The many faces of systemic mastocytosis.

OBJECTIVE: This short review article will augment the reader's knowledge of mast cell physiology and will offer an overview of current information on the pathophysiology, heterogeneity, and treatment of human mastocystosis. DATA SOURCES AND STUDY SELECTION: Articles published since 1980, textbooks, information from computerized databases, references identified from bibliographies of relevant articles, and books published in the last 10 years. RESULTS AND CONCLUSIONS: Mastocytosis is a complex disease with a multitude of clinical presentations, often misdiagnosed, which can embrace characteristics of other diseases and generate a chameleon-like picture. Mast cells possess many important physiologic functions in the human body, but as a consequence of poorly understood events, they can also start a cascade of pathologic reactions. Although a great deal is known about mechanisms involved in physiologic and pathologic processes of mast cells, many areas are waiting to be explored in this millennium.

Effects of protein kinase C inhibitors on thromboxane production by thrombin-stimulated platelets.

The purpose of these studies was to identify a possible role for protein kinase C in thromboxane production. The effects of four putative protein kinase C inhibitors were studied with platelet stimulation by thrombin (0.5-150 nM), Thrombin Quick I (1.5-500 nM) or a thrombin receptor (protease activated receptor-1) agonist peptide (TRAP) (5-120 microM). Thromboxane production was increased by the bisindolylmaleimide derivative, 2-[1-(3-dimethylaminopropyl)-1H-indol-3-yl]-3-(1H-indol-3-yl)-maleimi de (GF 109203X), unchanged by the inhibitors 12-(2-cyanoethyl)-6,7, 12,13-tetrahydro-13-methyl-5-oxo-5H-indolo (2,3-a) pyrrolo (3, 4-c)-carbazole (Gö 6976) and 5,21:12,17-dimetheno-18H-dibenzo[i, o]pyrrolo[3,4-l][1,8]diazacyclohexadecine-18,20(19H)-dione, 8-[(dimethylamino)methyl]-6,7,8,9,10,11-hexahydro-, monomethanesulfonate (379196), the latter of which is protein kinase C beta-selective, and decreased by 1-[6-[(3-acetyl-2,4, 6-trihydroxy-5-methylphenyl)methyl]-5,7-dihydroxy-2, 2-dimethyl-2H-1-benzopyran-8-yl]-3-phenyl-2-propen-1-one (rottlerin), an inhibitor selective for protein kinase C delta. These results indicate complex regulation of thromboxane synthesis in human platelets including a probable role for protein kinase C delta. The results taken together further suggest that GF 109203X may suppress negative feedback resulting from an unidentified kinase and that the classical protein kinase C isoforms alpha and beta do not have a significant role in regulating thromboxane production by platelets.

Prothrombin Greenville, Arg517-->Gln, identified in an individual heterozygous for dysprothrombinemia.

A 64-year-old white male was referred for evaluation of prolonged prothrombin time (PT) and activated partial thromboplastin time (aPTT) obtained before elective surgery with initial PT and PTT results of 14.9 and 38.4 seconds, respectively, which corrected to normal in 1:1 mixes with normal plasma. Functional prothrombin assay indicated a level of 51% with thromboplastin as an activator. The prothrombin antigen was 102%. This discordance in the functional and immunologic prothrombin levels was evidence for dysprothrombinemia. Western blotting showed that thrombin was formed at a normal rate in diluted plasma consistent with a mutation within the thrombin portion of prothrombin. DNA was isolated from leukocytes and the thrombin exons were amplified by polymerase chain reaction, cloned, and sequenced. For exon 13, eight clones were sequenced with four clones showing a point mutation in the codon for Arg517, which would result in substitution by Gln. Arg517 is part of the Arg-Gly-Asp(RGD) sequence in thrombin and contributes to an ion cluster with aspartic acid residues 552 and 554. Mutation at this residue most probably distorts the structure of the Na+ binding site in thrombin. This is the first report indicating the critical role of Arg517 in the normal physiological interaction of thrombin with fibrinogen. This dysprothrombin is designated Prothrombin Greenville.

Thrombin-induced thromboxane synthesis by human platelets. Properties of anion binding exosite I-independent receptor.

These studies have examined the effects of thrombin-related agonists in stimulating thromboxane production by human platelets. The results presented show that (1) the maximal response elicited by thrombin receptor agonist peptide (TRAP) stimulation was 40% to 50% of that seen with thrombin or the thrombin mutant Thrombin Quick I; (2) pretreatment of platelets with prostaglandin E1 or genistein resulted in differential inhibition of thromboxane production in response to TRAP compared with either enzyme agonist; (3) an antibody to the thrombin receptor cleavage site that inhibits increases in intracellular [Ca2+] only partially reduced thromboxane production in response to 5 nmol+L thrombin and 15 nmol/L Thrombin Quick I; (4) preincubation with 20 mumol/L TRAP resulted in desensitization to further stimulation by 100 mumol/L TRAP, but not by 100 nmol/L thrombin; and (5) the response to thrombin after TRAP desensitization was completely inhibited by the tyrosine kinase inhibitor genistein and was independent of an intracellular [Ca2+] flux, The cumulative results may be explained by the existence of two proteolytically activated receptors that result in thromboxane production in response to thrombin. One is the thrombin receptor/substrate, PAR-1. Stimulation through the second receptor/substrate depends on a genistein-sensitive step, is independent of an intracellular Ca2+ flux, and is initiated by a thrombin-activated receptor that does not depend on interaction with anion-binding exosite I, as previously indicated by the relative activity of Thrombin Quick I in stimulating platelet aggregation and thromboxane production. The proposed second thrombin receptor on platelets represents an additional member of the class of proteolytically activated receptors.

alpha-Thrombin-induced human platelet activation results solely from formation of a specific enzyme-substrate complex.

Prior studies using the mutant thrombin, thrombin Quick I, indicate that this protease induces maximum platelet aggregation and intraplatelet [Ca2+] fluxes at agonist concentrations where dissociable, equilibrium platelet binding is undetectable and led to the conclusion that thrombin interaction with its platelet "receptor" is best described kinetically by formation of an enzyme-substrate complex. This conclusion was substantiated further in the present studies by demonstrating that both thrombin Quick I and thrombin mimicked the thrombin receptor agonist peptide in the induction of the platelet activation-dependent events required for functional Prothrombinase assembly and that a rabbit antibody raised against KATNATLDPRSFLLR, a pentadecapeptide which represents amino acids 32-46 in the platelet thrombin receptor/substrate and spans the thrombin cleavage site, inhibited both thrombin- and thrombin Quick I-induced platelet activation responses equivalently. The antipeptide antibody had a more pronounced inhibitory effect on the rate of the thrombin-induced response rather than the magnitude of the response suggesting competition for the cleavage site, consistent with the observation that pretreatment of metabolically-inhibited platelets with thrombin, which was removed by washing, eliminated specific antibody binding due to removal and/or masking of antibody epitopes. Concentrations of the antipeptide antibody that inhibited thrombin- and thrombin Quick I-induced increases in intracellular [Ca2+] flux by as much as 97% did not alter the dissociable equilibrium binding of 125-I-FPR-thrombin to platelets. These combined data indicate that the hydrolytic event initiated by thrombin or thrombin Quick I interaction with the platelet receptor/substrate for thrombin is unrelated to the dissociable equilibrium binding of thrombin to membrane sites described previously by classical receptor-ligand binding analyses.

Inhibition of dysthrombins Quick I and II by heparin cofactor II and antithrombin.

Heparin cofactor II and antithrombin are plasma serine proteinase inhibitors whose ability to inhibit alpha-thrombin is accelerated by glycosaminoglycans. Dysfunctional thrombin mutants Quick I (Arg67-->Cys) and Quick II (Gly226-->Val) were used to further compare heparin cofactor II and antithrombin interactions. Quick I, Quick II, and alpha-thrombin were eluted at the same salt concentration from heparin-Sepharose suggesting that the putative heparin-binding site (also termed anion binding exosite-II) is functional. Antithrombin yielded similar inhibition rates for Quick I and alpha-thrombin in the absence or presence of various amounts of heparin. Also, Quick I was inhibited similarly to alpha-thrombin by heparin cofactor II in the absence of glycosaminoglycan. In contrast, glycosaminoglycan-accelerated Quick I inhibition by heparin cofactor II was greatly reduced indicating that anion binding exosite-I (where the mutation occurs in Quick I) is critical for increased inhibition by heparin cofactor II. We also found that heparin cofactor II formed a SDS-resistant bimolecular complex with Quick II and alpha-thrombin at similar rates and the rate of complex formation was accelerated in the presence of glycosaminoglycans. A three-dimensional molecular model of the Quick II active site compared to alpha-thrombin suggested that the heparin cofactor II Leu-Ser-reactive site sequence (P1-P1') is a compatible "pseudosubstrate" in contrast to the Arg-Ser sequence found in antithrombin. The importance of heparin cofactor II as a thrombin regulator will depend upon its ability to interact with glycosaminoglycans and the functional availability of thrombin exosites.

The thrombin high-affinity binding site on platelets is a negative regulator of thrombin-induced platelet activation. Structure-function studies using two mutant thrombins, Quick I and Quick II.

To elucidate the thrombin domains required for high-affinity binding and platelet activation, the platelet binding properties of thrombin and two mutant thrombins, thrombin Quick I and Quick II, were compared to their agonist effects in elevating intraplatelet [Ca2+]. In Quick I, a mutation within the fibrinogen binding groove results in decreased clotting and platelet aggregating activities, whereas in Quick II, a mutation in the primary substrate binding pocket abolishes both activities. Dysthrombin binding was decreased compared to thrombin. The fibrinogen binding groove appeared more important than the primary substrate pocket for high-affinity binding since Quick I showed drastically reduced, and Quick II only slightly reduced, binding affinity (Kd approximately 200 and approximately 10 nM, respectively). The deduced interaction of thrombin with its high-affinity binding site indicated that the thrombin catalytic site is directed toward the platelet surface and therefore, when bound, is proteolytically inactive. Quick I (0.5-5 nM) elicited intraplatelet [Ca2+] fluxes at concentrations where high-affinity binding was undetectable. Saturation of high-affinity binding sites with active-site-modified thrombin did not affect thrombin-induced (0.5 nM) or Quick I-induced (5 nM) responses. In contrast, addition of D-Phe-Pro-Arg chloromethyl ketone (FPRCK) subsequent to thrombin or Quick I stimulation of platelets abolished agonist-induced responses. Since Quick I was only 10-17% as effective as thrombin in increasing intraplatelet [Ca2+], our data support a model in which thrombin acts enzymatically on a platelet membrane "substrate", through an interaction mediated in part by the fibrinogen binding groove of thrombin. This conclusion is consistent with the inhibition observed with high concentrations (greater than 100 nM) of Quick II and FPRCK-modified thrombin (FPR-thrombin) in platelets stimulated with low concentrations of thrombin (less than 0.5 nM) or Quick I (less than 2 nM), consistent with inhibition by substrate depletion. In contrast, concentrations of FPR-thrombin or Quick II (less than 100 nM), which saturated predominantly the high-affinity binding sites, enhanced the platelet responses induced by thrombin (less than 0.5 nM). Thus, occupation of the high-affinity sites with inactive thrombin increased the concentration of active thrombin available for substrate interaction. Quick I-induced responses were not enhanced, consistent with its inability to interact with the high-affinity site. Since thrombin bound to the high-affinity site is proteolytically inactive, we hypothesize that the thrombin high-affinity binding site on platelets functions to alter thrombin activity and platelet activation.

Interaction of hirudin with the dysthrombins Quick I and II.

The interaction of hirudin with the dysfunctional enzymes thrombin Quick I and II has been investigated. Natural and recombinant hirudin caused nonlinear competitive inhibition of thrombin Quick I. The results were consistent with thrombin Quick I existing in two forms that have different affinities for hirudin. The affinities of these forms for natural hirudin were respectively 10(4)- and 10(6)-fold lower than that of alpha-thrombin. In contrast, truncated hirudin molecules lacking the C-terminal tail of the molecule caused linear inhibition of thrombin Quick I. These results indicate that different modes of interaction of the two forms of thrombin Quick I with the C-terminal tail of hirudin were the cause of the nonlinear inhibition. Comparison of the dissociation constants of thrombin Quick I with the truncated and full-length forms of hirudin suggested that the interactions that normally occur between the C-terminal tail of hirudin and thrombin were completely disrupted with the low-affinity form of thrombin Quick I. Thrombin Quick II displayed an affinity for natural hirudin that was 10(3)-fold lower than that observed with alpha-thrombin. In contrast, it bound a mutant hirudin with altered N-terminal amino acids only 16-fold less tightly. These results are discussed in terms of structural alterations in the active-site cleft in thrombin Quick II.

Substitution of valine for glycine-558 in the congenital dysthrombin thrombin Quick II alters primary substrate specificity.

Thrombin Quick II is one of two dysfunctional forms of thrombin derived from the previously described congenital dysprothrombin prothrombin Quick. Thrombin Quick II does not clot fibrinogen, hydrolyze p-nitroanilide substrates of thrombin, or bind N2-[5-(dimethylamino)naphthalene-1-sulfonyl]arginine N,N-(3-ethyl-1,5-pentanediyl)amide, a high-affinity competitive inhibitor of thrombin. To determine the structural alteration in thrombin Quick II, the reduced, carboxymethylated protein was hydrolyzed by a lysyl endopeptidase. A peptide not present in a parallel thrombin hydrolysate was identified by reverse-phase chromatography. The peptide was purified by rechromatography and subjected to Edman degradation which showed that Gly-558 of human prothrombin had been replaced by Val. This corresponds to a point mutation of the Gly codon GGC to GUC. This Gly residue, which is highly conserved in the chymotrypsin family of serine proteases, forms part of the substrate binding pocket for bulky aromatic and basic side chains in chymotrypsin and trypsin, respectively. However, in porcine elastase 1, the corresponding residue is threonine. Consistent with the identified structural alteration, thrombin Quick II incorporates [3H]diisopropyl fluorophosphate stoichiometrically and hydrolyzes the elastase substrate succinyl-Ala-Ala-Pro-Leu-p-nitroanilide with a relative kcat/KM of 0.14 when compared to thrombin. This results from a 3-fold increase in KM and a 2.5-fold decrease in kcat for thrombin Quick II when compared to thrombin acting on the same substrate. These results and those of other investigators studying mutant trypsins support the conclusion that the catalytic activity of serine proteases is very sensitive to structural alterations in the primary substrate binding pocket.

A dose escalation study of ORG 10172 (low molecular weight heparinoid) in stroke.

An intravenous infusion of a low molecular weight heparinoid, with a reduced risk of hemorrhage, may be an alternative to heparin in the management of acute ischemic stroke. To evaluate this hypothesis, we studied the safety of the heparinoid, ORG 10172, in a dose-escalation study in 26 patients. The drug was administered as a loading bolus followed by a 7-day infusion in five rates with target anti-factor Xa levels from 0.2 to 1.0 U/ml. The drug was well tolerated; no major bleeding complications or thrombocytopenia occurred. There were no deaths or hemorrhagic transformation of cerebral infarctions. The results indicate that ORG 10172 at doses to achieve a level of 1.0 U/ml or less may be used safely in management of acute cerebral infarction.

Identification of the primary structural defect in the dysthrombin thrombin Quick I: substitution of cysteine for arginine-382.

A congenitally dysfunctional form of prothrombin, prothrombin Quick, was isolated from the plasma of an individual with less than 2% of normal prothrombin activity. Following activation of prothrombin Quick, two dysfunctional thrombins, thrombin Quick I and thrombin Quick II, were isolated. Functional characterization of thrombin Quick I indicated an increase in KM and a decrease in kcat, relative to thrombin, for release of fibrinopeptide A. Comparison of kcat/KM for thrombin Quick I to the value obtained for thrombin yielded a relative catalytic efficiency of 0.012 for thrombin Quick I [Henriksen, R. A., & Owen, W. G. (1987) J. Biol. Chem. 262, 4664-4669]. Lysyl endopeptidase digestor of reduced and S-carboxymethylated thrombin and thrombin Quick I has resulted in the identification of an altered peptide in this dysthrombin. Edman degradation of the isolated peptide has shown that the altered residue in this protein is Arg-382 which is replaced by Cys. This could result from a point mutation in the Arg codon, CGC, to yield TGC. Together, these results indicate that Arg-382 is a critical residue in determining the specificity of thrombin toward fibrinogen. Similar relative activities for thrombin Quick I in stimulating platelet aggregation, in the release of prostacyclin from human umbilical vein endothelium, and in the release of fibrinopeptide A suggest that these activities of thrombin share the same specificity determinants.

Pentastarch may cause fewer effects on coagulation than hetastarch.

Hetastarch, the currently marketed preparation of hydroxyethyl starch, affects coagulation by prolonging partial thromboplastin, prothrombin, and bleeding times; by lowering clotting proteins such as fibrinogen via hemodilution; by lowering clotting factor VIII (coagulant, von Willebrand antigen, and von Willebrand activity) to a greater degree than can be explained simply by hemodilution (i.e., presumably factor VIII affected by both hemodilutional plus additional, independent effects); and, finally, by shortening thrombin, reptilase, and urokinase-activated clot lysis times. Pentastarch, a new analog of hetastarch, was found to exert lesser effects on blood coagulation, despite its greater hemodiluting properties. When compared with hetastarch, pentastarch had little effect on factor VIII (except that due to hemodilution), shortened thrombin times to a significantly lesser degree, exerted no effect on the urokinase-activated clot lysis time, and did not prolong the bleeding time. Even when plasma hydroxyethyl starch levels were similar, pentastarch seemed to alter the results of coagulation assays to lesser degree than did hetastarch, which suggests the possibility of greater safety. Therefore, pentastarch may be a desirable drug, not only for leukapheresis, but also for plasma volume expansion in trauma and surgical patients who often have additional hemostatic abnormalities that place them at increased risk of hemorrhage.

Characterization of the catalytic defect in the dysthrombin, Thrombin Quick.

The dysthrombin, Thrombin Quick, is chromatographically separable into two components designated Thrombin Quick I and Thrombin Quick II. Thrombin Quick II lacks observable catalytic activity toward thrombin substrates. The steady-state kinetics of hydrolysis of benzoylarginine ethyl ester and Tos-Gly-Pro-Arg-p-nitroanilide by Thrombin Quick I are equivalent to those of thrombin. These results, in addition to binding studies with the active site titrant N2-(5-dimethylaminonaphthalene-1-sulfonyl)arginine N-(3-ethyl-1,5-pentanediyl)amide, indicate that binding interactions at the catalytic site of Thrombin Quick I are unaltered. Thrombin Quick I is inhibited by anti-thrombin III at the same rate as thrombin. Steady-state kinetic parameters for the release of fibrinopeptide A indicate defects in both kcat and Km for Thrombin Quick I with kcat/Km equal to 0.012 of the value for thrombin, corresponding to the relative fibrinogen clotting activity of 0.013. The results are interpreted as indicating a defect in Thrombin Quick I at a binding site, external to the catalytic site, which is essential for determining specificity toward fibrinogen. The defect in kcat may result secondarily from small perturbations in the steric relationship of the catalytic triad residues. The rate of hydrolysis by Thrombin Quick I of the protein substrates bovine prothrombin and bovine protein C (in the absence of cofactors) is about one-third of that observed for thrombin, indicating that hydrolysis of these substrates by thrombin involves different specificity determinants than does the hydrolysis of fibrinogen.

Visualization of the multimeric structure of von Willebrand factor using a peroxidase-conjugated second antibody.

We describe a technique for visualizing the multimeric structure of von Willebrand factor that does not require use of radioisotopes. This procedure uses a previously described discontinuous dodecyl sulfate agarose gel electrophoretic method followed by transfer of the protein to a nitrocellulose filter and detection by a double-antibody technique in which the second antibody is conjugated to horseradish peroxidase. In the presence of H2O2 and 4-chloro-1-napthol, the antigen appears as a series of about 15 colored bands. This method results in resolution of the high molecular weight components, does not require the use of radioisotopes, and can be completed in 2 days. It should be useful for diagnostic and investigational studies in clinical and research laboratories.

Effects of hydroxyethyl starch on blood coagulation, particularly factor VIII.

The effects of hydroxyethyl starch (HES) on hemostasis were investigated extensively. In order to simulate acute blood loss due to surgery or trauma, one unit (450 ml) of blood was drawn from normal healthy men. This was followed by a 1-liter infusion over 60 minutes of either 6 percent HES, 5 percent albumin, or 0.9 percent sodium chloride (NaCl) as replacement. Coagulation studies were performed before phlebotomy, before infusion and at 0, 4, 20, 27, and 92 hours following infusion. Following infusion of HES and albumin, plasma fibrinogen and antithrombin-III levels fell slightly due to plasma volume expansion and hemodilution. In subjects receiving HES, partial thromboplastin times (PTTs) were significantly (p less than .05) prolonged and factor VIII activities were significantly (p less than .05) decreased when compared to the albumin and NaCl groups. These findings could not be attributed solely to hemodilution. The effects of HES on PTT and factor VIII could not be correlated with plasma HES levels; neither could they be reproduced in vitro by mixing HES with normal plasma. Mean values of the following studies remained normal after infusion of all replacement fluids: prothrombin time, bleeding time, fibrin monomer, fibrin-fibrinogen degradation products, platelet adhesion, circulating platelet aggregates, and platelet count.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of hydroxyethyl starch on fibrinogen, fibrin clot formation, and fibrinolysis.

The effects of hydroxyethyl starch on the final stages of hemostasis were investigated in vivo and in vitro. When compared to control solutions of either 5 percent albumin or isotonic (0.9%) NaCl, 6 percent hydroxyethyl starch (HES) exerted several effects. Results of in vivo studies were as follows: following infusion of 1 liter of 6 percent HES into healthy subjects, fibrinogen and antithrombin-III concentrations fell slightly due to plasma volume expansion and consequent dilution. Concentrations of fibrin monomer and fibrin-fibrinogen degradation products remained unchanged. Thrombin and reptilase clotting times were shortened to indicate rapid detection (and presumably accelerated formation) of fibrin clots. Urokinase-activated clot lysis times were shortened to suggest rapid fibrinolysis. Results of in vitro studies were similar. Shortened thrombin, reptilase, and urokinase-activated clot lysis times were reproduced in vitro by mixing HES, but not albumin or NaCl, with normal plasma. Although these findings qualitatively are similar to those reported previously for dextran, the molecular mechanisms involved and the clinical importance, if any, of the hemostatic effects remain to be defined. Thus, it would be premature to conclude either that HES or dextran exert identical biological effects on hemostasis or that the two agents possess similar clinical properties. HES has an excellent safety record when it has been used during leukocytapheresis and for plasma volume expansion in recommended doses. Its effects when given in larger doses remain to be defined.

Hydroxyethyl starch accentuates von Willebrand's disease.

A healthy man with previously undiagnosed, mild von Willebrand's disease received one 1 of 6 percent hydroxyethyl starch solution intravenously. Following infusion, the bleeding time lengthened, platelet adhesion decreased, and the partial thromboplastin time was prolonged in association with decreased plasma levels of factor VIII coagulant activity, factor VIII-related antigen, and factor VIII ristocetin cofactor. Abnormalities persisted for days, but overt bleeding did not occur. Care should be taken to screen and possibly reject prospective granulocyte donors with positive personal or family bleeding histories. Caution should be used when administering hydroxyethyl starch as a colloidal plasma volume expanding agent to patients with underlying hemostatic defects.

Evidence that activation of platelets and endothelium by thrombin involves distinct sites of interaction. Studies with the dysthrombin, Thrombin Quick I.

Previous results indicate extensive similarity of the active site regions of thrombin (EC 3.4.21.5) and Thrombin Quick, a congenital dysthrombin. A binding defect of Thrombin Quick toward fibrinogen is indicated by an increased KI when fibrinogen is present as a competitive inhibitor in the hydrolysis of tosyl-Gly-Pro-Arg-p-nitroanilide. In the present study, Thrombin Quick I is shown to have an activity of 1.3 and 34%, respectively, toward fibrinogen and prothrombin. Like the activity observed in prothrombin hydrolysis, Thrombin Quick I was 30% as effective as thrombin in stimulating release of thromboxane from platelets. Thrombin Quick was 1.7 and 2.4%, as effective as thrombin in stimulating platelet aggregation and prostacyclin production, respectively. Based on the activity of Thrombin Quick I in the reactions investigated, it is concluded that 1) the three cellular responses studied are initiated by proteolytic action of thrombin, 2) thrombin stimulation of aggregation and thromboxane release from platelets occurs via two different receptors, 3) the thrombin cellular interaction resulting in platelet aggregation and prostacyclin release must involve the thrombin active site as well as a secondary binding site required for optimal interaction with fibrinogen, and 4) the release of thromboxane from platelets does not involve the interaction of thrombin at the extrinsic binding site.