Snake venoms and the hemostatic system

Snake venoms are complex mixtures containing many different biologically active proteins and peptides. A number of these proteins interact with components of the human hemostatic system. This review is focused on those venom constituents which affect the blood coagulation pathway, endothelial cells, and platelets. Only highly purified and well characterized snake venom proteins will be discussed in this review. Hemostatically active components are distributed widely in the venom of many different snake species, particularly from pit viper, viper and elapid venoms. The venom components can be grouped into a number of different categories depending on their hemostatic action. The following groups are discussed in this review: (i) enzymes that clot fibrinogen; (ii) enzymes that degrade fibrin(ogen); (iii) plasminogen activators; (iv) prothrombin activators; (v) factor V activators; (vi) factor X activators; (vii) anticoagulant activities including inhibitors of prothrombinase complex formation, inhibitors of thrombin, phospholipases, and protein C activators; (viii) enzymes with hemorrhagic activity; (ix) enzymes that degrade plasma serine proteinase inhibitors; (x) platelet aggregation inducers including direct acting enzymes, direct acting non-enzymatic components, and agents that require a cofactor; (xi) platelet aggregation inhibitors including: -fibrinogenases, 5′-nucleotidases, phospholipases, and disintegrins. Although many snake venoms contain a number of hemostatically active components, it is safe to say that no single venom contains all the hemostatically active components described here. Several venom enzymes have been used clinically as anticoagulants and other venom components are being used in pre-clinical research to examine their possible therapeutic potential. The disintegrins are an interesting group of peptides that contain a cell adhesion recognition motif, Arg–Gly–Asp (RGD), in the carboxy-terminal half of their amino acid sequence. These agents act as fibrinogen receptor (integrin GPIIb/IIIa) antagonists. Since this integrin is believed to serve as the final common pathway leading to the formation of platelet–platelet bridges and platelet aggregation, blockage of this integrin leads to inhibition of platelet aggregation regardless of the stimulating agent. Clinical trials suggest that platelet GPIIb/IIIa blockade is an effective therapy for the thrombotic events and restenosis frequently accompanying cardiovascular and cerebrovascular disease. Therefore, because of their clinical potential, a large number of disintegrins have been isolated and characterized.     

Haemostatically active proteins in snake venoms

Snake venom proteins that affect the haemostatic system can cause (a) lowering of blood coagulability, (b) damage to blood vessels, resulting in bleeding, (c) secondary effects of bleeding, e.g. hypovolaemic shock and organ damage, and (d) thrombosis. These proteins may, or may not, be enzymes. We review the data on the most relevant haemostatically active proteinases, phospholipases A₂, l-amino acid oxidases and 5′-nucleotidases from snake venoms. We also survey the non-enzymatic effectors of haemostasis from snake venoms - disintegrins, C-type lectins and three-finger toxins. Medical applications have already been found for some of these snake venom proteins. We describe those that have already been approved as drugs to treat haemostatic disorders or are being used to diagnose such health problems. No clinical applications, however, currently exist for the majority of snake venom proteins acting on haemostasis. We conclude with the most promising potential uses in this respect.     

Fractionation of snake venom metalloproteinases by metal ion affinity: A purified cobra metalloproteinase, Nk, from Naja kaouthia binds Ni-agarose

Snake venom metalloproteinases represent unique probes for analyzing platelet adhesion receptors regulating hemostasis and thrombosis. Snake venom metalloproteinase-disintegrins consist of a propeptide domain, a catalytic domain containing a metal ion-coordination sequence (HEXXHXXGXXH), a disintegrin domain, and a Cys-rich domain. Here, we investigate whether metal ion-affinity chromatography may be used to fractionate venom metalloproteinases based on the metal ion-coordination motif. First, we showed that a purified cobra metalloproteinase, Nk, from Naja kaouthia bound Ni²⁺-agarose, and was eluted by 10 mM imidazole, confirming the validity of the approach. Nk cleaved the platelet von Willebrand factor (VWF) receptor, glycoprotein (GP)Ib, with similar activity to the previously reported cobra metalloproteinase, mocarhagin, as shown by EDTA-inhibitable Nk-dependent proteolysis of a purified GPIb extracellular fragment (glycocalicin), and inhibition of ¹²⁵I-VWF binding to GPIb on washed human or canine platelets. Second, crude venom from the viper, Trimeresurus albolabris, was fractionated on Ni²⁺-agarose. Samples of flow-through, wash, and imidazole-eluted (0–30 mM gradient) fractions were analyzed by (i) SDS-polyacrylamide gel electrophoresis, (ii) immunoblotting with a rabbit anti-mocarhagin antibody, and (iii) assessing metalloproteinase activity using human fibrinogen as substrate. The combined results support the general concept of using Ni²⁺-agarose to fractionate snake venom metalloproteinases.     

三种蛇毒类凝血酶对纤维蛋白原的作用方式

目的以纤维蛋白原为底物,考察巴西矛头蝮蛇(Bothrops atrox)、尖吻蝮蛇(Agkistrodon acutus)、长白白眉蝮蛇(Agkistrodon halys pullas)3种蛇毒类凝血酶对纤维蛋白原的作用方式。方法采用SDS-PAGE及RP-HPLC法对作用结果进行检测。结果 3种蛇毒类凝血酶对纤维蛋白原的作用方式不完全相同,巴西矛头蝮蛇、尖吻蝮蛇2种蛇毒类凝血酶只作用于纤维蛋白原的α链,对β、γ链则无作用,长白白眉蝮蛇毒类凝血酶起初作用于纤维蛋白原的β链,对α链作用较弱,随着时间的延长对α链作用增强,对γ链无作用。结论巴西矛头蝮蛇、尖吻蝮蛇2种蛇毒类凝血酶属于SVTLE-A型,而长白白眉蝮蛇毒类凝血酶则属于SVTLE-AB型。     

Characterization of a novel protein from Proatheris superciliaris venom: proatherocytin, a 34-kDa platelet receptor PAR1 agonist.

Many toxins from viperid venoms have been characterised as powerful activators of platelets. Here, the venom from the East African Lowland viper, Proatheris superciliaris, was investigated for its effect on platelets and the coagulation system. Whole P. superciliaris venom stimulated platelet shape change and aggregation; however, the stimulation of platelet activation was unaffected by the structurally distinct Src family kinase inhibitors PP1 and PD0173952, suggesting that platelet activation was mediated by a G protein-coupled receptor. A platelet reactive 34-kDa protein was isolated from P. superciliaris venom which we have designated proatherocytin. This protein induced Src kinase-independent aggregation of both human and mouse platelets that was inhibited by the serine protease inhibitor AEBSF. Proatherocytin did not clot bovine or human fibrinogen, degrade fibrinogen or hydrolyse the serine protease substrate benzoyl-FVR-pNA. It activated human PAR1 on stably transfected rat kidney epithelial cells, whereas no activation of the trypsin receptor PAR2 was shown. Surprisingly, Edman degradation of proatherocytin revealed sequence identity with existing disintegrin-like domains of snake venom metalloproteinases. These results suggest that proatherocytin is a highly selective PAR1 agonist that also causes mouse platelet aggregation, probably through cleavage of PAR4.     

Exploring the Utility of Recombinant Snake Venom Serine Protease Toxins as Immunogens for Generating Experimental Snakebite Antivenoms

Snakebite is a neglected tropical disease that causes high rates of global mortality and morbidity. Although snakebite can cause a variety of pathologies in victims, haemotoxic effects are particularly common and are typically characterised by haemorrhage and/or venom-induced consumption coagulopathy. Despite polyclonal antibody-based antivenoms being the mainstay life-saving therapy for snakebite, they are associated with limited cross-snake species efficacy, as there is often extensive toxin variation between snake venoms, including those used as immunogens for antivenom production. This restricts the therapeutic utility of any antivenom to certain geographical regions. In this study, we explored the feasibility of using recombinantly expressed toxins as immunogens to stimulate focused, pathology-specific, antibodies in order to broadly counteract specific toxins associated with snakebite envenoming. Three snake venom serine proteases (SVSP) toxins, sourced from geographically diverse and medically important viper snake venoms, were successfully expressed in HEK293F mammalian cells and used for murine immunisation. Analyses of the resulting antibody responses revealed that ancrod and RVV-V stimulated the strongest immune responses, and that experimental antivenoms directed against these recombinant SVSP toxins, and a mixture of the three different immunogens, extensively recognised and exhibited immunological binding towards a variety of native snake venoms. While the experimental antivenoms showed some reduction in abnormal clotting parameters stimulated by the toxin immunogens and crude venom, specifically reducing the depletion of fibrinogen levels and prolongation of prothrombin times, fibrinogen degradation experiments revealed that they broadly protected against venom- and toxin-induced fibrinogenolytic functional activities. Overall, our findings further strengthen the case for the use of recombinant venom toxins as supplemental immunogens to stimulate focused and desirable antibody responses capable of neutralising venom-induced pathological effects, and therefore potentially circumventing some of the limitations associated with current snakebite therapies.     

Potential Role of Platelet-Activating C-Type Lectin-Like Proteins in Viper Envenomation Induced Thrombotic Microangiopathy Symptom

Envenomation by viperid snakes may lead to severe bleeding, consumption coagulopathy, and thrombotic microangiopathy symptoms. The exact etiology or toxins responsible for thrombotic microangiopathy symptoms after snake envenomation remain obscure. Snake C-type lectin-like proteins (snaclecs) are one of the main non-enzymatic protein constituents in viper venoms, of which a majority are considered as modulators of thrombosis and hemostasis. In this study, we demonstrated that two snaclecs (mucetin and stejnulxin), isolated and identified from Protobothrops mucrosquamatus and Trimeresurus stejnegeri venoms, directly induced platelet degranulation and clot-retraction in vitro, and microvascular thrombosis has been confirmed in various organs in vivo. These snaclecs reduced cerebral blood flow and impaired motor balance and spatial memories in mice, which partially represent the thrombotic microangiopathy symptoms in some snakebite patients. The functional blocking of these snaclecs with antibodies alleviated the viper venom induced platelet activation and thrombotic microangiopathy-like symptoms. Understanding the pathophysiology of thrombotic microangiopathy associated with snake envenoming may lead to emerging therapeutic strategies.     

South American Snake Venoms Affecting Haemostasis

Abstract

The venom of the South American snakes, Bothrops, Crotalus and Lachesis possess venom components which affect the haemostatic mechanism. These components can interfere with blood coagulation and platelet function either by activation or inhibition. They are rich sources of serine proteinases called thrombin-like enzymes (TLEs) which induce direct clotting of fibrinogen, and also metalloproteinases activators of prothrombin and Factor X. They are also rich in phospholipases which have a dual inhibitory action on blood coagulation factors and platelets; however, the mechanism of action is still unclear. Among the platelet activators, botrocetin from Bothrops jararaca venom is the most extensively studied in the investigation of platelet function and von Willebrand Factor abnormalities. RGD-containing polypeptides, platelet antagonists found in Bothrops and Lachesis venoms are not only important as tools for platelet studies but are also very promising candidates for reducing the risks of thromboembolic disease. Here some of the most important components in these venoms and the haemostatic alterations caused by them in reported cases of envenoming are described.     

Platelets as targets of snake venom metalloproteinases

For centuries snake venoms have been known to interfere with haemostasis and this is now known basically due either to toxins activating/inhibiting clotting factors, having effects on blood vessels or interfering with platelet function. In this short review, the interaction of one major group of toxins, the snake venom metalloproteinases, with platelets is considered. This is relevant for understanding the mechanism of haemorrhage induced by these toxins.     

Efficacy of antivenom against the procoagulant effect of Australian brown snake (Pseudonaja sp.) venom: in vivo and in vitro studies.

Snake venom induced consumption coagulopathy (VICC) is a common complication of snake bite due to prothrombin activators or thrombin-like enzymes in the venom. This study aimed to determine the efficacy and dose of antivenom for treating VICC in patients envenomed by brown snakes (Pseudonaja spp.), including in vitro coagulation studies. In serial blood samples from patients with brown snake envenoming, venom and antivenom concentrations were measured using enzyme immunoassays. In vitro mixtures of brown snake venom and antivenom were used to investigate antivenom binding, neutralisation of prothrombin activity, prevention of venom-mediated clotting and effect on thrombin generation parameters using a thrombinoscope. In 27 envenomed patients the median venom concentration was 20 ng/mL (Interquartile range[IQR]:12-44 ng/mL) prior to antivenom and was not detected after antivenom administration, including 9 patients given one vial. In vitro, 200 microg/mL of antivenom bound all free venom at venom concentrations seen in patients. In vitro prothrombinase activity of the venom (using a chromogenic substrate) was not neutralised by antivenom. However, for venom concentrations seen in humans, 100 microg/mL of antivenom prevented venom clotting activity in human plasma and 479 microg/mL neutralised procoagulant venom activity measured by triggering thrombin generation. One vial of antivenom appears to be sufficient to bind and neutralise all venom in patients with severe brown snake envenoming.     

Snake venom probes of platelet adhesion receptors and their ligands

Snake venom proteins that modulate platelet adhesive interactions are chiefly from either of two main structural families: the C-type lectin-like family, or the metalloproteinase-disintegrins. Snake venom probes from both families selectively target platelet adhesion receptors, including glycoprotein (GP) Ib-IX-V, GP VI, 2β1 and IIbβ3 (GP IIb-IIIa). These receptors act together to mediate platelet adhesion, activation and aggregation (thrombus formation) under hydrodynamic shear stress in flowing blood. The receptors are members of the leucine-rich repeat family (GP Ib-IX-V), the immunoglobulin superfamily (GP VI), or integrins (2β1, IIbβ3). In addition, adhesive glycoproteins in matrix and/or plasma such as von Willebrand factor (that binds GP Ib and IIbβ3), collagen (that binds GP V, GP VI and 2β1), or fibrinogen (that binds IIbβ3), are also targeted by C-type lectin family or metalloproteinase-disintegrin snake venom proteins. Emerging structural and functional evidence is beginning to explain how interactions between the conserved structural module-domains that make up these mammalian and snake proteins are regulated. Whether homologous adhesion/counter-receptors on platelets and other vascular cells are also potential snake venom targets is as yet largely unexplored.     

Effects of snake venom proteins on blood platelets

R. M. and H. J. . Review article—Effects of snake venom proteins on blood platelets. Toxicon 28, 1387–1422, 1990.—Snake venoms are complex mixtures which contain pharmacologically active polypeptides and proteins. Several snake venom constituents interfere in platelet aggregation, an important cellular process in thrombosis and hemostasis. These components range in size from small molecular weight polypeptides to high molecular weight proteins. Some of the proteins are enzymes, such as phospholipase A₂, proteinases, nucleotidases, or -amino acid oxidase, while others do not exhibit enzymatic activity. These components may initiate and/or inhibit platelet aggregation. Some venom factors induce platelet agglutination. This review deals with the physical characteristics of these venom factors, the mechanisms of their platelet effects, structure-function relationships, and their physiological significance.     

Structural and functional properties of snake venom prothrombin activators

In this review we have summarized the current knowledge about the prothrombin activating principles present in the venom of a large number of different snake species. It appears that snake venom prothrombin activators can be classified into four different groups based on their structural properties and on their functional properties in prothrombin activation. Group I activators efficiently convert prothrombin into meizothrombin and their activity is not influenced by the non-enzymatic cofactors of the prothrombinase complex (CaCl₂, factor V_a and phospholipid). Group II and III activators can cleave both peptide bonds in prothrombin necessary to convert prothrombin into thrombin. The prothrombin-converting activity of Group II activators is strongly stimulated by phospholipids and factor V_a in the presence of CaCl₂, whereas the activity of group III activators is only stimulated by CaCl₂ and phospholipid. Group IV consists of snake venom proteases which do not convert prothrombin into enzymatically active products but cleave peptide bonds in prothrombin, resulting in the formation of inactive precursor forms of thrombin.     

Snake Venom Neurotoxins: Pharmacological Classification

Neurotoxic proteins isolated from various snake venoms, because of their high affinity for a particular target site are used extensively as pharmacological tools to gain insights into the function of the nervous system. The potency of these molecules lies in their affinities towards the biomolecules involved in the functioning of neuromuscular transmission. Neuromuscular and pathophysiological effects of neurotoxic proteins result from their interaction with various microcompartments based on their similarities in mass and conformation to the types of amino acids and disulfide bridges in the normal ligands. Snake venom toxins can be broadly classified depending on whether their site of action is at the skeletal neuromuscular junction, or at sites other than the skeletal neuromuscular junction. Skeletal neuromuscular junction‐specific neurotoxins include the following: postsynaptic toxins, presynaptic toxins, presynaptic toxins with musculotropic or myonecrotic actions, presynaptic and postsynaptic, presynaptic and postsynaptic toxins with musculotropic or myonecrotic actions, myotoxic and antiAChE neurotoxins, etc. Snake venom neurotoxins with affinities selective to the sites other than the skeletal NMJ were categorised as non‐skeletal neuromuscular junction snake venom neurotoxins and they include toxins with affinity for muscarinic and neuronal receptors; toxins with affinity for K⁺ and Ca^{2 +} ion channels, toxins with affinity for enzymes and muscle elements, centrally‐acting neurotoxins, peptide neurotoxin and miscellaneous neurotoxins. There is an additional miscellaneous class of snake venom neurotoxins that includes weak neurotoxin, muscarinic toxin‐like proteins and vipoxin. The toxic mechanisms of well‐studied snake venom neurotoxins and their sites of action underlying neurotoxicity are discussed in this review, and they form the basis for classification of snake venom neurotoxins.     

Hemostatic changes due to the venom gland extract of the red-necked keelback snake (Rhabdophis subminiatus).

After a bite by the aglyphous red-necked keelback snake Rhabdophis subminiatus a complete defibrinogenation syndrome with severe hemorrhagic diathesis developed in a 25-year-old man. In vitro studies showed that the venom gland extract of the snake contains a very active prothrombin (Factor II) activator. The thrombin generated is inhibited neither by antithrombin III nor the antithrombin-III-heparin complex. The venom gland extract stimulated also the tissue plasminogen activator; however, it did not cause direct activation of plasminogen, protein C, Factor X or direct degradation of fibrinogen.     

Agacutase体外水解牛纤维蛋白原机制的研究(英文)

Agacutase是自尖吻蝮蛇蛇毒中分离出的新的具有止血功能的蛇毒类凝血酶,它能够将纤维蛋白原转化为纤维蛋白单体。通过SDS-PAGE和ELISA方法,我们研究了Agacutase体外水解牛纤维蛋白原的分子机制。实验结果显示,Agacutase仅仅水解牛纤维蛋白原的α亚基并释放血纤肽A,而对牛纤维蛋白原的β和/或γ亚基没有影响。研究表明Agacutase属于血纤肽A类(FP-A类型)的类凝血酶。     

Prothrombin Activation by Snake Venom Proteases

Abstract

Snake venom prothrombin activators can be classified into four groups on the basis of their structural and functional properties in prothrombin activation. Group I activators (the best known example of which is the activator present in Echis carinalus venom) are metalloproteases that efficiently convert prothrombin into meizothrombin. Prothrombin activation by these activators is not affected by the presence of the prothrombinase cofactors, negatively charged phospholipids, CaCl₂ or factor Va. Group II activators (e.g. the Notechis scutatus scutatus activator) are serine proteases that require the presence of negatively charged phospholipids, CaCl₂ and factor Va for efficient prothrombin activation. Activators belonging to group III (e.g. Oxyuranus scutellatus scutellatus) are serine proteases that are also stimulated by negatively charged phospholipids and CaCl₂ but not by factor Va. These activators have a high molecular weight (Mr > 250,000) and are composed of a catalytic unit that is tightly associated with a factor Va-like cofactor unit An additional group of activators can be defined that consists of snake venoms which do not activate prothrombin but which convert prothrombin into inactive precursor forms of thrombin. In this review we describe a representative example of each group using experimental techniques currently available for the analysis of prothrombin activation.     

A novel 25 kDa protein from the venom of Bitis arietans with similarity to C-type lectins causes fibrinogen-dependent platelet agglutination.

Snake venoms affect blood coagulation and platelet functions in various ways. Venom from the Viperidae and Crotalidae family of snakes contains biologically active proteins that possess coagulant and anticoagulant activities, as well as platelet aggregating and inhibitory activities. Many of these proteins belong to the C-type lectin family. C-type lectins from viper venoms can act by prohibiting the interaction between platelet receptors, such as GPIIbIIIa and the GPIb/V/IX complex, and their ligands. We report on the purification of a novel 25 kDa protein, Ba25, from Bitis arietans with a primary structure that possesses similarity to other C-type lectins from viper venom. This protein has a profound effect on the clotting of whole blood, as well as being able to cause agglutination of platelets in platelet rich plasma without degranulation of the cells, but not of washed platelets in the absence of fibrinogen. Ba25 interacts with the platelet via the GPIb/V/IX, as well as the GPIIbIIIa receptor, and causes an increase in binding of fibrinogen to platelets. These results suggest that Ba25 may be a potent mediator of platelet-platelet interactions, and other coagulatory mechanisms.     

Drug development from Australian elapid snake venoms and the Venomics pipeline of candidates for haemostasis: Textilinin-1 (Q8008), Haempatch™ (Q8009) and CoVase™ (V0801)

Snake venoms are attractive for drug discovery and development, with a number of therapeutics derived from snake venom either in clinical use or in development. Recognising this opportunity, Australian biopharmaceutical company QRxPharma Ltd and its subsidiary Venomics Pty Ltd (VPL) has partnered with the University of Queensland (UQ) to screen and develop drug candidates from Australian elapid snake venoms. VPL has three haemostasis candidates in early preclinical development. Textilinin-1 (Q8008) is a 7 kDa potent and selective plasmin inhibitor that has application as an anti-fibrinolytic agent to reduce blood loss associated with complex surgeries. Haempatch? (Q8009) is a Factor Xa-like protein that displays potent procoagulant effects and is being developed as a topical haemostatic agent to reduce blood loss resulting from surgery or trauma. CoVase? (V0801) is a procoagulant cofactor that may have application as a systemic anti-bleeding agent in the treatment of internal bleeding and non-compressible haemorrhage. This review focuses on drug discovery from Australian elapid snake venoms, with emphasis on the QRxPharma/VPL drug discovery project undertaken in collaboration with UQ and candidates at further stages of development.     

Study of haemostasis in depressive patients treated with fluoxetine

The object of this study was to investigate a possible pharmacological effect of fluoxetine on haemostatic function, with special attention on primary haemostasis, in order to explain haemorrhagic complications reported in some treated, depressed patients. The haemostatic function of depressive patients, who required fluoxetine therapy, was studied before and after 1 month of treatment with fluoxetine 20 or 40 mg daily. Exclusion criteria were: pregnancy, initial abnormal haemostatic function, history of coagulation abnormalities, treatment with drugs that interfere with haemostasis, and recent fluoxetine therapy. The following tests were performed: prothrombin time, partial thromboplastin time, thrombin time, plasma fibrinogen, platelet counts, bleeding time, platelet aggregation induced by ADP, epinephrine, ristocetin, collagen, arachidonic acid, and plasma determination of fluoxetine and norfluoxetine levels. Statistical analysis was performed by Wilcoxon paired sample, one-tailed test (alpha=0.05). Among 18 patients included, only eight completed the trial. The single statistically significant difference was a decreased velocity in platelet aggregation induced by epinephrine without increased bleeding time. The results failed to demonstrate any compromised haemostatic function after 20 mg daily fluoxetine therapy in patients with initial haemostatic function. However, the results suggest possible effects of fluoxetine on platelet adrenoreceptors.