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Moore GW. Thrombophilia Screening: Not So Straightforward. Semin Thromb Hemost 2024. [PMID: 38733983 DOI: 10.1055/s-0044-1786807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2024]
Abstract
Although inherited thrombophilias are lifelong risk factors for a first thrombotic episode, progression to thrombosis is multifactorial and not all individuals with inherited thrombophilia develop thrombosis in their lifetimes. Consequently, indiscriminate screening in patients with idiopathic thrombosis is not recommended, since presence of a thrombophilia does not necessarily predict recurrence or influence management, and testing should be selective. It follows that a decision to undertake laboratory detection of thrombophilia should be aligned with a concerted effort to identify any significant abnormalities, because it will inform patient management. Deficiencies of antithrombin and protein C are rare and usually determined using phenotypic assays assessing biological activities, whereas protein S deficiency (also rare) is commonly detected with antigenic assays for the free form of protein S since available activity assays are considered to lack specificity. In each case, no single phenotypic assay is capable of detecting every deficiency, because the various mutations express different molecular characteristics, rendering thrombophilia screening repertoires employing one assay per potential deficiency, of limited effectiveness. Activated protein C resistance (APCR) is more common than discrete deficiencies of antithrombin, protein C, and protein S and also often detected initially with phenotypic assays; however, some centres perform only genetic analysis for factor V Leiden, as this is responsible for most cases of hereditary APCR, accepting that acquired APCR and rare F5 mutations conferring APCR will go undetected if only factor V Leiden is evaluated. All phenotypic assays have interferences and limitations, which must be factored into decisions about if, and when, to test, and be given consideration in the laboratory during assay performance and interpretation. This review looks in detail at performance and limitations of routine phenotypic thrombophilia assays.
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Affiliation(s)
- Gary W Moore
- Specialist Haemostasis Laboratory, Cambridge Haemophilia and Thrombophilia Centre, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
- Department of Natural Sciences, Middlesex University, London, United Kingdom
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Kállai J, Gindele R, Pénzes-Daku K, Balogh G, Bogáti R, Bécsi B, Katona É, Oláh Z, Ilonczai P, Boda Z, Róna-Tas Á, Nemes L, Marton I, Bereczky Z. Clinical and Molecular Characterization of Nine Novel Antithrombin Mutations. Int J Mol Sci 2024; 25:2893. [PMID: 38474138 DOI: 10.3390/ijms25052893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Revised: 02/27/2024] [Accepted: 02/28/2024] [Indexed: 03/14/2024] Open
Abstract
Antithrombin (AT) is the major plasma inhibitor of thrombin (FIIa) and activated factor X (FXa), and antithrombin deficiency (ATD) is one of the most severe thrombophilic disorders. In this study, we identified nine novel AT mutations and investigated their genotype-phenotype correlations. Clinical and laboratory data from patients were collected, and the nine mutant AT proteins (p.Arg14Lys, p.Cys32Tyr, p.Arg78Gly, p.Met121Arg, p.Leu245Pro, p.Leu270Argfs*14, p.Asn450Ile, p.Gly456delins_Ala_Thr and p.Pro461Thr) were expressed in HEK293 cells; then, Western blotting, N-Glycosidase F digestion, and ELISA were used to detect wild-type and mutant AT. RT-qPCR was performed to determine the expression of AT mRNA from the transfected cells. Functional studies (AT activity in the presence and in the absence of heparin and heparin-binding studies with the surface plasmon resonance method) were carried out. Mutations were also investigated by in silico methods. Type I ATD caused by altered protein synthesis (p.Cys32Tyr, p.Leu270Argfs*14, p.Asn450Ile) or secretion disorder (p.Met121Arg, p.Leu245Pro, p.Gly456delins_Ala_Thr) was proved in six mutants, while type II heparin-binding-site ATD (p.Arg78Gly) and pleiotropic-effect ATD (p.Pro461Thr) were suggested in two mutants. Finally, the pathogenic role of p.Arg14Lys was equivocal. We provided evidence to understand the pathogenic nature of novel SERPINC1 mutations through in vitro expression studies.
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Affiliation(s)
- Judit Kállai
- Division of Clinical Laboratory Science, Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary
- HUN-REN-UD Cell Biology and Signaling Research Group, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary
| | - Réka Gindele
- Division of Clinical Laboratory Science, Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary
| | - Krisztina Pénzes-Daku
- Division of Clinical Laboratory Science, Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary
| | - Gábor Balogh
- Division of Clinical Laboratory Science, Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary
| | - Réka Bogáti
- Division of Clinical Laboratory Science, Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary
| | - Bálint Bécsi
- Department of Medical Chemistry, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary
| | - Éva Katona
- Division of Clinical Laboratory Science, Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary
| | - Zsolt Oláh
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary
| | - Péter Ilonczai
- Jósa András Teaching Hospital of University of Debrecen, 4400 Nyíregyháza, Hungary
| | - Zoltán Boda
- Department of Internal Medicine, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary
| | - Ágnes Róna-Tas
- Department Medical Center of the Hungarian Defence Forces, National Hemophilia Center and Hemostasis, 1134 Budapest, Hungary
| | - László Nemes
- Department Medical Center of the Hungarian Defence Forces, National Hemophilia Center and Hemostasis, 1134 Budapest, Hungary
| | - Imelda Marton
- Department of Medicine, Albert Szent-Györgyi Medical School, University of Szeged, 6720 Szeged, Hungary
- Department of Transfusion Medicine, Albert Szent-Györgyi Medical School, University of Szeged, 6720 Szeged, Hungary
| | - Zsuzsanna Bereczky
- Division of Clinical Laboratory Science, Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary
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Ruf M, Cunningham S, Wandersee A, Brox R, Achenbach S, Strobel J, Hackstein H, Schneider S. SERPINC1 c.1247dupC: a novel SERPINC1 gene mutation associated with familial thrombosis results in a secretion defect and quantitative antithrombin deficiency. Thromb J 2024; 22:19. [PMID: 38347553 PMCID: PMC10860291 DOI: 10.1186/s12959-024-00589-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 02/01/2024] [Indexed: 02/16/2024] Open
Abstract
BACKGROUND Antithrombin (AT) is an important anticoagulant in hemostasis. We describe here the characterization of a novel AT mutation associated with clinically relevant thrombosis. A pair of sisters with confirmed type I AT protein deficiency was genetically analyzed on suspicion of an inherited SERPINC1 mutation. A frameshift mutation, c.1247dupC, was identified and the effect of this mutation was examined on the cellular and molecular level. METHODS Plasmids for the expression of wild-type (WT) and mutated SERPINC1 coding sequence (CDS) fused to green fluorescent protein (GFP) or hemagglutinin (HA) tag were transfected into HEK293T cells. Subcellular localization and secretion of the respective fusion proteins were analyzed by confocal laser scanning microscopy and Western blot. RESULTS The c.1247dupC mutation results in a frameshift in the CDS of the SERPINC1 gene and a subsequently altered amino acid sequence (p.Ser417LysfsTer48). This alteration affects the C-terminus of the AT antigen and results in impaired secretion as confirmed by GFP- and HA-tagged mutant AT analyzed in HEK293T cells. CONCLUSION The p.Ser417LysfsTer48 mutation leads to impaired secretion, thus resulting in a quantitative AT deficiency. This is in line with the type I AT deficiency observed in the patients.
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Affiliation(s)
- Maximilian Ruf
- Department of Transfusion Medicine and Hemostaseology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), University Hospital Erlangen, Krankenhausstr. 12, 91054, Erlangen, Germany
| | - Sarah Cunningham
- Department of Transfusion Medicine and Hemostaseology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), University Hospital Erlangen, Krankenhausstr. 12, 91054, Erlangen, Germany
| | - Alexandra Wandersee
- Department of Transfusion Medicine and Hemostaseology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), University Hospital Erlangen, Krankenhausstr. 12, 91054, Erlangen, Germany
| | - Regine Brox
- Department of Transfusion Medicine and Hemostaseology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), University Hospital Erlangen, Krankenhausstr. 12, 91054, Erlangen, Germany
| | - Susanne Achenbach
- Department of Transfusion Medicine and Hemostaseology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), University Hospital Erlangen, Krankenhausstr. 12, 91054, Erlangen, Germany
| | - Julian Strobel
- Department of Transfusion Medicine and Hemostaseology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), University Hospital Erlangen, Krankenhausstr. 12, 91054, Erlangen, Germany
| | - Holger Hackstein
- Department of Transfusion Medicine and Hemostaseology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), University Hospital Erlangen, Krankenhausstr. 12, 91054, Erlangen, Germany
| | - Sabine Schneider
- Department of Transfusion Medicine and Hemostaseology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), University Hospital Erlangen, Krankenhausstr. 12, 91054, Erlangen, Germany.
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Huang Y, Wang Y, Wang X, Liu J, Luo B, Gao Y. Multiple venous thromboembolisms in a pregnant patient carrying a novel mutation in SERPINC1 (p.M313T) that causes a transient antithrombin deficiency: a case report. Thromb J 2023; 21:123. [PMID: 38093370 PMCID: PMC10720155 DOI: 10.1186/s12959-023-00571-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Accepted: 12/06/2023] [Indexed: 12/17/2023] Open
Abstract
BACKGROUND Congenital antithrombin deficiency is an autosomal dominant disease that results in deep venous thrombosis and pulmonary embolism, which is mainly caused by mutations in the antithrombin gene (SERPINC1). Since SERPINC1 is highly susceptible to alterations, severe structural and functional changes that promote thrombosis may occur. Clinical presentations vary from different alterations. We report a pregnant case with novel mutation in SERPINC1 presenting transient antithrombin deficiency and multiple venous thromboembolisms. CASE PRESENTATION We report a case of a 36-year-old pregnant patient who was diagnosed with congenital antithrombin deficiency for carrying a novel heterozygous mutation, NM_000488:exon5:c.T9 38 C:p. M313T in SERPINC1 presenting transient antithrombin deficiency and multiple venous thromboembolisms. Thrombolytic with alteplase and anticoagulant therapies with low-molecular-weight heparin and warfarin were administrated. After confirming the genetic analysis and the termination of pregnancy, rivaroxaban was administrated, and the thrombosis reduced. CONCLUSIONS Our study enriched the mutation database of SERPINC1 gene, provided some new theoretical basis for gene diagnosis and genetic counseling of patients with transient antithrombin deficiency. While it still needs for subsequent exploration of molecular pathogenesis.
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Affiliation(s)
- Yuwen Huang
- Department of Respiratory and Critical Care Medicine, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Yinling Wang
- Department of Critical Care Medicine, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Xiaoli Wang
- Maternal and Child Office, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Jue Liu
- Medical Imaging Department, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Bing Luo
- Blood Transfusion Department, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Yuanmei Gao
- Department of Respiratory and Critical Care Medicine, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China.
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Rodgers GM, Mahajerin A. Antithrombin Therapy: Current State and Future Outlook. Clin Appl Thromb Hemost 2023; 29:10760296231205279. [PMID: 37822179 PMCID: PMC10571690 DOI: 10.1177/10760296231205279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 09/11/2023] [Accepted: 09/18/2023] [Indexed: 10/13/2023] Open
Abstract
Antithrombin (AT) is a natural anticoagulant pivotal in inactivating serine protease enzymes in the coagulation cascade, making it a potent inhibitor of blood clot formation. AT also possesses anti-inflammatory properties by influencing anticoagulation and directly interacting with endothelial cells. Hereditary AT deficiency is one of the most severe inherited thrombophilias, with up to 85% lifetime risk of venous thromboembolism. Acquired AT deficiency arises during heparin therapy or states of hypercoagulability like sepsis and premature infancy. Optimization of AT levels in individuals with AT deficiency is an important treatment consideration, particularly during high-risk situations such as surgery, trauma, pregnancy, and postpartum. Here, we integrate the existing evidence surrounding the approved uses of AT therapy, as well as potential additional patient populations where AT therapy has been considered by the medical community, including any available consensus statements and guidelines. We also describe current knowledge regarding cost-effectiveness of AT concentrate in different contexts. Future work should seek to identify specific patient populations for whom targeted AT therapy is likely to provide the strongest clinical benefit.
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Affiliation(s)
- George M. Rodgers
- Division of Hematology, University of Utah Medical Center, Salt Lake City, UT, USA
| | - Arash Mahajerin
- Division of Hematology, Children's Hospital of Orange County, Orange, CA, USA
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Bravo-Pérez C, Toderici M, Chambers JE, Martínez-Menárguez JA, Garrido-Rodriguez P, Pérez-Sanchez H, de la Morena-Barrio B, Padilla J, Miñano A, Cifuentes-Riquelme R, Vicente V, Lozano ML, Marciniak SJ, de la Morena-Barrio ME, Corral J. Full-length antithrombin frameshift variant with aberrant C-terminus causes endoplasmic reticulum retention with a dominant-negative effect. JCI Insight 2022; 7:161430. [PMID: 36214221 PMCID: PMC9675572 DOI: 10.1172/jci.insight.161430] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 08/24/2022] [Indexed: 02/02/2023] Open
Abstract
Antithrombin, a major endogenous anticoagulant, is a serine protease inhibitor (serpin). We characterized the biological and clinical impact of variants involving C-terminal antithrombin. We performed comprehensive molecular, cellular, and clinical characterization of patients with C-terminal antithrombin variants from a cohort of 444 unrelated individuals with confirmed antithrombin deficiency. We identified 17 patients carrying 12 C-terminal variants, 5 of whom had the p.Arg445Serfs*17 deletion. Five missense variants caused qualitative deficiency, and 7, including 4 insertion-deletion variants, induced severe quantitative deficiency, particularly p.Arg445Serfs*17 (antithrombin <40%). This +1 frameshift variant had a molecular size similar to that of WT antithrombin but possessed a different C-terminus. Morphologic and cotransfection experiments showed that recombinant p.Arg445Serfs*17 was retained at the endoplasmic reticulum and had a dominant-negative effect on WT antithrombin. Characterization of different 1+ frameshift, aberrant C-terminal variants revealed that protein secretion was determined by frameshift site. The introduction of Pro441 in the aberrant C-terminus, shared by 5 efficiently secreted variants, partially rescued p.Arg445Serfs*17 secretion. C-terminal antithrombin mutants have notable heterogeneity, related to variant type and localization. Aberrant C-terminal variants caused by 1+ frameshift, with similar size as WT antithrombin, may be secreted or not, depending on frameshift site. The severe clinical phenotypes of these genetic changes are consistent with their dominant-negative effects.
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Affiliation(s)
- Carlos Bravo-Pérez
- Servicio de Hematología y Oncología Médica, Hospital Universitario Morales Meseguer, Centro Regional de Hemodonación, University of Murcia, Biomedical Research Institute of Murcia, CB15/00055-CIBERER, Murcia, Spain
| | - Mara Toderici
- Servicio de Hematología y Oncología Médica, Hospital Universitario Morales Meseguer, Centro Regional de Hemodonación, University of Murcia, Biomedical Research Institute of Murcia, CB15/00055-CIBERER, Murcia, Spain
| | - Joseph E. Chambers
- Cambridge Institute for Medical Research, University of Cambridge, Cambridge, United Kingdom
| | - José A. Martínez-Menárguez
- Department of Cell Biology and Histology, Medical School, Biomedical Research Institute of Murcia, University of Murcia, Campus Mare Nostrum, Murcia, Spain
| | - Pedro Garrido-Rodriguez
- Servicio de Hematología y Oncología Médica, Hospital Universitario Morales Meseguer, Centro Regional de Hemodonación, University of Murcia, Biomedical Research Institute of Murcia, CB15/00055-CIBERER, Murcia, Spain
| | - Horacio Pérez-Sanchez
- Structural Bioinformatics and High Performance Computing Research Group, Universidad Católica de Murcia, Murcia, Spain
| | - Belén de la Morena-Barrio
- Servicio de Hematología y Oncología Médica, Hospital Universitario Morales Meseguer, Centro Regional de Hemodonación, University of Murcia, Biomedical Research Institute of Murcia, CB15/00055-CIBERER, Murcia, Spain
| | - José Padilla
- Servicio de Hematología y Oncología Médica, Hospital Universitario Morales Meseguer, Centro Regional de Hemodonación, University of Murcia, Biomedical Research Institute of Murcia, CB15/00055-CIBERER, Murcia, Spain
| | - Antonia Miñano
- Servicio de Hematología y Oncología Médica, Hospital Universitario Morales Meseguer, Centro Regional de Hemodonación, University of Murcia, Biomedical Research Institute of Murcia, CB15/00055-CIBERER, Murcia, Spain
| | - Rosa Cifuentes-Riquelme
- Servicio de Hematología y Oncología Médica, Hospital Universitario Morales Meseguer, Centro Regional de Hemodonación, University of Murcia, Biomedical Research Institute of Murcia, CB15/00055-CIBERER, Murcia, Spain
| | - Vicente Vicente
- Servicio de Hematología y Oncología Médica, Hospital Universitario Morales Meseguer, Centro Regional de Hemodonación, University of Murcia, Biomedical Research Institute of Murcia, CB15/00055-CIBERER, Murcia, Spain
| | - Maria L. Lozano
- Servicio de Hematología y Oncología Médica, Hospital Universitario Morales Meseguer, Centro Regional de Hemodonación, University of Murcia, Biomedical Research Institute of Murcia, CB15/00055-CIBERER, Murcia, Spain
| | - Stefan J. Marciniak
- Cambridge Institute for Medical Research, University of Cambridge, Cambridge, United Kingdom
| | - Maria Eugenia de la Morena-Barrio
- Servicio de Hematología y Oncología Médica, Hospital Universitario Morales Meseguer, Centro Regional de Hemodonación, University of Murcia, Biomedical Research Institute of Murcia, CB15/00055-CIBERER, Murcia, Spain
| | - Javier Corral
- Servicio de Hematología y Oncología Médica, Hospital Universitario Morales Meseguer, Centro Regional de Hemodonación, University of Murcia, Biomedical Research Institute of Murcia, CB15/00055-CIBERER, Murcia, Spain
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Yu H, Gai X, Wang J, Zhuang J, Guo W, Qiao R, Zhu H, Sun Y. Missense mutation of SERPINC1 (p.Ser426Leu) in a young patient presenting as refractory and recurrent venous thromboembolism: A case report. Front Cardiovasc Med 2022; 9:903785. [PMID: 36093136 PMCID: PMC9448915 DOI: 10.3389/fcvm.2022.903785] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 06/28/2022] [Indexed: 11/13/2022] Open
Abstract
Genetic and acquired risk factors are extremely important mechanisms in the development of venous thromboembolism (VTE). Inherited antithrombin (AT) deficiency due to mutations in the SERPINC1 gene is a well-known risk factor for genetic thrombophilia. In this case, we reported a 28-year young abroad student who presented with refractory and recurrent VTE in-hospital. This patient presented with a 2-month history of right lower limb pain and 1 week of fever. The ultrasound showed deep venous thrombosis in the right common and superficial femoral veins. The CTPA confirmed acute pulmonary embolism with multiple filling defects in both pulmonary arteries. He was diagnosed with “pulmonary embolism, pneumonia, lower extremity venous thrombosis”. The level of serum antithrombin was normal, yet gene sequencing revealed a heterozygous missense mutation of SERPINC1, c.1277C>T (p.Ser426Leu). The patient underwent anticoagulant therapy of heparin and inferior vena cava filter implantation. The patient had undergone recurrent VTE despite adequate anticoagulation with heparin during the first 2 weeks. The swelling, pain, and thrombosis of lower extremity veins got resolved from warfarin and rivaroxaban. Inherited antithrombin deficiency due to mutations in the SERPINC1 gene is the genetic basis of this patient, and warfarin/rivaroxaban, other than heparin, is beneficial.
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Affiliation(s)
- Haixu Yu
- Department of Pulmonary and Critical Care Medicine, Peking University Third Hospital, Beijing, China
- National Health Commission (NHC) Key Laboratory of Cardiovascular Molecular Biology and Regulatory Peptides, Key Laboratory of Molecular Cardiovascular Science, Ministry of Education, Beijing Key Laboratory of Cardiovascular Receptors Research, Department of Cardiology and Institute of Vascular Medicine, Peking University Third Hospital, Beijing, China
| | - Xiaoyan Gai
- Department of Pulmonary and Critical Care Medicine, Peking University Third Hospital, Beijing, China
| | - Jianli Wang
- Department of Pulmonary and Critical Care Medicine, Peking University Third Hospital, Beijing, China
| | - Jinman Zhuang
- Department of Interventional Vascular Surgery, Peking University Third Hospital, Beijing, China
| | - Wanwan Guo
- Department of Laboratory Medicine, Peking University Third Hospital, Beijing, China
| | - Rui Qiao
- Department of Laboratory Medicine, Peking University Third Hospital, Beijing, China
| | - Hong Zhu
- Department of Pulmonary and Critical Care Medicine, Peking University Third Hospital, Beijing, China
| | - Yongchang Sun
- Department of Pulmonary and Critical Care Medicine, Peking University Third Hospital, Beijing, China
- *Correspondence: Yongchang Sun
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8
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Antithrombin deficiency: no sugar, no diagnosis! Blood 2022; 140:83-85. [PMID: 35834281 DOI: 10.1182/blood.2022016677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 04/20/2022] [Indexed: 11/20/2022] Open
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9
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Kim S, Lee WJ, Moon J, Jung KH. Utility of the SERPINC1 Gene Test in Ischemic Stroke Patients With Antithrombin Deficiency. Front Neurol 2022; 13:841934. [PMID: 35720094 PMCID: PMC9203840 DOI: 10.3389/fneur.2022.841934] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 05/09/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveAntithrombin (AT) plays a critical role in the coagulation system, and its deficiency induces hypercoagulability. AT deficiency is caused not only by inherited variants in the SERPINC1 gene but also by acquired conditions. Therefore, AT deficiency alone could not ensure the presence of the SERPINC1 mutation. We evaluated the utility of the SERPINC1 gene test in ischemic stroke, an important clinical type of arterial thrombosis.MethodsThis retrospective, observational study investigated symptomatic patients who underwent the SERPINC1 gene test because of decreased AT activity (<80%) during 2009-2021 at a tertiary hospital. For the detection of sequence variants in the SERPINC1 gene, direct Sanger sequencing and multiplex ligation-dependent probe amplification were performed. The phenotypes of patients with SERPINC1 gene mutations were examined, and the conditions associated with the pathogenic variants were analyzed.ResultsIn our cohort (n = 19), 13 of 19 patients (68.4%) had the pathogenic variant of the SERPINC1 gene. Ischemic stroke (n = 7) was significantly associated with the pathogenic variants (p = 0.044), and the pathogenicity detection rate was 100%. For any kind of arterial thrombosis (n = 8), the detection rate of the pathogenic variant was 87.5%, but was not statistically significant (p = 0.177). The detection rates of the pathogenic variant in ischemic stroke or arterial thrombosis groups were both higher than those in the venous thrombosis-only group (54.5%).ConclusionThe SERPINC1 gene test was useful in determining the cause of AT deficiency-related arterial thrombosis, especially ischemic stroke. We propose the diagnostic flow of SERPINC1-related ischemic stroke.
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Affiliation(s)
- Seondeuk Kim
- Department of Neurology, Seoul National University Hospital, Seoul, South Korea
| | - Woo-Jin Lee
- Department of Neurology, Seoul National University Hospital, Seoul, South Korea
| | - Jangsup Moon
- Department of Neurology, Seoul National University Hospital, Seoul, South Korea
- Department of Genomic Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Keun-Hwa Jung
- Department of Neurology, Seoul National University Hospital, Seoul, South Korea
- Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
- *Correspondence: Keun-Hwa Jung
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Two SERPINC1 variants affecting N-glycosylation of Asn224 cause severe thrombophilia not detected by functional assays. Blood 2022; 140:140-151. [PMID: 35486842 DOI: 10.1182/blood.2021014708] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 04/08/2022] [Indexed: 11/20/2022] Open
Abstract
Antithrombin deficiency, the most severe congenital thrombophilia, might be underestimated, as some pathogenic variants are not detected by routine functional methods. We have identified two new SERPINC1 variants, p.Glu227Lys and p.Asn224His, in four unrelated thrombophilic patients with early and recurrent thrombosis that had normal antithrombin activity. In one case, the mutation was identified by whole genome sequencing, while in the 3 remaining cases, the mutation was identified by sequencing SERPINC1 based on a single functional positive finding supporting deficiency. The two variants shared a common functional defect, an impaired or null N-glycosylation of Asn224 according to a eukaryotic expression model. Carriers had normal anti-FXa or anti-FIIa activities, but impaired anti-FVIIa activity and a detectable loss of inhibitory function when incubating the plasma 1 hour at 41ºC. Moreover, the beta glycoform of the variants, lacking two N-glycans, had reduced secretion, increased heparin affinity, no inhibitory activity, and a potential dominant negative effect. These results explain the increased thrombin generation observed in carriers. Mutation experiments reflected the role that Lysine residues close to the N-glycosylation sequon have in impairing the efficacy of N-glycosylation. Our study shows new elements involved in the regulation of N-glycosylation, a key post-translational modification that, according to our results affects folding, secretion and function, providing new evidence of the pathogenic consequence of an incorrect N-glycosylation of antithrombin. This study supports that antithrombin deficiency is underestimated and encourages the development of new functional and genetic tests to diagnose this severe thrombophilia.
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