Antithrombin III deficiency: a report of 14 cases belonging to three different kindreds

A hereditary deficiency of AT III is described in 14 subjects belonging to three different kindreds. There is no consanguineity in any of the families investigated. The pattern of inheritance of defect appears autosomal dominant. Seven of the affected subjects presented thrombotic episodes (deep vein thrombosis, splanchnic thrombosis, pulmonary embolization). The main laboratory features were: normal routine clotting tests, decreased AT III activity in all assay systems and concomitantly reduced AT III antigen levels. Crossed immunoelectrophoresis showed only reduced peaks with respect to normal in both plasma and serum. No correlation was found between age of patients and AT III levels.     

Changes of antithrombin III (AT III) in AT III deficient patients during long-term anticoagulant treatment

Antithrombin III deficient patients with manifest thromboembolic diseases need long term coumarin treatment. There are contradictory data on the change of AT III during this therapy. The authors observed 5 patients with severe AT III decrease type I, 3 with functional abnormality and 2 with a pathological heparin binding. AT III function was determined by the Gerendás-Rák method and with chromogenic substrate. AT III antigen was measured with Behring M-Partigen and Laurell rocket electrophoresis. Crossed immunoelectrophoresis was carried out in all patients. In patients with type I AT III decrease, AT III hasn't changed even in a long period of more than 10 years. In the other types AT III became normal. The pathological heparin binding wasn't changed.     

Short heparin thrombin clotting time, increased fibrinogen and platelet aggregates count in coronary disease: a probable hypercoagulable state.

Several indices of plasmatic and platelet coagulability (H.T.C.T., AT III, fibrinogen and Wu-Hoak test) were studied in 82 patients with acute and chronic coronary artery disease. The results were compared with those obtained in a control group. The most interesting result is the consistent shortening of H.T.C.T. as compared to the control group, particularly in patients with acute myocardial infarction. H.T.C.T. was always inversely correlated with the fibrinogen level. Those data suggest an important influence of fibrinogen levels on H.T.C.T., but this observation does not rule out the possibility that the heparin neutralizing activity (PF 4) will also influence the test. No positive correlation between H.T.C.T. and AT III could be observed. The elevated levels of AT III in acute myocardial infarction did not confirm the existence of a consumption of AT III due to chronic intravascular coagulation in these patients. The Wu-Hoak test increased only in patients with acute coronary disease, never in the other groups. In conclusion, H.T.C.T. may be assumed to be a valid test for indicating the existence of a possible hypercoagulability state.     

Antithrombin III mRNA in adult rat liver and kidney and in rat liver during development

Using Northern blots the size of antithrombin III (AT III) mRNA in rat liver was found to be 1650 nucleotides. Adult rat kidney also contained a slightly smaller mRNA at about 20% the level in liver. The ontogeny of AT III mRNA in the liver was assessed by dot blot hybridization. The mRNA was detectable at the earliest age examined (14th day of gestation) at about 15% of the adult levels. After the 17th day of gestation the levels of antithrombin III mRNA rise reaching 50% of adult levels at birth. After birth the mRNA levels rise to 75% of adult levels by the 5th day and reach adult levels by 40 days after birth. We suggest that foetal AT III is produced by both the foetal liver and by placental transfer of the maternal inhibitor.     

Treatment with AT III concentrates in hereditary and acquired AT III deficiency

41 patients with hereditary and acquired antithrombin II deficiency received a substitution therapy with human plasma fraction of antithrombin III from the GDR blood-transfusion service. In 6 patients a hereditary AT III deficiency was substituted and in this context the substitution in case of thromboses during pregnancy was explained. 35 patients with acquired AT III deficiency were substituted with AT III concentrate because of thromboembolic complication in the macro-circulatory system in case of AT III deficiency due to reduced synthesis, loss, increased consumption or a combination of these conditions or because of DIC. The substitution effect was good. Dosage and injection intervals depend on the clinical condition. Side-effects have not been observed.     

Fluctuation of thrombin-antithrombin III complex in patients with acute myocardial infarction: influence of low-dose heparin administration.

The haemostatic parameters were studied within 14 days of acute myocardial infarction (AMI) in 103 patients randomly allocated into a group receiving low-dose heparin or into a group treated without anticoagulants. Patients with isotopic evidence of deep vein thrombosis were excluded from the analysis. An important formation of thrombin-antithrombin III complex (TAT) in the plasma was detected in the early stage of the disease. It was accompanied by an activation of plasma intrinsic fibrinolysis (IF), an elevation of fibrinogen and its degradation products (FDP) and a reduction of extrinsic plasma fibrinolytic activity (EF) together with normal levels of factor X, antithrombin III (AT III), protein C and alpha-2-antiplasmin. Sequentially studies periods of the disease revealed a diminution of TAT complex concentration in the plasma on the seventh day of AMI together with a rise of the both plasma fibrinolytic activities (IF, EF) as well as an elevation of fibrinogen and its degradation products, returning to the initial values on the 14 day of AMI. In the patients treated with heparin the augmentation of TAT complex in the plasma was prolonged until the fifth day of AMI. Moreover, heparin administration was connected with significantly higher levels of AT III and protein C along with a lower concentration of factor X and FDP on the seventh day of the disease. The fluctuation of fibrinolytic activities (IF, EF) in the plasma was heparin-independent. The present results indicate that low-dose heparin treatment modulates the plasmatic fluctuation of TAT complex as well as factor X, AT III and protein C levels in patients with acute myocardial infarction.     

Molecular analysis of urinary AT III related antigen in liver cirrhosis

Urinary antithrombin III (AT III) related antigen was analyzed by SDS-polyacrylamide gel electrophoresis and Western blotting, and the nitrocellulose membrane was scanned with a 2-wavelength TLC scanner. The urinary AT III related antigen was found to be located in three different molecular weight regions: the AT III region, and molecular weight regions higher and lower than that of AT III. The ratio of the higher molecular weight region to the AT III region divided by the urinary creatinine, was taken as an "index" and was analyzed in liver cirrhosis patients as well as in normal controls. The "index" in liver cirrhosis was higher than that in the controls. Further, the "index" revealed a significant proportional correlation with the total bilirubin and direct bilirubin, and also a significant inversely proportional correlation with the plasma AT III, suggesting that the "index" tends to become higher as liver function decreases. The pathophysiological significance of the "index" is briefly discussed.     

A tentative classification of AT III congenital abnormalities

Twenty two families with an abnormal antithrombin III have been described so far. A classification of these abnormality encounters many difficulties. In fact, the available classifications seem inadequate. On the basis of 5 tests, namely AT III progressive and/or global activity, heparin co-factor activities, crossed immunoelectrophoresis (CIE) without and with heparin, AT III antigen and heparin affinity studies, a "new" tentative classification is proposed. On the basis of these tests, AT III abnormalities may be subdivided in 5 groups: Group 1 includes asymptomatic patients with a variable defect in heparin cofactor activities with normal total or progressive AT III activity and with a slow peak in the heparin modified CIE. Group 2 comprises symptomatic patients with the same laboratory features as presented by group 1 patients. Group 3 includes families in which there is a variable reduction of all AT III activities. There is always a slow peak in the heparin modified CIE and patients are symptomatic. Group 4 includes patients with a variable decrease of all AT III activities but a normal CIE. Patients are symptomatic. Group 5 comprises symptomatic patients with variable decreased AT III activity, and with a fast moving peak in the plain (without heparin) CIE.     

Coagulation inhibitors and glycaemic control in non-insulin-dependent diabetes mellitus

The relationship between long-term glycaemic control and the activity of coagulation inhibitors was investigated in 60 non-insulin-dependent diabetes mellitus (NIDDM) patients not on insulin therapy. Overall, the activities of antithrombin III (AT III) (median 96%, range 65–133%), protein C (127%, 24–190%) and protein S (130%, 54–163%) were not reduced. Patients in poor long-term glycaemic control as verified by increased glycated haemoglobin (HbA1c) demonstrated significantly decreased median AT III activity in comparison with patients in good glycaemic control (92% vs 101%,P=0.016). However, individual values for AT III activity were not below the critical limit of 60%. An inverse correlation between AT III activity and long-term glycaemic control (HbA1c) was calculated (r=–0.378,P=0.0029). As AT III concentrations were found to be normal, we propose that non-enzymatic glycation leads to reduced activity of AT III without affecting its concentration.     

Fibrin monomer complexes (SFMC) after substitution of antithrombin III (AT III) in consumption coagulopathy

The report refers to substitution therapy of 33 patients who suffered consumption coagulopathy. Various blood coagulation and fibrinolytic variables were measured. After successful AT III donation to patients suffering DIC, soluble fibrin monomer complexes (SFMC) disappeared within 0.5-12 hours. If AT III decreases SFMC proves positive again. In addition to analysis of AT III we recommend to analyse SFMC to detect thrombin induced consumption reaction (DIC). Furthermore we found the fibrin split product D-dimer was a particularly sensitive indicator of DIC in case of hyperfibrinolysis (D-dimer was analysed in six patients). The reactions of fibronectin and SFMC proved inversely proportional.     

Associated von Willebrand disease as a possible cause of lack of thrombosis in an AT III abnormality (AT III Trento)

In a family with a known antithrombin III abnormality (AT III Trento) an associated von Willebrand defect (Type I) was found. The two defects seem to segregate independently. In fact four types of individuals were present, namely: subjects with isolated AT III abnormality, subjects with isolated von Willebrand defect, patients with double defect and normal subjects. Only one of the two patients with isolated AT III abnormality showed a thrombotic tendency. None of the patients with double defect showed thrombotic disease, indicating a possible protective action of the von Willebrand defect against thrombotic manifestations. Patients with isolated von Willebrand defect showed neither thrombotic nor bleeding manifestations. The study emphasizes the need for a careful evaluation of the hemostatic balance of patients with AT III abnormalities before concluding that they are symptomatic or asymptomatic.     

Detection of soluble fibrin monomer complexes. Comparison of a haemagglutination assay with the ethanol gelation test

Hypercoagulability and disseminated intravascular coagulation (DIC) are characterized by the presence of circulating fibrin monomer complexes in plasma. In 342 patients with possible DIC fibrin monomers, fibrinogen, Reptilase Time, antithrombin III and other coagulation parameters were determined at frequent intervals. Testing of soluble fibrin monomer complexes was performed using a sensitive and reliable hemagglutation assay with red cells sensitized by fibrin monomers (FM-Test) and the ethanol gelation test (EGT). Method comparison regarding the influence of fibrinogen levels and fibrin degradation products shows that high fibrinogen levels lead to false-positive results with EGT. The same effect is observed for fibrin degradation products and EGT whereas no influence of fibrinogen level and fibrin degradation products on the FM-Test occurs. It is well-known that during DIC AT III level decreases caused by proteolytic activity. In this study it could be shown that fibrin monomer increases parallel to the decrease of AT III. The same effect does not occur due to fibrin degradation products.     

Alterations of antithrombin III after acute myocardial infarction

The antithrombin III (AT III) activity and the AT III concentration were investigated in 62 consecutive patients with acute myocardial infarction (AMI). To identify the reactant pattern of AT III in postaggressive situations, we also determined labile and acute phase proteins. Firstly, 29 patients were nourished orally and then 33 patients were fed by i.v. hyperalimentation (additional caloric intake of approximately 1,000 cal). AT III activities and concentrations as well as prealbumin and retinol-binding protein decreased concomittantly and significantly whereas haptoglobin, C-reactive protein and fibrinogen increased significantly after AMI. The changes cannot be interpreted as being alterations of the haematocrit. The alterations of AT III correlated significantly with the changes of labile proteins but not with the acute phase reactant proteins. The AT III decrease in the postinfarctional phase may promote a prethrombotic state. In In addition it can be concluded from our results that AT III reacts as (nutritive-dependent) labile protein, which is lowered in postaggressive situation and does not increase as an acute phase reactant. This is in accordance with results from recent animal experiments.     

Sheep plasma protease inhibitors influencing protease activity and growth of Lucilia cuprina larvae in vitro

The enzyme inhibitors alpha 2-macroglobulin (alpha 2M), anti-thrombin III (AT III) and alpha 1-proteinase inhibitor (alpha 1PI) were isolated from sheep plasma and tested for their ability to affect L. cuprina larval proteases and larval growth in vitro. Casein radial diffusion gels indicated that both alpha 2M and alpha 1PI completely inhibited the protease activity of a larval excretory-secretory preparation, while AT III had a partial effect. Casein zymograms revealed that alpha 2M inhibited all of the larval proteases, while AT III was able to modify the normal plaque pattern; alpha 1PI inhibited all plaques except a doublet present at pI 8.5. Larval growth in vitro was significantly inhibited by alpha 2M and AT III (P less than 0.05) when compared to albumin controls but was not affected by alpha 1PI. The levels of alpha 2M in sheep serum were monitored over the course of a larval fly infection. A significant increase in alpha 2M (P less than 0.05) was recorded in the serum of flystruck sheep. It is suggested that, under certain circumstances, these inhibitors may be involved in influencing flystrike through reducing the activity of larval proteases necessary for wound formation and larval nutrition.     

Copper concentrations are prevalently associated with antithrombin III,but also with prothrombin time and fibrinogen in patients with liver cirrhosis: A cross-sectional retrospective study

BackgroundConcerning the link between copper excess and the pathogenesis of chronic liver diseases, its retention is reckoned to develop as a complication of cholestasis. Recently, it has been found that cholestatic liver injury involves largely inflammatory cell-mediated liver cell necrosis, with consequent reduced hepatic mass, more than occurring through direct bile acid-induced apoptosis. On the other hand, interference with protein synthesis could be expected to result, ending in an altered ability of the liver to retain copper. Little is known about the association between serum copper and clotting factors in cirrhotics. We aimed at studying a possible relationship between increased levels of copper and an aspect of the haemostatic process in liver cirrhosis patients, assessing an index of protein synthesis (albumin) and parameters of protein synthesis/coagulation/fibrinolysis, such as prothrombin time (PT), antithrombin (AT) III and fibrinogen.MethodsRecords from 85 patients suffering from liver cirrhosis of various aetiology and different severity were retrospectively examined. Serum concentrations of copper were determined by atomic absorption spectrophotometer. An index of protein synthesis, such as albumin and parameters of both synthesis and coagulation/hypercoagulation such as PT %, AT III%, levels of fibrinogen were taken into account to study possible correlations to serum copper. The severity of cirrhosis was evaluated by the Child-Pugh (C–P) classification. The relationship among variables were studied by linear regression.ResultsCopper levels of patients suffering from liver cirrhosis were increased respect to those of controls, 102.7+/-28.7 versus 80.4+/-19.5 mcg/dL, (P = .0009), independently from disease severity, and were positively predicted by PT% (P = 0. 017), fibrinogen (P = 0.007) and AT III% (P = 0.000), at linear regression. Among the previous parameters, to which serum albumin was added, the unique predictor of copper levels was AT III%, at multiple regression (P = 0. 010); AT III% was negatively predicted by the C–P classification (P = 0.000); copper levels, adjusted for C–P classification, were predicted by AT III% (P = 0.020) and fibrinogen concentrations, but not by PT% (P = 0.09).ConclusionThe copper concentration is reckoned as responsible for production of the hydroxyl radicals. On the basis that oxidants may enhance the activity of the extrinsic coagulation cascade, ultimately leading to thrombin formation, via their combined effects on stimulation of tissue factor activity and inhibition of fibrinolytic pathways, the positive relationship of copper to coagulation/hypercoagulation parameters (mainly AT III) in our research could find a plausible interpretation.     

Central nervous system mediated vasodepressor action of atrial natriuretic factor

Administration of 20, 4 or 2.5 micrograms/kg of atriopeptin III (AT III) into the fourth ventricle of the brain of spontaneously hypertensive rats produced a 13, 14 and 7 mm Hg decrease in MAP respectively, while 1 microgram/kg had no effect on MAP and was significantly different from 20 or 4 micrograms/kg (p less than 0.025). In contrast, injection of AT III 20 micrograms/kg into the lateral ventricle did not produce a change in MAP. To examine an interaction of AT III with the opioidergic system, the opiate antagonist, naloxone HCl, 10 micrograms, was given by ICV injection 10 minutes prior to AT III, and significantly prevented the depressor response to AT III (p less than 0.025 compared with AT III alone). Injection of specific anti-sera to beta-endorphin failed to prevent the AT III-induced depressor response. Our results demonstrate that AT III can act within the central nervous system to decrease the MAP of rats, most likely at a locus in proximity to the fourth ventricle of the brain. Further, an interaction with the central opioidergic nervous system underlies the central effects of AT III.     

The in situ inhibition of prothrombinase-formed human alpha-thrombin and meizothrombin(des F1) by antithrombin III and heparin

The inhibition of thrombin by antithrombin III (AT III) and heparin has been studied in pure systems to determine the kinetics of inhibition during human prothrombin activation. The present study shows that prothrombinase-catalyzed prothrombin activation resulted in the generation of thrombin and meizothrombin(des F1). In the absence of heparin the second-order rate constants of the inactivation of both thrombin and meizothrombin(des F1) formed in the reaction mixture appeared to be identical, k = 3.7 X 10(5) M-1 min-1. The rate constant of inhibition of purified thrombin was 6.5 X 10(5) M-1 min-1. In the presence of heparin the decay of the amidolytic activity was biexponential and could be modeled by a four-parameter equation to determine the pseudo first-order rate constants of inhibition as well as the composition of the reaction with respect to the levels of thrombin and meizothrombin(des F1). The ratio of thrombin over meizothrombin(des F1) varied with the initial prothrombin concentration. Heparin catalyzed the AT III inhibition of thrombin but not meizothrombin(des F1) formed during the prothrombin activation. Thrombin, generated by (Xa-Va-phospholipid-Ca2+) was inhibited by AT III/heparin more slowly than purified thrombin, and the saturation kinetics of the inhibition with respect to AT III differed from those found with purified thrombin.     

Antithrombin III binds to human platelets

The receptor site for antithrombin III (AT III) was investigated in normal human platelets. [¹²⁵I] iodinated AT III was utilized as tracer for the binding assay. Equilibrium of AT III binding was reached within 2 min. The binding capacity was pH-dependent with the optimum around pH 7.0. Binding specificity was demonstrated by inhibition of [¹²⁵I] AT III ligation using an excess amount of non-labeled AT III. The AT III·heparin complex did not supress [¹²⁵I] AT III binding. Analysis of binding data by Scatchard plot revealed a single class of binding sites with K_d of 3.2 × 10^?7 M and binding capacity of 3840 per platelet.     

Antithrombin III stimulates prostacyclin production by cultured aortic endothelial cells

Prostacyclin (PGI2) is a potent vasodilator and an inhibitor of platelet aggregation. We found that antithrombin III (AT III), an anticoagulant present in circulating blood, stimulated PGI2 production by cultured bovine aortic endothelial cells in a dose- and time-dependent manner. The stimulation of PGI2 production by AT III was observed at physiological concentrations and was inhibited by the addition of anti-AT III antiserum and heparin. These results suggest that AT III may stimulate PGI2 production by binding to heparin-like molecules on the endothelial cell membrane.     

Characterization of an antiserum to guinea pig antithrombin III (AT III). II. Stimulation of T lymphocyte proliferation

A goat antibody specific for an antigenic determinant shared between guinea pig antithrombin III (AT III) and thymocytes was shown to be mitogenic for lymph node T lymphocytes in the presence of macrophages. Although the antiserum was not mitogenic for purified populations of B lymphocytes, B lymphocytes were as efficient as T lymphocytes in absorbing the mitogenic activity of the serum. The shared antigenic determinant appeared to be carbohydrate in nature in that native and guanidine-treated AT III, but not periodate oxidized AT III, were capable of inhibiting the mitogenic activity of the serum when added continuously to the cultures. The possibility that the plasma protease inhibitor AT III or an antigenically related membrane protein are involved in the regulation of T cell activation is discussed.