Although patients with thromboembolic disease frequently have family histories of thrombosis, well-defined defects such as inherited deficiencies of anticoagulant proteins are found only in a minority of cases. Based on the hypothesis that a poor anticoagulant response to activated protein C (APC) would predispose to thrombosis, a set of new coagulation assays was developed that measure the anticoagulant response in plasma to APC. A middle-aged man with a history of multiple thrombotic events was identified. The addition of APC to his plasma did not result in a normal anticoagulant response as measured by prolongation of clotting time in an activated partial thromboplastin time (APTT) assay. Four of the proband's relatives had medical histories of multiple thrombotic events, and they and several other family members responded poorly to APC in the APTT-based assay. Subnormal anticoagulant responses to APC were also found in factor IXa- and Xa-based assays. Several possible mechanisms for the observed phenomenon were ruled out, such as functional protein S deficiency, a protein C-inhibitory antibody, or a fast-acting protease inhibitor against APC. Moreover, restriction fragment-length polymorphism analysis excluded possible linkage of the underlying molecular defect to factor VIII and von Willebrand factor genes. We now describe a previously unrecognized mechanism for familial thromboembolic disease that is characterized by poor anticoagulant response to APC. This would appear to be explained best by a hypothesized inherited deficiency of a previously unrecognized cofactor to APC. As we have identified two additional, unrelated cases with thrombosis and inherited poor anticoagulant response to APC, this may constitute an important cause for familial thrombophilia.

Protection of the endothelium is provided by circulating sphingosine-1-phosphate (S1P), which maintains vascular integrity. We show that HDL-associated S1P is bound specifically to both human and murine apolipoprotein M (apoM). Thus, isolated human ApoM + HDL contained S1P, whereas ApoM − HDL did not. Moreover, HDL in Apom −/− mice contains no S1P, whereas HDL in transgenic mice overexpressing human apoM has an increased S1P content. The 1.7-Å structure of the S1P-human apoM complex reveals that S1P interacts specifically with an amphiphilic pocket in the lipocalin fold of apoM. Human ApoM + HDL induced S1P 1 receptor internalization, downstream MAPK and Akt activation, endothelial cell migration, and formation of endothelial adherens junctions, whereas apoM − HDL did not. Importantly, lack of S1P in the HDL fraction of Apom −/− mice decreased basal endothelial barrier function in lung tissue. Our results demonstrate that apoM, by delivering S1P to the S1P 1 receptor on endothelial cells, is a vasculoprotective constituent of HDL.endothelial function | crystal structure | sphingolipids | vascular permeability | atherosclerosis S phingosine-1-phosphate (S1P), the phosphorylated metabolite of D-sphingosine, binds to five G protein-coupled receptors (S1P 1 -S1P 5 ) and regulates a plethora of biological actions (1-6). In particular, the prototypical S1P 1 receptor is essential for vascular maturation during development and promotes endothelial cell migration, angiogenesis, and barrier functions (7-9). Thus, S1P is required for maintenance of the barrier property of the lung endothelium (10). Plasma S1P, which is derived from several cellular sources (11,12), is associated with HDL (∼65%) and albumin (∼35%) (3, 5). HDLinduced vasorelaxation as well as barrier-promoting and prosurvival actions on the endothelium have been attributed to S1P signaling (2, 4, 13). Hence, much of the endothelium-protective actions of HDL may result from the actions of S1P on the endothelial S1P receptors. However, the molecular nature of the S1P binding to HDL and interaction with S1P receptors has not been characterized.Apolipoprotein M (apoM) is a lipocalin that resides mainly in the plasma HDL fraction (14). The retained hydrophobic NH 2 -terminal signal peptide anchors apoM in the phospholipid layer of the lipoprotein and prevents filtration of the ∼22-kDa protein in the kidney (15). The biological functions of apoM are understood only partly. Studies in apoM gene-modified mice suggest that apoM has antiatherogenic effects, possibly related in part to apoM's ability to increase cholesterol efflux from macrophage foam cells, to increased preβ-HDL formation, and to antioxidative effects (16)(17)(18). The recent elucidation of the crystal structure of human recombinant apoM (r-apoM) demonstrated a typical lipocalin fold characterized by an eightstranded antiparallel β-barrel enclosing an internal binding pocket that probably facilitates binding of small lipophilic ligands (19).Indeed, r-apoM expressed in Escherichia coli was found to co...

There was a high prevalence of APC resistance among young persons with a history of venous thrombosis, and this resistance appeared to be inherited as an autosomal dominant trait.

Under normal circumstances, the coagulation system is balanced in favour of anticoagulation. Thrombin is the key effector enzyme of the clotting cascade. Antagonists of vitamin K inhibit a vitamin-K-dependent post-translational modification of several coagulation proteins, which is required for these proteins to attain a phospholipid-binding conformation. Heparin stimulates the activity of antithrombin, a serine-protease inhibitor. Analysis of knock-out mice has shown the relative importance of the coagulation factors in vivo. Gene therapy may soon be a therapeutic option for inherited deficiencies of factors VIII and IX.