Progressive Antithrombin Research Articles

Report of a novel kindred with antithrombin heparin-binding site variant (47 Arg to His): Demand for an automated progressive antithrombin assay to detect molecular variants with low thrombotic risk

Report of a novel kindred with antithrombin heparin-binding site variant (47 Arg to His): Demand for an automated progressive antithrombin assay to detect molecular variants with low thrombotic risk -

Antithrombin III Nagasaki (Serll6-Pro): A Heterozygous Variant With Defective Heparin Binding Associated With Thrombosis

A novel variant of antithrombin III (AT III) that lacks affinity for heparin was found in a 33-year-old man who suffered from recurrent cerebral infarction. The propositus had a history of recurrent ischemic attacks from the age of 28. He was obese and had a smoking habit (30 to 40 cigarettes/day), low high-density lipoprotein cholesterol, and a mild glucose intolerance as the possible risk factors for thrombosis. No family history of thromboembolic episodes was observed. Coagulation studies found low heparin cofactor activity (55%) of AT III, with a normal immunoreactive level (109.7%) and progressive antithrombin activity (117%). Other factors capable of predisposing him to hereditary thrombophilia were within normal ranges. Analysis by crossed immunoelectrophoresis in the presence of heparin and affinity chromatography on heparin-Sepharose demonstrated that the propositus' AT III was composed of two populations, one having no affinity for heparin and the other binding heparin normally. Nucleotide sequencing of 7 exons of the propositus' AT III gene using polymerase chain reaction and subcloning disclosed a transition of thymine to cytosine in exon 3a (codon 116) of the AT III gene leading to a Ser116-Pro conversion. Allele-specific oligonucleotide hybridization procedures confirmed the presence of the mutation in the propositus' genomic DNA. Using the same technique, the mutation was also found in his father's genomic DNA, but not in that of his mother. These findings indicate that Ser116 is an important amino acid residue in heparin binding and that the propositus is heterozygous for the abnormality. Furthermore, the fact that the propositus suffered from recurrent cerebral infarction suggested that being heterozygous for a heparin-binding defect would lead to a predisposition to thrombosis when associated with various risk factors. The name AT III Nagasaki is proposed for this variant AT III containing a novel Ser116-Pro mutation.

Antithrombin III Nagasaki (Ser116-Pro): a heterozygous variant with defective heparin binding associated with thrombosis

A novel variant of antithrombin III (AT III) that lacks affinity for heparin was found in a 33-year-old man who suffered from recurrent cerebral infarction. The propositus had a history of recurrent ischemic attacks from the age of 28. He was obese and had a smoking habit (30 to 40 cigarettes/day), low high-density lipoprotein cholesterol, and a mild glucose intolerance as the possible risk factors for thrombosis. No family history of thromboembolic episodes was observed. Coagulation studies found low heparin cofactor activity (55%) of AT III, with a normal immunoreactive level (109.7%) and progressive antithrombin activity (117%). Other factors capable of predisposing him to hereditary thrombophilia were within normal ranges. Analysis by crossed immunoelectrophoresis in the presence of heparin and affinity chromatography on heparin-Sepharose demonstrated that the propositus' AT III was composed of two populations, one having no affinity for heparin and the other binding heparin normally. Nucleotide sequencing of 7 exons of the propositus' AT III gene using polymerase chain reaction and subcloning disclosed a transition of thymine to cytosine in exon 3a (codon 116) of the AT III gene leading to a Ser116-Pro conversion. Allele-specific oligonucleotide hybridization procedures confirmed the presence of the mutation in the propositus' genomic DNA. Using the same technique, the mutation was also found in his father's genomic DNA, but not in that of his mother. These findings indicate that Ser116 is an important amino acid residue in heparin binding and that the propositus is heterozygous for the abnormality. Furthermore, the fact that the propositus suffered from recurrent cerebral infarction suggested that being heterozygous for a heparin-binding defect would lead to a predisposition to thrombosis when associated with various risk factors. The name AT III Nagasaki is proposed for this variant AT III containing a novel Ser116-Pro mutation.

The Molecular Pathology of Inherited Human Antithrombin III Deficiency

H UMAN ANTITHROMBIN III is a single chain plasma glycoprotein of molecular mass of approximately 60,000 daltons. I -3 It is the primary inhibitor of the activated clotting factors lIa/·4 IXa,5 Xa,5,6 XIa,7 Xlla,8 as well as kallikrein,9 plasmin,1O urokinase,l1 and trypsin. 12 The most important function of antithrombin ill is the inhibition of thrombin, which is relatively slow under physiologic conditions, but greatly accelerated in the presence of heparin. 13-16 Human plasma antithrombin III comprises 432 amino acid residues, 4 N-linked oligosaccharide side chains (for a total carbohydrate content of approximately 15%), and 3 disulphide bonds.3,l7,18 The tertiary structure, as determined by peptide modeling of the amino acid sequence and by analogy with the structure of human alpha-I-antitrypsin, consists of 31% alpha helix, 16% beta sheet, 9% beta turn, and 44% random coil. 19,20 Antithrombin III is synthesized in the liver and is a member of a family of serine protease inhibitors and related molecules that are referred to as the serpins. The history of the elucidation of antithrombin III as an inhibitor of coagulation has been extensively reviewed elsewhere2 and will be summarized only briefly in this article. The existence of a circulating anticoagulant was first postulated when it was noted that thrombin added to plasma lost its activity, progressively over time.2,24 This antithrombin activity was given the name progressive antithrombin activity. With the isolation, purification, and subsequent clinical use of heparin in the 1930s, it was found that heparin had the ability,

Homozygous Variant of Antithrombin III that Lacks Affinity for Heparin, AT III Kumamoto

Abnormal antithrombin III (AT III) was found in the plasma of a 31-year-old female who suffered from recurrent thrombotic episodes. Heparin cofactor activity was 28% of normal and undetectable when measured by inhibition of thrombin and factor Xa (F.Xa), while both progressive antithrombin and antifactor Xa activities were normal. The concentration of plasma AT III antigen was 37 mg/dl. Analysis by crossed-immunoelectrophoresis (CIE) in the presence of heparin and affinity chromatography on heparin-Sepharose revealed that the propositus' AT III did not bind to heparin. When heparin cofactor II (HC II) was removed from propositus' plasma, heparin cofactor activity of AT III was not detected. Thus, HC II seemed to account for the plasma heparin cofactor activity found in the presence of thrombin. The patient's parents and three of her brothers demonstrated qualitative abnormality of AT III; heparin cofactor activity was 30-50% of normal levels in the presence of both thrombin and F.Xa. These findings indicate that the propositus' AT III lacks affinity for heparin and the mode of its inheritance seems to be autosomal dominant and, hence, the propositus would be a homozygote. For this variant, the name of AT III Kumamoto is proposed.

Abnormal antithrombin III with defective serine protease binding (antithrombin III "Denver").

A hereditary (three family members) deficiency of antithrombin III (AT-III) in which AT-III antigen (AT-III ag) is normal in spite of low heparin cofactor and antithrombin activity is described. Plasma levels were: AT-III ag, 0.92-0.96 U/ml; AT-III heparin cofactor activity, 0.54-0.62 U/ml; progressive antithrombin activity index, 0.13-0.18; anti-Xa activity, 0.50-0.56 U/ml. Plasma crossed immunoelectrophoresis (CIE) patterns performed with and without added heparin were normal, but serum CIE revealed a decreased complex peak. Purification of the patient's plasma AT-III by heparin-sepharose affinity chromatography showed a normal protein recovery and elution profile, but the purified AT-III fraction showed only 50% of the normal progressive thrombin neutralization and anti-Xa activity. When thrombin-antithrombin (TAT) complexes were formed by incubating with excess thrombin, SDS-polyacrylamide gel electrophoresis (PAGE) analysis revealed that half the patient AT-III formed TAT complexes while the remainder migrated as free AT-III. All the control AT-III formed TAT complexes. The patient's nonreacting AT-III (AT-III "Denver"), isolated by affinity chromatography, showed CIE and SDS-PAGE migration patterns characteristic of normal AT-III but failed to bind thrombin or Xa. Calculations from turnover studies in one patient and normal subjects with autologous 131I-AT-III suggested that AT-III "Denver" is removed from the plasma slightly more rapidly than normal. These studies indicate that the patients' variant AT-III molecule was characterized by normal heparin interaction but defective binding and inhibition of thrombin and Xa. These characteristics allow isolation of the nonreactive variant molecule by heparin-sepharose affinity chromatography.

Antithrombin III “Northwick Park”: A Variant Antithrombin with Normal Affinity for Heparin but Reduced Heparin Cofactor Activity

Further studies have been carried out in a previously reported family with congenital antithrombin III (AT III) deficiency due to an abnormal variant of AT III (AT III Northwick Park). The variant has been identified in five members of the family, three of whom had a history of venous thrombosis. Inheritance followed an autosomal dominant pattern. The affected family members have reduced levels of antithrombin heparin cofactor (41-67%) and progressive antithrombin activity (44-62%) but normal levels of immunoreactive AT III (91-162%). Two dimensional immunoelectrophoresis (2 DIE) of AT III in the absence of heparin revealed an abnormal fast-moving peak in addition to the normal peak but 2 DIE in the presence of heparin appeared normal. Further studies confirmed that the abnormal AT III binds completely to heparin but has no heparin cofactor or progressive antithrombin activity. These results would be consistent with a mutation affecting the binding site for thrombin.

Characterization of the biological activity of antithrombin III in patients with hepatic cirrhosis

A discrepancy was found in hepatic cirrhosis patients between two forms of biological activities, i.e. progressive antithrombin activity (prog AT) and heparin cofactor activity (heparin AT). A reduced level of heparin AT was obtained in comparison with that of prog AT, despite the fact that both activities correlated well in normal controls. The binding ability of AT III to heparin was observed by crossed immunoelectrophoresis, and showed a reduced second peak of AT III with a faster mobility. These results indicate the possible presence in hepatic cirrhosis of abnormal AT III with a qualitative defect in its binding ability to heparin due to impaired protein synthesis.

Antithrombin III Toyama: replacement of arginine-47 by cysteine in hereditary abnormal antithrombin III that lacks heparin-binding ability.

Structural analyses of a hereditary abnormal antithrombin III, antithrombin III Toyama, which has normal progressive antithrombin activity but no heparin cofactor activity, have been carried out to elucidate the molecular abnormality causing recurrent thrombophlebitis of a patient and to identify an amino acid residue essential for the binding with heparin. Abnormal antithrombin III was reduced, S-pyridylethylated, and treated with cyanogen bromide. Eleven fragments were isolated by the combination of Sephadex G-50 gel filtration and reversed-phase HPLC and compared with those from normal antithrombin III. One large fragment (CN-III) that appeared to have a different amino acid composition from that of the corresponding fragment from normal antithrombin III was digested with trypsin, and the digests were separated by HPLC. The abnormal peptide was identified by comparing the peptide map with that from normal antithrombin III. Amino acid sequence analysis of the abnormal peptide indicated that the arginine-47 of normal antithrombin III had been replaced by cysteine in antithrombin III Toyama. One base mutation, C leads to T, in the 5' terminal position of the arginine-47 genetic codon (CGT) is probably responsible for this substitution. These results also suggest that arginine-47 is an essential amino acid residue for the binding with heparin.

Antithrombin "Chicago": a functionally abnormal molecule with increased heparin affinity causing familial thrombophilia

A family with a high incidence of spontaneous thromboembolism over four generations has been investigated. The propositus is a 21-yr-old male with a history of thrombophlebitis. Medical histories of 46 family members were obtained. Twelve of these individuals have experienced deep venous thromboses and/or pulmonary emboli. Seven members of the kindred, with a prior history of thrombotic phenomena, were investigated in detail. These subjects were found to have normal plasma concentrations of immunoreactive antithrombin (mean 96%), decreased plasma levels of progressive antithrombin activity (mean 50%), and greatly reduced amounts of plasma heparin cofactor activity (mean 42%). The abnormal antithrombin (“Chicago”) was found to elute from heparin- Sepharose at a higher ionic strength than normal inhibitor. The functionally defective antithrombin molecules exhibit a reduced ability to neutralize thrombin in the presence or absence of heparin (approximately 10%-20% of normal). The molecular defect of this protease inhibitor thus appears to be distinct from those of previously described abnormal antithrombins.

Antithrombin “Chicago”: A Functionally Abnormal Molecule With Increased Heparin Affinity Causing Familial Thrombophilia

A family with a high incidence of spontaneous thromboembolism over four generations has been investigated. The propositus is a 21-yr-old male with a history of thrombophlebitis. Medical histories of 46 family members were obtained. Twelve of these individuals have experienced deep venous thromboses and/or pulmonary emboli. Seven members of the kindred, with a prior history of thrombotic phenomena, were investigated in detail. These subjects were found to have normal plasma concentrations of immunoreactive antithrombin (mean 96%), decreased plasma levels of progressive antithrombin activity (mean 50%), and greatly reduced amounts of plasma heparin cofactor activity (mean 42%). The abnormal antithrombin ("Chicago") was found to elute from heparin-Sepharose at a higher ionic strength than normal inhibitor. The functionally defective antithrombin molecules exhibit a reduced ability to neutralize thrombin in the presence or absence of heparin (approximately 10%-20% of normal). The molecular defect of this protease inhibitor thus appears to be distinct from those of previously described abnormal antithrombins.

Studies of the heterogeneity of antithrombin III concentrates.

The biological activities of antithrombin III (At III) concentrates, prepared by several manufacturers for clinical use, have been compared by three assay methods, and their heparin-binding properties studied by crossed immunoelectrophoresis and heparin affinity chromatography. Concentrates from two of the four manufacturers showed discrepancies between assay methods, with concentrations by heparin co-factor assays significantly lower than those by immunological and progressive antithrombin methods. Heterogeneity was also found by heparin binding studies, with about half the total At III antigen in these concentrates being unable to bind to heparin. These results confirm previous findings of heterogeneity in At III concentrates and show that some concentrates contain substantial amounts of altered At III molecules in which the heparin-binding site has been denatured but the thrombin-neutralizing site left largely intact.

Antithrombin III toyama: A hereditary abnormal antithrombin III of a patient with recurrent thrombophlebitis

A familial abnormal antithrombin III (AT-III) is reported. The characteristic of the abnormality in this family is low heparin cofactor activity with normal progressive antithrombin activity and normal or rather increased level of AT-III antigen. The patient is a 23-year-old female who had suffered from recurrent thrombophlebitis involving her lower extremities. Her plasma AT-III antigen concentration was 54 mg/dl and progressive antithrombin and factor Xa inhibitory activities were of normal level. However, the heparin cofactor activity of her plasma was as low as 26 % of normal control. On crossed immunoelectrophoresis (CIE) containing heparin in the first dimension agarose, patient's AT-III showed no increase in electrophoretic mobility compared to that in the absence of heparin, suggesting that the patient's AT-III has no affinity for heparin. From CIE pattern in the presence of heparin, the patient was found to be a homozygote, and parents and one of her younger sisters were heterozygotes. Thus, the mode of inheritance is proposed to be autosomal dominant.

Synthetic peptide substrates in hemostatic testing.

Since the introduction of synthetic chromogenic and fluorogenic peptide substrates from serine proteases, the testing of coagulation has undergone a dramatic conceptual and methodological change. The concept of coagulation profiling has emerged and automated methodologies are being introduced. Synthetic substrate methods for the evaluation of antithrombin-III; progressive antithrombin; plasminogen; antiplasmin; prekallikrein; antikallikrein ; alpha 1-antitrypsin; prothrombin; heparin; platelet factor IV; urokinase; tissue activator of plasminogen; factor assays; amidolytic equivalents of prothrombin time; and partial thromboplastin time have been developed. Studies on antithrombin-III indicate that immunological methods evaluate the total immunoreactive-antithrombin-III (antigenic) level and do not discriminate between functionally active forms and the AT-III serine protease complex. The clinical significance of AT-III measured by immunological methods is highly questionable. The coagulant assays for the measurement of AT-III require purified alpha-thrombin preparations. The noncoagulant forms of thrombin (beta- and gamma-) result in falsely low antithrombin-III quantitation. The molecular heterogeneity in a given thrombin preparation if standardized in terms of its amidolytic activity does not produce any errors in the quantitation of AT-III levels with synthetic peptide methods. None of the immunological methods provide clinically relevant information except in normal plasma where the immunological and functional activities are identical. Analysis of pathologic plasma samples using laser nephelometry, radial immunodiffusion and radioimmunoassay methods revealed that the functional activity of various serine protease inhibitors is greatly reduced but the reduction in the immunological quantities is minimal. Since coagulation proteins are functional, a ratio between their functional activity and absolute protein levels may be a useful parameter. Employing human and bovine thrombin; bovine and human Xa with their respective substrates, the absolute quantitation of heparin is satisfactorily carried out, however, these assays only measure heparin concentrations and do not reflect the overall anticoagulant effect of heparin. Using the synthetic substrates, the value of measuring absolute concentrations of heparin in a patient on heparin therapy is questionable. With the introduction of fluorogenic substrates, the presence of activated coagulation factors may be demonstrated in patients with thrombotic disorders.(ABSTRACT TRUNCATED AT 400 WORDS)

Antithrombin III Deficiency: Decreased Synthesis of a Biochemically Normal Molecule

A 29-yr-old white female has suffered from recurrent venous thromboses over the last 12 yr. Plasma antithrombin III (AT-III) levels were 48% of normal by immunoelectrophoresis and 56% by chromogenic assay. Three of four siblings and the father had similar AT-III levels without associated venous thromboses. Heparin-Sepharose chromatography demonstrated normal behavior of the patient's AT-III. Her purified AT-III could not be distinguished from AT-III purified from a normal control either by SDS polyacrylamide gel electrophoresis or by crossed immunoelectrophoresis, and the heparin cofactor activity and the progressive antithrombin activity of both AT-III samples were identical. Turnover studies were made in the patient using her own purified AT-III labeled with 131I, (*I). The results did not differ significantly from studies made with autologous *I-AT-III in two normal control women. Her fractional breakdown rate of 0.54 total plasma AT-III per day compared with 0.45 and 0.52 in the controls. These studies indicate that the patient synthesizes a normal AT-III molecule at half normal rates.

Antithrombin III deficiency: decreased synthesis of a biochemically normal molecule

A 29-yr-old white female has suffered from recurrent venous thromboses over the last 12 yr. Plasma antithrombin III (AT-III) levels were 48% of normal by immunoelectrophoresis and 56% by chromogenic assay. Three of four siblings and the father had similar AT-III levels without associated venous thromboses. Heparin-Sepharose chromatography demonstrated normal behavior of the patient's AT-III. Her purified AT- III could not be distinguished from AT-III purified from a normal control either by SDS polyacrylamide gel electrophoresis or by crossed immunoelectrophoresis, and the heparin cofactor activity and the progressive antithrombin activity of both AT-III samples were identical. Turnover studies were made in the patient using her own purified AT-III labeled with 131I, (*I). The results did not differ significantly from studies made with autologous *I-AT-III in two normal control women. Her fractional breakdown rate of 0.54 total plasma AT- III per day compared with 0.45 and 0.52 in the controls. These studies indicate that the patient synthesizes a normal AT-III molecule at half normal rates.

Heparin and the progressive anti-thrombin activity of α 2-macroglobulin

Interactions between α 2-macroglobulin (α 2M) and thrombin have been studied by spectroscopic, isotopic and electrophoretic methods in presence or in absence of heparin. It is shown that thrombin binds to α 2M in a 1:1 ratio. Fluorescamin labelled heparin of Mr 7 000 interacts with thrombin to form a 2:1 molar complex. This complex does not bind to α 2M and is unable to achieve any proteolytic cleavage of this protein. In contrast the interaction of α 2M with chymotrypsin is not significantly affected by the mucopolysaccharide. Moreover, heparin is unable to react with α 2M bound thrombin.

Progressive Antithrombin Activity and the Concentration of Three Thrombin Inhibitors in Liver Cirrhosis

Progressive Antithrombin Activity and the Concentration of Three Thrombin Inhibitors in Liver Cirrhosis

Studies on the neutralizing mechanism of antithrombin activity of heparin by protamine.

Abstract Protamine has been used as the principal neutralizing agent of heparin. The neutralizing mechanism was analyzed by means of two dimensional crossed immunoelectrophoresis and Heparin Sepharose affinity chromatography. Electrophoretic mobility of AT III of heparinized plasma was increased depending on the heparin concentrations, however it was returned to the original, when heparinized plasma was neutralized with protamine. Meanwhile protamine treatment did not affect on the electrophoretic mobility of AT III itself. AT III dissociated from Heparin Sepharose by protamine had progressive antithrombin activity and developed an immediate antithrombin activity in the presence of heparin. These results indicate that protamine dissociates AT III-heparin complex by means of binding to heparin and that the dissociated AT III recovers an original antithrombin activity.

Thrombin Inhibitors in Women on Oral Contraceptives

Progressive antithrombin activity and the immunological levels of antithrombin III, alpha 2-macroglobulin, and alpha 1-antitrypsin were measured in women at various intervals during treatment with oral contraceptives and in a group of untreated women. No significant changes were observed in any of the above parameters. In both control and treated women, there was a positive statistical correlation between progressive antithrombin activity and antithrombin III immunological levels, whereas no correlation was found between the former and alpha 1-antitrypsin or alpha 2-macroglobulin immunological levels. This study questions the possibility of thrombin inhibitors being selective signs of hypercoagulability during treatment with oral contraceptives.