ALBERT

Description: Hereditary von Willebrand factor (vWF ) deficiency in Dutch Kooiker dogs, which have undetectable levels of vWF, causes spontaneous hemorrhage of mucosal surfaces similar to the clinical picture of von Willebrand disease in humans. Therefore, we used this canine model to study the in vivo effects of a new recombinant von Willebrand factor (rvWF ) preparation containing all species of vWF multimers compared with a rvWF fraction containing only low molecular weight multimers (LMW-rvWF ) and with a plasma-derived factor VIII/vWF concentrate (pdvWF ). In the vWF-deficient dogs, the half-life of vWF:Ag was 21.6 and 22.1 hours for rvWF, 7.7 hours for pdvWF, and 9 hours for LMW-rvWF; in vivo recovery of vWF:Ag was 59%, 64%, and 70% for rvWF, 33% for pdvWF and 92% for LMW-rvWF; in vivo recovery of RCoF was 78%, 110%, and 120% for rvWF, and 25% for pdvWF. Both rvWF and pdvWF caused increases in factor VIII, which were sustained even when vWF:Ag had decreased to nearly undetectable levels and only monomeric or dimeric species were detectable on agarose gels. At the dosages used, no effect was seen on bleeding time, but the rate of blood flow from cuticle wounds was reduced after a single bolus administration of rvWF. The rvWF was able to control a severe nose bleed in one dog.

Description: Background/Objectives Red blood cell (RBC) transfusion can be lifesaving and is an essential therapy in conditions associated with tissue hypoxia due to anemia. However, recent clinical studies show that both the number of RBCs and the age of RBCs transfused are independent risk factors for an increase in transfusion related morbidity and mortality. It has been suggested that the so called “storage lesion” of RBCs, a reduction of quality of erythrocytes and changes in the erythrocyte concentrate storage medium, is the causal factor. Recently it has been shown that cold storage of erythrocytes induces microparticle formation. These erythrocyte microparticles are pro-coagulant and can cause thrombin formation. Another phenomenon of the storage lesion is the rapid and considerable loss of donor erythrocytes from the circulation of transfused patients. We wondered whether thrombin generated by transfused erythrocyte microparticles could contribute to red blood cell adherence to the vascular endothelium. Cytoadherence of red blood cells could contribute to the loss of circulating transfused red blood cells and vascular obstruction and could explain the observed transfusion associated complications in clinical practice. Methods/Results Employing FACS analysis and a microparticle analyzer we showed that erythrocyte cold storage indeed induces microparticle formation. We confirmed the pro-coagulant properties of these microparticles using a chromogenic substrate specific for thombin and a thrombin-anti-thrombin complex ELISA. To determine whether thrombin could induce adhesion of red blood cells to endothelial cells, we cultured human umbilical vein endothelial cells in micro-perfusion chambers and used live-imaging to define the adherence potential of the erythrocytes to endothelial cells at post-capillary flow rate. Thrombin stimulation of the endothelial cells did increase erythrocyte adhesion to endothelial cells. Moreover, the adhesion of erythrocytes followed a pattern resembling platelets binding to von Willebrand factor (VWF). By using live immunofluoresence imaging we confirmed that the erythrocytes did bind to VWF secreted from endothelial cells. Since erythrocyte-VWF interactions may be mediated by platelets, we used fluorescence cell sorting to remove platelets and erythrocyte-platelet complexes from erythrocyte concentrates. The purified erythrocytes did also bind to VWF secreted by endothelial cells and thereby we confirmed that erythrocytes can bind to VWF in a platelet-independent fashion. We further analyzed the specificity of the erythrocyte-VWF interaction by using different protein coatings in micro-perfusion chambers. Erythrocytes did bind to recombinant high molecular weight VWF multimers. Furthermore, they adhered more potently to VWF when compared to fibrinogen or fibrin but showed little binding to fibronectin, collagen type I, or subendothelial extra-cellular matrix proteins. Conclusion Our results suggest that transfusion of RBCs is able to induce endothelial binding of erythrocytes based on a VWF-erythrocyte interaction. We propose that passive infusion of cold stored erythrocyte derived microparticles promotes thrombin generation which subsequently activates endothelial cells and induces VWF secretion. This results in binding of red blood cells to endothelial cells in a platelet-independent fashion which requires the presence of VWF. Based on our results we hypothesize that binding of erythrocytes to VWF may occlude micro-capillaries thereby contributing to transfusion associated complications. Disclosures No relevant conflicts of interest to declare.

Description: Background: Protein S is a vitamin K-dependent plasma protein and involved in down-regulation of the coagulation process. Protein S serves as a cofactor of activated protein C (APC) in the proteolytic inactivation of activated factor V and VIII. Protein S is also able to exert its anticoagulant activity independent of APC, e.g. by supporting the anticoagulant activity of tissue factor pathway inhibitor (TFPI). The anticoagulant properties of protein S have been thoroughly characterized by in vitro methods. However, fewer studies focus on protein S function on vascular cells. These studies are limited to model systems employing purified coagulation factors. The aim of this study was to investigate the role of protein S in plasma that is in contact with natural cell membranes, including endothelial cells, smooth muscle cells and platelets. Method: We employed thrombography to evaluate protein S function in 50 % v/v recalcified citrated plasma in the presence of washed platelets, cultured umbilical vein endothelial cells or cultured umbilical artery smooth muscle cells. Since we aimed at a comparison between different cellular membranes, micro-particle free plasma was used. As a reference, we also examined synthetic phospholipid membranes composed of phosphatidyl serine, phosphatidyl choline and phosphatidyl ethanolamine in a 2/6/2 molar ratio. Thrombin activity was measured employing the fluorogenic substrate z-Gly-Gly- Arg-AMC. Protein S activity was probed with CLB-PS13, an antibody directed against the protein S Gla-domain. The APC-independent activity of protein S was assayed in the presence of an inhibitory antibody against protein C. In studies employing phospholipids, thrombin generation was triggered with relipidated tissue factor (TF). Expression of TF on endothelial cells was induced during a 6-hour preincubation with PMA. Results: In the presence of CLB-PS13, the APC-independent activity of protein S became apparent as an increase in peak height in the thrombogram. Lag time, time to peak and area under the curve remained essentially unaffected. Peak height was increased two-fold when examining phospholipids at standard conditions (4 μM lipids and 1 pM TF). This increase in peak height by CLB-PS13 was concentration dependent and complete at 10 μg/ml IgG. Increasing the TF concentration from 1 to 5 pM resulted in loss of the APC-independent activity of protein S on these membranes. APC cofactor activity was assessed in the presence of APC. Addition of APC resulted in inhibition of the thrombin formation on phospholipids with an IC50 of 0.4 nM. CLB-PS13 completely abolished this decrease in thrombin generation up to 50 nM APC, irrespective whether 1 or 5 pM TF was present. Our results are compatible with the view that at high procoagulant stimuli the TFPI-cofactor activity of protein S is abolished. Furthermore, these results show that in plasma APC is completely dependent on protein S. Protein S activity on platelets was studied in the presence of 1 pM TF. As for synthetic lipid membranes and in the absence of APC, CLB-PS13 increased the peak height in the thrombogram. APC inhibited platelet mediated thrombin generation (IC50 = 19 nM), and this inhibition was completely abolished by CLB-PS13. These observations suggest that platelets support both APC-dependent and APC-independent anticoagulant activities of protein S. Thrombography on TF-expressing endothelial cells and smooth muscle cells revealed massive thrombin generation that could not be enhanced with CLB-PS13, indicating that protein S does not contribute to regulation of thrombin formation under these conditions. The APC-dependent activity of protein S became apparent as an abolished inhibition by APC in the presence of CLB-PS13. However, APC proved relatively inefficient in inhibiting thrombin generation on TF-expressing vascular cells (IC50 〉 50 nM). Inhibition of TF restored the APC-independent protein S activity. Conclusion: Our results indicate that, in plasma, vascular cells and platelets are able to support the APC-dependent as well as the APC-independent anticoagulant activities of protein S. The APC-independent activity on vascular cells is abolished upon increasing TF expression, while the APC-dependent activity of protein S is limited by the relatively low anticoagulant activity of APC on these cell surfaces. We conclude that protein S activity on cells require relatively high levels of APC or low expression of TF.

Description: Abstract 2124 Poster Board II-101 Background: Protein S, a vitamin K-dependent plasma protein, is one of the molecules involved in down-regulation of the coagulation process. Protein S serves as a cofactor of activated protein C (APC) in the proteolytic inactivation of activated factor V and VIII. Protein S is also able to exert its anticoagulant activity independent of APC, e.g. by supporting the anticoagulant activity of tissue factor pathway inhibitor. In plasma, protein S circulates in two forms: a single chain molecule with full anticoagulant activity and a two-chain form with reduced anticoagulant activity. This two-chain variant is the result of cleavage in the protease sensitive loop, the so-called thrombin sensitive region (TSR). The enzyme responsible for the presence of cleaved protein S in the circulation is not known yet. In vitro, thrombin and factor Xa, both enzymes of the coagulation cascade, are able to cleave the TSR. In a recent study (Brinkman et al, J Thromb Haemost 2005; 3: 2712-2720), it was shown that these enzymes do not cleave protein S under physiological conditions. Instead, a platelet protease was found to cleave protein S in plasma during tissue factor induced clotting in vitro. We hypothesize that this platelet protease may be responsible for the presence of cleaved protein S in the circulation. Objective: To correlate cleaved protein S levels in the circulation with the activity of platelet-associated protein S cleaving protease and to evaluate the impact of protein S cleavage on its anticoagulant activity in terms of total protein S activity. Method: Protein S cleavage was evaluated by immunological methods employing a monoclonal antibody specific for uncleaved, single chain protein S. The total anticoagulant activity of protein S (APC-independent and APC-dependent) was assessed employing thrombography. Results: We observed in the in vitro thrombin generation test massive generation of thrombin in protein S deficient plasma that was dose-dependently inhibited by intact, single chain protein S. TSR-cleaved protein S had totally lost its anticoagulant activity. In plasma from healthy volunteers, cleaved protein S expressed as % of the total amount of protein S ranged between 8 and 51% with an average normal value of 26 ± 9% (mean ± SD, n=46). Levels of intact protein S correlated well with total protein S activity in the individual plasma samples, while this correlation was not observed for levels of TSR-cleaved protein S. These data suggest that not only in vitro but also in vivo, cleavage of protein S has an impact on its anticoagulant activity. A significant reduction of levels of cleaved protein S was observed in chemotherapy induced thrombocytopenia in hematological patients (see Figure). At a platelet count 〈 50, the average protein S cleavage was dropped to 16 ± 7% (mean ± SD, n=15). Upon platelet transfusion, cleavage of protein S dramatically increased to 36 ± 11% (mean ± SD, n=11). Levels of total protein S were similar in healthy volunteers and thrombocytopenic patients before and after platelet transfusion. It thus appears that platelets contribute to protein S cleavage in vivo. However, in healthy individuals showing a wide range of protein S cleavage (see Figure), no correlation was observed between platelet count (200-400 .109/l) and protein S cleavage. This suggests additional sources of protease that cleave protein S in vivo. We therefore examined lysates of a variety of cell types for protein S proteolytic activity. Protein S proteolytic activity was absent in lysates of erytrocytes, vascular smooth muscle cells and fibroblasts. Lysates of HUVEC did show protein S proteolytic activity similar to platelets. Conclusion: Our results strongly suggest that platelets contribute to the proteolytic modification of protein S in vivo resulting in an abolished anticoagulant activity. An additional source of protein S proteolytic activity may be the endothelium. Cleavage of protein S provoked by platelet infusion may contribute to the beneficial effect of platelet transfusion in the treatment of bleeding episodes. Disclosures: No relevant conflicts of interest to declare.

Description: The propeptide of von Willebrand factor (VWFpp) has been demonstrated to be critical for multimerization and intracellular storage of the mature von Willebrand factor (VWF) protein. Although VWFpp and VWF have been shown to circulate at a distinct ratio in plasma, they are stored in endothelial cells in equimolar amounts and stimulation of the endothelium results in acute simultaneous release of these polypeptides in equimolar concentrations. This includes following DDAVP administration to healthy individuals. An increased ratio of plasma VWFpp to VWF antigen (VWF:Ag) may reflect increased clearance of VWF:Ag or reduced clearance of VWFpp. We have quantitated plasma VWFpp levels and the VWFpp to VWF:Ag ratio in patients with type 1 VWD and examined their relationship with the plasma clearance of VWF:Ag and VWFpp. We have also examined the endothelial release of VWFpp and VWF:Ag following DDAVP stimulation in these patients. Plasma molar VWF:Ag and VWFpp concentrations were determined by immunosorbent assay1 in 27 patients with type 1 VWD and 21 normal controls. In the VWD patients VWF:Ag and VWFpp levels were quantitated over 6 hours following the administration of intravenous DDAVP. The half-lives of VWF:Ag (VWF:Ag t1/2) and VWFpp (VWFpp t1/2) were calculated by determining the first-order rate constant for the elimination phase of the respective proteins.2 To determine the molar ratio of VWFpp and VWF:Ag released following DDAVP, values at 30 mins were extrapolated from semi-log plots of VWFpp and VWF:Ag against time. Median concentrations of VWFpp and VWF:Ag were 2.9nmol/L (range, 1.4–10.9) and 24.5nmol/L (2.5–42) pre-DDAVP in VWD group and 9.7nmol/L (5.8–18.1) and 51.5nmol/L (32–98.5) at baseline in normal subjects. The median VWFpp/VWF:Ag ratio was 0.13 (0.06–1.5) in the VWD group as compared to 0.23 (0.08–0.34) in the normals. Median VWF:Ag t1/2 and VWFpp t1/2 values in the VWD patients were 4 hours (0.9–8.7) and 2.5 hours (1.7–8) respectively. VWF:Ag normally has a half-life of 8–12 hours in plasma,3 while that of VWFpp is 2–3 hours.1 In the patient group, inverse correlation was found between VWFpp/VWF:Ag ratio and VWF:Ag t1/2, r=−0.48, p=0.01. There was also significant inverse correlation between VWFpp and VWF:Ag t1/2, r=−0.53, p0.1. The values for VWFpp and VWF:Ag extrapolated 30 mins post DDAVP were corrected for baseline values and plotted to give a slope of 0.48, representing release of two moles of VWF per mole VWFpp in the patient group. The range of the plasma VWFpp/VWF:Ag ratio is wide in type 1 VWD patients and this may reflect heterogeneity in the pathophysiological processes, including post secretion events such as increased clearance of VWF:Ag, that contribute towards disease phenotype. The finding of inverse correlation between VWF:Ag t1/2 and the ratio of VWFpp to VWF:Ag indicates that increased plasma clearance of VWF:Ag is not associated with an increased VWFpp clearance in some patients with type 1 VWD. In addition, we have not demonstrated equimolar release of VWFpp and mature VWF in patients with type 1 VWD.