The molecule is made up of 20complement control protein (CCP) modules (also referred to as Short Consensus Repeats or sushi domains) connected to one another by short linkers (of between three and eightamino acid residues) and arranged in an extended head to tail fashion. Each of the CCP modules consists of around 60 amino acids with fourcysteine residuesdisulfide bonded in a 1–3 2–4 arrangement, and a hydrophobic core built around an almost invarianttryptophan residue. The CCP modules are numbered from 1–20 (from the N-terminus of the protein); CCPs 1–4 and CCPs 19–20 engage withC3b while CCPs 7 and CCPs 19–20 bind to GAGs andsialic acid.[8] To date atomic structures have been determined for CCPs 1–3,[9] CCP 5,[10] CCP 7,[11] CCPs 10–11 and CCPs 11–12,[12] CCPs 12–13,[13] CCP 15, CCP 16,[14] CCPs 15–16,[15] CCPs 18–20,[16] and CCPs 19–20.[17][18] The atomic structure for CCPs 6–8 bound to the GAG mimic sucrose octasulfate,[19] CCPs 1–4 in complex with C3b[20] and CCPs 19–20 in complex with C3d (that corresponds to the thioester domain of C3b)[21][22] have also been determined. Although an atomic resolution structure for intact factor H has not yet been determined, low resolution techniques indicate that it may be bent back in solution.[23] Information available to date indicates that CCP modules 1–4 is responsible for the cofactor and decay acceleration activities of factor H, whereas self/non-self discrimination occurs predominantly through GAG binding to CCP modules 7 and/or GAG or sialic acid binding to 19–20.[23][24]
The principal role of Factor H is to regulate thealternative pathway of thecomplement system, a key component of innate immunity. It ensures that complement activation is directed againstpathogens or abnormal surfaces, while preventing damage to host tissues. This is accomplished through two main mechanisms: serving as a cofactor forFactor I-mediated cleavage ofC3b, and accelerating the decay of the alternative pathwayC3-convertase, C3bBb.
Factor H selectively exerts its regulatory activity on self cells and surfaces, but not on the surfaces ofbacteria orviruses. However, some pathogens, such asNeisseria meningitidis (the meningococcus), have evolved mechanisms to bind human FH, thereby evading complement-mediated destruction.[25] This interaction enables the bacteria to survive and proliferate in the bloodstream, contributing to invasive disease.[26]
The ability of Factor H to protect self surfaces is believed to depend on its capacity to adopt different conformational states, each associated with varying levels of cofactor and decay-accelerating activity.[27] In solution, FH predominantly exists in a low-activity conformation sufficient to regulate complement in the fluid phase. Upon binding toglycosaminoglycans (GAGs) orsialic acids—molecules typically found on host cells—FH undergoes conformational changes that enhance its regulatory function. This mechanism ensures that complement activation is inhibited on self surfaces while proceeding unimpeded on foreign cells.[28][29]
Due to the central role that factor H plays in the regulation of complement, there are a number of clinical implications arising from aberrant factor H activity. Overactive factor H may result in reduced complement activity on pathogenic cells – increasing susceptibility to microbial infections. Underactive factor H may result in increased complement activity on healthy host cells – resulting in autoimmune diseases. It is not surprising, therefore, that raremutations or commonsingle nucleotide polymorphisms (SNPs) in the complement factor H gene (CFH) often result in pathologies. Moreover, the complement inhibitory activities of factor H, and other complement regulators, are often used by pathogens to increasevirulence.
In 2005, several independent research groups identified an SNP in CFH, which results in the protein change p.Y402H, as a risk factor forAge Related Macular Degeneration (AMD) present in around a third of Europeans.[30] Although its allele frequency varies considerably between different populations, Y402H has been consistently associated with AMD onset and progression.[30]Homozygous individuals have an approximately seven-fold greater odds of association with AMD whileheterozygotes have a two-to-three-fold greater odds of association with the disease.[30] This SNP, located in CCP module 7 of factor H, has been shown to affect the ability of factor H protein to localise to sites of inflammation in retinal tissues (e.g. bypolyanions and pentraxins) and to regulate the activation of complement and immune cells.[30] The SNP has also been shown to affect the function of factor H-like protein 1, an alternatively spliced version of factor H consisting of CCPs 1 to 7 only, which is thought to have a greater role in intraocular complement regulation.[30] The British complementologist,Simon J. Clark demonstrated that FHL-1 was the predominant form of FH protectingBruch's membrane,[31] an integral part of the outerBlood-retinal barrier and a major site of early AMD. Further studies suggested that haploinsufficiency of FHL-1 lead to the manifestation of an AMD-like disease at a significantly earlier age.[32] However, the genetic variants in CFH with the greatest effect on an individual's risk of AMD have been shown to affect CCPs 1 to 4, which are involved in dampening the effects of the alternative pathway of complement.[30] A rare functional coding change, p.R1210C, in CFH results in a functional deficiency in factor H and leads to a substantially higher risk of macular degeneration as well as complement-mediated renal conditions.[30][33]
Variation in other genes of the regulators of complement activation locus, such as complement factor H-related genes, as well as in other complement proteins (e.g. factor I, C2/factor B, and C3) have also been associated with greater AMD risk.[30] The current theory is that complement dysregulation is a key driver of chronic inflammation in AMD.[30]
Gemini Therapeutics Inc. was a Massachusetts based precision medicine company focused on the development of new therapies through a deeper understanding of disease. Based on the biological activity of human factor H, Gemini was developing a recombinant human factor H protein, GEM103, for the treatment of dry AMD. GEM-103 was evaluated in phase I (NCT04246866) and II (NCT04643886) clinical trials in AMD patients, but failed to achieve its clinical end points and the developmental program was terminated[34] Gemini Therapeutics merged with Disc Medicine in 2022[35]
Other companies currently focusing on developing FH, FHL-1, or variations thereof, as therapeutics for treating AMD, include Character Biosciences Inc,[36] and 4D Molecular Therapeutics[37]
Hemolytic uremic syndrome (HUS) is a disease associated with microangiopathic hemolytic anemia, thrombocytopenia, and acute renal failure. It can be either acquired (e.g. following infection with shigatoxigenicEscherichia coli), or inherited (also known as atypical hemolytic uremic syndrome, aHUS). aHUS has been strongly linked to mutations in genes of the complement system, especially factor H.[30] In contrast to AMD and C3 glomerulopathy (another complement-mediated renal disorder) which are mainly associated with variation in the N-terminus (CCPs 1 to 4), predisposing mutations in factor H mainly affect the C-terminus of the protein (CCP modules 19 and 20),[30] which has been shown to be responsible for adherence to renal tissues and the regulation of complement components and their downstream effectors.[30][38][39]
Alterations in the immune response are involved in pathogenesis of many neuropsychiatric disorders includingschizophrenia. Recent studies indicated alterations in thecomplement system, including those which may result in the overactivation of thealternative complement pathway, may predispose to schizophrenia. For example, the CFH SNP rs424535 (2783-526T>A) was positively associated with schizophrenia.[40]
It was found that rs800292(184G >A) SNP was positively associated with stroke and rs800912 minor allele of the CFH gene might be considered as a risk factor for ischemic stroke.[40]
The Gram-negative bacteriumB. burgdorferi has five factor H–binding proteins: CRASP-1, CRASP-2, CRASP-3, CRASP-4 and CRASP-5.[44] Each CRASP protein also bindsplasminogen.[44] It is possible that the allele frequency of CFH variants across the globe reflects selective pressure from infectious diseases.[30]
Factor H has been shown tointeract withcomplement component 3, amongst other complement proteins and factors, leading to regulation of the alternative pathway of complement in particular.[30][45][46]
Biologically active Factor H has been produced byRalf Reski and coworkers in themoss bioreactor,[47] in a process calledmolecular farming. Large quantities of biologically active human Factor H, potentially suitable for therapeutic purposes, were produced using a syntheticcodon-optimised gene expressed in theyeast expression host,Pichia pastoris.[48]
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