Antithrombin (AT) is a single-chain glycoprotein in plasma and belongs to t
he family of the serpins. It is synthesized in liver parenchymal cells, and
its plasma concentration is between 112-140 mg/L. AT is a unique inhibitor
of the clotting system and neutralizes most of the enzymes generated durin
g activation of the clotting cascade, especially thrombin, factors Xa and M
a. Equimolar, irreversible complexes are formed between AT and the enzymes,
The interaction between AT and the activated clotting factors is at least
1,000-fold increased in the presence of heparins. Heparins bind to multiple
sites of the AT molecule resulting in a steric reconfiguration. Heparins c
ontain a specific pentasaccharide unit which is the minimum requirement for
AT binding. The glycosaminoglycan (GAG) heparan sulfate found on endotheli
al cell surfaces also contains this pentasaccharide and can thus "activate"
AT. It is believed that much of the physiological inactivation of enzymes
by AT occurs on the endothelium, mediated by heparan sulfate. The binding o
f AT to the GAGs also releases prostacyclin which possesses strong antiinfl
ammatory properties.
Deficiencies of AT are inherited or acquired. Only acquired defects due to
increased consumption are discussed, most notably AT in DIG, especially DIC
in sepsis. During acute DIG, clotting factors and inhibitors are consumed
faster than they can be reproduced. This consumption of AT is of great sign
ificance in DIC and sepsis, and plasma AT levels predict outcome. AT levels
drop early in sepsis and laboratory signs of DIC can already be found in p
atients with SIRS and early sepsis. The important role of AT in DIC and sep
sis is the basis for considering antithrombin concentrates as an additional
therapeutic modality.