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Endogenous bradykinin and B1-B5 during angiotensin-converting enzyme inhibitor–associated angioedema

2018; Elsevier BV; Volume: 142; Issue: 5 Linguagem: Inglês

10.1016/j.jaci.2018.06.037

1097-6825

Scott Hubers, Kevin S. Kohm, Shouzuo Wei, Chang Yu, Hui Nian, Ryan C. Grabert, Daniel J. Sexton, Nancy J. Brown,

Vitamin K Research Studies

Angiotensin-converting enzyme (ACE) inhibitor–associated angioedema is presumed to result from bradykinin. Although hereditary angioedema results from increased bradykinin production, ACE inhibitor–associated angioedema could result from decreased degradation of vasoactive ACE substrates. Bradykinin B2 receptor antagonism decreases the duration of attacks of angioedema in patients with C1 inhibitor deficiency.1Cicardi M. Banerji A. Bracho F. Malbran A. Rosenkranz B. Riedl M. et al.Icatibant, a new bradykinin-receptor antagonist, in hereditary angioedema.N Engl J Med. 2010; 363: 532-541Crossref PubMed Scopus (411) Google Scholar However, clinical trials provide conflicting results about the efficacy of the B2 receptor antagonist icatibant in patients with ACE inhibitor–associated angioedema.2Bas M. Greve J. Stelter K. Havel M. Strassen U. Rotter N. et al.A randomized trial of icatibant in ACE-inhibitor-induced angioedema.N Engl J Med. 2015; 372: 418-425Crossref PubMed Scopus (135) Google Scholar, 3Straka B.T. Ramirez C.E. Byrd J.B. Stone E. Woodard-Grice A. Nian H. et al.Effect of bradykinin receptor antagonism on ACE inhibitor-associated angioedema.J Allergy Clin Immunol. 2017; 140: 242-248.e2Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar, 4Sinert R. Levy P. Bernstein J.A. Body R. Sivilotti M.L.A. Moellman J. et al.Randomized trial of icatibant for angiotensin-converting enzyme inhibitor-induced upper airway angioedema.J Allergy Clin Immunol Pract. 2017; 5: 1402-1409.e3Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar The lack of effect of bradykinin B2 receptor antagonism in 2 of 3 trials in patients with ACE inhibitor-associated angioedema2Bas M. Greve J. Stelter K. Havel M. Strassen U. Rotter N. et al.A randomized trial of icatibant in ACE-inhibitor-induced angioedema.N Engl J Med. 2015; 372: 418-425Crossref PubMed Scopus (135) Google Scholar, 3Straka B.T. Ramirez C.E. Byrd J.B. Stone E. Woodard-Grice A. Nian H. et al.Effect of bradykinin receptor antagonism on ACE inhibitor-associated angioedema.J Allergy Clin Immunol. 2017; 140: 242-248.e2Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar, 4Sinert R. Levy P. Bernstein J.A. Body R. Sivilotti M.L.A. Moellman J. et al.Randomized trial of icatibant for angiotensin-converting enzyme inhibitor-induced upper airway angioedema.J Allergy Clin Immunol Pract. 2017; 5: 1402-1409.e3Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar could suggest that bradykinin does not cause ACE inhibitor–associated angioedema, that substance P or other ACE substrates contribute to angioedema during B2 receptor blockade, or that patients with ACE inhibitor–associated angioedema present for medical attention too late for B2 receptor blockade to be effective. In the study that reported benefit of B2 receptor blockade, the mean time to treatment was 6 hours, whereas in the 2 negative studies it was 7.8 and 10 hours. Nussberger et al5Nussberger J. Cugno M. Cicardi M. Bradykinin-mediated angioedema.N Engl J Med. 2002; 347: 621-622Crossref PubMed Scopus (183) Google Scholar reported that circulating bradykinin concentrations are increased in patients with ACE inhibitor–associated angioedema and decrease after withdrawal of the ACE inhibitor but did not include ACE inhibitor–treated control subjects without angioedema. To determine whether bradykinin concentrations are increased in patients with ACE inhibitor–associated angioedema, we measured bradykinin concentrations in blood from patients with acute ACE inhibitor–associated angioedema and ACE inhibitor–treated control subjects. We also measured concentrations of bradykinin 1 to 5 (BK1-5 or RPPGF), the stable product of sequential degradation of bradykinin by ACE and neprilysin (NEP). To assess whether the release of bradykinin from high-molecular-weight kininogen (HMWK) by plasma kallikrein is increased, we measured concentrations of cleaved HMWK (cHMWK). We analyzed samples from 41 patients who presented to Vanderbilt University Medical Center with acute ACE inhibitor–associated angioedema. Twenty-seven patients participated in placebo-controlled randomized clinical trials of icatibant (NCT00517582 and NCT01574248).3Straka B.T. Ramirez C.E. Byrd J.B. Stone E. Woodard-Grice A. Nian H. et al.Effect of bradykinin receptor antagonism on ACE inhibitor-associated angioedema.J Allergy Clin Immunol. 2017; 140: 242-248.e2Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar Samples were collected at presentation, an average of 14.0 ± 9.5 hours after the initial onset of symptoms, and in 15 patients after resolution of symptoms ("convalescent" samples). Patients were defined as having ACE inhibitor–associated angioedema if they had swelling of the lips, pharynx, or face while taking an ACE inhibitor and had never had swelling in the absence of an ACE inhibitor.3Straka B.T. Ramirez C.E. Byrd J.B. Stone E. Woodard-Grice A. Nian H. et al.Effect of bradykinin receptor antagonism on ACE inhibitor-associated angioedema.J Allergy Clin Immunol. 2017; 140: 242-248.e2Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar Patients with hereditary angioedema were excluded. Patients with angioedema of the bowel alone were excluded to avoid delayed diagnosis. Patients who presented with features of hypersensitivity, pruritus, or urticaria were excluded. Patients who had recurrent angioedema after discontinuation of an ACE inhibitor were excluded. Samples were obtained from 19 control subjects who had taken an ACE inhibitor for at least 1 year and never had signs or symptoms of angioedema. Control subjects were group matched to cases by race and sex and, to the extent possible, by age. All studies were approved by the Vanderbilt Institutional Review Board and conducted in accordance with the Declaration of Helsinki. Participants provided written informed consent. For bradykinin and BK1-5 measurement, blood was collected in polypropylene tubes containing chilled ethanol to denature kallikrein and kininases. After 30 minutes at 4°C, samples were centrifuged, and supernatants were stored at −80°C. For cHMWK, samples were collected in citrate-containing polypropylene tubes on ice and centrifuged within 20 minutes, and plasma supernatants were stored at −80°C. Bradykinin and BK1-5 concentrations were measured with ultraperformance liquid chromatography–electrospray ionization–tandem mass spectrometry (UPLC-ESI-MS/MS) by using a modification of a previously published assay for BK1-5.6Murphey L.J. Hachey D.L. Vaughan D.E. Brown N.J. Morrow J.D. Quantification of BK1-5, the stable bradykinin plasma metabolite in humans, by a highly accurate liquid-chromatographic tandem mass spectrometric assay.Anal Biochem. 2001; 292: 87-93Crossref PubMed Scopus (33) Google Scholar For further information, see the Methods section in this article's Online Repository at www.jacionline.org. Serum ACE activity was measured with a commercial kinetic assay (LabCorp, Knoxville, Tenn). NEP activity was measured but not detected in plasma by using a fluorometric assay (SensoLyte; AnaSpec, Fremont, Calif). A recombinant human antibody (M004-B04) specific for cHMWK was discovered by using phage display, and an ELISA was developed to quantify cHMWK concentrations in human plasma (see the Methods section in this article's Online Repository). Data are presented as numbers or means ± SDs in Table E1 in this article's Online Repository at www.jacionline.org and as individual values with medians ± interquartile ranges in figures. For results of less than the level of detection (D), D/2 values were used in analyses. Comparisons between groups were made by using a Pearson or Wilcoxon test. Acute and convalescent samples were compared by using the Wilcoxon signed-rank test. A 2-sided P value of less than .05 was considered significant. Table E1 provides characteristics of patients with ACE inhibitor–associated angioedema and ACE inhibitor–treated control subjects. Serum ACE activity was not significantly different between cases and control subjects. ACE inhibitor use was discontinued in all patients. In 10 patients with angioedema, ACE activity was measured at presentation and after resolution of symptoms, and there was a trend toward an increase in ACE activity from 15.1 ± 11.8 to 25.8 ± 12.8 U/L over time (P = .08). Bradykinin concentrations were significantly greater in patients with ACE inhibitor–associated angioedema compared with ACE inhibitor–treated control subjects (Fig 1) and similar to those reported previously during acute attacks in patients with C1 inhibitor deficiency and during ACE inhibitor–associated angioedema.5Nussberger J. Cugno M. Cicardi M. Bradykinin-mediated angioedema.N Engl J Med. 2002; 347: 621-622Crossref PubMed Scopus (183) Google Scholar BK1-5 concentrations were not different between the groups. As a result, the ratio of bradykinin to BK1-5 concentrations was increased in the blood of patients with ACE inhibitor–associated angioedema compared with that in control subjects. There was no difference in total kinin (bradykinin plus BK1-5) concentrations in cases and control subjects. There were no differences in concentrations of bradykinin, concentrations of BK1-5, or the molar ratio of bradykinin to BK1-5 among racial groups, between men and women, according to smoking history, or between diabetics and nondiabetics.The characteristics of patients with ACE inhibitor-associated angioedema were similar among tertiles of bradykinin (see Table E2 in this article's Online Repository at www.jacionline.org). In 15 patients samples were collected after resolution of symptoms; the median time to collection was 48 hours (range, 16-2160 hours; see Table E3 in this article's Online Repository at www.jacionline.org). Bradykinin concentrations did not differ significantly in acute and convalescent samples. There was no effect of icatibant on convalescent BK concentrations (P = 1.0 vs placebo). BK1-5 concentrations were significantly greater in convalescent samples, which is consistent with discontinuation of ACE inhibition (Fig 2). We measured cHMWK concentrations in 6 control subjects, in 13 patients at presentation with angioedema, and in convalescent samples obtained from 11 of the latter. There were no significant differences in cHMWK concentrations in plasma from patients with ACE inhibitor–associated angioedema and ACE inhibitor–treated control subjects (see Fig E1 in this article's Online Repository at www.jacionline.org). For the first time, we found that bradykinin concentrations and the ratio of bradykinin to BK1-5, its cleavage product by ACE and NEP, are increased in patients presenting with acute ACE inhibitor–associated angioedema compared with ACE inhibitor–treated control subjects. The finding that bradykinin concentrations, but not BK1-5 concentrations, were increased in patients with angioedema compared with those in ACE inhibitor–treated control subjects whereas ACE activity was not significantly different, suggests that degradation of bradykinin to BK1-5 through non-ACE pathways is impaired in patients with ACE inhibitor–associated angioedema. NEP also cleaves bradykinin at the carboxy terminus, and a polymorphism in the gene encoding NEP has been associated with ACE inhibitor–associated angioedema.7Pare G. Kubo M. Byrd J.B. McCarty C.A. Woodard-Grice A. Teo K.K. et al.Genetic variants associated with angiotensin-converting enzyme inhibitor-associated angioedema.Pharmacogenet Genomics. 2013; 23: 470-478Crossref PubMed Scopus (53) Google Scholar In addition, use of the NEP inhibitor/angiotensin receptor blocker sacubitril/valsartan is associated with angioedema. Unfortunately, we were not able to measure NEP activity in plasma in the present study. Unlike in patients with hereditary angioedema,8Suffritti C. Zanichelli A. Maggioni L. Bonanni E. Cugno M. Cicardi M. High-molecular-weight kininogen cleavage correlates with disease states in the bradykinin-mediated angioedema due to hereditary C1-inhibitor deficiency.Clin Exp Allergy. 2014; 44: 1503-1514Crossref PubMed Scopus (32) Google Scholar there was no evidence for increased bradykinin production through cleavage of HMWK by plasma kallikrein. This validates the hypothesis that excess bradykinin results from decreased degradation in patients with ACE inhibitor–associated angioedema and also explains the observation that plasma kallikrein inhibition is ineffective in the treatment of ACE inhibitor–associated angioedema.9Lewis L.M. Graffeo C. Crosley P. Klausner H.A. Clark C.L. Frank A. et al.Ecallantide for the acute treatment of angiotensin-converting enzyme inhibitor-induced angioedema: a multicenter, randomized, controlled trial.Ann Emerg Med. 2015; 65: 204-213Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar These data support the understanding that bradykinin contributes to ACE inhibitor–associated angioedema and suggest that the lack of efficacy of B2 receptor antagonism in most trials in patients with ACE inhibitor–associated angioedema reflects late presentation or involvement of additional vasoactive peptides. Briefly, a mixture of peptides containing stable isotope-labeled arginine (13C6H1415N4O2; New England Peptide, Gardner, Mass; 2.0 ng of bradykinin and 0.5 ng of BK1-5 in 15 μL of ethanol) as internal standards and 30 μL of 50 mmol/L dithiotreitol (Sigma-Aldrich, St Louis, Mo) were added to the ethanolic supernatants. The resulting solution was evaporated in a 40°C water bath under a stream of nitrogen. The residue was then reconstituted in 1.0 mL of 10 mmol/L potassium phosphate buffer, pH 7.0, and applied to a 3-mL, 60-mg Nexus cartridge (Agilent Technologies, Santa Clara, Calif) preconditioned with 3.0 mL of methanol, 6.0 mL of water, and 6.0 mL of 10 mmol/L phosphate buffer. The cartridge was washed with 5 mL of water. Peptides were then eluted with 1.5 mL of methanol containing 1% 1N HCl, and the eluate was evaporated at 40°C under a stream of nitrogen. The residue was redissolved in 1 mL of 1.0% (vol/vol) trifluoracetic acid (TFA)/water solution and applied to a 1-mL, 100-mg HyperSep C18 cartridge (Thermo Scientific, Waltham, Mass) preconditioned with 3.0 mL of acetonitrile and 5.0 mL of 1% (vol/vol) TFA/water. The sample was then eluted with 1.5 mL of 60% (vol/vol) acetonitrile and 1% (vol/vol) TFA/water into polypropylene tubes after the cartridge was washed with 3.0 mL 5% (vol/vol) TFA/water. The eluate was evaporated at 40°C under a stream of nitrogen. The final residue was stored at −80°C until analysis by using UPLC-ESI-MS/MS. The residue was dissolved in 30 μL of 30% (vol/vol) acetonitrile and 1.0% (vol/vol) TFA/water solution. Samples were centrifuged at 14,000g for 5 minutes to remove any pellet. Samples were then resolved by using UPLC (Waters, Milford, Mass) at 40°C by using an ACQUITY BEH octadecylsilane (C18) column (1.7 μm, 1.0 × 100 mm; Waters) by using a solvent mixture of acetonitrile/water/formic acid (94.9/5/0.1 [vol/vol/vol] to 69.9/30/0.1 [vol/vol/vol]) at a flow rate of 0.14 mL/min with a 7-minute linear gradient. Resolved peptides were delivered to a mass spectrometer (TSQ Vantage; Thermo Scientific) equipped with a heated ESI probe running at a positive SRM mode: spray voltage, 3500 V; vaporizer temperature, 297°C; sheath gas pressure, 40 psi; and capillary temperature, 325°C. The observed product ions produced by sample were as follows: m/z 70 originating from m/z 531 (bradykinin), m/z 70 originating from m/z 536 ([13C,15N]bradykinin), m/z 408 originating from m/z 287 (BK1-5), and m/z 418 originating from m/z 292 ([13C,15N]BK1-5). Peak ratios of sample to internal standard were used for quantification. The limit of detection for BK1-5 is 1 pg, and that for bradykinin is 0.5 pg. A recombinant human antibody (M004-B04) specific for cHMWK was discovered by using phage display, and an ELISA was developed to quantify cHMWK concentrations in human plasma by screening against both cHMWK and intact HMWK (both from Enzyme Research Laboratories, South Bend, Ind; presented in abstracts at the European Academy of Allergy and Clinical Immunology in 2016 and 2017). The antibody appears to be highly specific for cHMWK and was validated by means of correlation with an HMWK Western blot assay with fluorescent detection (LI-COR, Lincoln, Neb) in patients with C1 inhibitor deficiency.E1Banerji A. Busse P. Shennak M. Lumry W. Davis-Lorton M. Wedner H.J. et al.Inhibiting plasma kallikrein for hereditary angioedema prophylaxis.N Engl J Med. 2017; 376: 717-728Crossref PubMed Scopus (93) Google Scholar The Fab fragment of M004-B04 was coated on 96-well plates (Nunc Maxisorp) overnight in PBS before being washed and blocked with 2% BSA Buffer. Samples, standards, and quality controls diluted in 0.1% BSA buffer were added to the plate, and after a subsequent incubation, plate-bound cHMWK was detected by adding pooled mouse anti-HMWK mAbs (clones 11H05 and 13B12). The plate was washed, and a secondary goat anti-mouse horseradish peroxidase is added to the plate, followed by tetramethylbenzidene substrate, stopping with phosphoric acid and the OD measured at 450 nm with subtraction at 630 nm. Plasma samples from patients with hereditary angioedema caused by C1 inhibitor deficiency have increased cHMWK concentrations measured by using the cHMWK ELISA used in this study, as well as by using HMWK Western blotting, liquid chromatography–tandem mass spectrometry, or an ELISA based on a different cHMWK-specific antibody.E1Banerji A. Busse P. Shennak M. Lumry W. Davis-Lorton M. Wedner H.J. et al.Inhibiting plasma kallikrein for hereditary angioedema prophylaxis.N Engl J Med. 2017; 376: 717-728Crossref PubMed Scopus (93) Google Scholar, E2Zhang G. Sexton D.J. Faucette R.R. Qiu Y. Wu J. 2D-LC-MS/MS to measure cleaved high-molecular-weight kininogen in human plasma as a biomarker for C1-INH-HAE.Bioanalysis. 2017; 9: 1477-1491Crossref PubMed Scopus (10) Google Scholar, E3Hofman Z.L.M. de Maat S. Suffritti C. Zanichelli A. van Doom C. Sebastian S.A.E. et al.Cleaved kininogen as a biomarker for bradykinin release in hereditary angioedema.J Allergy Clin Immunol. 2017; 140: 1700-1703Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar, E4Suffritti C. Zanichelli A. Maggioni L. Bonanni E. Cugno M. Cicardi M. High-molecular-weight kininogen cleavage correlates with disease states in the bradykinin-mediated angioedema due to hereditary C1-inhibitor deficiency.Clin Exp Allergy. 2014; 44: 1503-1514Crossref PubMed Scopus (60) Google Scholar Data are presented as means ± SDs of the mean or as numbers. Data are presented as means ± SDs of the mean or as numbers. BK, Bradykinin.