during attack activates thrombin activatable fibrinolysis inhibitor, which may in‑dicate its effect on the regulation of fibrinolysis in this clinical setting. The involvement of endo‑thelial activation in the pathogenesis of C1INH‑‑HAE is in line with the study by Kajdácsi et al,12 who showed a significantly increased activity of von Willebrand factor.Our study shows that thrombin generation re‑lated with increased FVIII activity rather than im‑paired fibrinolytic potential may be involved in modulating angioedema attacks in patients with C1INH ‑HAE. However, the major study limitation was a small sample size, thus the presented data should be interpreted with caution. In order to fully understand the pathophysiology of C1INH‑‑HAE as well as the role of thrombin formation, blood clotting, fibrinolysis, and endothelial dam‑age in this disease, further investigation on larg‑er group with long ‑term follow ‑up is required.ARTICLE INFORMATIONACKNOWLEDGMENTS This study was supported by a grant from the National Science Centre (No. UMO ‑2014/13/B/NZ6/00246; to KO).CONFLICT OF INTEREST None declared.OPEN ACCESS This is an Open Access article distributed under the terms of the Creative Commons Attribution -NonCommercial -ShareAlike 4.0 Inter-national License (CC BY -NC -SA 4.0), allowing third parties to copy and re-distribute the material in any medium or format and to remix, transform, and build upon the material, provided the original work is properly cited, distrib-uted under the same license, and used for noncommercial purposes only. For commercial use, please contact the journal office at pamw@mp.pl.HOW TO CITE Obtułowicz K, Dyga W, Natorska J, et al. Elevated thrombin generation and factor VIII activity during angioedema attack in patients with hereditary C1 inhibitor deficiency. Pol Arch Intern Med. 2019; 129: 936-938. doi:10.20452/pamw.15096

Elevated thrombin generation and factor VIII activity during angioedema attack in patients with hereditary C1 inhibitor deficiency

https://ruj.uj.edu.pl/xmlui/bitstream/handle/item/257184/obtulowicz_et-al_elevated_thrombin_generation_and_factor_8_activity_during_angioedema_attack_2019.pdf?sequence=1&isAllowed=y

Elevated thrombin generation and factor VIII activity during angioedema attack in patients with hereditary C1 inhibitor deficiency

Abstract

Similar works

Full text

Available Versions

Jagiellonian Univeristy Repository