Pitfalls in the genetic diagnosis of hereditary hemochromatosis

Risk of Misdiagnosis Due to Allele Dropout and False-Positive PCR Artifacts in Molecular Diagnostics: Analysis of 30,769 Genotypes

Quality control is a complex issue for clinical molecular diagnostic applications. In the case of genotyping assays, artifacts such as allele dropout represent a risk of misdiagnosis for amplification-based methods. However, its frequency of occurrence in PCR-based diagnostic assays remains unknown. To maximize the likelihood of detecting allele dropout, our clinical genotyping PCR-based assays are designed with two independent assays for each allele (nonoverlapping primers on each DNA strand). To estimate the incidence of allelic dropout, we took advantage of the capacity of our clinical assays to detect such events. We retrospectively studied their occurrence in the initial PCR assay for 30,769 patient reports for mutations involved in four diseases produced over 8 years. Ninety-three allele dropout events were detected and all were solved before reporting. In addition, 42 cases of artifacts caused by amplification of an allele ultimately confirmed to not be part of the genotype (drop-in events) were detected and solved. These artifacts affected 1:227 genotypes, 94% of which were due to nonreproducible PCR failures rather than sequence variants interfering with the assay, suggesting that careful primer design cannot prevent most of these errors. This provides a quantitative estimate for clinical laboratories to take this phenomenon into account in quality management and to favor assay designs that can detect (and minimize) occurrence of these artifacts in routine clinical use.

Hardy-Weinberg analysis of a large set of published association studies reveals genotyping error and a deficit of heterozygotes across multiple loci

In genetic association studies, deviation from Hardy-Weinberg equilibrium (HWD) can be due to recent admixture or selection at a locus, but is most commonly due to genotyping errors. In addition to its utility for identifying potential genotyping errors in individual studies, here we report that HWD can be useful in detecting the presence, magnitude and direction of genotyping error across multiple studies. If there is a consistent genotyping error at a given locus, larger studies, in general, will show more evidence for HWD than small studies. As a result, for loci prone to genotyping errors, there will be a correlation between HWD and the study sample size. By contrast, in the absence of consistent genotyping errors, there will be a chance distribution of p-values among studies without correlation with sample size. We calculated the evidence for HWD at 17 separate polymorphic loci investigated in 325 published genetic association studies. In the full set of studies, there was a significant correlation between HWD and locus-standardised sample size (p = 0.001). For 14/17 of the individual loci, there was a positive correlation between extent of HWD and sample size, with the evidence for two loci (5-HTTLPR and CTSD) rising to the level of statistical significance. Among single nucleotide polymorphisms (SNPs), 15/23 studies that deviated significantly from Hardy-Weinberg equilibrium (HWE) did so because of a deficit of hetero-zygotes. The inbreeding coefficient (F(is)) is a measure of the degree and direction of deviation from HWE. Among studies investigating SNPs, there was a significant correlation between F(is) and HWD (R = 0.191; p = 0.002), indicating that the greater the deviation from HWE, the greater the deficit of heterozygotes. By contrast, for repeat variants, only one in five studies that deviated significantly from HWE showed a deficit of heterozygotes and there was no significant correlation between F(is) and HWD. These results indicate the presence of HWD across multiple loci, with the magnitude of the deviation varying substantially from locus to locus. For SNPs, HWD tends to be due to a deficit of heterozygotes, indicating that allelic dropout may be the most prevalent genotyping error.

A common 1317TC polymorphism in MTHFR can lead to erroneous 1298AC genotyping by PCR-RE and TaqMan probe assays

Multiple polymorphisms of the methylenetetrahydrofolate reductase gene (MTHFR) have been documented, and some are associated with decreased enzyme activity. One polymorphism, 677CT, is commonly tested in the context of thrombosis. Recently, consideration has also been extended to 1298AC, which is also associated with reduced catalytic activity. This report describes problems arising during the development of a PCR restriction enzyme assay for 1298AC. In the process of validating a PCR-MboII assay, it was realized that a nearby 1317TC polymorphism rendered a restriction fragment length polymorphism (RFLP) pattern that was virtually indistinguishable from a 1298A allele. An alternate approach, involving primer mutagenesis and Fnu4HI digestion, resolved the problem. To validate the latter assay, samples were obtained from a CLIA-approved facility that had developed a multiplexed real-time PCR using TaqMan probes for simultaneous assessment of 677CT and 1298AC. Interlaboratory results concurred for 10 out of 11 samples; however, one sample was consistently heterozygous by PCR-Fnu4HI and homozygous 1298CC by real-time PCR. Bidirectional sequencing confirmed that the sample was a compound 1298AC/1317TC heterozygote. It is likely that the 1317C variant, residing with 1298A on one chromosome, disrupted primer annealing in the TaqMan assay, leading to preferential amplification of the 1298C/1317T chromosome and hence an aberrant homozygous 1298CC genotype. This validation exercise emphasizes the need for comprehensive appraisal and continual reassessment of the optimal performance of molecular diagnostic assays. It is hoped that laboratories offering MTHFR 1298AC testing are cognizant of some of the inherent problems in published methods.

Conversion technology and its role in genetic testing of inherited diseases

Identification of germline mutations in a sensitive and specific manner presents a continuing challenge. A major contributing factor to this is that humans are diploid and therefore mutations in one allele are often masked by the normal sequence present on the other copy of the chromosome. Mutation analysis on haploid templates (one copy of a chromosome), rather than on diploid templates (both copies of a chromosome), overcomes this problem and obscured mutations are unmasked. Conversion technology converts a sample from diploid to haploid state by isolating individual alleles in somatic cell hybrids. From each sample, a series of stable hybrids is generated that contains the human chromosome complement in the haploid state. This article describes conversion technology and its applications. The utility of this technique in increasing the sensitivity of genetic testing has been demonstrated for the predisposition to hereditary nonpolyposis colorectal cancer and it is proposed that a similar approach may be applicable to many different diseases.