During surface-initiated blood coagulation in vitro, activated factor XII (fXIIa) converts factor XI (fXI) to fXIa. Whereas fXI deficiency is associated with a hemorrhagic disorder, factor XII deficiency is not, suggesting that fXI can be activated by other mechanisms in vivo. Thrombin activates fXI, and several studies suggest that fXI promotes coagulation independent of fXII. However, a recent study failed to find evidence for fXII-independent activation of fXI in plasma. Using plasma in which fXII is either inhibited or absent, we show that fXI contributes to plasma thrombin generation when coagulation is initiated with low concentrations of tissue factor, factor Xa, or ␣-thrombin. The results could not be accounted for by fXIa contamination of the plasma systems. Replacing fXI with recombinant fXI that activates factor IX poorly, or fXI that is activated poorly by thrombin, reduced thrombin generation. An antibody that blocks fXIa activation of factor IX reduced thrombin generation; however, an antibody that specifically interferes with fXI activation by fXIIa did not. The results support a model in which fXI is activated by thrombin or another protease generated early in coagulation, with the resulting fXIa contributing to sustained thrombin generation through activation of factor IX. (Blood. 2009;114:452-458)
IntroductionThe plasmas of placental and marsupial mammals contain factor XI (fXI), 1 the zymogen of a protease (fXIa) that contributes to fibrin formation and stability through activation of factor IX (fIX). [2][3][4] Congenital fXI deficiency is associated with a variable traumainduced bleeding disorder in humans and other species. [5][6][7][8] The mechanism by which fXI is converted to fXIa during blood coagulation has been a topic of recent debate. 9,10 When blood is exposed to a surface in vitro, the process of contact activation converts factor XII (fXII) to the protease fXIIa, which then activates fXI. 3,4 Substances, such as RNA, 11 polyphosphates, 12 and collagen, 13 induce pathologic coagulation in mice in a fXIIdependent manner 13,14 and may represent physiologic surfaces for fXII activation. However, the contribution of fXIIa-mediated fXI activation to normal hemostasis is unclear, as fXII deficiency, unlike fXI deficiency, is not associated with abnormal bleeding in any species in which it has been identified. 4 This key observation supports hypotheses proposing that fXI is either activated during hemostasis by a protease other than fXIIa or that auxiliary mechanisms for fXI activation compensate in the absence of fXII. 3,[15][16][17] Candidates for fXI-activating proteases include ␣-thrombin, 15,16 meizothrombin, 18 and fXIa (autoactivation). 15,16 Thrombin has received much attention in this regard. Several laboratories have presented evidence suggesting that a protease generated early in coagulation, such as thrombin, converts fXI to fXIa. [19][20][21][22][23] This hypothesis has been challenged by a recent study that did not find evidence for fXI activation in thrombin or tissue facto...