Bradykinin Is a Proximal Event in Experimental Cerebral Malaria

Human malaria is a complex disease and a leading cause of mortality in children under 5 years of age. Plasmodium falciparum (Pf) is the agent responsible for cerebral malaria. Parasite infected erythrocytes are sequestered in the brain vasculature, disrupting the blood-brain-barrier, and with systemic inflammation leading to progressive brain edema. The precise pathophysiologic mechanism(s) underlying brain swelling in CM is not known. Recent work from our laboratories indicates that there is a role for bradykinin (BK) in fluid transport in human brain microvascular endothelial cells (Front Med 6:75, 2019). We examined the role of bradykinin (BK) in pediatric CM. Initial studies showed recombinant falcipain-2, a cysteine protease contained in the parasite digestive vacuole, was inhibited by high molecular weight kininogen (HK), with an IC 50=36 nM. Further, falcipain-2, but not the related protease falcipain 3, hydrolyzed the chromogenic substrate S2302 (Pro-Phe-Arg-pNA) at pH 7.4 with an 88 nM K m. These results suggest that falcipain-2 has plasma kallikrein-like activity. HK is both an inhibitor and substrate of falcipain-2. Molar excess HK to falcipain-2 (ratio 8:1 to 2:1) blocked the proteolytic activity of the cysteine protease at pH 7.4. Equal molar falcipain-2 to HK (1:1) resulted in kallikrein-like cleavage of HK with stable BK liberation over 1 h. Molar excess falcipain-2 to HK (1:2 and greater) led to progressive HK cleavage into smaller proteins and peptides. The falcipain-2 major cleavages observed by N-terminal sequencing were in Domain 3 of the heavy chain of HK, the cysteine protease inhibitory region (I 292ASFSQNCDIYPGKDF 303, D 320IPTNSPELEETLT 334, and E 412KKIYPTVNCQPLG 425). P. falciparum trophozoite lysates completely hydrolyzed purified and plasma HK into a ~64 kDa heavy chain and ~46 kDa light chain in buffer containing EDTA, pepstatin, and PMSF. The cysteine proteinase inhibitor E64 blocked this cleavage, suggesting that the relevant activity was that of a cysteine protease. Plasma from Kenyan children presenting with CM (fever, parasitemia, coma) had evidence of circulating cHK, indicative of BK released from HK. Forty percent (8 of 20) of CM patients had no intact 120 kDa HK at hospital entry. In contrast, only 16% (3 of 8) of children with uncomplicated malaria had detectable cHK. In CM patients, the HK level before antimalarial treatment (58 ± 3.9 µg/ml) was significantly lower than the value after clinical recovery (69 ± 3.6 µg/ml; p<0.04) as measured by competitive ELISA. We also examined the roles of BK and HK in experimental cerebral malaria. 10 6 infected red blood cells with P. berghei ANKA were injected intraperitoneally into wild-type (C57BL/6) and total kininogen deficient (kgn1 -/-) C57BL/6 mice. The level of parasitemia on day 5 post-infection was ≥ 8% for both groups of mice (Figure 1). The kgn1 -/- mice had protected neuronal function measured by SHIRPA score relative to wild-type mice. Cerebral edema detected in wild- type mice by Evans Blue dye extravasation test was nearly completely attenuated in kgn1 -/- mice. Corroborative studies were performed in BK B2 receptor deleted (bdkrb2 -/-) mice. In mice with 15% parasitemia for both genotypes, there was significantly less neurologic function deterioration and a 30% reduction in cerebral Evans blue extravasation into brain parenchyma in the bdkrb2 -/- mice. These data strongly suggest that falcipain-2 liberates BK from HK by acting like plasma kallikrein and in high concentrations destroys HK's cysteine protease inhibitory region. Some children with CM have in vivo evidence of prior HK proteolysis. Total kininogen deficiency protects mice from lethal experimental CM. Taken together, these data suggest that bradykinin is a proximal mediator of cerebral malaria. Figure 1 Figure 1. Disclosures McCrae: Dova, Novartis, Rigel, and Sanofi Genzyme: Consultancy; Sanofi, Novartis, Alexion, and Johnson & Johnson: Consultancy, Honoraria.

Predictive Value for Increased Factor XIa and Plasma Kallikrein Activity in Acute Venous Thromboembolism

Venous thromboembolism (VTE) is associated with increased coagulation activity, which in part can be attributed to the contact pathway of coagulation. Evidence from pre-clinical and epidemiological studies suggests that deficiency in factors of contact activation (e.g. coagulation factors (F) XI and FXII) protects against VTE. However, limited information exists regarding the activation of the contact system in the setting of acute VTE. In the current study, patients with confirmed VTE events (n=321) from the VTEval study and controls (n=300) from the population-based PREVENT-it pilot study were included. Plasma samples were collected from patients after confirmed VTE events or controls upon inclusion in the study. FXI as well as FXIa and plasma kallikrein (PKa) levels were assessed in plasma samples from all subjects using an activated thromboplastin time-based assay (FXI:c), a thrombin generation-based assay (CAT:FXIa) and by measuring inhibitory complexes (FXIa:antithrombin (AT), FXIa:alpha-1-antitrypsin (α1AT), FXIa:C1 esterase inhibitor (C1Inh) and PKa:C1Inh) using enzyme-linked immunoassay (ELISA). After a 2-year follow up period, a composite endpoint of recurrent VTE or death was determined. Increased FXI:c levels were determined in VTE patients compared to control individuals (124.08 ± 37.48% vs. 113.55 ± 27.99%), whereas CAT:FXIa levels were reduced in VTE patients (0 pM [IQR, 0-0.56] vs 0.56 pM [IQR, 0-0.88]). Levels of FXIa:α1AT and FXIa:AT inhibitory complexes were increased in VTE patients compared to controls (median[IQR]; 311.8 pM [238.2-424.0] vs. 202.5 pM [143.7 - 287.5] and 29.1 pM [23.4-38.3] vs 23.2 pM [19.7-29.8], respectively). Considering that 86% of the VTE patients were already on anticoagulant treatment (Table 1), investigation of their possible effect on the biomarkers revealed that only the CAT:FXIa was influenced by the presence of anticoagulants. Logistic regression models revealed a good discriminatory value for FXI:c and FXIa:α1AT (AUC=0.64 [0.6/0.69] and AUC=0.67 [0.62/0.71], respectively) to distinguish VTE from controls, whereas the other biomarkers were not able to distinguish between groups. The outcome recurrent VTE or death could be predicted by the inhibitory complexes, but not by the FXI(a) levels (Figure 1). Only the FXIa:α1AT complexes were able to both detect the presence of VTE (OR per SD [95%CI]: 1.28 [1.01-1.63], p=0.04) and predict recurrent VTE or death (HR per SD [95%CI]: 1.40 [1.2-1.62], p<0.0001). In summary, acute VTE is associated with both elevated FXI:c levels and increased activation of FXI and plasma prekallikrein, the latter specifically indicating contact activation. The generation of FXIa during acute VTE and its association with recurrent VTE suggests an important risk contribution of FXI activation. This study has added evidence favouring the utility of FXIa inhibition in the setting of acute VTE. Figure 1 Figure 1. Disclosures Knoeck: Bayer AG: Consultancy. ten Cate: Bayer AG: Other; Pfizer: Other; LEO Pharma: Other; Gideon Pharmaceuticals: Other; Alveron Pharma: Other. Wild: Bayer AG: Other, Research Funding; Boehringer Ingelheim: Other, Research Funding; Novartis Pharma: Other, Research Funding; Sanofi-Aventis: Other, Research Funding; Astra Zeneca: Other, Research Funding; Daiichi Sankyo Europe: Other, Research Funding.

Identification of the factor XII contact activation site enables sensitive coagulation diagnostics

Contact activation refers to the process of surface-induced activation of factor XII (FXII), which initiates blood coagulation and is captured by the activated partial thromboplastin time (aPTT) assay. Here, we show the mechanism and diagnostic implications of FXII contact activation. Screening of recombinant FXII mutants identified a continuous stretch of residues Gln317–Ser339 that was essential for FXII surface binding and activation, thrombin generation and coagulation. Peptides spanning these 23 residues competed with surface-induced FXII activation. Although FXII mutants lacking residues Gln317–Ser339 were susceptible to activation by plasmin and plasma kallikrein, they were ineffective in supporting arterial and venous thrombus formation in mice. Antibodies raised against the Gln317–Ser339 region induced FXII activation and triggered controllable contact activation in solution leading to thrombin generation by the intrinsic pathway of coagulation. The antibody-activated aPTT allows for standardization of particulate aPTT reagents and for sensitive monitoring of coagulation factors VIII, IX, XI.

Plasma Kallikrein as a Modulator of Liver Injury/Remodeling

The occurrence and persistence of hepatic injury which arises from cell death and inflammation result in liver disease. The processes that lead to liver injury progression and resolution are still not fully delineated. The plasma kallikrein-kinin system (PKKS) has been shown to play diverse functions in coagulation, tissue injury, and inflammation, but its role in liver injury has not been defined yet. In this study, we have characterized the role of the PKKS at various stages of liver injury in mice, as well as the direct effects of plasma kallikrein on human hepatocellular carcinoma cell line (HepG2). Histological, immunohistochemical, and gene expression analyses were utilized to assess cell injury on inflammatory and fibrotic factors. Acute liver injury triggered by carbon tetrachloride (CCl4) injection resulted in significant upregulation of the plasma kallikrein gene (Klkb1) and was highly associated with the high mobility group box 1 gene, the marker of cell death (r = 0.75, p < 0.0005, n = 7). In addition, increased protein expression of plasma kallikrein was observed as clusters around necrotic areas. Plasma kallikrein treatment significantly increased the proliferation of CCl4-induced HepG2 cells and induced a significant increase in the gene expression of the thrombin receptor (protease activated receptor-1), interleukin 1 beta, and lectin–galactose binding soluble 3 (galectin-3) (p < 0.05, n = 4). Temporal variations in the stages of liver fibrosis were associated with an increase in the mRNA levels of bradykinin receptors: beta 1 and 2 genes (p < 0.05; n = 3–10). In conclusion, these findings indicate that plasma kallikrein may play diverse roles in liver injury, inflammation, and fibrosis, and suggest that plasma kallikrein may be a target for intervention in the states of liver injury.

The Toxicology of Native Fucosylated Glycosaminoglycans and the Safety of Their Depolymerized Products as Anticoagulants

Fucosylated glycosaminoglycan (FG) from sea cucumber is a potent anticoagulant by inhibiting intrinsic coagulation tenase (iXase). However, high-molecular-weight FGs can activate platelets and plasma contact system, and induce hypotension in rats, which limits its application. Herein, we found that FG from T. ananas (TaFG) and FG from H. fuscopunctata (HfFG) at 4.0 mg/kg (i.v.) could cause significant cardiovascular and respiratory dysfunction in rats, even lethality, while their depolymerized products had no obvious side effects. After injection, native FG increased rat plasma kallikrein activity and levels of the vasoactive peptide bradykinin (BK), consistent with their contact activation activity, which was assumed to be the cause of hypotension in rats. However, the hemodynamic effects of native FG cannot be prevented by the BK receptor antagonist. Further study showed that native FG induced in vivo procoagulation, thrombocytopenia, and pulmonary embolism. Additionally, its lethal effect could be prevented by anticoagulant combined with antiplatelet drugs. In summary, the acute toxicity of native FG is mainly ascribed to pulmonary microvessel embolism due to platelet aggregation and contact activation-mediated coagulation, while depolymerized FG is a safe anticoagulant candidate by selectively targeting iXase.