DEFECTS IN SERINE PROTEASE INHIBITORS
Authors: Sas G 
Published: August 2018

Several serine protease inhibitorsof plasma inhibit the activated coagulation enzymes but only antithrombin III(AT-III)and heparin cofactor II (HC-II) are implicated in the pathogenesisof the familial thrombosis. Since thefirst publication (1965) many thrombophilic families with reduced AT-III synthesis have been investigated. These studies have proved that the disorder is associated with a high risk forvenous thrombosis and the inheritanceis autosomal dominant. The AT-III activity in the plasma of the affected patients is about 50% of the normalvalue.

In recent years the heterogeneity of the inherited AT-III deficiency has been verified. The various AT-III abnormalities are not mere interestingrarities but they provide naturally occurring models for the solution of theoretical problems such as the function of AT-III molecule, the physiological significance of heparin, etc. Furthermore, the clinical manifestationof the particular variants greatly differs from symptomless abnormality tosevere thrombotic cases.

In the majority of cases, reduced functional activity is accompanied with a parallel decrease of antigen concentration of AT-III. This is the characteristic feature of the quantitative or Type I ("classical")AT-III deficiency. By means of crossed immunoelectrophoresis, electro-focussing and recombinant DNA techniques the heterogeneity of this group has been established. In one subgroup (Type la) AT-III molecules are normal as regards their biochemical characteristics. In Type lb, subnormal AT-IIIquantity is accompanied with decreased heparin affinity. Differentiation of these subgroups has practical consequences: therapeutic concentrations of heparin apparently does not decrease AT-III level in the plasma of patients with Type lb AT-III deficiency.

The other main form is the qualitative deficiency of AT-III (Type II) which is characterised by reduced functional activity at normal antigen concentration. In general, two populations of AT-III molecules can be detected in the blood of these patients: a normal and an abnormal one. Up till now at least 24 different abnormalities were found and designatedwith toponymes. These disorders can be classified with relatively simple laboratory methods such as functional anti-IIaXaFirstDepartment of Medicine, Postgraduate Medical University, Budapest, Hungary.arin cofactor activity, crossed immunoelectrophoresiswith and without heparin, heparin-affinity chromatography. Type na is characterised by profound structural changes of the molecule,variably: reflected in reduced inactivation of F Ha and F Xa, abnormal heparin-AT-III reaction and aberrant immunochemical structure Seven different abnormalities fall into this group (Budapest I, Tokyo, MalmÖ, Chicago, Milano, Trento and Northwick Park). The last three abnormalities are very similar.In Type lib an isolated defect of protease inactivation can be detected and an isolated disturbance of the active centre ofthe molecule is assumed.Until now 6 apparently different variants belonging to this group have been described. (Aalborg, Vicenza, Denver, Hvidovre, Charleville, Milano 2.) Type lie abnormality is characterised by an isolated defect of the heparin-AT-III reaction. In these cases a disturbance of the heparin binding site(s) is assumed. Eleven families with this type of abnormality have been recorded (Ann Arbor, Basel, Paris 1 and 2, Toyama* Tours, Padova I and 2, Algers, Fontainebleu and Budapest 2). This subgroup is heterogeneous in respect ofheparin affinity: in the majority of cases the abnormal AT-III molecules have no heparin affinity at all while in rare cases (such as Basel, Budapest 2) they have reduced affinity.TheType lie AT-III deficiency has several distinctive features compared with the other subtypesJClinically, the thromboembolic complications are rare: in 4 families thrombosis has notoccurred at all. Only one member in each of 4 other families had thrombosis. In 3 families homozygous patients suffered severe thrombosis in young age and/or in unusual localisations (intraarterial, intracardiac, etc.) butthe other heterozygous members were free of thrombotic symptoms. No increased intravascular coagulation could be detected in Type lie heterozygous cases incontrast to the "classical" AT-III deficiency.

These observations suggest a different mechanism and clinical manifestation of the deficiency of progressiveserine protease inactivation and of heparin cofactor activity. In case of progressive inactivation, reduction of 50% of the activity predisposes mainly to venous thrombosis as a consequence of the hypercoagulability of theblood. The isolated reduction of heparin cofactor activity seems to bringabout thrombosis in any part of the vascular system, but only if this reduction is as severe as that of the coagulant factors in case of coagulopathies.In accordance with this finding, rare cases of HCII deficiency give rise to thrombosis in both the arteries and the veins. Heparin cofactor activities may play an important role in the antithrombotic mechanism along theendothelial surface of the whole vascular system.