Coagulation Factor IX concentrate: method of preparation and assessment of potential in vivo thrombogenicity in animal models.

Thrombosis and/or disseminated intravascular coagulation (DIC) are complications specifically associated with the use of factor IX complex in some patients. Assuming that these complications might result from zymogen overload, we have produced, using diethylaminoethyl (DEAE)-Sephadex (Pharmacia, Piscataway, NJ) and sulfated dextran chromatography, a factor IX concentrate (coagulation factor IX) that is essentially free of prothrombin, factor VII, and factor X. Factor IX specific activity is at least 5 U/mg protein, a 250-fold purification compared to plasma. Amounts of factors II, VII, and X are less than 5 units each per 100 units of factor IX. The concentrate is essentially free of activated clotting factors and contains no added heparin. In the rabbit stasis model, a dose of 200 factor IX U/kg was less thrombogenic than 100 factor IX U/kg of the DEAE-Sephadex eluate from which the concentrate was derived. Infusion of 200 factor IX U/kg did not induce DIC in the nonstasis rabbit model, whereas 100 factor IX U/kg of the DEAE-Sephadex eluate resulted in DIC in this model. Several factor IX lots were found to have shortened nonactivated partial thromboplastin times (PTTs), but were nonthrombogenic in both animal models. These data indicate that coagulation factor IX concentrate is less thrombogenic than factor IX complex.

Effects of human antithrombin III on mortality and blood coagulation induced in rabbits by endotoxin.

Twenty-one rabbits were infused with 20 micrograms/kg/hr of E. coli endotoxin for 6 hr. Eight of the animals were preinjected immediately before the infusion of endotoxin, with a bolus dose of human AT III calculated to increase the antithrombin content of the plasma by about 4 units/ml. All eight animals which were preinjected with AT III survived, while 5 of the 13 control rabbits infused with endotoxin alone died. The changes in coagulation parameters from the baseline values, between the 8 control rabbits which survived and the 8 animals which were preinjected with AT III were compared. The concentration of the preinjected human AT III declined significantly faster (P: less than 0.01) than that of the native rabbit AT III. AT III prevented the decline of F.XII throughout the infusion of the endotoxin. However, the decline in F.V, fibrinogen, prothrombin and platelets was not affected (P: greater than 0.5) by the injection of AT III.

Thrombin generation in normal plasma enriched with purified coagulation factors.

During the intrinsic coagulation of normal platelet-rich plasma only 11% of the prothrombin is converted to thrombin. Complete conversion of prothrombin to thrombin occurs only via the extrinsic pathway (1). Addition of purified prothrombin to normal plasma to double or triple its concentration, doubled or tripled the amount of the generated thrombin as determined by the thrombin elution assay (1), so that the percentage of the proenzyme which was converted to thrombin remained the same. At the same time the activated partial thromboplastin time (APTT) was prolonged. Proportionality of the amount of the generated thrombin to the amount of prothrombin added and a delay in the appearance of thrombin activity was also observed with the thrombin generation test. Normalization of the APTT was observed when factor IX was added together with prothrombin. Addition of factor IX or X to normal plasma shortened the APTT but did not increase the amount of prothrombin which was converted to thrombin as determined by both the thrombin elution assay and the thrombin generation test. Further experiments indicated that (a) more factor X is activated per mg tissue factor than per mg of activated partial thromboplastin and (b) more thrombin is generated per unit of factor Xa in the presence of tissue factor than in the presence of activated partial thromboplastin. Thus, the two pathways differ not only by the mechanism of factor X activation but also by the extent to which prothrombin is activated by factor Xa.

Replacement therapy in hereditary angioedema: successful treatment of acute episodes of angioedema with partly purified C1 inhibitor.

Although considerable progress has been made during the past two decades in the use of androgens to prevent attacks of hereditary angioedema, replacement of the deficient C1-inhibitor protein would provide a useful menas of treatment once an attack has begun. We studied the clinical use of C1 inhibitor that was partly purified on a large scale from pooled plasma. The in vivo efficacy and safety of this protein concentrate were evaluated during 11 intravenous infusions in eight patients with hereditary angioedema. Three patients received the C1-inhibitor preparation during an asymptomatic period. Increases in serum C4 activity provided evidence of the biologic activity of the infused inhibitor. Intravenous administration of the concentrate during acute abdominal or laryngeal attacks of hereditary angioedema in five patients resulted in abatement of symptoms in addition to increased serum C4 activity. No untoward effects of the intravenous administration of the C1 inhibitor were observed in these eight patients. Thus, this C1-inhibitor preparation seems to offer the potential for safe, effective replacement therapy and may provide a means of controlling an attack of hereditary angioedema that is in progress.

Inactivation of factor VIII by a mechanism independent of the generation of thrombin.

Thrombin first activates and then inactivates factor VIII and for this reason thrombin has been considered responsible for the inactivation of factor VIII which occurs during clotting. Experiments described in this paper indicated that the activity of factor VIII is not reduced in factor IX or factor X deficient sera, while on the other hand this factor becomes inactivated in blood anticoagulated with high concentrations of hirudin which inhibit thrombin activity completely. This suggests that some other factor, besides thrombin, which is generated only in trace amounts in factor IX or factor X deficient plasmas, is also able to inactivate factor VIII. Purified factor X activated with insolubilized trypsin was added to purified preparations of factor VIII, which were free of both fibrinogen and prothrombin. Factor X a was allowed to act for 5-60 minutes and then inactivated with phenylmethanesulfonyl fluoride. Depending on the duration of the action of factor X a partial or complete inactivation of factor VIII was observed. This inactivation was also observed in the presence of hirudin, thus excluding the possibility that the effect was due to contamination with trace amounts of thrombin.

Fibrin digestion by thrombin. Comparison with plasmin-digested fibrinogen.

Solutions of plasminogen-free human fibrinogen alone or (1) treated with sodium p-chloromercuribenzoate in order to inactivate factor XIII, or (2) enriched with factor XIII, cysteine and CaC12, were clotted with plasmin-free human thrombin and incubated under sterile conditions. The clots dissolved gradually within 2 days (fibrin from sodium p-chloromercuribenzoate-treated fibrinogen) to 15 days (fibrin from factor XIII-enriched fibrinogen). This proteolytic process was not affected by soybean trypsin inhibitor but was completely inhibited by hirudin. Gel electrophoresis of the thrombin digests indicated the formation of bands equivalent to bands X, Y, D and E of plasmin digests of fibrinogen. The two latter bands, whose identity was confirmed by immunoelectrophoresis, appeared at a more advanced stage of proteolysis than the corresponding bands of plasmin digests. The number of isopeptide bonds present did not appear to affect the rate of release of acid-soluble peptides. Gel electrophoresis and the rate of release of acid-soluble peptides indicated that fewer bonds are hydrolysed by thrombin at the time of the complete solubilization of the clot than are split by plasmin when fibrinogen becomes unclottable by thrombin.

Fibrinogen and its derivatives: cofactors in the intrinsic generation of thrombin.

The simultaneous additon of suboptimal concentrations of factor VIII and intact or plasmin-lysed fibrinogen into mixtures of the vitamin K dependent factors, phospholipids, adsorbed bovine serum (supplier to factor V) and calcium, increased the amount of thrombin which was generated three to twenty times over the sum of the amounts which were generated when factor VIII, or fibrinogen, or its derivatives were added separately into the thrombin generating mixture. When factor VIII was added together with both fibrinogen and its derivatives, the amount of thrombin generated was even greater, about 130% larger than the amount which was generated in the presence of equal concentrations of only intact fibrinogen plus factor VIII. Addition of albumin instead of fibrinogen or its derivatives has a similar but significantly lower effect on thrombin generation. It appears, therefore, that both intact fibrinogen and its plasminolytic derivatives, singly or in combination, and to a lesser extent albumin, act as cofactors in the reaction which is regulated by factor VIII.

Physiological effects of the plasminolytic derivatives of fibrinogen.

The macromolecular breakdown products of fibrinogen are known mainly for their inhibitory effect on the clotting of fibrinogen by thrombin. This inhibitory effect is due to interference with both the proteolytic action of thrombin and the polymerization of the fibrin monomers. However, the action of these products is not limited to these effects. They can on the one hand inhibit the consumption of Factors II and XIII and promote the inactivation of Factor VIII by thrombin. On the other hand, they can potentiate the activation of prothrombin in purified systems via the intrinsic pathway. The incidental observation was also made that Factor IXa and or Factor Xa inactivate Factor VIII. As substrates of both thrombin and plasmin the large fragments protect these two enzymes from spontaneous inactivation, while at the same time they inhibit their respective proteolytic activities. Contradictory results were obtained regarding their effect on platelets. The micromolecular (dialyzable) breakdown products prolong the thrombin, prothrombin, and partial thromboplastin times of plasma and retard the generation of the intrinsic prothrombin activator. They can also potentiate the effects of biologically active peptides and amines on the smooth muscles and on vascular permeability.