Prothrombin loading of vascular smooth muscle cell-derived exosomes regulates coagulation and calcification

Objective-The drug warfarin blocks carboxylation of vitamin K dependent proteins and acts as an anticoagulant and an accelerant of vascular calcification. The calcification inhibitor matrix Gla protein (MGP), produced by vascular smooth muscle cells (VSMCs), is a key target of warfarin action in promoting calcification, however it remains unclear whether proteins in the coagulation cascade also play a role in calcification.
Approach and Results-Vascular calcification is initiated by exosomes and proteomic analysis
revealed that VSMC exosomes are loaded with Gla-containing coagulation factors; IX and X, prothrombin (PT) and proteins C and S. Tracing of Alexa488-labeled PT showed that exosome loading occurs by direct binding to externalized phosphatidylserine (PS) on the exosomal surface and by endocytosis and recycling via late endosomes/multivesicular bodies (LE/MVB). Notably, the PT Gla domain and a synthetic Gla-domain peptide inhibited exosome-mediated VSMC calcification by preventing nucleation site formation on the exosomal surface. PT was deposited in the calcified vasculature and there was a negative correlation between vascular calcification and the levels of circulating PT. In addition, we found that VSMC exosomes induced thrombogenesis in a tissue factor (TF)- and PS-dependent manner.
Conclusions- Gamma carboxlyated coagulation proteins are potent inhibitors of vascular calcification suggesting warfarin action on these factors also contributes to accelerated calcification in patients receiving this drug. VSMC exosomes link calcification and coagulation acting as novel activators of the extrinsic coagulation pathway and inducers of calcification in the absence of Gla-containing inhibitors.