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In vivo, factor XII is activated by binding (contact) to [[polyanions]] termed contact-activation. Multiple polymers, the white clay material kaolin and glass are non-physiological factor XII contact activators. Activated platelets release inorganic polymers, [[polyphosphate]]s. Contact to polyphosphates activates factor XII and initiates [[fibrin]] formation by the intrinsic pathway of coagulation with critical importance for [[thrombus]] formation and the factor XII-activated pro inflammatory kallikrein kinin-system. Targeting polyphosphates with [[phosphatase]]s interfered with procoagulant activity of activated [[platelet]]s and blocked platelet-induced thrombosis in mice. Addition of polyphosphates restored defective plasma clotting of [[Hermansky–Pudlak syndrome]] patients, indicating that the inorganic polymer is the endogenous factor XII activator in vivo. Platelet polyphosphate-driven factor XII activation provides the link from primary hemostasis (formation of a [[platelet plug]]) to secondary hemostasis (fibrin meshwork formation).<ref name="pmid20005807">{{cite journal | vauthors = Müller F, Mutch NJ, Schenk WA, Smith SA, Esterl L, Spronk HM, Schmidbauer S, Gahl WA, Morrissey JH, Renné T | display-authors = 6 | title = Platelet polyphosphates are proinflammatory and procoagulant mediators in vivo | journal = Cell | volume = 139 | issue = 6 | pages = 1143–1156 | date = December 2009 | pmid = 20005807 | pmc = 2796262 | doi = 10.1016/j.cell.2009.11.001 }}</ref> Polyphosphate exerts differential effects on plasma clotting in test tubes ex vivo, depending on polymer size and it was shown in vitro that platelet-size soluble polyphosphates induce little activaton of factor XII in solution but that they are accelerators of thrombin-induced activation of factor XI.<ref>{{cite journal | vauthors = Smith SA, Choi SH, Davis-Harrison R, Huyck J, Boettcher J, Rienstra CM, Reinstra CM, Morrissey JH | display-authors = 6 | title = Polyphosphate exerts differential effects on blood clotting, depending on polymer size | journal = Blood | volume = 116 | issue = 20 | pages = 4353–4359 | date = November 2010 | pmid = 20709905 | doi = 10.1182/blood-2010-01-266791 | pmc = 2993633 }}</ref> The mystery was solved upon the discovery that short chain polyphosphate forms insoluble calcium-rich [[nanoparticle]]s in vivo. These aggregates accumulate on the platelet surface and activate factor XII independently of the chain length go the individual polymer.<ref name="pmid28049643">{{cite journal | vauthors = Verhoef J, Barendrecht A, Nickel KF, Dijkxhoorn K, Kenne E, Labberton L, McCarty O, Schiffelers R, Heijnen H, Hendrickx A, Schellekens H, Fens MH, de Maat S, Renné T, Maas C | title = Polyphosphate nanoparticles on the platelet surface trigger contact system activation | journal = Blood | volume = 129 | issue = 23 | pages = 1707–1717 | date = January 2017 | pmid = 28049643 | pmc = 5364341 | doi = 10.1182/blood-2016-08-734988 }}</ref> Regulation of polyphosphates in platelets has remained poorly understood. Combinations of systems biology, genetics and functional analyses has identified the phosphate-exporter XPR1 as important regulator of polyphosphates in platelets. Targeting XPR1 increases polyphosphate content and leads to accelerated arterial and venous thrombosis in mouse models.<ref>{{cite journal | pmid=32932519 | year=2021 | last1=Mailer | first1=R. K. | last2=Allende | first2=M. | last3=Heestermans | first3=M. | last4=Schweizer | first4=M. | last5=Deppermann | first5=C. | last6=Frye | first6=M. | last7=Pula | first7=G. | last8=Odeberg | first8=J. | last9=Gelderblom | first9=M. | last10=Rose-John | first10=S. | last11=Sickmann | first11=A. | last12=Blankenberg | first12=S. | last13=Huber | first13=T. B. | last14=Kubisch | first14=C. | last15=Maas | first15=C. | last16=Gambaryan | first16=S. | last17=Firsov | first17=D. | last18=Stavrou | first18=E. X. | last19=Butler | first19=L. M. | last20=Renné | first20=T. | title=Xenotropic and polytropic retrovirus receptor 1 regulates procoagulant platelet polyphosphate | journal=Blood | volume=137 | issue=10 | pages=1392–1405 | doi=10.1182/blood.2019004617 | pmc=7955403 }}</ref>
Based on the seminar role of factor XII in thrombosis while sparing haemostats, targeting the protease has emerged as a promising drug traget for safe anticoagulant drugs that in contrast to currently used anticoagulants, do not increase bleeding. Multiple factor XII inhibitors have been developed and some of them are in clinical trials <ref>{{cite journal | url=https://pubmed.ncbi.nlm.nih.gov/32883641/ | pmid=32883641 | year=2020 | last1=Davoine | first1=C. | last2=Bouckaert | first2=C. | last3=Fillet | first3=M. | last4=Pochet | first4=L. | title=Factor XII/XIIa inhibitors: Their discovery, development, and potential indications | journal=European Journal of Medicinal Chemistry | volume=208 | page=112753 | doi=10.1016/j.ejmech.2020.112753 | hdl=2268/251278 | s2cid=221496237 | hdl-access=free }}</ref>
== Genetics ==
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