RSS-Feed abonnieren
DOI: 10.1055/s-0041-1735154
Aprotinin Inhibits Thrombin Generation by Inhibition of the Intrinsic Pathway, but is not a Direct Thrombin Inhibitor
Funding This study was sponsored in part by an unrestricted educational grant of Nordic Pharma to TL. In addition, this collaboration project is co-financed by the Ministry of Economic Affairs and Climate Policy of the Netherlands by means of the PPP-allowance made available by the Top Sector Life Sciences & Health to stimulate public-private partnerships.Abstract
Background Aprotinin is a broad-acting serine protease inhibitor that has been clinically used to prevent blood loss during major surgical procedures including cardiac surgery and liver transplantation. The prohemostatic properties of aprotinin likely are related to its antifibrinolytic effects, but other mechanisms including preservation of platelet function have been proposed.
Aim Here we assessed effects of aprotinin on various hemostatic pathways in vitro, and compared effects to tranexamic acid(TXA), which is an antifibrinolytic but not a serine protease inhibitor.
Methods We used plasma-based clot lysis assays, clotting assays in whole blood, plasma, and using purified proteins, and platelet activation assays to which aprotinin or TXA were added in pharmacological concentrations.
Results Aprotinin and TXA dose-dependently inhibited fibrinolysis in plasma. Aprotinin inhibited clot formation and thrombin generation initiated via the intrinsic pathway, but had no effect on reactions initiated by tissue factor. However, in the presence of thrombomodulin, aprotinin enhanced thrombin generation in reactions started by tissue factor. TXA had no effect on coagulation. Aprotinin did not inhibit thrombin, only weakly inhibited the TF-VIIa complex and had no effect on platelet activation and aggregation by various agonists including thrombin. Aprotinin and TXA inhibited plasmin-induced platelet activation.
Conclusion Pharmacologically relevant concentrations of aprotinin inhibit coagulation initiated via the intrinsic pathway. The antifibrinolytic activity of aprotinin likely explains the prohemostatic effects of aprotinin during surgical procedures. The anticoagulant properties may be beneficial during surgical procedures in which pathological activation of the intrinsic pathway, for example by extracorporeal circuits, occurs.
Author Contributions
TL: Designed the study, supervised experimental work, analyzed and interpreted data, wrote the manuscript; JA: Performed, analyzed and interpreted experiments, revised the manuscript; DH: Performed, analyzed and interpreted experiments, revised the manuscript; JCMM: Designed the study, interpreted data, revised the manuscript. All authors approved the final version of the manuscript.
Publikationsverlauf
Eingereicht: 16. April 2021
Angenommen: 29. Juni 2021
Artikel online veröffentlicht:
31. August 2021
© 2021. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)
Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany
-
References
- 1 Levi M, Cromheecke ME, de Jonge E. et al. Pharmacological strategies to decrease excessive blood loss in cardiac surgery: a meta-analysis of clinically relevant endpoints. Lancet 1999; 354 (9194): 1940-1947 https://pubmed.ncbi.nlm.nih.gov/10622296/
- 2 Molenaar IQ, Warnaar N, Groen H, Tenvergert EM, Slooff MJH, Porte RJ. Efficacy and safety of antifibrinolytic drugs in liver transplantation: a systematic review and meta-analysis. [Internet] Am J Transplant 2007; 7 (01) 185-194 https://pubmed.ncbi.nlm.nih.gov/17227567/
- 3 Fergusson DA, Hébert PC, Mazer CD. et al; BART Investigators. A comparison of aprotinin and lysine analogues in high-risk cardiac surgery. N Engl J Med 2008; 358 (22) 2319-2331 https://pubmed.ncbi.nlm.nih.gov/18480196/
- 4 Orchard MA, Goodchild CS, Prentice CRM. et al. Aprotinin reduces cardiopulmonary bypass-induced blood loss and inhibits fibrinolysis without influencing platelets. Br J Haematol 1993; 85 (03) 533-541 https://pubmed.ncbi.nlm.nih.gov/7510990/
- 5 Speekenbrink RGH, Wildevuur CRH, Sturk A, Eijsman L. Low-dose and high-dose aprotinin improve hemostasis in coronary operations. J Thorac Cardiovasc Surg 1996; 112 (02) 523-530 https://pubmed.ncbi.nlm.nih.gov/8751522/
- 6 Kaminishi Y, Hiramatsu Y, Watanabe Y, Yoshimura Y, Sakakibara Y. Effects of nafamostat mesilate and minimal-dose aprotinin on blood-foreign surface interactions in cardiopulmonary bypass. Ann Thorac Surg 2004; 77 (02) 644-650 https://pubmed.ncbi.nlm.nih.gov/14759453/
- 7 Santamaría A, Mateo J, Oliver A. et al. The effect of two different doses of aprotinin on hemostasis in cardiopulmonary bypass surgery: similar transfusion requirements and blood loss. Haematologica 2000; 85 (12) 1277-1284 https://pubmed.ncbi.nlm.nih.gov/11114135/
- 8 Campbell DJ, Dixon B, Kladis A, Kemme M, Santamaria JD. Activation of the kallikrein-kinin system by cardiopulmonary bypass in humans. Am J Physiol Regul Integr Comp Physiol 2001; 281 (04) R1059-R1070 https://pubmed.ncbi.nlm.nih.gov/11557611/
- 9 Dietrich W. Reducing thrombin formation during cardiopulmonary bypass: is there a benefit of the additional anticoagulant action of aprotinin?. J Cardiovasc Pharmacol 1996; 27 (27, Suppl 1) S50-S57 https://pubmed.ncbi.nlm.nih.gov/8938284/
- 10 Shigeta O, Kojima H, Jikuya T. et al. Aprotinin inhibits plasmin-induced platelet activation during cardiopulmonary bypass. Circulation 1997; 96 (02) 569-574 https://pubmed.ncbi.nlm.nih.gov/9244227/
- 11 Watabe A, Ohta M, Matsuyama N. et al. Characterization of plasmin-induced platelet aggregation. Res Commun Mol Pathol Pharmacol 1997; 96 (03) 341-352 https://pubmed.ncbi.nlm.nih.gov/9261893/
- 12 Adelman B, Michelson AD, Greenberg J, Handin RI. Proteolysis of platelet glycoprotein Ib by plasmin is facilitated by plasmin lysine-binding regions. Blood 1986; 68 (06) 1280-1284 https://pubmed.ncbi.nlm.nih.gov/2946332/
- 13 Royston D. Thoughts on the Mechanism of Action of Aprotinin. Transfus Altern Transfus Med 2005; 7 (01) 29-36 Available from https://onlinelibrary.wiley.com/doi/full/10.1111/j.1778-428X.2005.tb00152.x
- 14 Aoki N, Naito K, Yoshida N. Inhibition of platelet aggregation by protease inhibitors. Possible involvement of proteases in platelet aggregation. Blood 1978; 52 (01) 1-12 https://pubmed.ncbi.nlm.nih.gov/656619/
- 15 Kozek-Langenecker SA, Mohammad SF, Masaki T, Green W, Kamerath C, Cheung AK. The effects of aprotonin on platelets in vitro using whole blood flow cytometry. Anesth Analg 2000; 90 (01) 12-16 https://pubmed.ncbi.nlm.nih.gov/10624968/
- 16 Khan TA, Bianchi C, Voisine P, Sandmeyer J, Feng J, Sellke FW. Aprotinin inhibits protease-dependent platelet aggregation and thrombosis. Ann Thorac Surg 2005; 79 (05) 1545-1550 https://pubmed.ncbi.nlm.nih.gov/15854931/
- 17 Poullis M, Manning R, Laffan M, Haskard DO, Taylor KM, Landis RC. The antithrombotic effect of aprotinin: actions mediated via the proteaseactivated receptor 1. J Thorac Cardiovasc Surg 2000; 120 (02) 370-378 https://pubmed.ncbi.nlm.nih.gov/10917956/
- 18 Pintigny D, Dachary-Prigent J. Aprotinin can inhibit the proteolytic activity of thrombin. A fluorescence and an enzymatic study. Eur J Biochem 1992; 207 (01) 89-95 https://pubmed.ncbi.nlm.nih.gov/1378406/
- 19 Day JRS, Haskard DO, Taylor KM, Landis RC. Effect of aprotinin and recombinant variants on platelet protease-activated receptor 1 activation. Ann Thorac Surg 2006; 81 (02) 619-624 https://pubmed.ncbi.nlm.nih.gov/16427862/
- 20 Porte RJ, Molenaar IQ, Begliomini B. et al; EMSALT Study Group. Aprotinin and transfusion requirements in orthotopic liver transplantation: a multicentre randomised double-blind study. Lancet 2000; 355 (9212): 1303-1309 https://pubmed.ncbi.nlm.nih.gov/10776742/
- 21 Cardigan RA, Mackie IJ, Gippner-Steppert C, Jochum M, Royston D, Gallimore MJ. Determination of plasma aprotinin levels by functional and immunologic assays. Blood Coagul Fibrinolysis 2001; 12 (01) 37-42 https://pubmed.ncbi.nlm.nih.gov/11229825/
- 22 Royston D, Cardigan R, Gippner-Steppert C, Jochum M. Is perioperative plasma aprotinin concentration more predictable and constant after a weight-related dose regimen?. Anesth Analg 2001; 92 (04) 830-836 https://pubmed.ncbi.nlm.nih.gov/11273910/
- 23 Beath SM, Nuttall GA, Fass DN, Oliver Jr WC, Ereth MH, Oyen LJ. Plasma aprotinin concentrations during cardiac surgery: full- versus half-dose regimens. Anesth Analg 2000; 91 (02) 257-264
- 24 Lavee J, Savion N, Smolinsky A, Goor DA, Mohr R. Platelet protection by aprotinin in cardiopulmonary bypass: electron microscopic study. Ann Thorac Surg 1992; 53 (03) 477-481 https://pubmed.ncbi.nlm.nih.gov/1371665/
- 25 Wildevuur CRH, Eijsman L, Roozendaal KJ, Harder MP, Chang M, van Oeveren W. Platelet preservation during cardiopulmonary bypass with aprotinin. Eur J Cardiothorac Surg 1989; 3 (06) 533-537 , discussion 537–538 https://pubmed.ncbi.nlm.nih.gov/2483979/
- 26 Huang H, Ding W, Su Z, Zhang W. Mechanism of the preserving effect of aprotinin on platelet function and its use in cardiac surgery. J Thorac Cardiovasc Surg 1993; 106 (01) 11-18 https://pubmed.ncbi.nlm.nih.gov/7686594/
- 27 Okita Y, Takamoto S, Ando M. et al. Coagulation and fibrinolysis system in aortic surgery under deep hypothermic circulatory arrest with aprotinin: the importance of adequate heparinization. Circulation 1997; 96 (9, Suppl) II-376-II-381 https://pubmed.ncbi.nlm.nih.gov/9386127/
- 28 Day JRS, Punjabi PP, Randi AM, Haskard DO, Landis RC, Taylor KM. Clinical inhibition of the seven-transmembrane thrombin receptor (PAR1) by intravenous aprotinin during cardiothoracic surgery. Circulation 2004; 110 (17) 2597-2600 https://pubmed.ncbi.nlm.nih.gov/15262827/
- 29 Chabbat J, Porte P, Tellier M, Steinbuch M. Aprotinin is a competitive inhibitor of the factor VIIa-tissue factor complex. Thromb Res 1993; 71 (03) 205-215 https://pubmed.ncbi.nlm.nih.gov/7692618/
- 30 Meltzer ME, Lisman T, Doggen CJM, de Groot PG, Rosendaal FR. Synergistic effects of hypofibrinolysis and genetic and acquired risk factors on the risk of a first venous thrombosis. PLoS Med 2008; 5 (05) e97
- 31 Lisman T. Decreased Plasma Fibrinolytic Potential As a Risk for Venous and Arterial Thrombosis. Semin Thromb Hemost 2017; 43 (02) 178-184
- 32 Hemker HC, Giesen P, AlDieri R. et al. The calibrated automated thrombogram (CAT): a universal routine test for hyper- and hypocoagulability. Pathophysiol Haemost Thromb 2002; 32 (5-6): 249-253
- 33 Bar Barroeta A, van Galen J, Stroo I, Marquart JA, Meijer AB, Meijers JCM. Hydrogen-deuterium exchange mass spectrometry highlights conformational changes induced by factor XI activation and binding of factor IX to factor XIa. J Thromb Haemost 2019; 17 (12) 2047-2055 https://pubmed.ncbi.nlm.nih.gov/31519061/
- 34 Lisman T, Moschatsis S, Adelmeijer J, Nieuwenhuis HK, De Groot PG. Recombinant factor VIIa enhances deposition of platelets with congenital or acquired α IIb β 3 deficiency to endothelial cell matrix and collagen under conditions of flow via tissue factor-independent thrombin generation. Blood 2003; 101 (05) 1864-1870
- 35 Huskens D, Li L, Florin L. et al. Flow cytometric analysis of platelet function to improve the recognition of thrombocytopathy. Thromb Res 2020; 194: 183-189 https://pubmed.ncbi.nlm.nih.gov/32788114/
- 36 Sharma V, Fan J, Jerath A. et al. Pharmacokinetics of tranexamic acid in patients undergoing cardiac surgery with use of cardiopulmonary bypass. Anaesthesia 2012; 67 (11) 1242-1250 https://pubmed.ncbi.nlm.nih.gov/22827564/
- 37 Grassin-Delyle S, Tremey B, Abe E. et al. Population pharmacokinetics of tranexamic acid in adults undergoing cardiac surgery with cardiopulmonary bypass. Br J Anaesth 2013; 111 (06) 916-924 https://pubmed.ncbi.nlm.nih.gov/23880099/
- 38 España F, Estelles A, Griffin JH, Aznar J, Gilabert J. Aprotinin (trasylol) is a competitive inhibitor of activated protein C. Thromb Res 1989; 56 (06) 751-756 https://pubmed.ncbi.nlm.nih.gov/2483763/
- 39 Christensen U, Schiødt J. Effects of aprptinin on coagulation and fibrinolysis enzymes. Fibrinolysis Proteolysis 1997; 11 (04) 209-214 https://doi.org/10.1016/S0268-9499(97)80052-5
- 40 Fredenburgh JC, Weitz JI. New anticoagulants: Moving beyond the direct oral anticoagulants. J Thromb Haemost 2021; 19 (01) 20-29 https://pubmed.ncbi.nlm.nih.gov/33047462/