1
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Liu W, Xie S, Liang T, Chang F, Liu M, Zhai Z. Clinical and imaging risk factors for the persistence of thromboembolism following acute pulmonary embolism. Quant Imaging Med Surg 2022; 12:4047-4058. [PMID: 35919067 PMCID: PMC9338360 DOI: 10.21037/qims-21-753] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 05/05/2022] [Indexed: 11/28/2022]
Abstract
Background Predicting the progression of acute pulmonary embolism to chronic pulmonary thromboembolism (CPTE) disease is essential to monitoring and improving the long-term prognosis of pulmonary embolism. We explored the risk factors for chronic persistence of thromboembolism after acute pulmonary embolism. Methods Cases with newly onset acute pulmonary embolism in the China-Japan Friendship Hospital from November 2016 to November 2019 were retrospectively analyzed. The clinical characteristics, serological examination results, and treatment strategies of acute pulmonary embolism patients were obtained through the electronic medical record system (Goodwill E-Health Info Co., Ltd.). Imaging parameters on computed tomography pulmonary angiography (CTPA) images at the onset of the acute pulmonary embolism were measured and counted. Notably, we propose a new parameter based on CTPA images: the ratio of Sd (sum of residual segmental pulmonary artery diameter) to MPAd (the main pulmonary artery diameter) (Sd/MPAd). After 3 months of regular treatment for acute pulmonary embolism, patients were classified into a CPTE group or a non-CPTE group based on the presence of residual embolus. All data were compared between the CPTE group and non-CPTE group. Furthermore, logistic regression analysis was used to investigate risk factors for the progression of acute pulmonary embolism to CPTE. Results A total of 77 cases (male:female = 1:1.26) were included in the study. There were 43 cases (55.84%) in the CPTE group and 34 cases in the non-CPTE group (44.16%). The results of univariate analysis showed that there were statistically significant differences between the 2 groups in risk stratification (χ2=8.043; P=0.005), protein S activity (χ2=5.551; P=0.018), the ratio of sum of residual segmental pulmonary artery diameter to the main pulmonary artery diameter (Sd/MPAd; t=–2.103; P=0.039), Mastora score (U=362.500; P<0.001), and embolus location (χ2=16.969; P<0.001). However, there were no statistically significant differences between the 2 groups in treatment options (P=0.381). According to multivariate logistic-regression analysis, protein S activity <55% (P=0.025), Sd/MPAd ≥1.97 (P=0.011), and an embolus being located in the central pulmonary artery (P<0.001) were independent risk factors for chronic persistence of thromboembolism following acute pulmonary embolism. Conclusions The protein S activity, location of the embolus, and Sd/MPAd on CTPA at the onset of acute pulmonary embolism may suggest the progression of acute pulmonary embolism to CPTE.
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Affiliation(s)
- Weifang Liu
- Department of Radiology, Civil Aviation General Hospital, Beijing, China
| | - Sheng Xie
- Department of Radiology, China-Japan Friendship Hospital, Beijing, China
| | - Tian Liang
- Department of Radiology, China-Japan Friendship Hospital, Beijing, China
| | - Feiyan Chang
- Department of Radiology, China-Japan Friendship Hospital, Beijing, China
| | - Min Liu
- Department of Radiology, China-Japan Friendship Hospital, Beijing, China
| | - Zhenguo Zhai
- Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Beijing, China
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2
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Wu Y, Liu J, Zeng W, Hu B, Hu Y, Tang LV. Protein S Deficiency and the Risk of Venous Thromboembolism in the Han Chinese Population. Front Cardiovasc Med 2022; 8:796755. [PMID: 35815065 PMCID: PMC9260107 DOI: 10.3389/fcvm.2021.796755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Accepted: 12/13/2021] [Indexed: 11/13/2022] Open
Abstract
Plasma levels of the anticoagulant cofactor protein S and PROS1 mutation are reported to impart increased risk of thromboembolism in European and south east Asian populations, but the relationship is not yet documented in Han Chinese in population-based study. Therefore, we undertook a case-control study of this relationship among patients with venous thromboembolism, and probed the genetic factors contributing to low protein S deficiency. Among the 603 consecutively recruited venous thromboembolism patients, 51 (8.5%) proved to be deficient in free protein S antigen (lower than 38.6 U/dl), among whom 30 cases were identified to have a causative mutation by direct sequencing. In contrast, six cases (1.0%) of the 584 healthy controls had low free antigen levels, among whom direct sequencing confirmed disease-causing gene mutations in four controls (0.7%). After adjusting for age and gender, the odds ratio of developing venous thromboembolism in individuals with protein S deficiency based on free protein S tests was 8.1 (95% CI = 3.6–19.9, P < 0.001). Gene sequencing yielded 24 different heterozygous mutations in the 34 participants, of which 13 were newly described. 17 (50%) of the 34 mutations in our study cohort occurred in exons 12 and 13, indicating the LGR2 domain to be a hotspot mutation region for the protein. These findings are conducive to the clinical application of protein S assays for the molecular diagnosis of thrombophilia.
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Affiliation(s)
- Yingying Wu
- Department of Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jingdi Liu
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Clinical and Research Centre of Thrombosis and Haemostasis, Wuhan, China
| | - Wei Zeng
- Department of Radiation and Medical Oncology, Zhongnan Hospital, Wuhan University, Wuhan, China
| | - Bei Hu
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Clinical and Research Centre of Thrombosis and Haemostasis, Wuhan, China
| | - Yu Hu
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Clinical and Research Centre of Thrombosis and Haemostasis, Wuhan, China
| | - Liang V Tang
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Clinical and Research Centre of Thrombosis and Haemostasis, Wuhan, China
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3
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Rollins-Raval MA, Mitsios JV, Marlar RA. Cost-Effective Use of the Protein S Algorithm in Thrombophilia Testing. J Appl Lab Med 2022; 7:794-802. [DOI: 10.1093/jalm/jfab175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 11/10/2021] [Indexed: 11/14/2022]
Abstract
Abstract
Background
One of the most complex risk factors for the laboratory assessment of thrombophilia is Protein S (PS). The testing algorithm for PS employs the plasma-based assays of free PS antigen, total PS antigen, and PS activity creating a complex diagnostic scheme that can lead to misdiagnosis if incorrectly used, and a potential waste of resources and money.
Content
This paper compares the recently published evidence-based algorithm from the International Society for Hemostasis and Thrombosis (ISTH) with several commonly performed nonevidence-based testing schemes, to demonstrate the efficiency of the evidence-based algorithm for diagnostic efficiency with improved patient care and increased cost savings for the laboratory.
Summary
Significant savings (31%–60%) can be realized when the evidence-based algorithm is used in place of other testing modalities of initial PS activity testing (31%) or testing with all 3 assays simultaneously (60%). This study utilizing the PS testing evidence-based algorithm as part of a thrombophilia evaluation demonstrates that the appropriate testing methods can be used to limit wasteful practices while achieving the maximum level of information in this time of limited resources and need for increase monetary savings.
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Affiliation(s)
- Marian A Rollins-Raval
- Department of Pathology, University of New Mexico Health Sciences Center, TriCore Reference Laboratories, Albuquerque, NM
| | | | - Richard A Marlar
- Department of Pathology, University of New Mexico Health Sciences Center, TriCore Reference Laboratories, Albuquerque, NM
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4
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Larsen OH, Kjaergaard AD, Hvas AM, Nissen PH. Genetic Variants in the Protein S ( PROS1 ) Gene and Protein S Deficiency in a Danish Population. TH OPEN 2021; 5:e479-e488. [PMID: 34729451 PMCID: PMC8553426 DOI: 10.1055/s-0041-1736636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 09/08/2021] [Indexed: 12/01/2022] Open
Abstract
Protein S (PS) deficiency is a risk factor for venous thromboembolism (VTE) and can be caused by variants of the gene encoding PS (
PROS1
). This study aimed to evaluate the clinical value of molecular analysis of the
PROS1
gene in PS-deficient participants. We performed Sanger sequencing of the coding region of the
PROS1
gene and multiplex ligation-dependent probe amplification to exclude large structural rearrangements. Free PS was measured by a particle-enhanced immunoassay, while PS activity was assessed by a clotting method.
A total of 87 PS-deficient participants and family members were included. In 22 index participants, we identified 13
PROS1
coding variants. Five variants were novel. In 21 index participants, no coding sequence variants or structural rearrangements were identified. The free PS level was lower in index participants carrying a
PROS1
variant compared with index participants with no variant (0.51 [0.32–0.61] vs. 0.62 [0.57–0.73] × 10
3
IU/L;
p
< 0.05). The p.(Thr78Met) variant was associated with only slightly decreased free PS levels (0.59 [0.53–0.66] × 10
3
IU/L) compared with the p.(Glu390Lys) variant (0.27 [0.24–0.37] × 10
3
IU/L,
p
< 0.01). The frequency of VTE in participants with a coding
PROS1
variant was 43 and 17% in the group with normal
PROS1
gene (
p
= 0.05).
In conclusion, we report 13
PROS1
coding variants including five novel variants. PS levels differ by
PROS1
variant and the frequency of VTE was higher when a coding
PROS1
variant was present. Hence, molecular analysis of the
PROS1
gene may add clinical value in the diagnostic work-up of PS deficiency.
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Affiliation(s)
- Ole Halfdan Larsen
- Department of Molecular Medicine, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Alisa D Kjaergaard
- Steno Diabetes Center Aarhus, Aarhus University Hospital, Aarhus, Denmark
| | - Anne-Mette Hvas
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Steno Diabetes Center Aarhus, Aarhus University Hospital, Aarhus, Denmark
| | - Peter H Nissen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
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5
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Platelet protein S limits venous but not arterial thrombosis propensity by controlling coagulation in the thrombus. Blood 2021; 135:1969-1982. [PMID: 32276277 DOI: 10.1182/blood.2019003630] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 03/02/2020] [Indexed: 12/22/2022] Open
Abstract
Anticoagulant protein S (PS) in platelets (PSplt) resembles plasma PS and is released on platelet activation, but its role in thrombosis has not been elucidated. Here we report that inactivation of PSplt expression using the Platelet factor 4 (Pf4)-Cre transgene (Pros1lox/loxPf4-Cre+) in mice promotes thrombus propensity in the vena cava, where shear rates are low, but not in the carotid artery, where shear rates are high. At a low shear rate, PSplt functions as a cofactor for both activated protein C and tissue factor pathway inhibitor, thereby limiting factor X activation and thrombin generation within the growing thrombus and ensuring that highly activated platelets and fibrin remain localized at the injury site. In the presence of high thrombin concentrations, clots from Pros1lox/loxPf4-Cre- mice contract, but not clots from Pros1lox/loxPf4-Cre+ mice, because of highly dense fibrin networks. Thus, PSplt controls platelet activation as well as coagulation in thrombi in large veins, but not in large arteries.
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6
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Marlar RA, Gausman JN, Tsuda H, Rollins-Raval MA, Brinkman HJM. Recommendations for clinical laboratory testing for protein S deficiency: Communication from the SSC committee plasma coagulation inhibitors of the ISTH. J Thromb Haemost 2021; 19:68-74. [PMID: 33405382 DOI: 10.1111/jth.15109] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Revised: 09/01/2020] [Accepted: 09/08/2020] [Indexed: 11/26/2022]
Abstract
Hereditary deficiencies of protein S (PS) increase the risk of venous thrombosis; however, assessing the plasma levels of PS can be difficult because of its complex physiological interactions in plasma, sample-related preanalytical variables, and numerous acquired disease processes. Reliable laboratory assays are essential for accurate evaluation of PS when diagnosing a congenital deficiency based on the plasma phenotype alone. This report presents the current evidence-based recommendations for clinical PS assays as well as when to test for PS abnormalities.
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Affiliation(s)
- Richard A Marlar
- Department of Pathology, TriCore Reference Laboratories, University of New Mexico, Albuquerque, NM, USA
| | - Jana N Gausman
- OU Medicine, Inc, Laboratory, University of Oklahoma Medical Center, Oklahoma City, OK, USA
| | - Hiroko Tsuda
- Department of Nutritional Sciences, Nakamura Gakuen University, Fukuoka, Japan
| | - Marian A Rollins-Raval
- Department of Pathology, TriCore Reference Laboratories, University of New Mexico, Albuquerque, NM, USA
| | - Herm Jan M Brinkman
- Department of Molecular and Cellular Hemostasis, Sanquin Research, Amsterdam, The Netherlands
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7
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Chan NCN, Cheng CK, Chan KCF, Wong CML, Lau KM, Kwong JHY, Chan NPH, Wong WS, Chow EYD, Wong MLG, Chu RW, Ip RKL, Ng MHL. Distinctive regional-specific PROS1 mutation spectrum in Southern China. J Thromb Thrombolysis 2018; 46:120-124. [PMID: 29748776 DOI: 10.1007/s11239-018-1660-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Nelson C N Chan
- Blood Cancer Cytogenetics and Genomics Laboratory, Department of Anatomical and Cellular Pathology, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong Sar, Hong Kong
| | - Chi-Keung Cheng
- Blood Cancer Cytogenetics and Genomics Laboratory, Department of Anatomical and Cellular Pathology, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong Sar, Hong Kong
| | - Kelvin C F Chan
- Department of Pathology, Princess Margaret Hospital, Kwai Chung, Hong Kong
| | - Connie M L Wong
- Blood Cancer Cytogenetics and Genomics Laboratory, Department of Anatomical and Cellular Pathology, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong Sar, Hong Kong
| | - Kin-Mang Lau
- Blood Cancer Cytogenetics and Genomics Laboratory, Department of Anatomical and Cellular Pathology, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong Sar, Hong Kong
| | - Joyce H Y Kwong
- Department of Pathology, Princess Margaret Hospital, Kwai Chung, Hong Kong
| | - Natalie P H Chan
- Blood Cancer Cytogenetics and Genomics Laboratory, Department of Anatomical and Cellular Pathology, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong Sar, Hong Kong
| | - Wai-Shan Wong
- Department of Pathology, Queen Elizabeth Hospital, Yau Ma Tei, Hong Kong
| | - Eudora Y D Chow
- Department of Pathology, United Christian Hospital, Kwun Tong, Hong Kong
| | - Michael L G Wong
- Department of Pathology, Princess Margaret Hospital, Kwai Chung, Hong Kong
| | - Raymond W Chu
- Department of Clinical Pathology, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong
| | - Rosalina K L Ip
- Blood Cancer Cytogenetics and Genomics Laboratory, Department of Anatomical and Cellular Pathology, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong Sar, Hong Kong
| | - Margaret H L Ng
- Blood Cancer Cytogenetics and Genomics Laboratory, Department of Anatomical and Cellular Pathology, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong Sar, Hong Kong.
- State Key Laboratory in Oncology in South China, The Chinese University of Hong Kong, Shatin, Hong Kong.
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8
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Huang X, Xu F, Assa CR, Shen L, Chen B, Liu Z. Recurrent pulmonary embolism associated with deep venous thrombosis diagnosed as protein s deficiency owing to a novel mutation in PROS1: A case report. Medicine (Baltimore) 2018; 97:e0714. [PMID: 29742732 PMCID: PMC5959418 DOI: 10.1097/md.0000000000010714] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
RATIONALE Protein S (PS) deficiency that can be inherited or acquired is an independent risk factor for venous thromboembolism (VTE). PATIENT CONCERNS In this report, we present a case of recurrent pulmonary embolism (PE) and deep venous thrombosis (DVT) due to PS deficiency. DIAGNOSES A 32-year-old male patient with significant decrease in PS activity was detected by laboratory tests. Genetic examination of the PROS1 gene showed a transition of G to T in exon 14 (c.1792 G>T, p.E598X), which was a paternal inherited heterozygous G1792T substitution in the laminin G-type repeat domain, generating a premature stop codon at Glu598. INTERVENTIONS We considered that the inherited PS deficiency due to a PROS1 gene mutation may associate with recurrent VTE. The patient was suggested to have an extended anticoagulant therapy to avoid a severe VTE event. OUTCOMES The patient was discharged home with continued oral anticoagulants and was still seen in clinic for follow-up. LESSONS It is necessary for the young patient with recurrent idiopathic thrombosis to perform an inherited PS deficiency test and receive anticoagulant therapy for an extended period.
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Affiliation(s)
| | - Fangfang Xu
- Department of Radiology, the Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou
| | | | - Laigen Shen
- Department of Vascular Surgery, the Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Bing Chen
- Department of Vascular Surgery, the Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Zhenjie Liu
- Department of Vascular Surgery, the Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
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9
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Gene analysis of six cases of congenital protein S deficiency and functional analysis of protein S mutations (A139V, C449F, R451Q, C475F, A525V and D599TfsTer13). Thromb Res 2016; 151:8-16. [PMID: 28088608 DOI: 10.1016/j.thromres.2016.12.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2016] [Revised: 12/07/2016] [Accepted: 12/21/2016] [Indexed: 11/22/2022]
Abstract
Congenital deficiency of protein S (PS), an anticoagulant factor, leads to venous thrombosis, with onset predominantly beginning in adolescence. In the present study, gene analysis of six unrelated Japanese families diagnosed with congenital PS deficiency identified five missense mutations in the PROS1 gene - c.757C>T (Ala139Val; A139V), c.1346 G>T (Cys449Phe; C449F), c.1352G>A (Arg451Gln; R451Q), c.1424G>T (Cys475Phe; C475F) and c.1574C>T (Ala525Val; A525V) - and one frameshift mutation, c.2135delA (Asp599ThrfsTer13; D599TfsTer13). C449F, R451Q, A525V and D599TfsTer13 are novel mutations. Results from ELISA to measure PS antigen levels in culture supernatant showed that the A139V variant was similar to wild-type, but other variants showed reductions when compared with wild-type. Results from pulse-chase analysis confirmed that the A139V variant exhibited secretion equivalent to wild-type, but for the other variants, there was no extracellular secretion, and it had nearly all been degraded inside the cell within six hours. Results from pulse-chase analysis using proteasome inhibitors also showed that intracellular degradation of mutant protein was inhibited. Activity of the A139V variant was decreased to 71% of wild-type, and the phospholipid binding capacity fell to as low as 45%. These results suggest that although the A139V variant has normal secretion, it has abnormal phospholipid binding capacity, and therefore causes type II PS deficiency, in which PS activity is decreased. It is also thought that with the other variants, misfolding due to amino acid mutations causes nearly all PS to be degraded intracellularly, therefore leading to type I PS deficiency.
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10
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WANG ZHAOHUI, ZHAO ZHIJUN, XU KANG, SUN GUOBING, SONG LIN, YIN HONGXIANG, CHEN XIAOQI. Hereditary protein S deficiency leads to ischemic stroke. Mol Med Rep 2015; 12:3279-3284. [PMID: 25997409 PMCID: PMC4526054 DOI: 10.3892/mmr.2015.3793] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2014] [Accepted: 04/10/2015] [Indexed: 11/05/2022] Open
Abstract
Hereditary protein S (PS) deficiency is an independent risk factor for venous thromboembolism. However, the correlation between PS and arterial thrombotic disease, such as cerebral thrombosis, is not clear. The present study focused on the molecular mechanisms underlying ischemic stroke caused by a PS gene mutation in one family. The activity of antithrombin, protein C and PS in the plasma of the proband was measured, and the genes encoding PS were amplified and sequenced. The cellular localization and expression of PS were analyzed in HEK‑293 cells. The proband was a 50‑year‑old male. Plasma PS activity of the proband was 38.9%, which was significantly decreased compared with normal levels. Sequencing analysis revealed a PROS1 c.1486_1490delGATTA mutation on exon 12. This frameshift mutation converts Asp496 in the precursor PS into the termination codon. In addition, the PROS1 mutation was correlated with low PS activity in the family. Functional tests revealed that the mutant protein aggregated in the cytoplasm and its secretion and expression decreased. In conclusion, protein S mutation appeared to be the primary cause of thrombosis in the family of the present study. However, the correlation between PS deficiency and ischemic stroke requires further investigation.
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Affiliation(s)
- ZHAO-HUI WANG
- Department of Neurology, Hanyang Hospital, Wuhan University of Science and Technology, Wuhan, Hubei 430050, P.R. China
| | - ZHI-JUN ZHAO
- Department of Ultrasonic Diagnosis and Interventional Therapy, The First Hospital Affiliated to Henan University, Kaifeng, Henan 475001, P.R. China
| | - KANG XU
- Department of Neurology, Xinhua Hospital of Hubei, Wuhan, Hubei 430015, P.R. China
| | - GUO-BING SUN
- Department of Neurology, Xinhua Hospital of Hubei, Wuhan, Hubei 430015, P.R. China
| | - LIN SONG
- Department of Neurology, Xinhua Hospital of Hubei, Wuhan, Hubei 430015, P.R. China
| | - HONG-XIANG YIN
- Department of Neurology, Xinhua Hospital of Hubei, Wuhan, Hubei 430015, P.R. China
| | - XIAO-QI CHEN
- Department of Neurology, Xinhua Hospital of Hubei, Wuhan, Hubei 430015, P.R. China
- Correspondence to: Mr. Xiao-Qi Chen, Department of Neurology, Xinhua Hospital of Hubei, 11 Lingjiaohu Road, Wuhan, Hubei 430015, P.R. China, E-mail:
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11
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Nakashima MO, Rogers HJ. Hypercoagulable states: an algorithmic approach to laboratory testing and update on monitoring of direct oral anticoagulants. Blood Res 2014; 49:85-94. [PMID: 25025009 PMCID: PMC4090343 DOI: 10.5045/br.2014.49.2.85] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2014] [Revised: 06/17/2014] [Accepted: 06/19/2014] [Indexed: 12/19/2022] Open
Abstract
Hypercoagulability can result from a variety of inherited and, more commonly, acquired conditions. Testing for the underlying cause of thrombosis in a patient is complicated both by the number and variety of clinical conditions that can cause hypercoagulability as well as the many potential assay interferences. Using an algorithmic approach to hypercoagulability testing provides the ability to tailor assay selection to the clinical scenario. It also reduces the number of unnecessary tests performed, saving cost and time, and preventing potential false results. New oral anticoagulants are powerful tools for managing hypercoagulable patients; however, their use introduces new challenges in terms of test interpretation and therapeutic monitoring. The coagulation laboratory plays an essential role in testing for and treating hypercoagulable states. The input of laboratory professionals is necessary to guide appropriate testing and synthesize interpretation of results.
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Affiliation(s)
- Megan O Nakashima
- Department of Laboratory Medicine, Cleveland Clinic, Cleveland, OH, United States
| | - Heesun J Rogers
- Department of Laboratory Medicine, Cleveland Clinic, Cleveland, OH, United States
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12
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Protein S levels and the risk of venous thrombosis: results from the MEGA case-control study. Blood 2013; 122:3210-9. [DOI: 10.1182/blood-2013-04-499335] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Key PointsLow free protein S and low total protein S levels could not identify subjects at risk for venous thrombosis in a population-based study. Protein S testing and subsequent testing on PROS1 mutations should not be considered in unselected patients with venous thrombosis.
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13
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Tang L, Jian XR, Hamasaki N, Guo T, Wang HF, Lu X, Wang QY, Hu Y. Molecular basis of protein S deficiency in China. Am J Hematol 2013; 88:899-905. [PMID: 23813890 DOI: 10.1002/ajh.23525] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2013] [Revised: 06/18/2013] [Accepted: 06/20/2013] [Indexed: 11/07/2022]
Abstract
Protein S (ProS) is a physiological inhibitor of coagulation with an important function in the down-regulation of thrombin generation. ProS deficiency is a major risk factor for venous thrombosis. This study enrolled 40 ProS-deficient probands to investigate the molecular basis of hereditary ProS deficiency in Chinese patients. A mutation analysis was performed by resequencing the PROS1 gene. Large deletions were identified by multiplex ligation-dependent probe amplification (MLPA) analysis. A total of 20 different mutations, including 15 novel mutations, were identified in 21 of the 40 index probands. Small mutations were detected in 18 (45.0%) probands, and large deletions were found in 3 (7.5%) probands, leaving 19 (47.5%) patients without causative variants. To evaluate the functional consequences of 2 novel missense variants, ex vivo thrombin-generation assays, bioinformatics tools, and in vitro expression studies were employed. The p.Asn365Lys ProS variant was found to have moderately impaired secretion and reduced activated protein C cofactor activity. In contrast, the p.Pro410His mutant appeared to have severely impaired secretion but full anticoagulant activity. This study is the largest investigation of ProS deficiency in China and the first investigation of the influence of Type I ProS missense mutations on the global level of coagulation function. The p.K196E mutation, which is common in the neighboring Japanese population, was not found in our Chinese population, and null mutations were common in our Chinese population but not common in Japan. Further genetic analysis is warranted to understand the causes of ProS deficiency in patients without a genetic explanation.
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Affiliation(s)
- Liang Tang
- Institute of Hematology; Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan; Hubei China
- Hubei Clinical and Research Center of Thrombosis and Haemostasis, Wuhan; Hubei China
- Targeted Biotherapy Key Laboratory of Ministry of Education, Wuhan; Hubei China
| | - Xiao-Rong Jian
- Institute of Hematology; Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan; Hubei China
- Hubei Clinical and Research Center of Thrombosis and Haemostasis, Wuhan; Hubei China
- Targeted Biotherapy Key Laboratory of Ministry of Education, Wuhan; Hubei China
| | - Naotaka Hamasaki
- Department of Pharmaceutical Science; Nagasaki International University, 2825-7 Huis Ten Bosch Sasebo; Nagasaki Japan
| | - Tao Guo
- Institute of Hematology; Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan; Hubei China
- Hubei Clinical and Research Center of Thrombosis and Haemostasis, Wuhan; Hubei China
- Targeted Biotherapy Key Laboratory of Ministry of Education, Wuhan; Hubei China
| | - Hua-Fang Wang
- Institute of Hematology; Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan; Hubei China
- Hubei Clinical and Research Center of Thrombosis and Haemostasis, Wuhan; Hubei China
- Targeted Biotherapy Key Laboratory of Ministry of Education, Wuhan; Hubei China
| | - Xuan Lu
- Institute of Hematology; Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan; Hubei China
- Hubei Clinical and Research Center of Thrombosis and Haemostasis, Wuhan; Hubei China
- Targeted Biotherapy Key Laboratory of Ministry of Education, Wuhan; Hubei China
| | - Qing-Yun Wang
- Institute of Hematology; Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan; Hubei China
- Hubei Clinical and Research Center of Thrombosis and Haemostasis, Wuhan; Hubei China
- Targeted Biotherapy Key Laboratory of Ministry of Education, Wuhan; Hubei China
| | - Yu Hu
- Institute of Hematology; Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan; Hubei China
- Hubei Clinical and Research Center of Thrombosis and Haemostasis, Wuhan; Hubei China
- Targeted Biotherapy Key Laboratory of Ministry of Education, Wuhan; Hubei China
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Lind-Halldén C, Dahlen A, Hillarp A, Zöller B, Dahlbäck B, Halldén C. Small and large PROS1 deletions but no other types of rearrangements detected in patients with protein S deficiency. Thromb Haemost 2012; 108:94-100. [PMID: 22627709 DOI: 10.1160/th12-01-0040] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2012] [Accepted: 04/19/2012] [Indexed: 11/05/2022]
Abstract
Protein S deficiency is a dominantly inherited disorder that results from mutations in the PROS1 gene. Previous sequencing of the gene failed to detect mutations in eight out of 18 investigated Swedish families, whereas segregation analyses detected large deletions in three out of the eight families. The present study investigates more thoroughly for the presence of deletions but also for other types of rearrangements. FISH analysis confirmed the existence of the three previously identified large deletions, but failed to identify any other type of rearrangement among the eight analysed families. MLPA analysis of the PROS1 gene revealed two smaller deletions covering two and four exons, respectively. Thus, deletions could be found in five out of eight families where no point mutations could be found despite sequencing of the gene. Twelve additional, not previously analysed, families were subsequently analysed using MLPA. The analysis identified two smaller deletions (3 and 4 exons). Including all PS-deficient families, i.e. also the 10 families where sequencing found a causative point mutation, deletions were identified in seven out of 30 PS-deficient families. A strategy of sequencing followed by MLPA analysis in mutation-negative families identified the causative mutation in 15 out of 18 of Swedish PS-deficient families. Most deletions were different as determined by their sizes, locations and flanking haplotypes. FISH (8 families) and MLPA analysis (20 families) failed to identify other types of rearrangements.
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15
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Duebgen S, Kauke T, Marschall C, Giebl A, Lison S, Hart C, Dick A, Spannagl M. Genotype and laboratory and clinical phenotypes of protein s deficiency. Am J Clin Pathol 2012; 137:178-84. [PMID: 22261441 DOI: 10.1309/ajcp40uxnbtxgkux] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
Abstract
The diagnosis of thrombophilia caused by protein S deficiency remains difficult. From 2005 to 2010, we documented 135 patients with suspected hereditary protein S deficiency for whom mutational analysis of the PROS1 gene had been performed by direct double-stranded sequencing of the amplified 15 exons including splice sites. Multiplex ligation-dependent probe amplification was performed on 12 of 15 exons in cases with no mutation found but a large deletion in the PROS1 gene was suspected. Mutations were identified in 49 patients, 9 by familial screening. Altogether, 17 new and 11 previously described mutations of PROS1 were identified among the 49 patients. After the exclusion of acquired protein S deficiency due to pregnancy or hormonal contraceptives, there remained only 1 case with protein S activity levels less than 40% that could not be explained by sequence variations or deletions in the examined regions of the PROS1 gene. After the exclusion of conditions associated with acquired protein S deficiency, persistently low protein S activity levels are highly indicative of a genetic alteration in PROS1. We observed a clear correlation between the laboratory phenotype and the type of mutation.
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Mulder R, ten Kate MK, Kluin-Nelemans HC, Mulder AB. PROS1 Heerlen polymorphism is associated with increased free plasma tissue factor pathway inhibitor levels. Thromb Haemost 2012; 107:594-6. [PMID: 22273984 DOI: 10.1160/th11-08-0549] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2011] [Accepted: 12/05/2011] [Indexed: 11/05/2022]
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Abstract
Heterozygous deficiency of Protein S (PS) increases the risk for developing thrombosis. Many acquired conditions alter plasma PS levels. These complex interactions of PS in plasma make it imperative that clinical PS assay limitations are understood so that the assays are reliable, reproducible and specific to diagnose true genetic abnormalities based on plasma phenotype alone. Unfortunately, the diagnosis of PS deficiency is difficult and complicated. Three basic assays can be utilized for assessing PS in plasma: PS activity assay, Free PS antigen assay, and Total PS antigen assay. This article will review these clinical assays and their associated problems. We also discuss the confounding and interfering factors that make it difficult to obtain an accurate diagnosis of PS deficiency.
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Affiliation(s)
- Richard A Marlar
- Pathology and Laboratory Medicine Service, Oklahoma City VA Medical Center, Oklahoma City, OK, USA.
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19
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Associations between high factor VIII and low free protein S levels with traditional arterial thrombotic risk factors and their risk on arterial thrombosis: Results from a retrospective family cohort study. Thromb Res 2010; 126:e249-54. [DOI: 10.1016/j.thromres.2010.07.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2010] [Revised: 06/03/2010] [Accepted: 07/19/2010] [Indexed: 12/20/2022]
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Castoldi E, Maurissen LFA, Tormene D, Spiezia L, Gavasso S, Radu C, Hackeng TM, Rosing J, Simioni P. Similar hypercoagulable state and thrombosis risk in type I and type III protein S-deficient individuals from families with mixed type I/III protein S deficiency. Haematologica 2010; 95:1563-71. [PMID: 20421270 DOI: 10.3324/haematol.2010.021923] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Protein S, which circulates in plasma in both free and bound forms, is an anticoagulant protein that stimulates activated protein C and tissue factor pathway inhibitor. Hereditary type I protein S deficiency (low total and low free protein S) is a well-established risk factor for venous thrombosis, whereas the thrombosis risk associated with type III deficiency (normal total and low free protein S) has been questioned. DESIGN AND METHODS Kaplan-Meier analysis was performed on 242 individuals from 30 families with protein S deficiency. Subjects were classified as normal, or having type I or type III deficiency according to their total and free protein S levels. Genetic and functional studies were performed in 23 families (132 individuals). RESULTS Thrombosis-free survival was not different between type I and type III protein S-deficient individuals. Type III deficient individuals were older and had higher protein S, tissue factor pathway inhibitor and prothrombin levels than type I deficient individuals. Thrombin generation assays sensitive to the activated protein C- and tissue factor pathway inhibitor-cofactor activities of protein S revealed similar hypercoagulable states in type I and type III protein S-deficient plasma. Twelve PROS1 mutations and two large deletions were identified in the genetically characterized families. CONCLUSIONS Not only type I, but also type III protein S deficiency is associated with a hypercoagulable state and increased risk of thrombosis. These findings may, however, be restricted to type III deficient individuals from families with mixed type I/III protein S deficiency, as these represented 80% of type III deficient individuals in our cohort.
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Affiliation(s)
- Elisabetta Castoldi
- Department of Biochemistry, Maastricht University P.O. Box 616, 6200 Maastricht, The Netherlands.
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21
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Bereczky Z, Kovács KB, Muszbek L. Protein C and protein S deficiencies: similarities and differences between two brothers playing in the same game. Clin Chem Lab Med 2010; 48 Suppl 1:S53-66. [DOI: 10.1515/cclm.2010.369] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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23
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Yoo JH, Kim HJ, Maeng HY, Kim YA, Sun YK, Song JW, Choi JR, Kim SH, Lee KA. Hereditary protein S deficiency from a novel large deletion mutation of the PROS1 gene detected by multiplex ligation-dependent probe amplification (MLPA). Thromb Res 2009; 123:793-5. [DOI: 10.1016/j.thromres.2008.12.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2008] [Revised: 11/25/2008] [Accepted: 12/05/2008] [Indexed: 11/15/2022]
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Clinical relevance of decreased free protein S levels: results from a retrospective family cohort study involving 1143 relatives. Blood 2008; 113:1225-30. [PMID: 18945960 DOI: 10.1182/blood-2008-08-174128] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Conflicting data have been reported on the risk for venous thrombosis in subjects with low free protein S levels. We performed a post-hoc analysis in a single-center retrospective thrombophilic family cohort, to define the optimal free protein S level that can identify subjects at risk for venous thrombosis. Relatives (1143) were analyzed. Relatives with venous thrombosis (mean age 39 years) had lower free protein S levels than relatives without venous thrombosis (P < .001), which was most pronounced in the lowest quartile. Only relatives with free protein S levels less than the 5th percentile (< 41 IU/dL) or less than the 2.5th percentile (< 33 IU/dL) were at higher risk of first venous thrombosis compared with the upper quartile (> 91 IU/dL); annual incidence 1.20% (95% confidence interval [CI], 0.72-1.87) and 1.81% (95% CI, 1.01-2.99), respectively; adjusted hazard ratios 5.6, (95% CI, 2.7-11.5) and 11.3 (95% CI, 5.4-23.6). Recurrence rates were 12.12% (95 CI, 5.23-23.88) and 12.73% (95% CI, 5.12-26.22) per year; adjusted hazard ratios were 3.0 (95% CI, 1.03-8.5) and 3.4 (95% CI, 1.1-10.3). In conclusion, free protein S level can identify young subjects at risk for venous thrombosis in thrombophilic families, although the cutoff level lies far below the normal range in healthy volunteers.
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Abstract
Protein S (PS) is an extensively studied protein with an important function in the down-regulation of thrombin generation. Because of the presence of a pseudogene and two different forms of PS in plasma, a bound and a free form, it is one of the most difficult thrombophilias to study. A deficiency of PS predisposes subjects to (recurrent) venous thromboembolism (VTE) and foetal loss. However, the conundrum of diagnosing PS deficiency has led to conflicting reports of PS as a risk factor for VTE. In this review, we aim to present a clinical perspective of PS deficiency.
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Affiliation(s)
- M K ten Kate
- Division of Haemostasis, Thrombosis, and Rheology, Department of Hematology, University Medical Center Groningen, Groningen, The Netherlands
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