Plasma Prekallikrein, Factor XII, Antithrombin III, C7 -Inhibitor
and a2-Macroglobulin in Critically III Patients with Suspected
Disseminated Intravascular Coagulation (DIC)
BERNHARD LAMMLE, M.D., TRI H. TRAN, PH.D., RUDOLF RITZ, M.D., AND FRANCOIS DUCKERT, PH.D.
In nine patients with suspected disseminated intravascular coagulation (DIC) and five controls, the following analyses were
performed on admission and 7-29 hours later: Routine coagulation studies (fibrinogen, platelet count,fibrin(ogen)degradation
products, ethanol gelation, reptilase time, Factor V) providing
a semiquantitative DIC score, prekallikrein (PK), Factor XII,
antithrombin III (AT-III), Cr-inhibitor and a2-macroglobulin.
Significant correlations were found: PK or AT III with the DICscore, PK with AT-III and Factor XII, AT-III with Factor XII.
The changes (expressed as a percentage of normal plasma) of
PK and AT-III from the first to the second evaluation were
nearly identical. The two patients with rapidly fatal irreversible
shock showed the highest DIC score and a pronounced decrease
of PK and AT-III, whereas in reversible shock stable or increasing PK and AT-III values were found. The other variables
showed an overlap between reversible and irreversible shock.
DIC in these shock patients, accompanied by a decrease in PK,
probably was mediated via Factor XII activation. PK and ATIII might be of prognostic value in patients with (septic) shock.
(Key words: Disseminated intravascular coagulation (DIC);
Septic shock; Prekallikrein; Factor XII; Antithrombin III; CrInhibitor; a2-Macroglobulin; Prognostic markers) Am J Clin
Pathol 1984; 82: 396^(04
GRAM-NEGATIVE AND GRAM-POSITIVE septicemia, shock, especially septic shock, and also liver disease
frequently are associated with disseminated intravascular
coagulation (DIC).3-8-33353647-49
It has been suggested that DIC in septicemia is mediated
via the intrinsic system by activation of Hageman Factor
(Factor XII); Factor XII activation, in turn, is supposed
to be induced by endothelial damage caused by bacteria
or endotoxins.8,34-35 Moreover, it is clearly established that
activated Factor XII not only triggers the intrinsic coagulation cascade but also is able to activate plasma prekallikrein (PK), high molecular weight (HMW) kininogen
Coagulation and Fibrinolysis Laboratory and the Medical
Intensive Care Unit, Kantonsspital, 4031 Basel, Switzerland
being a nonenzymatic cofactor for this reaction.17 Colman
and associates9 presented evidence of prekallikrein activation in typhoid fever finding a decrease in prekallikrein
and antikallikrein functional activities and demonstrating
kallikrein -C7-inhibitor complex formation in crossed
immunoelectrophoresis. Moreover, even in uncomplicated, self-limited endotoxemia or bacteremia after genitourinary instrumentation or resection a slight decrease
in prekallikrein esterase activity and a parallel decrease
in systemic vascular resistance were demonstrated and
interpreted as a prekallikrein activation with consequent
bradykinin liberation from HMW-kininogen by kallikreiti.40
In the present study, we examined if in critically ill
patients with suspected DIC the coagulation disorders
were paralleled by a decrease in PK or Factor XII. In
addition, the protease inhibitors antithrombin HI (ATIII), Cr-inhibitor (C7-Inh) and a2-macroglobulin (a 2 -M)
were evaluated, the two latter being the most important
physiologic kallikrein inhibitors.14'54 It was also evaluated
if the determination of these parameters might be useful
in assessing the prognosis in these intensive care patients.
Materials and Methods
Patients
Nine patients admitted to the medical intensive care
unit with a clinical condition known to be associated
frequently with DIC were investigated together with five
control patients with acute coronary heart disease without
shock in whom no DIC was expected. Details on patients
and controls are given in Table 1.
Received November 15, 1983; received revised manuscript and accepted for publication January 4, 1984.
Supported by the Schweizerische Nationalfonds zur Forderung der
Wissenschaft.
Presented in part at a local Swiss Meeting (28) and at the IX International Congress on Thrombosis and Haemostasis (30).
Blood Sampling, Handling of Plasma
Dr. Lammle's present address is as follows: Scripps Clinic and Research
Foundation, Department of Immunology, 10666 N. Torrey Pines Rd.,
Blood was obtained by clean venipuncture or through
La Jolla, California 92037.
arterial/venous
catheters using plastic syringes. The first
Address reprint requests to Dr. Lammle: Coagulation and Fibrinolysis
10
mL
were
discarded,
and the blood immediately was
Laboratory, Kantonsspital, 4031 Basel, Switzerland.
396
Vol. 82 • No. 4
PREKALLIKREIN, FACTOR XII, INHIBITORS IN DIC
added to % of its volume of trisodium citrate, 0.13 M,
in polypropylene tubes. Plasma was obtained by centrifugation at room temperature at 2,500 g for 5 minutes
and either used immediately or deep-frozen in small aliquots in polystyrene tubes at -70°C. Vacutainer® (Becton-Dickinson, Rutherford, NJ) tubes were used for the
collection of EDTA blood for the platelet count and of
native blood. After centrifugation, the serum was pipetted
into a Thrombo Wellco® test tube for the assay of fibrinogen) degradation products (FDP)(within 20 minutes
of blood collection).
Blood was taken upon admission in the intensive care
unit and at intervals thereafter as indicated in Table 1.
Routine Coagulation Studies
The following routine analyses were performed immediately: Fibrinogen according to Clauss,7 Factor V according to Kappeler,24 ethanol gelation test according to
Godal, 16 FDPs by Thrombo-Wellco-Test' 0 according to
the manufacturer's instructions with the following exception: to 1 mL serum from heparinized patients, 0.1
mL of hexadimethrine bromide (Polybrene®, AldrichEurope, Beerse, Belgium), 1 g/L, was added before pipetting the serum into the Thrombo-Wellco tube in order
to ensure complete clotting. The Reptilase-time was
measured as follows: 0.2 mL of plasma was incubated in
a glass tube at 37°C for 30 seconds, whereafter 0.1 mL
of Reptilase (Boehringer Mannheim FRG) was added
and the clotting time determined. The heparin-insensitive
Reptilase time was done instead of the thrombin time,
because several patients were treated with heparin (Table
1). Platelet count in EDTA-blood was done in the Hematology Laboratory using a Coulter-S+®. In order to
assess the severity of the suspected DIC, a semiquantitative
DIC score was established based on the abovementioned
routine parameters (Table 2).52
Special Laboratory Studies:
(1) Factor XII clotting activity was assayed on the frozen plasma samples using hexadimethrine bromide in
order to neutralize heparin as described previously.32
(2) Prekallikrein amidolytic activity was determined,
with a modification29 of the method of Friberger and
associates." It should be noted that values obtained by
assaying frozen plasma samples with addition of frozen
normal plasma in order to obtain complete activation of
prekallikrein26,29 are reported here. Because of the presence
of at least 50% of Factor XII in the assay mixture the
method is heparin insensitive.29
(3) Antithrombin III was assayed in the frozen samples
as heparin cofactor activity using bovine thrombin and
the chromogenic substrate Chromozym-TH as previously
described.51
397
(4) C7-Inhibitor was determined by rocket immunoelectrophoresis using 150 fiL rabbit antiserum (Behringwerke AG, FRG) in 12 mL agarose, 1%, by applying 5
//L of appropriately diluted plasma within round wells.
(5) a2-Macroglobulin-assay was performed similarly
using 100 nL rabbit antiserum (Behringwerke) in 12 mL
agarose, 1%. In both cases, rocket immunoelectrophoresis
lasted for 16-18 hours at 40 mA/plate ( 9 X 1 2 cm) with
running tap water for cooling. After washing with saline
and drying, the plates were stained with Coomassie blue,
0.02%. On each plate were run duplicate samples of five
different dilutions of a standard plasma, and each patient
sample was assayed at least twice on different plates.
(6) All laboratory studies were performed in duplicate
and the values averaged. A normal human plasma pool
from ten healthy volunteers, frozen at —70°C was used
as a reference and considered to represent 100% for each
parameter.
Statistical Analysis
Correlation between different parameters was analyzed
using the Spearman rank correlation test. Significance
was assumed for two-tailed P values < 0.05.
Results
DIC scores and fibrinogen, Factor XII, PK, AT-III,
Cf-Inh, and a2M values are shown in Table 3.
The two patients dying from irreversible shock within
36 hours (Group 1) not only showed the highest DIC
scores but also a marked decrease of PK and AT III from
the first to the second evaluation. Patients with reversible
shock (groups 2 and 3) showed similar PK and AT III
levels as the two patients with irreversible shock (Group
1) at the first examination, but all showed either stable
or increasing values at the second evaluation.
It is also evident that the course of fibrinogen and
Factor XII levels does not clearly distinguish the cases
with irreversible from those with reversible shock. The
immunologically determined C7-Inh and a2M values also
showed a considerable overlap between Groups 1 through
3. Nevertheless, both patients with irreversible shock
showed a pronounced decrease of these parameters within
the period of observation, whereas Group 2 and 3 patients
had either increasing, stable, or only slightly decreasing
values of C7-Inh and a2M.
Not unexpectedly, none of these laboratory tests was
able to discriminate Group 2 from Group 3 patients.
Finally all controls had low DIC scores as well as normal
and stable levels of Factor XII, PK, and AT-III (only
patient 12 showed a subnormal AT-III activity at the
second evaluation, and patient 13 had stable but low
levels of Factor XII, C7-Inh was elevated in patient 11
and a2M in patient 14).
e 1. Nine Critically 111 Patients with Suspected DIC and Five Control Patients, Grouped According to the Clinical Outcome (see "R
utcome Group
versible shock, lethal
within 30-36 hrs
versible shock,
atients dying several
ays later from
econdary
omplications
versible shock,
atients surviving
Initials
Sex
Age (yrs)
• Clinical Condition*
Time interval
First to
Second
Evaluation
(hrs)
Other Treatment}:
Intravenous Fluidf
1. GE
F
69
Rheumatoid arthritis, treated with
steroids. Urosepticemia
(Proteus mirabilis), septic shock
(Pa 70/22 mmHg)§
a) 200 mL Albumin 20%/500 mL F. MV VA a-M-P
b) 1,750 mL PPL/1,200 mL F
Antibiotics
Heparin 10,000 U/24 h
2. BG
F
67
Metastasiz. breast cancer.
Staphylococcus aureus
septicemia, probable
pneumonia, septic shock (Pa
80/50 mmHg)
Rheumatoid arthritis. Subacute
Staphylococcus aureus
gonarthritis/omarthritis, treated
with antibiotics. Shock,
probably septic (Pa 95/50
mmHg)
a) 500 mL PPL
b) 750 mL PPL/200 mL albumin
20%/1,500 mL F/2 U PRC/500
mL FFP
3. ZW
F
57
4. BHU Liver cirrhosis. Acute bleeding
F
from erosive.gastritis and
56
possibly esophageal varices (RR
130/70 mmHg)§
5. SE Subacute deep venous
M
thrombosis, probable
65
pulmonary embolism.
Cholecystitis, liver abscess with
septicemia (Escherichia coli
and Enterococci), convulsions,
septic shock (Pa 93/40 mmHg)
6. AI
F
69
Pneumonia with septicemia
(Diplococcus pneumoniae),
septic shock (Pa 90/46 mmHg)
7. HG
M
60
Subacute myocardial infarction.
Pneumonia with septicemia
(Klebsiella), septic shock (RR
85/60 mmHg)
24
a) 1,500 mL PPL/200 mL albumin
20%/500 mL dextran/750 mL
FFP/1 U PRC/950 mL F
b) 2 U PRC/1,200 mlF
Heparin 25,000 U/24 hrs
VA a-M-P
Antibiotics
T
VA a-M-P
Antibiotics
I Heparin 10,000 U/24 hrs
I
29
a) 300 mL FFP/950 mL F/7 U
PRC
b) 250 mL FFP/1,750 mL F
a) 2,000 mL PPL/2,700 mL F/I U
PRC/2 U FWB
Vasopressin
Somatostatin
MV VA Antibiotics
a-M-P
19
Dialysis
b) 1,100 mLF/1 U FWB
24
15
a) 250 mL PPL/1,100 mL F/l U
PRC
b) 1;650 mL F/3 U PRC
MV VA a-M-P
OAC/hepar
25,000 U
Benzodiaze
Phenobarbi
Dipheny
Antibiotics
Heparin 10
a) 500 mL PPL
Antibiotics
b) 100 mL F
a-M-P
Phenprocou
Heparin
.25,000 U/2
Heparin
25,000 U/2
trol patients without
shock
8. DE
M
64
Pneumoconiosis, chronic
obstructive lung disease,
alcoholism, macrocytic anemia.
Fever and shock of unknown
origin, possibly septic (Pa 95/50
mmHg)
9. JW
M
74
Chronic obstructive lung disease,
polycystic renal disease with
mild chronic renal failure.
Diarrhea, Vomitus, fever,
tachyarrhythmia, neutrophilic
leucocytosis, shock of unknown
origin, possibly septic (Pa 95/52
mmHg)
10. VG
M
47
11. SO
F
61
12. SF
M
60
13. ME
M
69
14. GK
M
72
Chronic coronary heart disease
Acute myocardial infarction,
no complications except
transient pericarditis
Chronic renal failure, Diabetes
mellitus type I. Chronic
coronary heart disease. Acute
myocardial infarction, no
complications except
ventricular premature beats
Chronic coronary heart disease.
Acute myocardial infarction,
no complications except
ventricular premature beats
Chronic coronary heart disease.
Diabetes mellitus type II. Acute
myocardial infarction without
complications
Chronic coronary heart disease.
Acute intermediate coronary
syndrome without
complications
18
a) 300 mL albumin 20%/900 mL
F/2 U PRC
b) 300 mL albumin 20%/1350 mL
F/l U PRC
VA Antibiotics
a) 1,000 mL PPL/1,150 mL F
VA antibiotics
Electroconversion
Chinidin
b) 1,200 mL F
22
a) 300 mL F
24
Aminophyll
Cortisol
a-M-P
Heparin 25
hrs
Heparin 10
hrs
a-M-P
Heparin 25
Nitroglycerin, hrs
Morphine
b) 200 mL F
a) 25
b) 400 mL F
a) -
21
b) 650 mL F
a) 18
b) 350 mL F
Digoxin, clonidine, isosorb
Dihydralazine
Nitroglycerin
Nifedipine
Heparin
" Morphine
10,000 U/2
[Lidocaine-Inf Insulin sc
Nitroglycerin
Nitroglycerin Heparin 25
lidocaine-) hrs
inf
J
Morphine
Nitroglycerin
Morphine
Nitroglycerin Heparin 25
Nifedipine
hrs
Morphine
a) 23
Digoxin
b) 100 mL F
Heparin 10
hrs
% MV: mechanical ventilation. VA: vasoactive drugs (dopamine, dobutamine, or isoprenaline).
diagnosis of septic shock was based on at least one positive blood culture in addition to the clinical shock syndrome.
0.5-2 g iv X 3. at 8 hour intervals, except in control patient 10 (once 40 mg iv). OAC: or
had previous antibiotic therapy, negative blood cultures but a clear septic focus (= probable septic shock). In cases
the etiology of shock could not be clarified, septic shock most likely was present (= possible septic shock). given by continuous infusion.
otes intravenous fluid therapy administered before the first laboratory examination, b) means ivfluidadministration § Pa is the intraarterial blood pressure; RR is the blood pressure obtained by the Riva-Rocc
f Patient 4 no more was in shock when admitted to our intensive care unit.
e first and second evaluation. F = Ruid: isotonic NaO or 3% glucose. PPL: pasteurized plasma protein solution.
kedredcells. FFP: fresh frozen plasma. FWB: fresh whole blood.
400
LAMMLE ET AL.
A.J.C.P. • October 1984
Table 2. DIC Score
Score Points
1
0
Fibrinogen g/L (at second evaluation)
or —A%* fromfirstto second evaluation
Platelet count X 103/mm3 (second evaluation)
or -A%* fromfirstto second evaluation
FQP's Mg/ml at second evaluation
Ethanol gelation at second evaluation
Reptilase time (sec) at second evaluation
Factor V (% of normal pool plasma) at second evaluation
S2.0
<20%
>150
<20%
<10
Negative
<25
>70
1.50-1.99
20-29%
100-149
20-39%
10-40
Positive
2*25
51-70
2
3
1.00-1.49
30-49%
60-99
40-59%
<1.00
5*50%
<60
3=60%
>40
—
—
—
—
—
«50
evaluation. The DIC score was obtained
by adding the score points for the six individual parameters.
- A% denotes percentage change offibrinogenor platelet count from thefirstto the second
According to Tran and associates.'2
As shown in Figures 1-5, PK (Fig. 1) and AT III (Fig.
2) correlated significantly with the DIC score. PK further
correlated significantly with Factor XII (Fig. 3) and with
AT-III (Fig. 4) and AT-III with Factor XII (Fig. 5). Most
interesting was the exact parallelism of the behavior of
PK and AT-III: Despite the rather small variation of these
parameters from the first to the second evaluation, an
excellent correlation of the respective changes (denoted
as APK and AAT-III, respectively) was found (Fig. 6).
APK also correlated significantly (rs = 0.85, P < 0.005)
with Aa 2 M, whereas the correlation of APK with ACi~Inh was less pronounced (rs = 0.62, P < 0.05).
Discussion
Our results show that in critically ill intensive care
patients the severity of DIG as reflected by a semiquantitative DIC score (Table 2) was related closely to the
decrease in plasma PK and AT-III levels (Figs. 1 and 2).
A very interesting finding was the parallel course of ATIII and PK: The decrease of the values of both parameters
in the two rapidly fatal shock cases as well as the increase
in patients with reversible shock were nearly identical
when quantitatively expressed as a percentage of normal
plasma (Fig. 6). Furthermore, the data—though obtained
from a too small number of patients to draw firm conclusions—suggest that the behavior of both PK and ATIII might be related to the clinical outcome of shock and
hence be useful as a prognostic marker in these patients
(Table 3).
It must be admitted that the diagnosis of DIC based
on routine coagulation assays is difficult. Thus, for instance, thrombocytopenia in septicemia may not only be
due to DIC but also to some other, probably immunologic
mechanism.37 Impaired liver function with reduced synthetic capacity may be associated with low Factor V and
fibrinogen values, and elevated FDP levels may not necessarily prove intravascular fibrin(ogen) breakdown as
Table 3. DIC Score, Fibrinogen, Factor XII, Prekallikrein, Inhibitors in the Different Patients.
DIC
Score*
Fibrinogenf
(g/L)
Factor Xllf
(%)
PKf
(%)
AT-IIIt
(%)
crInhf (%)
a2Mt
(%)
GE
BG
ZW
BH
SE
AI
9
9
3
7
2
4
6.20-3.70
2.35-1.90
5.80-9.00
2.20-1.70
3.10-3.10
6.50-5.60
52-32
60-51
45-65
89-78
38-48
61-60
46-35
56-34
51-53
45-48
46-63
35-42
39-26
51-29
48-62
51-54
54-69
65-77
92-64
205-162
116-185
115-135
141-170
185-228
83-52
89-76
54-67
113-119
60-76
70-69
7 HG
DE
9 JW
10 VG
11 SO
12 SF
13 ME
14 GK
5
5
2
0
1
0
0
2
8.00-7.30
3.30-2.60
4.70-5.20
3.15-3.05
5.00-4.40
2.30-2.80
3.20-3.50
2.90-3.50
78-90
56-50
50-50
120-108
108-104
73-74
45-46
78-80
78-81
53-54
71-68
100-100
100-98
87-78
74-77
75-81
82-91
52-53
64-58
93-93
119-114
81-73
89-82
84-84
123-155
153-145
100-115
138-147
188-170
128-122
107-105
119-110
43-47
141-133
147-140
75-69
113-100
121-100
72-72
147-145
Outcome Groups
Initials
Irreversible shock
1
2
3
4
5
6
Reversible shock, ~~|
patients dying
several days
f
later f. second.
complicat.
-/
Reversible shock,
patients
r
surviving
Control patients "1
without shock
r
8
Fibrinogen 1.7-4.0 g/L. Factor XII 70-130%; PK 75-125%; AT-III 80-120%; C7-lnh 60-140%;
• DIC score determined at the second evaluation (see "Materials and Methods").
«2-M 70-130%.
t For all parameters, the values of thefirstand second evaluation are given. Normal values:
PREKALLIKREIN, FACTOR XII, INHIBITORS IN DIC
Vol. 82 • No. 4
401
II
Prekallikrein
100 •
0
Prekallikrein
7.
o
n = V,
110 J
rs = -0.75
100 -
p < 0.01
0
80-
n = U
rs = 0.62
p < 0.05
90 -
A
7.
o
80 •
8
70 -
•
60 -
60-
•
A
50 -
A
•
•
40 -
•
•
40 -
-
•
A
1
A
•
o
o
o
o
X
X
30 •
i
20 10 -
Factor XII V.
20-
0
1
2
3
4
5
6
7
8
10
9
20
30
40
50
60
70
80
90
100
110
120
DIC Score
FIG. 3. Prekallikrein and Factor XII in shock and
control patients. See key for symbols in Figure I.
FIG. 1. Prekallikrein and DIC score in nine shock patients and five
controls. X = irreversible shock; • = reversible shock, patients dying
from secondary complications; A = reversible shock, patients surviving;
O = controls with myocardial infarction, r, in Figs. 1-6 denotes Spearman
rank correlation coefficient.
pointed out by Straub.50 Moreover, the decrease of coagulation factors due to DIC may be accentuated by
plasma dilution or capillary leakage.2,50 Nonetheless, the
1
clinician nowadays still must rely on the combined evaluation of these rapidly assessable routine coagulation
analyses as well as their changes over a short period of
time in order to diagnose DIC taking into consideration
also the clinical context. Thus, with these limitations in
i\
i
AT HI -Act vity
7.
n= \U
120 -
rs=-0.68
p < 0.02
D
Prek allikrein
7°
110 -
n = U
rs = 0.85
p < 0.005
100 -
90 -
o
o
100-
o
A
o
0
80 -
O
80 -
o
70 -
•
o
'
A
o
A
•
60 •
•
50 -
•
60-
•
A
•
40 -
•
A
xx
30 -
40-
20 H
X
X
20i
10 -
AT III-Activity
»
0
1
2
3
4
5
6
7
8
9
10
20
30
40
50
60
70
80
90
100
110
DIC Score
FIG. 2. Antithrombin III activity and DIC score in shock and
control patients. See key for symbols in Figure 1.
FIG. 4. Prekallikrein and antithrombin III in shock and
control patients. See key for symbols in Figure 1.
7.
120
402
LAMMLE ET AL.
AT III-
Activity °U
120 •
•
0
110 •
n = U
h = 0.67
P < 0.02
100 90 -
o
4
0
0
80 -
•
o
•
70 60 1
•
*
•
4
SO 40 X
30 •
X
20 •
10 -
Factor XII
10
~ I
I
20
30
I
V.
I
40
SO
60
70
60
90
100
110 120
FIG. 5. Antithrombin III and Factor XII in shock patients
and controls. See key for symbols in Figure 1.
mind, the DIC score described is probably useful for a
rapid diagnosis and estimation of severity of DIC.
Concerning the pathogenesis of DIC, it has been suggested by Mason and co-workers35 that DIC in septicemia
probably might be mediated via the intrinsic system as
opposed to DIC caused by neoplasia. Lowering of Factor
XII antigen2223-44 or clotting activity 2334 as well as of
4 Prekallikrein V.
n = 14
~i
+
rs = 0.79
p < 0.005
-20
-15
-10
I.
cf
+
I '
5
10 15 20
A Antithrombin I I I Act. V.
FIG. 6. Changes of prekallikrein (APrekallikrein) and antithrombin
III (AAntithrombin III) from thefirstto the second evaluation in shock
and control patients. See key for symbols in Figure 1. APrekallikrein
and AAntithrombin III are expressed as a percentage of normal human
plasma.
A.J .C. P. • October 1984
PK antigen,19-22-23-43 clotting,22-39-43 esterase,9-34-38-40 and
amidolytic1,2,12,13,22,25,48 activity in septicemia, septic
shock, or DIC has been reported. High molecular weight
(HMW) kininogen, the nonenzymatic cofactor in contact
activation reactions, which circulates as a complex with
PK and Factor XI in blood 1746 also is consumed in DIC,
septicemia, and/or septic shock as reflected by its low
clotting activity19,23'42 or antigenic concentration 22,23 or
the decreased in vitro liberation of bradykinin from plasma
exposed to kallikrein.12,13,20 The demonstration by radioimmunoassay of elevated bradykinin levels in hypotensive septicemia38 is probably a more direct proof of
kallikrein formation, but the assay is more difficult and
the in vivo half-life of bradykinin is of the order of 20
seconds only.38 A decrease of functional global antikallikrein2'913'2''34'38-48 and also of the immunologic a 2 -M
concentration, 23 a physiologically important antikallikrein,1418'54 has been described in patients with septicemia,
septic shock, and/or DIC. On the other hand, immunochemically assayed Cf-Inh, the most important in vivo
antikallikrein14,15,54 was found to be normal or elevated
in uncomplicated bacteremia9,23 and normal even in septic
shock.23 However, it should be considered that C7-inhibitor-enzyme complexes may be co-measured in immunologic assays explaining higher antigenic than functional Cr-Inhibitor values.9 The demonstration of spontaneous estero-, or amidolytic "kallikrein-like" activity15
in patients or experimental animals with septicemia and/
or DIC1,34 ' 40 is probably always due to the formation of
a2-M-kallikrein complex, which still displays some amidolytic but no proteolytic activity.I4-31-54 Nevertheless, in
vitro contact or cold-induced prekallikrein activation, e.g.,
by using inadequately siliconized glass tubes 27 * or by
exposing the plasma to low temperatures before the assay6
strictly must be avoided. Clear evidence for in vivo prekallikrein activation and consequent kallikrein inhibition
was presented by Colman and associates9 in patients with
typhoid fever by the demonstration of circulating kallikrein-C7-Inh complexes in crossed immunoelectrophoresis studies. These authors argued that these complexes
were responsible for the discrepancy of low functional
but normal antigenic PK levels found in these patients,
kallikrein retaining its antigenicity but losing its functional
activity after complex binding to Cf-Inh.
Unfortunately, in several of the abovementioned reports information on the severity, cause, and clinical
* Vacutainer* tubes containing citrate anticoagulant used in a previous
study on normal subjects in 197927 gave a much greater spontaneous
"kallikrein-like" activity" than polypropylene tubes. It seems that the
currently available Vacutainer* tubes are better siliconized, giving a
much lower "kallikrein-like" activity (Lammle, unpublished). Nevertheless, in the present study, polypropylene and polystyrene tubes were
used (see Materials and Methods) in order to avoid even a very small
in vitro contact activation.
Vol. 82 • No. 4
PREKALLIKREIN, FACTOR XII, INHIBITORS IN DIC
course of DIC is lacking. However, Ragni and associates39
found low PK clotting activity not only in DIC due to
septicemia but also in DIC associated with hematologic
malignancy. This is in disagreement with the findings of
Mason and colleagues,35 which suggested that DIC in
neoplasia would be mediated via the extrinsic system,
leaving the Hageman-Factor-dependent pathways unaffected.
Our results of decreased PK amidolytic activity in eight
out of nine patients with shock (Table 3) are compatible
with in vivo PK consumption in these patients. In all but
one instances (patient 4, BH) the shock was of (probable)
septic origin. Nonetheless, impaired liver synthesis (e.g.,
in patient 4, Table 1) and dilution by the considerable
amount of intravenous plasma replacement in some cases
(Table 1) also may have contributed to the lowering of
its level. The demonstration of an inverse correlation of
PK levels with the severity of DIC (DIC score) (Fig. 1)
points to a common etiology of both the decrease of PK
and occurrence of DIC, namely, the activation of Factor
XII with consequent activation of prekallikrein on the
one hand and the intrinsic clotting system on the other.
Factor XII activation on the other hand is supposed to
be caused by endothelial damage induced by endotoxins
or bacteria.8,34
Lowering of AT-III in DIC, shock, and septicemia is
well known4'5,25,4548 and confirmed by the present findings.
Interesting is the very close parallelism of the levels and
course of PK and AT-III (Figs. 4 and 6) found in this
study. AT-III is a kallikrein inhibitor of only minor in
vivo importance, although in the presence of heparin its
significance for the inhibition of kallikrein is increased.54
Nevertheless, it is probable that consumption of AT-III
by other proteases, e.g., Factor Ila or Factor Xa,41 was
of the same order of magnitude as consumption of PK,
whereby plasma dilution may have contributed to the
parallel decreases of AT-III and PK in the two rapidly
lethal shock cases. On the other hand, the parallel increases
of both proteins in patients with reversible shock points
to similar synthetic rates for PK and AT III.
Besides these pathophysiologic implications, it is most
important for the clinician that PK levels seem to be of
prognostic importance, a hypothesis supported by some
other recent reports.2'23,25'48 Indeed, as briefly reviewed
by Vaage53 PK, Factor XII and also AT-III seem to be
better prognostic markers in patients with trauma and
sepsis than various hemodynamic, pulmonary or other
metabolic data.
Conclusion
In our opinion, it is certainly worthwhile to perform
further studies in order to assess the significance of the
contact activation system, the protease inhibitors, and
403
possibly also the fibrinolytic system25,48 in a larger number
of patients with septicemia, shock, and DIC of various
etiologies. This not only will shed light on the pathophysiology but also may be of clinical importance, i.e.,
for the assessment of prognosis and possibly for the control
of treatment. It is clear that for clinical purposes, assays
will be needed that can be performed rapidly, a condition
that is well met by chromogenic peptide substrate assays.
Acknowledgment. The expert technical assistance of Miss Esther
Grossmann and the secretarial work of Miss Lotti Miiller and Mrs. Inge
Chodnekar are gratefully acknowledged.
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