Factor XI deficiency is associated with a bleeding diathesis, but factor XII deficiency is not, indicating that, in normal hemostasis, factor XI must be activated in vivo by a protease other than factor XIIa. Several groups have identified thrombin as the most likely activator of factor XI, although this reaction is slow in solution. Although certain nonphysiologic anionic polymers and surfaces have been shown to enhance factor XI activation by thrombin, the physiologic cofactor for this reaction is uncertain. Activated platelets secrete the highly anionic polymer polyphosphate, and our previous studies have shown that polyphosphate has potent procoagulant activity. We now report that polyphosphate potently accelerates factor XI activation by ␣-thrombin, -thrombin, and factor XIa and that these reactions are supported by polyphosphate polymers of the size secreted by activated human platelets. We therefore propose that polyphosphate is a natural cofactor for factor XI activation in plasma that may help explain the role of factor XI in hemostasis and thrombosis. (Blood. 2011;118(26):6963-6970)
IntroductionIn the original cascade or waterfall model of coagulation, 1 factor XI (FXI) is activated by factor XIIa (FXIIa), a member of the contact pathway of blood clotting. Patients with severe FXI deficiency may exhibit bleeding tendencies, 2,3 especially postoperative or posttraumatic bleeding in tissues with robust fibrinolytic activity. [4][5][6] Conversely, individuals with severe deficiencies in FXII, high-molecularweight kininogen, or prekallikrein do not exhibit bleeding diatheses at all, indicating that the proteins responsible for triggering the classic contact pathway of blood clotting are completely dispensable for hemostasis. 7 Thus, in normal hemostasis, FXI must be activated in vivo by a protease other than FXIIa. A solution to this conundrum was proposed in 1991 by Naito and Fujikawa 8 and by Gailani and Broze,9 who reported that thrombin up-regulates its own generation by feeding back to activate FXI, leading to a "revised model of coagulation." [9][10][11] More recently, Matafonov et al identified that -thrombin and ␥-thrombin, proteolyzed derivatives of ␣-thrombin, also can activate FXI in plasma. 12 The proposal that FXI activation by thrombin plays a significant role in blood clotting in vivo is somewhat controversial. [13][14][15] In solution, the rates both of FXI activation by thrombin and of FXI autoactivation are slow but are markedly enhanced in the presence of polyanions, 8,9,16,17 although most studies have used nonphysiologic cofactors such as dextran sulfate or high concentrations of sulfatides. The relevant physiologic cofactors for FXI activation by thrombin in plasma, if any, have yet to be definitely determined.Polyphosphate (polyP), a linear polymer of inorganic phosphate residues, accumulates in a variety of microorganisms 18 and is secreted by activated human platelets. 19 We recently showed that polyP is a potent modulator of the human blood clotting system, acting at 3 points in...