CT Esmon

The coagulation process presents unusual problems with respect to control mechanisms.To limit the scope of the review, the protein C anticoagulant pathway will serve as a model to illustrate some of the biochemical mechanisms involved in control.It is perhaps worthwhile to consider initiaIly some of the fundamental observations that indicate where and how the system must be regulated.The cascade of zymogen activation events in coagulation provides the potential for explosive amplification (reviewed in Ref. 1) ultimately leading to the formation of thrombin, the serine protease responsible for clot formation, platelet activation, activation of factor XI11 with subsequent cross-linking of the fibrin network, and the feedback activation of the two regulatory proteins, factors V and VI11 (reviewed in Ref. 2).The circulating levels of the thrombin precursor, prothrombin, is at least 100 times greater than that required for rapid and complete clot formation (1, 2).This provides the potential for massive clotting in the face of a triggering event.In healthy individuals, the coagulation system is very effectively controlled, and the balance clearly lies in favor of the negative regulation of this process (3).This contrasts to the observation that when blood is shed into containers, coagulation is complete and relatively rapid.In selected disease states, especially those with an ongoing inflammatory process, the propensity to form blood clots is apparent, suggesting that these individuals might have depressed anticoagulant mechanisms.This hypothesis is supported by the observation that infants born without protein C, a component of a major anticoagulant mechanisms, often die with massive thrombotic complications in infancy (4).

Gram-negative septicemia elicits multiple abnormalities of the coagulation system. Although products of coagulation can lead to clot formation, thereby potentiating organ damage, recent work has shown that low concentrations of thrombin can protect animals from the shock state. Because these amounts of thrombin also lead to formation in vivo of the anticoagulant enzyme, activated protein C, we examined the role of protein C in modulation of Escherichia coli shock in baboons. First, we infused activated protein C and lethal concentrations of E. coli organisms, which prevented the coagulopathic, hepatotoxic, and lethal effects of E. coli. Second, using an antibody to protein C we blocked protein C activation in vivo to determine if this influenced the response to lethal and sublethal concentrations of E. coli organisms. Under these conditions the response to lethal concentrations of E. coli organisms was made more severe and the response to sublethal concentrations of E. coli was made lethal. The coagulopathic, hepatotoxic, and lethal responses in this latter case were prevented by infusion of exogenous protein C.

Human protein C and activated protein C are shown to bind to endothelium specifically, selectively and saturably (Kd = 30 nM, 7000 sites per cell) in a Ca(2+)-dependent fashion. Expression cloning revealed a 1.3-kilobase pair cDNA that coded for a novel type 1 transmembrane glycoprotein capable of binding protein C. This protein appears to be a member of the CD1/major histocompatibility complex superfamily. Like thrombomodulin, the receptor involved in protein C activation, the endothelial cell protein C receptor function and message are both down-regulated by exposure of endothelium to tumor necrosis factor. Identification of endothelial cell protein C receptor as a member of the CD1/major histocompatibility complex superfamily provides insights into the role of protein C in regulating the inflammatory response.

Protein S, is a natural anticoagulant protein which serves as a cofactor for activated protein C. During pregnancy and in the postpartum period, functional protein S levels are significantly reduced (38% +/- 17.3%, mean +/- 1 SD) when compared to nonpregnant females (97% +/- 31.6%) (P less than 0.001). In plasma an equilibrium exists between functionally active free protein S and protein S complexed with C4b-binding protein, which is functionally inactive. As a result of this equilibrium either a decreased level of total protein S antigen or an elevation of C4b-binding protein could lead to reduced protein S activity. C4b-binding protein levels measured by enzyme-linked immunoassay are not significantly different in pregnant women versus nonpregnant controls (103.5% +/- 21.2% v 100% +/- 16.9%). However, during pregnancy and in the postpartum period, total protein S levels are reduced (68% +/- 10.7%) compared to nonpregnant controls (100% +/- 17.0%). This difference is significant at P less than 0.001. These data demonstrated that the reduction in protein S activity observed during pregnancy is a result of reduced total protein S antigen.

Assembly of the terminal complement proteins C5b-9 on human endothelial cells results in increased cytosolic calcium and nonlytic secretion of high molecular weight multimers of von Willebrand factor from intracellular storage granules. We now demonstrate that this C5b-9-induced secretory response is accompanied by vesiculation of membrane particles from the endothelial surface which express binding sites for factor Va and support prothrombinase activity. Exposure of factor Va binding sites after C5b-9 assembly was accompanied by greater than 2-fold increase in prothrombinase activity, which was not observed for cells exposed to C5b-8 (in the absence of C9). By contrast, only a 3-16% increase in prothrombinase activity was observed when these cells were maximally stimulated to secrete by either histamine, thrombin, or the Ca2+ ionophore A23187. Increased prothrombinase activity after C5b-9 was not accompanied by a change in thrombomodulin activity, and was unrelated to cell lysis, the complement-treated cells remaining greater than 99% viable. Endothelial prothrombinase activity was predominately associated with small membrane vesicles (less than 1 microns diameter) released from the cell monolayer. Analysis by fluorescence-gated flow cytometry revealed that these vesicles incorporate the C5b-9 proteins and express binding sites for factor Va. The capacity of the C5b-9 proteins to induce vesiculation of the endothelial plasma membrane and thereby expose catalytic surface for the prothrombinase enzyme complex may contribute to fibrin deposition associated with immune endothelial injury.