11 Protein Z

Ovid: Hemostasis and Thrombosis: Basic Principles and Clinical Practice
1 de 20
Editors:
http://gateway.ut.ovid.com/gw1/ovidweb.cgi
Colman, Robert W.; Clowes, Alexander W.;
Goldhaber, Samuel Z.; Marder, Victor J.; George, James N.

Title:
Hemostasis and Thrombosis: Basic Principles and
Clinical Practice, 5th Edition

Copyright 2006 Lippincott Williams & Wilkins
> Tabl e of C ontents > P art I - B asi c Pri nci pl es of Hem ostasi s and
Throm bosi s > Secti on A - C oagul ati on and i ts Regul ati on > C hapter 11 Protei n Z and P rotei n Z D ependent Proteas e I nhi bi tor
Chapter 11
Protein Z and Protein ZDependent
Protease Inhibitor
George J. Broze Jr.
In 1977, Prowse and Esnouf identified an additional vitamin
Kdependent protein circulating in bovine plasma and named it
protein Z (PZ) because it was the last of the vitamin Kdependent
proteins to elute during anion exchange chromatography (1). PZ
serves as a cofactor for the inhibition of factor Xa by another
plasma protein called protein Zdependent protease inhibitor (ZPI)
(2). ZPI is a member of the serpin superfamily of proteinase
inhibitors and not only inhibits factor Xa in a PZdependent
fashion, but also inhibits factor XIa in the absence of PZ (3,4). The
physiologic importance of the regulation of coagulation by PZ and
ZPI is not yet clear and is the focus of ongoing research.
PROTEIN Z
Structure
The human counterpart to bovine PZ was isolated in 1984 (5).
Mature human PZ is a 62,000molecular weight, 360amino acid,
single-chain glycoprotein whose structure is very similar to the
other vitamin Kdependent proteins, factors VII, IX, X, and protein
C (see Fig. 11-1) (5,6,7). A prepro-leader sequence directs the
vitamin Kdependent -Carboxylation of 13 glutamic acid residues
24/06/2006 01:19 p.m.
2 de 20
within an N-terminal -carboxyglutamic acid (Gla) domain that is

followed by two epidermal growth factor (EGF)like domains and a
C-terminal pseudocatalytic domain. PZ contains five potential
N-linked glycosylation sites (Fig. 11-1). In the first EGF-like
domain, a disaccharide or trisaccharide is attached to Ser53, and
Asp64 is probably a hydroxyaspartic acid residue (8,9). Two
extra cysteine residues are present in PZ, but it is not
determined whether they form a disulfide bond. In contrast to
other coagulation factors that are serine proteinase zymogens, in
PZ, the region around the typical activation site is absent and
the histidine and serine residues of the canonical catalytic triad
have been replaced with lysine and aspartic acid residues,
respectively (7,9). The active site aspartic acid residue is
conserved. Therefore, like protein S, PZ does not serve a
proteolytic function.
The PZ gene is at chromosome 13q34, the location where the
genes for factor VII and factor X reside side by side (10). It spans
14 kb and consists of nine exons, including an alternatively spliced
exon that inserts a unique peptide of 22 amino acids in the
prepro-leader sequence of PZ. The exonintron organization of the
PZ gene is identical to that of factors VII, IX, X, and protein C,
indicating that these genes were derived from a common ancestor
during evolution (Fig. 11-1) (10). Several polymorphisms have
been identified in the PZ gene, including one in the promoter
(a-13g) and one in exon 8 that leads to Arg255His replacement in
the encoded protein (11). A polymorphism in intron A (g103a) and
a polymorphism in intron F (g79a), which is in a high degree of
linkage disequilibrium with the a-13g and Arg255His
polymorphisms, are associated with reduced plasma levels of PZ
(12,13).
Properties
The range of PZ plasma levels in normal individuals is very broad
(95% interval of 32% to 168% of the mean) and appears to be
influenced predominantly by heritable factors (13,14,15). Reported
mean concentrations of PZ in adult plasmas have varied from 1.2
to 2.9 g per mL, but the reason for this discrepancy is not
obvious. PZ circulates in plasma complexed with ZPI (see
24/06/2006 01:19 p.m.
3 de 20
subsequent text).
Similar to other coagulation factors, the liver appears to be the
major source of PZ. The level of PZ is reduced in individuals with
severe liver disease and is low in newborn infants (16,17). Oral
contraceptive use substantially increases PZ levels (18). Plasma PZ
is reportedly increased with chronic hemodialysis and reduced in
the nephrotic syndrome (19,20). Whether PZ behaves as a
negative acute-phase reactant is controversial (19,21).
Immunoreactive PZ has been detected in atherosclerotic plaques
(22).
In contrast to other plasma vitamin Kdependent proteins, the
coumarin class of oral anticoagulants dramatically affects levels of
PZ. For example, in patients on stable warfarin therapy, levels of
antigenic and -carboxylated PZ are 8% 4% and 1% 2%
respectively, in comparison to levels of antigenic and
carboxylated protein C of 53 8 and 28 + 6 (14). The interaction
of PZ with phospholipid vesicles also differs distinctively from that
of the other vitamin Kdependent coagulation factors. Although the
ultimate binding affinity of PZ is comparable to that of the other
proteins, its association (3.4 10 - 5 per second M) and dissociation
(0.06 per second) rate constants are markedly slower (23).
Despite its isolation, the physiologic function of PZ remained an
enigma for many years. Bovine PZ was shown to interact with
diisopropylphosphoryl (DIP)-inactivated thrombin (K d = 0.15 M)
and mediate the binding of DIP-thrombin to phospholipids (24).
Human PZ, however, binds thrombin poorly (K d = 8.9 M) and has
a minimal impact on thrombin's association with phospholipids
(25). Additional studies showed that the enhanced binding of
thrombin to bovine PZ requires the 36amino acid C-terminal
extension present in bovine but absent in human PZ (25).
Thrombin cleavage of bovine PZ at Arg365 releases this C-terminal
peptide (25,26).
Subsequently, it was noted that the procoagulant activity of factor
Xa in a one-stage plasma coagulation assay was reduced if factor
Xa was first incubated with PZ (2). This inhibitory effect of PZ
required the presence of phospholipids
P.216
24/06/2006 01:19 p.m.
4 de 20
and Ca 2+ ions and was time dependent, apparently reflecting the

slow association of PZ with phospholipids (23). PZ that was
proteolytically cleaved at Arg43, thereby separating its Gla domain
from the remainder of the molecule, lacked inhibitory activity (2).
These results suggested that an interaction between factor Xa and
PZ occurs at the phospholipid surface, and additional studies
showed that the inhibitory effect of PZ on factor Xa activity in the
one-stage coagulation assay was due, at least in part, to a plasma
ZPI that recognizes the factor XaPZ complex (2).
24/06/2006 01:19 p.m.
5 de 20
FIGURE 11-1. Amino acid sequence of protein Z. Disulfide

bonds have been placed by analogy to other vitamin
Kdependent proteins. Cysteine residues at positions 131 and
233 are not present in the homologous vitamin Kdependent
proteins. Solid diamonds indicate potential N-linked
glycosylation sites. The solid circle denotes site of a
disaccharide or trisaccharide linked to Ser53. Shaded residues
are sites of amino acids involved in the catalytic triad of serine
proteases. Dashed lines indicate intronexon boundaries (27).
, carboxylated acid; , potential -hydroxyaspartic acid at
residue 64. (Modified from Ichinose A, Davie E. The blood
coagulation factors: their cDNAs, genes, and expression. In:
Colman R, Hirsh J, Marder V, et al., eds. Hemostasis and
thrombosis: basic principles and clinical practice. Philadelphia,
PA: JB Lippincott Co, 1994:1954, with permission.)
PROTEIN ZDEPENDENT PROTEASE

INHIBITOR
Structure
ZPI was isolated from human plasma in 1998 and shown to be a
previously unidentified, 72,000molecular weight, single-chain
glycoprotein (2). ZPI cDNA is 2.44 kb in length and has
P.217
a relatively long 5 region (466 nt) that contains six potential ATG
translation start codons (3). ATGs 1 to 4 are followed by short,
open reading frames, whereas ATG5 and ATG6 1 to 4 are in an
uninterrupted open reading frame that includes the encoded ZPI
protein. In vitro experiments show that ATG6 is sufficient for the
expression of rZPI in cultured Chinese hamster ovary (CHO) cells.
Northern analysis suggests that the liver is the major site of ZPI
synthesis (3). The predicted 423 residue amino acid sequence of
mature ZPI is 25% to 35% homologous with members of the serpin
superfamily of protease inhibitors and is 78% identical to the
amino acid sequence predicted by a previously described cDNA
isolated from rat liver, regeneration-associated serpin protein-1
24/06/2006 01:19 p.m.
6 de 20
(rasp-1) (28). Therefore, ZPI is likely the human homolog of rat

rasp-1, which was identified as a gene whose transcription is
increased following subtotal hepatectomy in rats (28). Alignment of
the amino acid sequence of ZPI with those of other serpins predicts
that Tyr387 is the P 1 residue at the reactive center of the ZPI
molecule (see Fig. 11-2). Consistent with this notion,
rZPI(Tyr387Ala), an altered form of ZPI in which tyrosine 387 has
been changed to alanine, lacks PZ-dependent factor Xa inhibitory
activity (3).
FIGURE 11-2. Carboxy-terminal sequences of protein

Zdependent protease inhibitor (ZPI) and other serpins.
Diamond denotes P 1 -P 1 cleavage site. Residues identical to
ZPI are indicated in bold type. Rasp-1, rat
regeneration-associated serpin protein; 1 AT, 1 -trypsin; AT,
antithrombin; HC-II, heparin cofactor-II; and PN-1, protease
nexin-1.
Properties
Although less marked than PZ, plasma levels of ZPI also span a
broad range (95% interval 46% to 154% of the mean) with a mean
concentration of ZPI of approximately 4.0 g per mL (9). PZ and
ZPI form a complex and in pooled normal plasma, which contains
excess ZPI, all the PZ appears to be bound to ZPI (29). Therefore,
an early report that found a t 1/2 of 2 to 3 days for PZ in plasma
was likely studying the clearance of the PZZPI complex (14). The
24/06/2006 01:19 p.m.
7 de 20
plasma level of ZPI is related to the level of PZ: Oral contraceptive

use raises both PZ (approximately 35%) and ZPI (approximately
17%) levels, whereas warfarin treatment reduces PZ
(approximately 92%) and ZPI (approximately 53%) levels (18).
This interrelation of plasma concentrations of PZ and ZPI might be
explained if the rate of clearance of the PZZPI complex differs
from that of PZ or ZPI alone. Alternatively, the synthesis,
secretion, or extraplasma localization of one of these proteins may
be affected by the presence of the other.
PROTEIN Z AND PROTEIN ZDEPENDENT

PROTEASE INHIBITOR FUNCTION
Factor Xa Inhibition
In the presence of phospholipids and Ca 2+ the rate of factor Xa
inhibition by ZPI is enhanced greater than 1,000-fold (t 1/2 <10
seconds vs. 210 minutes) by preincubation of factor Xa with PZ
(3,4). Indirect evidence strongly suggests that the inhibitory
process involves the formation of a stoichiometric complex of
factor Xa-ZPI-PZ at the phospholipid surface (3,4). Heparin does
not affect ZPI-mediated inhibition of factor Xa in the presence of
PZ. The combination of PZ and ZPI dramatically delays the
initiation and reduces the ultimate rate of thrombin generation in
mixtures containing prothrombin, factor V, phospholipids, and Ca 2+
(4). In similar mixtures containing factor Va, however, PZ and ZPI
do not inhibit thrombin generation. Therefore, the antifactor Xa
action of PZ and ZPI presumably must precede the activation of
factor V and the formation of the prothrombinase complex. With
coagulation induced in plasma by factor IXa, the presence of PZ
delays the onset and the extent of thrombin production (30).
PZ is not the only protein that has been shown to function as a
cofactor to enhance the inhibitory activity of a serpin toward an
enzyme. Thrombomodulin increases the rate of thrombin inhibition
by protein C inhibitor approximately 140-fold (31). This effect of
thrombomodulin reportedly depends primarily on the interaction
between thrombin and thrombomodulin. Vitronectin increases the
rate of thrombin inhibition by plasminogen activator inhibitor-1
(PAI-1) approximately 200-fold (32). Vitronectin appears to
24/06/2006 01:19 p.m.
8 de 20
produce this enhancement by both binding PAI-1, thereby inducing

a conformational change at its reactive center, and through a
proteinprotein interaction with thrombin. Similarly, the cofactor
action of PZ presumably involves its ability both to bind and to
bring ZPI to the phospholipid surface, as well as its ability to
interact with factor Xa at this surface (2,29).
Two potential pathways for PZdependent factor Xa inhibition by
ZPI are shown in Figure 11-3. On the left, PZ and
P.218
factor Xa first form a complex at the phospholipid surface, and this
complex is subsequently recognized by ZPI. On the right, a
preformed PZZPI complex is directed to the phospholipid surface
by its PZ moiety and binds factor Xa. The final result of either
pathway is the formation of a Ca 2+ -dependent complex at the
phospholipid surface that contains PZ, factor Xa, and ZPI. Because
PZ circulates bound to ZPI, the pathway on the right presumably
reflects the inhibitory mechanism that occurs in the plasma milieu.
FIGURE 11-3. Two pathways for the inhibition of factor Xa by

protein Zdependent protease inhibitor (ZPI) with protein Z
(PZ). On the left, ZPI binds to a preformed PZfactor Xa
24/06/2006 01:19 p.m.
9 de 20
complex at the phospholipid surface. On the right, the

circulating PZZPI complex binds to factor Xa at the
phospholipid surface. Both pathways result in a final inhibitory
complex containing PZ-factor Xa-ZPI. PL, phospholipid surface;
Ca 2+ denotes Ca 2+ binding of factor Xa and PZ to the
phospholipid surface (33). (Reproduced from Broze G, Jr.
Protein Z and thrombosis. Lancet 2001;357:900901, with
permission.)
Factor XIa Inhibition

ZPI also inactivates factor XIa in a reaction that does not require
the presence of PZ, phospholipids, or Ca 2+ and that is not affected
by the presence of high-molecular-weight kininogen (4). Heparin
increases the rate and extent of factor XIa inhibition produced by
ZPI (4), whereas factor XIa inhibition by ZPI is reduced when ZPI
is bound to PZ (29). An apparent interaction between factor XIa
and ZPI can be detected in the plasma milieu (see subsequent
text), suggesting that ZPI competes effectively with other factor
XIa inhibitors (e.g., 1 -antitrypsin, C 1 esterase inhibitor,
antithrombin) and the substrate factor IX in plasma for the active
site of factor XIa.
Instability of Protein ZDependent

Protease InhibitorProteinase Complexes
As is typical for members of the serpin superfamily of proteinase
inhibitors, ZPI is proteolytically cleaved during its inhibition of
factor Xa and factor XIa with a reduction in its size from 72 kDa to
68 kDa. The N-terminal amino acid sequences of the peptides
(4.2-kDa) released from ZPI following its interaction with factor Xa
and factor XIa are identical, SMPPVIKVDRPF, and correspond to the
amino acid sequence in the ZPI molecule following Tyr387 (4).
Therefore, the reactive center of ZPI that is involved in its
inactivation of both factors Xa and XIa is Tyr387-Ser388 (P 1 -P 1 ).
The factor XaZPI and factor XIaZPI inhibitory complexes,
however, are dramatically less stable than other proteaseserpin
24/06/2006 01:19 p.m.
10 de 20
complexes. In contrast to the thrombinantithrombin interaction,

for example, the factor XaZPI and factor XIaZPI complexes do
not survive sodium dodecyl (lauryl) surfatepolyacrylamide gel
electrophoresis (SDS-PAGE) but can be detected in the less
denaturing conditions of native-PAGE (without SDS) (4).
Dissociation of the thrombinantithrombin complex is very slow
(approximately 2.5 10 -6 per second) and appears to proceed
exclusively through the cleavage of antithrombin (34). Dissociation
of the factor XaZPI complex is much more rapid (approximately
1.7 10 - 4 per second) and likely also occurs through the cleavage
of ZPI (4). In this regard, therefore, ZPI behaves as a very poor
substrate for the factor Xa-PZ-phospholipid Ca 2+ complex and for
factor XIa. In view of the instability of the complexes of factor Xa
and factor XIa with ZPI, it seems likely that these proteinases
would ultimately be transferred from ZPI to alternative proteinase
inhibitors.
Consumption of Protein ZDependent

Protease Inhibitor During Coagulation
Serum produced from plasma in vitro by the induction of
coagulation with kaolin, phospholipids, and Ca 2+ or tissue factor
and Ca 2+ , contains little ZPI functional activity. Western blot
analysis shows that during coagulation of plasma in vitro, ZPI is
proteolytically cleaved at its C-terminus with reduction in its
apparent molecular weight from 72 kDa to 68 kDa (4). Factor Xa,
in the presence of PZ, is responsible for the consumption of ZPI in
tissue factorinduced coagulation. Factor XIa also contributes,
however, when coagulation is initiated by direct contact activation
(e.g., kaolin) and relatively large concentrations of factor XIa are
generated (4).
PROTEIN Z/PROTEIN Z-DEPENDENT

PROTEASE INHIBITOR AND CLINICAL
COAGULATION
Protein Z and Hemorrhage
It has been suggested that PZ deficiency is associated with a
hemorrhagic disorder, perhaps related to capillary fragility (35).
24/06/2006 01:19 p.m.
11 de 20
Thirty-six individuals with bleeding disorders of unknown etiology

were studied. Many of these individuals had a positive
Rumpel-Leede test (83%) and a prolonged bleeding time (43%).
The mean PZ level in the patients was 54% (range 22% to 112%).
In additional studies, prothrombin complex concentrates, which
contain PZ, have been used to prevent perioperative hemorrhage in
individuals with a bleeding history and perceived PZ deficiency
(36,37). Two subsequent studies, however, have failed to detect a
relation between PZ deficiency and a bleeding tendency (38,39),
and it should be noted that 10% of apparently healthy individuals
(Red Cross blood donors) have PZ levels of less than 50% (14).
Further, PZ-null mice have normal bleeding times and do not have
a hemorrhagic phenotype (30,40). Therefore, a clear relation
between low levels of PZ and a hemorrhagic diathesis remains to
be established.
Protein Z and Thrombosis

Unchallenged, PZ knockout mice do not express an obvious
phenotype. When combined with the homozygous factor
V L e ide n (FV / ) genotype, however, the genotype causes intrauterine
and perinatal thrombosis and an apparent consumptive
coagulopathy that leads to near absolute mortality (30). The
genetic combinations FV / / PZ + / - and FV / / PZ - / - also reduce the
survival of mice by greater than 50%. It should be noted that the
factor V genotype appears to produce a more severe thrombotic
phenotype in mice than the factor V genotype in humans.
Nevertheless, the results of the murine PZ FV crosses strongly
suggest that PZ deficiency is a prothrombotic trait and are
consistent with human data showing that a combination of
prothrombotic traits significantly increases the risk of thrombosis.
Studies exploring the association between PZ levels and ischemic
stroke have produced conflicting results (13,41,42,43,44,45). In a
group of 169 young patients (mean age 33 years) without
hypertension or dyslipidemia, Vasse et al. found that low
convalescent PZ levels (<15th percentile) were associated with a
fourfold increased risk of stroke (41). Heeb et al. studying 154
older individuals (median age 58 years), reported that low PZ
(<15th percentile) was associated with an increased risk of stroke
24/06/2006 01:19 p.m.
12 de 20
in men [odds ratio (OR), 3.6; 95% confidence intervals (CI), 1.5 to
4.3] and those aged above 58 years (OR, 2.6; 95% CI, 1.4 to 4.9)
(43). They (Heeb et al.) found that the risk of stroke associated
with a low PZ was most apparent in individuals without diabetes,
hypertension, or hypercholesterolemia, and other risk factors for
stroke.
In contrast, Kobelt et al. reported an association of high PZ levels
with stroke in a group of 125 patients (mean age 40 years) without
a history of venous thrombosis (42). After adjusting for possible
confounders (age, sex, hypertension, diabetes, smoking, body
mass index, hyperlipidemia, and fibrinogen), the risk of
P.219
stroke in individuals with PZ in the highest quartile (>150%)
versus the lowest quartile (<76%) was 2.5-fold (95% CI, 1.05 to
5.72). Lichy et al. analyzed the PZ intron F g79a polymorphism in
a group of 200 patients with stroke and found that the presence of
at least one a allele is associated with a reduced risk of stroke
(OR, 0.6; 95% CI, 0.4 to 0.95) after adjusting for age, sex,
hypertension, hypercholesterolemia, and family history (13). They
also noted a significant relation between the a allele and reduced
PZ plasma levels in healthy individuals, implying that lower levels
of PZ may protect against stroke. In this study of individuals from
southwest Germany, the genotypes of 30% (60/200) of the stroke
cases and 41% (81/199) of the healthy controls contained at least
one a. Interestingly, the prevalence of the intron F a allele in
an Italian population is 37%, whereas in an English population it
appears to be much lower, 20% (11,12). Because the intron F g79a
polymorphism is unlikely to directly affect PZ expression, its
association with PZ levels may reflect the effect of a separate
polymorphism with which it is in a high degree of linkage
disequilibrium.
Two additional studies detected no relation between stroke and
convalescent PZ levels (44,45). McQuillan et al. however, reported
that significantly higher PZ levels were found in plasma samples
from patients with stroke, taken within 7 days of the acute event
(45). In contrast, Fedi et al. found an association between low PZ
levels (<15th percentile) and the acute coronary syndrome (OR,
3.3; 95% CI, 1.1 to 9.7) that was increased further by concomitant
24/06/2006 01:19 p.m.
13 de 20
smoking (OR, 9.5; 95% CI, 2.4 to 37.2) (46). Low plasma
concentrations of PZ have also been reported in ischemic colitis
(47).
In regard to venous thrombosis, one study did not find a relation
with low levels of PZ in a small cohort of patients (41), and
another study, in which PZ levels were not determined, failed to
detect a relation with polymorphisms within the PZ gene (11). A
report (48) that low PZ affects the age of onset and the severity of
thrombosis in patients with the factor V L e ade n mutation was not
confirmed in a later study (18). Recent results from the Leiden
Thrombophilia Study (LETS) showed a modestly increased risk of
venous thrombosis with low PZ (<10th percentile) in men (OR, 2.4;
95% CI, 1.2 to 4.9) and older individuals (>55 years, OR, 3.3;
95% CI, 1.2 to 8.7) on subgroup analysis (18). These same
groups, men and older individuals, are those in which Heeb et al.
found an association between low PZ (<15th percentile) and
ischemic stroke (43). A mechanism, however, to explain why
younger women may be protected from the thrombotic risk
associated with low levels of PZ is lacking. In LETS, neither high
nor low concentrations of ZPI were related to venous thrombosis
(43).
Low levels (<5th percentile) of PZ are common in individuals with
antiphospholipid antibodies and are associated with the thrombotic
complications and fetal wastage of the antiphospholipid syndrome
(OR, 6.6; 95% CI, 2.3 to 19.4) ( 49,50,51). Reduced levels of PZ
(<15th percentile) are also associated with early miscarriage in the
absence of antiphospholipid antibodies (OR, 6.7; 95% CI, 3.1 to
14.8) and maternal anti-PZ antibodies are reportedly related to
early fetal death and other pregnancy complications (52,53,54).
In sum, available clinical data provide a conflicting picture of the
role of PZ (and ZPI) in thrombotic disease. That PZ and ZPI
produce potent inhibition of factor Xa suggests that deficiencies of
these proteins could be associated with a procoagulant state, and
the results of the studies in PZ - / - V mice appear to confirm this
notion (2,30). On the other hand, certain clinical studies report
that high levels of PZ predispose to stroke or that low levels of PZ
may protect from stroke (13,42). The biologic foundation for these
24/06/2006 01:19 p.m.
14 de 20
latter results is not readily apparent. The frequently offered

explanation of effect of bovine PZ on the binding of inactive
thrombin to phospholipids does not hold for active thrombin or
human PZ (13,24,25,26,35,42). Finally, it must be noted that the
very broad range of the plasma levels of PZ and ZPI implies that
their plasma concentrations need not be maintained near their
population means for a critical physiologic purpose. This suggests
that isolated low or high plasma levels of these proteins are
unlikely to produce a dramatic pathologic effect and/or,
alternatively, that the physiologically important roles of PZ and ZPI
occur outside the plasma milieu. Only additional investigation will
clarify these issues.
References
1. Prowse C, Esnouf M. The isolation of a new warfarin-sensitive
protein from bovine plasma. Biochem Soc Trans
1977;5:255256.
2. Han X, Fiehler R, Broze G Jr. Isolation of a protein
Z-dependent plasma protease inhibitor. Proc Natl Acad Sci U S
A 1998;97:67346738.
3. Han X, Huang Z-F, Fiehler R, et al. The protein Z-dependent
protease inhibitor is a serpin. Biochemistry
1999;38:1107311078.
4. Han X, Fiehler R, Broze G Jr. Characterization of protein
Z-dependent protease inhibitor. Blood 2000;96:30493055.
5. Broze G Jr, Miletich J. Human protein Z. J Clin Invest
1984;73:933938.
6. Sejima H, Hayashi T, Deyashiki Y, et al. Primary structure of
vitamin K-dependent human protein Z. Biochem Biophys Res
Commun 1990;171: 661668.
24/06/2006 01:19 p.m.
15 de 20
7. Ichinose A, Takeya H, Espling E, et al. Amino acid sequence

of human protein Z, a vitamin K-dependent plasma
glycoprotein. Biochem Biophys Res Commun
1990;172:11391144.
8. Nishimura H, Kawabata S, Kisiel W, et al. Identification of a
disaccharide (Xyl-Glc) and a trisaccharide (Xyl2-Glc)
O-glycosidically linked to a serine residue in the first epidermal
growth factorlike domain of human factors VII and IX and
human protein Z and bovine protein Z. J Biol Chem
1989;264:2032020325.
9. Hojrup P, Jensen M, Petersen T. Amino acid sequence of
bovine protein Z. A vitamin K-dependent serine protease
homologue. FEBS Lett 1985;184: 333338.
10. Fujimaki K, Yamzaki T, Masafumi T, et al. The gene for
human protein Z is localized to chromosome 13 at band q34 and
is coded by eight regular exons and one alternative exon.
Biochemistry 1998;37:68386846.
11. Rice G, Futers S, Grant P. Identification of novel
polymorphisms within the protein Z gene, haplotype distribution
and linkage analysis. Thromb Haemost 2001;85:10231024.
12. Santacroce R, Cappucci F, Di Perna P, et al. Protein Z gene
polymorphisms are associated with protein Z plasma levels. J
Thromb Haemost 2004;2:11971199.
13. Lichy C, Sropp S, Song-Si T, et al. A common polymorphism
of the protein Z gene is associated with protein Z plasma levels
and with risk of cerebral ischemia in the young. Stroke
2003;35:4045.
14. Miletich J, Broze G Jr. Human plasma protein Z antigen:
range in normal subjects and effect of warfarin therapy. Blood
24/06/2006 01:19 p.m.
16 de 20
1987;69:15801586.
15. Vossen C, Hasstedt S, Rosendaal F, et al. Heritability of
plasma concentrations of clotting factors and measures of a
prethrombotic state in a protein Cdeficient family. J Thromb
Haemost 2004;2:242247.
16. Kemkes-Matthes B, Matthes K. Protein Z, a new haemostatic
factor, in liver disease. Haemostasis 1995;25:312316.
17. Yurdakok M, Gurakan B, Ozbag E, et al. Plasma protein Z
levels in healthy newborn infants. Am J Hematol
1995;48:206207.
18. Al-Shanqeeti A, van Hycklama A, Berntorp E, et al. Protein
Z and protein Zdependent protease inhibitor: determinants of
levels and risk of venous thrombosis. Thromb Haemost
2005;93:411413.
19. Usalan C, Erdem Y, Altun B, et al. Protein Z levels in
haemodialysis patients. Int Urol Nephrol 1999;31:541545.
20. Malyszko J, Malyszko S, Mysliwiec M. Markers of endothelial
cell injury and thrombin activatable fibrinolysis inhibitor in
nephrotic syndrome. Blood Coagul Fibrinolysis
2002;13:615621.
21. Vasse M, Denoyelle C, Legrand E, et al. Weak regulation of
protein Z biosynthesis by inflammatory cytokines. Thromb
Haemost 2002;87: 350351.
22. Greten J, Kreis I, Liliensiek B, et al. Localisation of protein
Z in vascular lesions of patients with atherosclerosis. Vasa
1998;27:144148.
23. McDonald J, Shah A, Schwalbe R, et al. Comparison of
24/06/2006 01:19 p.m.
17 de 20
naturally occurring vitamin Kdependent proteins: correlation of

amino acid sequences and membrane binding properties
suggests a membrane contact site. Biochemistry
1997;36:51205127.
24. Hogg P, Stenflo J. Interaction of vitamin Kdependent
protein Z with thrombin. J Biol Chem 1990;266:1095310958.
25. Hogg P, Stenflo J. Interaction of human protein Z with
thrombin: evaluation of the species difference in the interaction
between bovine and human protein Z and thrombin. Biochem
Biophys Res Commun 1991;178:801807.
26. Morita T, Kaetsu H, Mizuguchi J, et al. A characteristic
property of vitamin Kdependent plasma protein Z. J Biochem
1988;104:368374.
27. Ichinose A, Davie E. The blood coagulation factors: their
cDNAs, genes, and expression. In: Colman R, Hirsh J, Marder V,
et al., eds. Hemostasis and thrombosis: basic principles and
clinical practice. Philadelphia, PA: JB Lippincott Co,
1994:1954.
P.220
28. New L, Liu K, Kamali V, et al. cDNA cloning of rasp-1, a
novel gene encoding a plasma protein associated with liver
regeneration. Biochem Biophys Res Commun
1996;223:404412.
29. Tabatabai A, Fiehler R, Broze G Jr. Protein Z circulates in
plasma in a complex with protein Zdependent protease
inhibitor. Thromb Haemost 2001;85:655660.
30. Yin Z-F, Huang Z-F, Cui J, et al. Prothrombotic phenotype of
protein Z deficiency. Proc Natl Acad Sci U S A
2000;97:67346738.
24/06/2006 01:19 p.m.
18 de 20
31. Rezaie A, Copper S, Church F, et al. Protein C inhibitor is a

potent inhibitor of the thrombin-thrombomodulin complex. J
Biol Chem 1995; 270:2533625339.
32. Ehrlich H, Gebbink R, Keijer J, et al. Alteration of serpin
specificity by a protein cofactor: vitronectin endows
plasminogen activator with thrombin inhibitory properties. J Biol
Chem 1990;265:1302913035.
33. Broze G Jr. Protein Z and thrombosis. Lancet
2001;357:900901.
34. Danielsson A, Bjork I. Properties of antithrombin-thrombin
complex formed in the presence and absence of heparin.
Biochem J 1983;213:345353.
35. Kemkes-Matthes B, Matthes K. Protein Z deficiency: a new
cause of bleeding tendency. Thromb Res 1995;79:4955.
36. Greten J, Kemkes-Matthes B, Nawroth P. Prothrombin
complex concentrate contains protein Z and prevents bleeding
in a patient with protein Z deficiency. Thromb Haemost
1995;74:992993.
37. Kemkes-Matthes B, Matthes K. Protein Z. Semin Thromb
Hemost 2001; 27:551556.
38. Gamba G, Bertolino G, Montani N, et al. Bleeding tendency
of unknown origin and protein Z levels. Thromb Res
1998;90:291295.
39. Ravi S, Mauron T, Lammle B, et al. Protein Z in healthy
human individuals and in patients with a bleeding tendency. Br
J Haematol 1998;102: 12191223.
24/06/2006 01:19 p.m.
19 de 20
40. Broze G Jr, Yin Z-F, Lasky N. A tail vein bleeding time
model and delayed bleeding in hemophiliac mice. Thromb
Haemost 2001;85:747748.
41. Vasse M, Guegan-Massardier E, Borg J-Y, et al. High
frequency of protein Z deficiency in patients with ischemic
stroke. Lancet 2001;357:933934.
42. Kobelt K, Biasiutti F, Mattle H, et al. Protein Z in ischaemic
stroke. Br J Haematol 2001;114:169173.
43. Heeb M, Paganini-Hill A, Griffin J, et al. Low protein Z levels
and risk of ischemic stroke: differences by diabetic status and
gender. Blood Cells Mol Dis 2002;29:139144.
44. Lopaciuk S, Bykowska K, Kwiecinski H, et al. Protein Z in
young survivors of ischemic stroke. Thromb Haemost
2002;88:436.
45. McQuillan A, Eikelboom J, Hankey G, et al. Protein Z in
ischemic stroke and its etiologic subtypes. Stroke
2003;34:24152419.
46. Fedi S, Sofi F, Brogi D, et al. Low protein Z plasma levels
are independently associated with acute coronary syndromes.
Thromb Haemost 2003;90: 11731178.
47. Koutroubakis I, Theodoropoulou A, Sfiridaki A, et al. Low
plasma protein Z levels in patients with ischemic colitis. Dig Dis
Sci 2003;48:16731676.
48. Kemkes-Matthes B, Matzdorff A, Matthes K. Protein Z
influences the prothrombotic phenotype of factor V Leiden in
humans. Thromb Res 2002; 106:183185.
24/06/2006 01:19 p.m.
20 de 20
49. Steffano B, Forastiero R, Marinuzzo M, et al. Low plasma

protein Z levels in patients with antiphospholipid antibodies.
Blood Coagul Fibrinolysis 2001;12:411412.
50. McColl M, Deans A, Maclean P, et al. Plasma protein Z
deficiency is common in women with antiphospholipid
antibodies. Br J Haematol 2003; 120:907915.
51. Forastiero R, Matinuzzo M, Broze G Jr. Autoimmune
antiphospholipid antibodies impair the inhibition of activated
factor X by protein Z/protein Z-dependent protease inhibitor. J
Thromb Haemost 2003;1:17541770.
52. Gris J-C, Quere I, Dechaud H, et al. High frequency of
protein Z deficiency in patients with unexplained early fetal
loss. Blood 2002;99:26062608.
53. Gris J-C, Amadio C, Mercier E, et al. Antiprotein Z
antibodies in women with pathologic pregnancies. Blood
2003;101:48504852.
54. Gris J-C, Mercier E, Quere I, et al. Low-molecular-weight
heparin versus low-dose aspirin in women with one fetal loss
and a constitutional thrombophilic disorder. Blood
2004;103:36953699.
24/06/2006 01:19 p.m.

11 Protein Z

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

11 Protein Z

Uploaded by

Copyright:

Available Formats

Ovid: Hemostasis and Thrombosis: Basic Principles and Clinical Practice

Colman, Robert W.; Clowes, Alexander W.;

Goldhaber, Samuel Z.; Marder, Victor J.; George, James N.

Hemostasis and Thrombosis: Basic Principles and

Clinical Practice, 5th Edition

24/06/2006 01:19 p.m.

Ovid: Hemostasis and Thrombosis: Basic Principles and Clinical Practice

within an N-terminal -carboxyglutamic acid (Gla) domain that is

24/06/2006 01:19 p.m.

Ovid: Hemostasis and Thrombosis: Basic Principles and Clinical Practice

24/06/2006 01:19 p.m.

Ovid: Hemostasis and Thrombosis: Basic Principles and Clinical Practice

and Ca 2+ ions and was time dependent, apparently reflecting the

24/06/2006 01:19 p.m.

Ovid: Hemostasis and Thrombosis: Basic Principles and Clinical Practice

FIGURE 11-1. Amino acid sequence of protein Z. Disulfide

PROTEIN ZDEPENDENT PROTEASE

24/06/2006 01:19 p.m.

Ovid: Hemostasis and Thrombosis: Basic Principles and Clinical Practice

(rasp-1) (28). Therefore, ZPI is likely the human homolog of rat

FIGURE 11-2. Carboxy-terminal sequences of protein

24/06/2006 01:19 p.m.

Ovid: Hemostasis and Thrombosis: Basic Principles and Clinical Practice

plasma level of ZPI is related to the level of PZ: Oral contraceptive

PROTEIN Z AND PROTEIN ZDEPENDENT

24/06/2006 01:19 p.m.

Ovid: Hemostasis and Thrombosis: Basic Principles and Clinical Practice

produce this enhancement by both binding PAI-1, thereby inducing

FIGURE 11-3. Two pathways for the inhibition of factor Xa by

24/06/2006 01:19 p.m.

Ovid: Hemostasis and Thrombosis: Basic Principles and Clinical Practice

complex at the phospholipid surface. On the right, the

Factor XIa Inhibition

Instability of Protein ZDependent

24/06/2006 01:19 p.m.

Ovid: Hemostasis and Thrombosis: Basic Principles and Clinical Practice

complexes. In contrast to the thrombinantithrombin interaction,

Consumption of Protein ZDependent

PROTEIN Z/PROTEIN Z-DEPENDENT

24/06/2006 01:19 p.m.

Ovid: Hemostasis and Thrombosis: Basic Principles and Clinical Practice

Thirty-six individuals with bleeding disorders of unknown etiology

Protein Z and Thrombosis

24/06/2006 01:19 p.m.

Ovid: Hemostasis and Thrombosis: Basic Principles and Clinical Practice

24/06/2006 01:19 p.m.

Ovid: Hemostasis and Thrombosis: Basic Principles and Clinical Practice

24/06/2006 01:19 p.m.

Ovid: Hemostasis and Thrombosis: Basic Principles and Clinical Practice

latter results is not readily apparent. The frequently offered

24/06/2006 01:19 p.m.

Ovid: Hemostasis and Thrombosis: Basic Principles and Clinical Practice

7. Ichinose A, Takeya H, Espling E, et al. Amino acid sequence

24/06/2006 01:19 p.m.

Ovid: Hemostasis and Thrombosis: Basic Principles and Clinical Practice

24/06/2006 01:19 p.m.

Ovid: Hemostasis and Thrombosis: Basic Principles and Clinical Practice

naturally occurring vitamin Kdependent proteins: correlation of

24/06/2006 01:19 p.m.

Ovid: Hemostasis and Thrombosis: Basic Principles and Clinical Practice

31. Rezaie A, Copper S, Church F, et al. Protein C inhibitor is a

24/06/2006 01:19 p.m.

Ovid: Hemostasis and Thrombosis: Basic Principles and Clinical Practice