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Sirvent AE, Urzola-Rodríguez G, Lorenzo A, Callejas-Martínez R, Saiz A, Calle-García L, Molina-Ordás Á, Rodríguez-Gómez A, Martin-Varas C, Fernández-Reyes-Luis MJ. Arterial thrombosis in a patient with nephrotic syndrome and antithrombin Cambrigde II. Nefrologia 2023; 42:729-731. [PMID: 36870820 DOI: 10.1016/j.nefroe.2023.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 10/12/2020] [Indexed: 03/06/2023] Open
Affiliation(s)
- Ana Esther Sirvent
- Servicio de Nefrología, Complejo Asistencial de Segovia, Segovia, Spain.
| | | | - Alicia Lorenzo
- Servicio de Hematología, Complejo Asistencial de Segovia, Segovia, Spain
| | | | - Ana Saiz
- Servicio de Anatomía Patológica, Hospital Universitario Ramón y Cajal, Madrid, Spain
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2
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Dilemmas in hematology: consults in patients with arterial thrombosis. J Thromb Haemost 2023; 21:421-432. [PMID: 36696207 DOI: 10.1016/j.jtha.2023.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 12/21/2022] [Accepted: 01/04/2023] [Indexed: 01/11/2023]
Abstract
Arterial thrombotic events, particularly ischemic stroke and myocardial infarction, are common, and mostly occur due to atherosclerotic disease or arrhythmias. The diagnosis and management of the majority of such events occurs without the involvement of a hematologist, following established guidelines or pathways. In this review, we discuss 3 scenarios in which optimal management is less certain. These scenarios concern patients with a left ventricular thrombus, in whom the duration and choice of anticoagulant has been debated, patients with ischemic stroke and a patent foramen ovale, in whom the role of patent foramen ovale closure requires careful consideration, and the role of thrombophilia testing in young patients after a stroke or myocardial infarction, which remains an area of contention. We consider the available evidence and published guidelines in order to provide a practical, evidence-based approach to these 3 clinical scenarios.
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3
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Kruijt M, Treep MM, Cobbaert CM, Ruhaak LR. Antithrombin diagnostics by mass spectrometry: Development and analytical validation of a next-generation test. Res Pract Thromb Haemost 2023; 7:100079. [PMID: 36949768 PMCID: PMC10025100 DOI: 10.1016/j.rpth.2023.100079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 01/06/2023] [Accepted: 01/25/2023] [Indexed: 02/11/2023] Open
Abstract
Background Antithrombin deficiency is a rare but severe disorder leading to high risk of thrombosis. The current clinical care pathway relies on activity tests, which only provide overall functional information on the in vitro activity of antithrombin. However, antithrombin exists in many different forms, also known as proteoforms, with varying clinical phenotypes. Precision diagnostics, facilitated by mass spectrometry, provides a strategy to improve patient diagnostics by molecular characterization. Objectives To develop and analytically validate a mass spectrometry-based test for molecular characterization of antithrombin. Methods The test was analytically validated based on predefined analytical performance specifications. The validation covered imprecision, carryover, linearity, stability, analytical specificity, a provisional reference interval, and an explorative method comparison. Results The test passed the predefined analytical performance specifications with a mean within-laboratory imprecision of 5.9%, linearity between 0.08 and 2.58 μmol/L, and a provisional reference interval of 1.07 to 1.49 μmol/L. When measuring samples with a suspected quantitative deficiency, the test showed a good correlation with a commercial activity test (Pearson r = 0.88). Conclusion The test passed the validation, and we now envision the use of the test for exploration of the clinical relevance of specific antithrombin proteoforms. Puzzling cases of antithrombin deficiency, for instance, due to ambiguous activity results or an atypical clinical presentation, can be investigated by the LC-MRM mass spectrometry test serving as an add-on to the activity test and providing a molecular diagnosis. Clinical studies are planned to investigate the potential of the test to improve antithrombin diagnostics. Furthermore, the molecular information gained using the test may aid in establishing better risk stratification and a basis for personalized medicine.
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Affiliation(s)
- Mirjam Kruijt
- Correspondence Mirjam Kruijt, Leiden University Medical Center, Department of Clinical Chemistry and Laboratory Medicine, Albinusdreef 2, 2333 ZA, Leiden, the Netherlands.
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Hart C, Rott H, Heimerl S, Linnemann B. Management of Antithrombin Deficiency in Pregnancy. Hamostaseologie 2022; 42:320-329. [DOI: 10.1055/a-1841-0399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
AbstractAntithrombin (AT) deficiency is a high-risk thrombophilia and a rare condition. The risk of venous thromboembolism (VTE) is increased in AT-deficient women during pregnancy and the postpartum period and is especially high in women with a prior history of VTE. A thorough assessment of VTE risk is recommended in pregnant AT-deficient women, comprising the degree and type of AT deficiency, genetic mutations, personal and family history, and additional preexisting or pregnancy-specific risk factors. Due to a lack of adequate study data, there is limited guidance on the management of AT deficiency in pregnancy, including the need for prophylactic anticoagulation, the appropriate dose of low-molecular-weight heparin (LMWH), and the role of AT substitution. LMWH is the medication of choice for the pharmacological prophylaxis and treatment of VTE in pregnancy. Patients with a history of VTE should receive full-dose LMWH during pregnancy and the postpartum period. AT concentrates are a treatment option when anticoagulation is withheld in potentially high-risk events such as childbirth, bleeding, or surgery and in cases of acute VTE despite the use of therapeutic dose anticoagulation. Women with AT deficiency should be counseled at specialized centers for coagulation disorders or vascular medicine, and close cooperation between obstetricians and anesthesiologists is warranted before delivery and during the peripartum period.
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Affiliation(s)
- Christina Hart
- Department of Haematology and Oncology, University Hospital Regensburg, Regensburg, Germany
| | | | - Susanne Heimerl
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Regensburg, Regensburg, Germany
| | - Birgit Linnemann
- Division of Angiology, University Hospital Regensburg - University Center of Vascular Medicine, Regensburg, Bavaria, Germany
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5
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Bouton MC, Corral J, Lucas AR. Editorial: The Serpin Family in the Cardiovascular System. Front Cardiovasc Med 2022; 8:821490. [PMID: 35187116 PMCID: PMC8847448 DOI: 10.3389/fcvm.2021.821490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 12/27/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- Marie-Christine Bouton
- LVTS, INSERM, U1148, Université de Paris, X. Bichat Hospital, Paris, France
- *Correspondence: Marie-Christine Bouton
| | - Javier Corral
- Servicio de Hematología y Oncología Médica, Hospital Universitario Morales Meseguer, Centro Regional de Hemodonación, Universidad de Murcia Campus Mare Nostrum, IMIB, CIBERER, Murcia, Spain
| | - Alexandra R. Lucas
- Center for Personalized Diagnostics and Center for Immunotherapy, Vaccines and Virotherapy, The Biodesign Institute, Arizona State University, Tempe, AZ, United States
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Bravo‐Pérez C, Morena‐Barrio ME, Morena‐Barrio B, Miñano A, Padilla J, Cifuentes R, Garrido P, Vicente V, Corral J. Molecular and clinical characterization of transient antithrombin deficiency: A new concept in congenital thrombophilia. Am J Hematol 2022; 97:216-225. [PMID: 34800304 DOI: 10.1002/ajh.26413] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 11/13/2021] [Accepted: 11/16/2021] [Indexed: 11/07/2022]
Abstract
Antithrombin deficiency, the most severe thrombophilia, might be underestimated, since it is only investigated in cases with consistent functional deficiency or family history. We have analyzed 444 consecutive, unrelated cases, from 1998 to 2021, with functional results supporting antithrombin deficiency in at least one sample. Plasma antithrombin was evaluated by functional and biochemical methods in at least two samples. SERPINC1 gene was analyzed by sequencing and MPLA. Hypoglycosylation was studied by electrophoresis and high-performance liquid chromatography (HPLC). In 260 of 305 cases (85.2%) with constitutive deficiency (activity < 80% in all samples), a SERPINC1 (N = 250), or N-glycosylation defect (N = 10) was observed, while 45 remained undetermined. The other 139 cases had normal antithrombin activity (≥ 80%) in at least one sample, what we called transient deficiency. Sixty-one of these cases (43.9%) had molecular defects: 48 had SERPINC1 variants, with two recurrent mutations (p.Ala416Ser[Cambridge II], N = 15; p.Val30Glu[Dublin], N = 12), and 13 hypoglycosylation. Thrombotic complications occurred in transient deficiency, but were less frequent, latter-onset, and had a higher proportion of arterial events than in constitutive deficiency. Two mechanisms explained transient deficiency: The limitation of functional methods to detect some variants and the influence of external factors on the pathogenic consequences of these mutations. Our study reveals a molecular defect in a significant proportion of cases with transient antithrombin deficiency, and changes the paradigm of thrombophilia, as the pathogenic effect of some mutations might depend on external factors and be present only at certain timepoints. Antithrombin deficiency is underestimated, and molecular screening might be appropriate in cases with fluctuating laboratory findings.
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Affiliation(s)
- Carlos Bravo‐Pérez
- Servicio de Hematología y Oncología Médica, Hospital Universitario Morales Meseguer, Centro Regional de Hemodonación, IMIB, CIBERER Universidad de Murcia Murcia Spain
| | - María Eugenia Morena‐Barrio
- Servicio de Hematología y Oncología Médica, Hospital Universitario Morales Meseguer, Centro Regional de Hemodonación, IMIB, CIBERER Universidad de Murcia Murcia Spain
| | - Belén Morena‐Barrio
- Servicio de Hematología y Oncología Médica, Hospital Universitario Morales Meseguer, Centro Regional de Hemodonación, IMIB, CIBERER Universidad de Murcia Murcia Spain
| | - Antonia Miñano
- Servicio de Hematología y Oncología Médica, Hospital Universitario Morales Meseguer, Centro Regional de Hemodonación, IMIB, CIBERER Universidad de Murcia Murcia Spain
| | - José Padilla
- Servicio de Hematología y Oncología Médica, Hospital Universitario Morales Meseguer, Centro Regional de Hemodonación, IMIB, CIBERER Universidad de Murcia Murcia Spain
| | - Rosa Cifuentes
- Servicio de Hematología y Oncología Médica, Hospital Universitario Morales Meseguer, Centro Regional de Hemodonación, IMIB, CIBERER Universidad de Murcia Murcia Spain
| | - Pedro Garrido
- Servicio de Hematología y Oncología Médica, Hospital Universitario Morales Meseguer, Centro Regional de Hemodonación, IMIB, CIBERER Universidad de Murcia Murcia Spain
| | - Vicente Vicente
- Servicio de Hematología y Oncología Médica, Hospital Universitario Morales Meseguer, Centro Regional de Hemodonación, IMIB, CIBERER Universidad de Murcia Murcia Spain
| | - Javier Corral
- Servicio de Hematología y Oncología Médica, Hospital Universitario Morales Meseguer, Centro Regional de Hemodonación, IMIB, CIBERER Universidad de Murcia Murcia Spain
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7
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Sirvent AE, Urzola-Rodríguez G, Lorenzo A, Callejas-Martínez R, Saiz A, Calle-García L, Molina-Ordás Á, Rodríguez-Gómez A, Martin-Varas C, Fernández-Reyes-Luis MJ. Arterial thrombosis in a patient with nephrotic syndrome and antithrombin Cambrigde II. Nefrologia 2021; 42:S0211-6995(21)00006-0. [PMID: 33593604 DOI: 10.1016/j.nefro.2020.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 10/12/2020] [Indexed: 11/24/2022] Open
Affiliation(s)
- Ana Esther Sirvent
- Servicio de Nefrología, Complejo Asistencial de Segovia, Segovia, España.
| | | | - Alicia Lorenzo
- Servicio de Hematología, Complejo Asistencial de Segovia, Segovia, España
| | | | - Ana Saiz
- Servicio de Anatomía Patológica, Hospital Universitario Ramón y Cajal, Madrid, España
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Bereczky Z, Gindele R, Fiatal S, Speker M, Miklós T, Balogh L, Mezei Z, Szabó Z, Ádány R. Age and Origin of the Founder Antithrombin Budapest 3 (p.Leu131Phe) Mutation; Its High Prevalence in the Roma Population and Its Association With Cardiovascular Diseases. Front Cardiovasc Med 2021; 7:617711. [PMID: 33614741 PMCID: PMC7892435 DOI: 10.3389/fcvm.2020.617711] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 12/22/2020] [Indexed: 11/13/2022] Open
Abstract
Background: Antithrombin (AT) is one of the most important regulator of hemostasis. AT Budapest 3 (ATBp3) is a prevalent type II heparin-binding site (IIHBS) deficiency due to founder effect. Thrombosis is a complex disease including arterial (ATE) and venous thrombotic events (VTE) and the Roma population, the largest ethnic minority in Europe has increased susceptibility to these diseases partly due to their unfavorable genetic load. We aimed to calculate the age and origin of ATBp3 and to explore whether the frequency of it is higher in the Roma population as compared with the general population from the corresponding geographical area. We investigated the association of ATBp3 with thrombotic events in well-defined patients' populations in order to refine the recommendation when testing for ATBp3 is useful. Methods and Results: Prevalence of ATBp3, investigated in large samples (n = 1,000 and 1,185 for general Hungarian and Roma populations, respectively) was considerably high, almost 3%, among Roma and the founder effect was confirmed in their samples, while it was absent in the Hungarian general population. Age of ATBp3—as calculated by analysis of 8 short tandem repeat sequences surrounding SERPINC1—was dated back to XVII Century, when Roma migration in Central and Eastern Europe occurred. In our IIHBS cohort (n = 230), VTE was registered in almost all ATBp3 homozygotes (93%) and in 44% of heterozygotes. ATE occurred with lower frequency in ATBp3 (around 6%); it was rather associated with AT Basel (44%). All patients with ATE were young at the time of diagnosis. Upon investigating consecutive young (<40 years) patients with ATE (n = 92) and VTE (n = 110), the presence of ATBp3 was remarkable. Conclusions: ATBp3, a 400-year-old founder mutation is prevalent in Roma population and its Roma origin can reasonably be assumed. By the demonstration of the presence of ATBp3 in ATE patients, we draw the attention to consider type IIHBS AT deficiency in the background of not only VTE but also ATE, especially in selected populations as young patients without advanced atherosclerosis. We recommend including the investigation of ATBp3 as part of thrombosis risk assessment and stratification in Roma individuals.
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Affiliation(s)
- Zsuzsanna Bereczky
- Division of Clinical Laboratory Science, Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Réka Gindele
- Division of Clinical Laboratory Science, Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Szilvia Fiatal
- Department of Public Health and Epidemiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Marianna Speker
- Division of Clinical Laboratory Science, Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Tünde Miklós
- Division of Clinical Laboratory Science, Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - László Balogh
- Department of Cardiology and Cardiovascular Surgery, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Zoltán Mezei
- Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Zsuzsanna Szabó
- Division of Clinical Laboratory Science, Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Róza Ádány
- Department of Public Health and Epidemiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary.,Magyar Tudományos Akadémia - Debrecen Public Health Research Group, University of Debrecen, Debrecen, Hungary
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9
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A novel mutation of SERPINC1 in a patient presenting as recurrent cerebral sinus venous and portal vein thrombosis. Blood Coagul Fibrinolysis 2020; 31:229-232. [PMID: 31990753 DOI: 10.1097/mbc.0000000000000893] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
: Inherited antithrombin deficiency (OMIM 107300) is a rare autosomal dominant disorder that could increase the risk of venous thromboembolism and is usually caused by mutations of SERPINC1. Herein, we present a case of a novel mutation in the SERPINC1 gene in a Chinese patient. The patient was a 54-year-old man who presented with recurrent venous thromboembolism and was without a recent history of any precipitating factors. Whole exome sequencing and Sanger sequencing identified a novel heterozygous variant on exon 2 of SERPINC1 gene (c.142G>A, p.P48S).
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10
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Ehrhardt JD, Boneva D, McKenney M, Elkbuli A. Antithrombin Deficiency in Trauma and Surgical Critical Care. J Surg Res 2020; 256:536-542. [PMID: 32799002 DOI: 10.1016/j.jss.2020.07.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Revised: 07/01/2020] [Accepted: 07/08/2020] [Indexed: 02/08/2023]
Abstract
Antithrombin deficiency (ATD) was described in 1965 by Olav Egeberg as the first known inherited form of thrombophilia. Today, it is understood that ATDs can be congenital or acquired, leading to qualitative, quantitative, or mixed abnormalities in antithrombin (AT). All ATDs ultimately hinder AT's ability to serve as an endogenous anticoagulant and antiinflammatory agent. As a result, ATD patients possess higher risk for thromboembolism and can develop recurrent venous and arterial thromboses. Because heparin relies on AT to augment its physiologic function, patients with ATD often exhibit profound heparin resistance. Although rare as a genetic disorder, acquired forms of ATD are seen with surprising frequency in critically ill patients. This review discusses ATD in the context of surgical critical care with specific relevance to trauma, thermal burns, cardiothoracic surgery, and sepsis.
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Affiliation(s)
- John D Ehrhardt
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, Florida
| | - Dessy Boneva
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, Florida; Department of Surgery, University of South Florida, Tampa, Florida
| | - Mark McKenney
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, Florida; Department of Surgery, University of South Florida, Tampa, Florida
| | - Adel Elkbuli
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, Florida.
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11
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Van Cott EM, Orlando C, Moore GW, Cooper PC, Meijer P, Marlar R. Recommendations for clinical laboratory testing for antithrombin deficiency; Communication from the SSC of the ISTH. J Thromb Haemost 2020; 18:17-22. [PMID: 31894660 DOI: 10.1111/jth.14648] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 08/31/2019] [Accepted: 09/19/2019] [Indexed: 12/16/2022]
Abstract
Hereditary deficiency of antithrombin, a natural anticoagulant, causes a thrombophilia with a high risk for venous thromboembolism. Guidance for laboratory testing to diagnose antithrombin deficiency include the use of an activity assay for initial testing, performing an antigen test and activity-to-antigen ratio when the activity level is low, using pediatric reference ranges until the age of 6 months, excluding acquired causes of low antithrombin (e.g. liver dysfunction, proteinuria, heparin, disseminated intravascular coagulation, thrombosis, surgery) or falsely normal/elevated results (e.g. argatroban, bivalirudin, dabigatran in factor IIa-based assays; rivaroxaban, apixaban, edoxaban, but not betrixaban in Xa-based assays). Molecular testing, if available, may help determine the risk for thrombosis as this might vary among the different mutations. Moreover, it will identify mutations that can be missed by traditional activity assays. Strategies for interpreting laboratory test results are provided.
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Affiliation(s)
| | - Christelle Orlando
- Department of Haematology, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium
| | - Gary W Moore
- Diagnostic Haemostasis and Thrombosis, Viapath Analytics, Guy's & St. Thomas' Hospitals, London, UK
| | - Peter C Cooper
- Coagulation Department, Sheffield Haemophilia and Thrombosis Centre, Royal Hallamshire Hospital, Sheffield, UK
| | | | - Richard Marlar
- Department of Pathology, Special Coagulation Laboratory, TriCore Reference Laboratories, University of New Mexico, Albuquerque, NM, USA
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12
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Ruhaak LR, Romijn FPHTM, Smit NPM, van der Laarse A, Pieterse MM, de Maat MPM, Haas FJLM, Kluft C, Amiral J, Meijer P, Cobbaert CM. Detecting molecular forms of antithrombin by LC-MRM-MS: defining the measurands. Clin Chem Lab Med 2019; 56:1704-1714. [PMID: 29708875 DOI: 10.1515/cclm-2017-1111] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Accepted: 03/16/2018] [Indexed: 12/20/2022]
Affiliation(s)
- L Renee Ruhaak
- Department of Clinical Chemistry and Laboratory Medicine, Leiden University Medical Center, Postzone E2-P, Albinusdreef 2, 2333 ZA Leiden, The Netherlands, Phone: +31-71526-6397
| | - Fred P H T M Romijn
- Department of Clinical Chemistry and Laboratory Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Nico P M Smit
- Department of Clinical Chemistry and Laboratory Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Arnoud van der Laarse
- Department of Clinical Chemistry and Laboratory Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Mervin M Pieterse
- Department of Clinical Chemistry and Laboratory Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | | | | | | | | | - Piet Meijer
- ECAT Foundation, Voorschoten, The Netherlands
| | - Christa M Cobbaert
- Department of Clinical Chemistry and Laboratory Medicine, Leiden University Medical Center, Leiden, The Netherlands
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13
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Bravo-Pérez C, Vicente V, Corral J. Management of antithrombin deficiency: an update for clinicians. Expert Rev Hematol 2019; 12:397-405. [PMID: 31116611 DOI: 10.1080/17474086.2019.1611424] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Introduction. Antithrombin is a serpin that inhibits multiple procoagulant serine proteases and acts as an endogenous anticoagulant. Thus, congenital antithrombin deficiency constitutes a major thrombophilic state, the most severe so far. Areas covered. In the present work, we globally review the biology, genetics, diagnosis, and management of congenital antithrombin deficiency, and also discuss puzzling questions and future perspectives regarding this severe inherited thrombophilia. Expert opinion. Although this disorder exerts high clinical heterogeneity, many carriers will need careful and long-term anticoagulation and/or thromboprophylaxis, especially in high-risk situations, such as surgery and pregnancy. Notably, antithrombin concentrates constitute a considerable arsenal for both treatment and prevention of acute venous thrombosis in subjects with antithrombin deficiency. Current evidences are based almost exclusively on retrospective case series, so an integrated functional, biochemical and molecular characterization will be of clinical relevance and guide hematologists' personalized decisions.
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Affiliation(s)
- Carlos Bravo-Pérez
- a Servicio de Hematología y Oncología Médica, Hospital Universitario Morales Meseguer, Centro Regional de Hemodonación , Universidad de Murcia, IMIB-Arrixaca, CIBERER , Murcia , Spain
| | - Vicente Vicente
- a Servicio de Hematología y Oncología Médica, Hospital Universitario Morales Meseguer, Centro Regional de Hemodonación , Universidad de Murcia, IMIB-Arrixaca, CIBERER , Murcia , Spain
| | - Javier Corral
- a Servicio de Hematología y Oncología Médica, Hospital Universitario Morales Meseguer, Centro Regional de Hemodonación , Universidad de Murcia, IMIB-Arrixaca, CIBERER , Murcia , Spain
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14
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Li YQ, Guo T, Wang QY, Liu H, Wu YY, Cheng ZP, Hu B, Lu X, Yu JM, Deng J, Wang HF, Sun CY, Yang Y, Zeng W, Tang L, Jian XR, Hu Y. Genetic analysis should be included in clinical practice when screening for antithrombin deficiency. Thromb Haemost 2017; 113:262-71. [DOI: 10.1160/th14-05-0446] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2014] [Accepted: 08/30/2014] [Indexed: 12/12/2022]
Abstract
SummaryAntithrombin (AT) deficiency increases the risk of thrombosis. Current evidence shows that some SERPINC1 mutations responsible for antithrombin deficiency often present a slightly decreased or normal activity and therefore could not be detected by functional tests. This study was designed to compare activity assays and direct genetic analyses in identifying hereditary antithrombin deficiency. In total, 400 consecutive patients with venous thrombosis were enrolled. Functional assays showed that 16 of the 400 individuals had decreased antithrombin activity, and 14 of them were confirmed by genetic analysis. Of the remaining 384 patients, 95 individuals without a known risk factor and 95 individuals with predisposing factors were also selected for gene sequencing. Eight additional causative mutations were identified in nine individuals and they should also be considered as antithrombin deficiency. In addition, a recurrent mutation, p.Arg356_Phe361del, was characterised. The mutant appeared to have a partially impaired secretion and a reduction in functional activity by 50 %. This study indicated that including genetic analysis in screening tests for identifying antithrombin deficiency was essential. Specifically, a genetic analysis of SERPINC1 is strongly recommended when individuals experience unprovoked thrombotic diseases, even if the AT activities are normal.
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15
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Celinska-Lowenhoff M, Iwaniec T, Alhenc-Gelas M, Musial J, Undas A. Arterial and venous thrombosis and prothrombotic fibrin clot phenotype in a Polish family with type 1 antithrombin deficiency (antithrombin Krakow). Thromb Haemost 2017; 106:379-81. [DOI: 10.1160/th11-02-0066] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2011] [Accepted: 05/15/2011] [Indexed: 11/05/2022]
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Gindele R, Selmeczi A, Oláh Z, Ilonczai P, Pfliegler G, Marján E, Nemes L, Nagy Á, Losonczy H, Mitic G, Kovac M, Balogh G, Komáromi I, Schlammadinger Á, Rázsó K, Boda Z, Muszbek L, Bereczky Z. Clinical and laboratory characteristics of antithrombin deficiencies: A large cohort study from a single diagnostic center. Thromb Res 2017; 160:119-128. [PMID: 29153735 DOI: 10.1016/j.thromres.2017.10.023] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Revised: 10/26/2017] [Accepted: 10/30/2017] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Inherited antithrombin (AT) deficiency is a heterogeneous disease. Due to low prevalence, only a few studies are available concerning genotype-phenotype associations. The aim was to describe the clinical, laboratory and genetic characteristics of AT deficiency in a large cohort including children and to add further laboratory data on the different sensitivity of functional AT assays. PATIENTS AND METHODS Non-related AT deficient patients (n=156) and their family members (total n=246) were recruited. Clinical and laboratory data were collected, the mutation spectrum of SERPINC1 was described. Three different AT functional assays were explored. RESULTS Thirty-one SERPINC1 mutations including 11 novel ones and high mutation detection rate (98%) were detected. Heparin binding site deficiency (type IIHBS) was the most frequent (75.6%) including AT Budapest3 (ATBp3), AT Padua I and AT Basel (86%, 9% and 4% of type IIHBS, respectively). Clinical and laboratory phenotypes of IIHBS were heterogeneous and dependent on the specific mutation. Arterial thrombosis and pregnancy complications were the most frequent in AT Basel and AT Padua I, respectively. Median age at the time of thrombosis was the lowest in ATBp3 homozygotes. The functional assay with high heparin concentration and pH7.4 as assay conditions had low (44%) sensitivity for ATBp3 and it was insensitive for AT Basel and Padua I. CONCLUSION Type IIHBS deficiencies behave differently in clinical and laboratory phenotypes from each other and from other AT deficiencies. Heparin concentration and pH seem to be the key factors influencing the sensitivity of AT functional assays to IIHBS.
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Affiliation(s)
- Réka Gindele
- Division of Clinical Laboratory Science, Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Anna Selmeczi
- Thrombosis and Haemostasis Center, Clinical Center, University of Debrecen, Debrecen, Hungary; National Haemophilia Center and Haemostasis Department, State Health Center, Budapest, Hungary
| | - Zsolt Oláh
- Thrombosis and Haemostasis Center, Clinical Center, University of Debrecen, Debrecen, Hungary
| | - Péter Ilonczai
- Thrombosis and Haemostasis Center, Clinical Center, University of Debrecen, Debrecen, Hungary
| | - György Pfliegler
- Division of Rare Diseases, Department of Internal Medicine, Clinical Center, University of Debrecen, Debrecen, Hungary
| | - Erzsébet Marján
- Department of Pediatrics, A. Jósa Teaching Hospital, Nyíregyháza, Hungary
| | - László Nemes
- National Haemophilia Center and Haemostasis Department, State Health Center, Budapest, Hungary
| | - Ágnes Nagy
- Department of Internal Medicine, University of Pécs, Pécs, Hungary
| | - Hajna Losonczy
- Department of Internal Medicine, University of Pécs, Pécs, Hungary
| | - Gorana Mitic
- Institute of Laboratory Medicine, Clinical Centre of Vojvodina, Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia
| | - Mirjana Kovac
- Blood Transfusion Institute of Serbia, Belgrade, Serbia
| | - Gábor Balogh
- Division of Clinical Laboratory Science, Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - István Komáromi
- Division of Clinical Laboratory Science, Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Ágota Schlammadinger
- Thrombosis and Haemostasis Center, Clinical Center, University of Debrecen, Debrecen, Hungary
| | - Katalin Rázsó
- Thrombosis and Haemostasis Center, Clinical Center, University of Debrecen, Debrecen, Hungary
| | - Zoltán Boda
- Thrombosis and Haemostasis Center, Clinical Center, University of Debrecen, Debrecen, Hungary
| | - László Muszbek
- Division of Clinical Laboratory Science, Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Zsuzsanna Bereczky
- Division of Clinical Laboratory Science, Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary.
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Alhenc-Gelas M, Plu-Bureau G, Hugon-Rodin J, Picard V, Horellou MH. Thrombotic risk according to SERPINC1 genotype in a large cohort of subjects with antithrombin inherited deficiency. Thromb Haemost 2017; 117:1040-1051. [PMID: 28300866 DOI: 10.1160/th16-08-0635] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Accepted: 02/23/2017] [Indexed: 12/24/2022]
Abstract
Inherited quantitative (type I) or qualitative (type II) antithrombin deficiency (ATD) due to mutations in the SERPINC1 gene is a well-known risk factor for venous thromboembolism. ATD may also increase risk for arterial thrombosis. Few studies have investigated risk for thrombosis according to mutations. We addressed this topic in a large retrospective cohort study of 540 heterozygous carriers of SERPINC1 mutations and compared risk for first venous or arterial thrombosis associated with carrying of different type II or type I mutations. No clear difference in risk for first venous thrombotic event was observed among type I (missense or null), type IIRS or type IIPE mutation carriers except for a few variants that displayed lower risk [all events, adjusted relative risk: Cambridge II: 0.42 (95 %CI 0.25-0.70), Dublin: 0.35 (95 %CI 0.13-0.99)]. IIHBS mutation carrying was associated with a clearly lower risk than type I mutation carrying [0.28 (95 %CI 0.20-0.40)]. These differences in risk were observed for both all venous thrombotic events and pulmonary embolism associated with deep venous thrombosis. The HBS group was also heterogeneous, with AT Budapest 3 carriers displaying a non-significantly different risk [0.61 (95 %CI 0.31-1.20)] compared to type I mutation carriers. We also studied risk for arterial thrombosis and found no significant influence of mutation type. Altogether, our findings suggest a place for SERPINC1 genotyping in the diagnosis of ATD.
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Affiliation(s)
- Martine Alhenc-Gelas
- M. Alhenc-Gelas, Laboratoire d'Hématologie, HEGP, 20 Rue Leblanc, 75015 Paris, France, Tel: +33 156093901, Fax: +33 156093393, E-mail:
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18
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Wang D, Cui G, Hu S, Wang DW. Subtypes of SERPINC1 mutations and the thrombotic phenotype of inherited antithrombin deficient individuals in Chinese Han population. Blood Cells Mol Dis 2016; 62:38-41. [PMID: 27863268 DOI: 10.1016/j.bcmd.2016.10.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Accepted: 10/30/2016] [Indexed: 11/15/2022]
Abstract
Inherited antithrombin (AT) deficiency is a rare autosomal disease that could increase the risk of venous thromboembolism (VTE) and usually caused by mutations of SERPINC1. Although a number of mutations of SERPINC1 have been reported in Chinese Han population, the impact of different subtypes of these mutations on the thrombotic phenotype is still unknown. Here, we performed a retrospective cohort study including 169 AT patients from 63 families to compare the clinical features between null mutation carriers and missense mutation carriers. We found that patients carrying null mutations have a higher risk of VTE (HR 2.29, 95% CI 1.16-4.69, P=0.02 adjusted for sex and VTE family history) and earlier median onset age of VTE (27 vs. 32years, P=0.045) as well as lower AT activities (47.6±1.0% vs. 59.1±2.3%, P<0.001) than those with missense mutations. We also observed that thrombus location sites showed no difference between null mutation carriers and missense mutation carriers, gene locations of the mutations did not relate with the incidence rate of VTE. This study demonstrated that different types of SERPINC1 mutations may play different roles in the development of VTE and should be considered in the prevention of VTE.
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Affiliation(s)
- Dong Wang
- Institute of Hypertension, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Guanglin Cui
- Institute of Hypertension, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
| | - Senlin Hu
- Institute of Hypertension, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Dao Wen Wang
- Institute of Hypertension, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
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19
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Gindele R, Oláh Z, Ilonczai P, Speker M, Udvari Á, Selmeczi A, Pfliegler G, Marján E, Kovács B, Boda Z, Muszbek L, Bereczky Z. Founder effect is responsible for the p.Leu131Phe heparin-binding-site antithrombin mutation common in Hungary: phenotype analysis in a large cohort. J Thromb Haemost 2016; 14:704-15. [PMID: 26748602 DOI: 10.1111/jth.13252] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Accepted: 12/27/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND Antithrombin (AT) is a key regulator of the coagulation. In type II deficiency, the heparin-binding-site defect (type II HBS) is considered to be relatively low thrombosis risk. OBJECTIVES Our aims were to search for SERPINC1 mutation(s) and to describe the clinical and laboratory phenotype of a large number of AT Budapest3 (ATBp3, p.Leu131Phe) carriers and confirm the presence of a founder effect. PATIENTS/METHODS AT-deficient patients were recruited and carriers of ATBp3, n = 102 (63 families) were selected. To investigate the founder effect, eight intragenic single nucleotide polymorphisms, a 5'-length dimorphism, and five microsatellite markers were detected. Clinical and laboratory data of the patients were collected and analyzed. RESULTS In AT deficiency, 16 different causative mutations were found, and the great majority of patients were of type II HBS subtype. Most of them (n = 102/118, 86.5%) carried the ATBp3 mutation. The ATBp3 mutant allele was associated with one single haplotype, while different haplotypes were detected in the case of normal allele. The anti-factor Xa-based AT activity assay that we used could detect all ATBp3 patients with high sensitivity in our cohort. ATBp3 homozygosity (n = 26) was associated with thrombosis at a young age and conferred a high thrombotic risk. Half of the heterozygotes (n = 41/76, 53.9%) also had venous and/or arterial thrombosis, and pregnancy complications were also recorded. CONCLUSION In Hungary, the founder mutation, ATBp3, is the most common AT deficiency. Our study is the first in which the clinical characterization of ATBp3 mutation was executed in a large population.
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Affiliation(s)
- R Gindele
- Division of Clinical Laboratory Science, Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Z Oláh
- Thrombosis and Haemostasis Center, Department of Internal Medicine, Clinical Center, University of Debrecen, Debrecen, Hungary
| | - P Ilonczai
- Thrombosis and Haemostasis Center, Department of Internal Medicine, Clinical Center, University of Debrecen, Debrecen, Hungary
| | - M Speker
- Division of Clinical Laboratory Science, Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Á Udvari
- Division of Clinical Laboratory Science, Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - A Selmeczi
- Thrombosis and Haemostasis Center, Department of Internal Medicine, Clinical Center, University of Debrecen, Debrecen, Hungary
| | - G Pfliegler
- Division of Rare Diseases, Department of Internal Medicine, Clinical Center, University of Debrecen, Debrecen, Hungary
| | - E Marján
- Department of Pediatrics, A. Jósa Teaching Hospital, Nyíregyháza, Hungary
| | - B Kovács
- Division of Clinical Laboratory Science, Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Z Boda
- Thrombosis and Haemostasis Center, Department of Internal Medicine, Clinical Center, University of Debrecen, Debrecen, Hungary
| | - L Muszbek
- Division of Clinical Laboratory Science, Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
- Haemostasis, Thrombosis and Vascular Biology Research Group of the Hungarian Academy of Sciences, University of Debrecen, Debrecen, Hungary
| | - Z Bereczky
- Division of Clinical Laboratory Science, Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
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20
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Nadir Y, Hoffman R, Corral J, Barak Y, Hasin T, Keren-Politansky A, Brenner B. A novel mutation of antithrombin deficiency in six family siblings and the clinical combat. Thromb Haemost 2015. [DOI: 10.1160/th-15-01-0040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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21
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Nadir Y, Hoffman R, Corral J, Barak Y, Hasin T, Keren-Politansky A, Brenner B. A novel mutation of antithrombin deficiency in six family siblings and the clinical combat. Thromb Haemost 2015; 114:859-61. [PMID: 26177694 DOI: 10.1160/th15-01-0040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Accepted: 04/16/2015] [Indexed: 11/05/2022]
Affiliation(s)
- Yona Nadir
- Yona Nadir, MD, PhD, Thrombosis and Hemostasis Unit, Rambam Health Care Campus, Haifa 31096, Israel, Tel.: +972 4 7773520, Fax: +972 4 7773886, E-mail:
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22
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Puzzling questions on antithrombin: Diagnostic limitations and real incidence in venous and arterial thrombosis. Thromb Res 2015; 135:1047-8. [DOI: 10.1016/j.thromres.2015.04.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Accepted: 04/06/2015] [Indexed: 11/23/2022]
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23
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Antithrombin heparin binding site deficiency: A challenging diagnosis of a not so benign thrombophilia. Thromb Res 2015; 135:1179-85. [DOI: 10.1016/j.thromres.2015.03.013] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Revised: 02/07/2015] [Accepted: 03/06/2015] [Indexed: 11/24/2022]
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24
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Shigekiyo T, Sekimoto E, Shibata H, Ozaki S, Kurushima A, Aihara KI. Antithrombin-p.Ala416Pro: the second reported case in Japan. Intern Med 2014; 53:477-81. [PMID: 24583439 DOI: 10.2169/internalmedicine.53.1087] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 42-year-old man was referred to our department due to recurrent deep venous thrombosis. He, his father and his aunt had low antithrombin (AT) heparin cofactor activity and progressive AT activity levels with normal AT antigen levels. A single nucleotide substitution of G to C was found at nucleotide position c.1246 in exon 7 of the patient's AT gene, resulting in a p.Ala416Pro mutation of AT. The same mutation was identified in his father and aunt, but not his sister, who had a normal AT level. These results show that the AT-p.Ala416Pro mutation was responsible for type IIa AT deficiency in this family.
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Affiliation(s)
- Toshio Shigekiyo
- Department of Hematology, Tokushima Prefectural Central Hospital, Japan
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25
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Recurrent ischemic cerebrovascular events in a patient with type I antithrombin deficiency caused by 9788 G>A splice site mutation: a case report. Blood Coagul Fibrinolysis 2013; 24:213-5. [PMID: 23358206 DOI: 10.1097/mbc.0b013e32835b2467] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Type I antithrombin deficiency is an autosomal dominant disorder associated with high risk for venous thromboembolism. Data on the association between antithrombin deficiency and arterial thromboembolism are inconsistent. We report here the case of AT deficiency in a 43-year-old man free of cardiovascular risk factors who experienced venous thromboembolism and ischemic stroke followed by two transient ischemic attacks after interruption of oral anticoagulation due to colonoscopy. DNA sequencing of the antithrombin gene revealed heterozygosity for the previously reported substitution G to A at nucleotide position 9788 in intervening sequence four. To our knowledge, this report is the first to show that this genetic abnormality can be associated with recurrent cerebrovascular ischemic events.
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26
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Luxembourg B, Pavlova A, Geisen C, Spannagl M, Bergmann F, Krause M, Alesci S, Seifried E, Lindhoff-Last E. Impact of the type of SERPINC1 mutation and subtype of antithrombin deficiency on the thrombotic phenotype in hereditary antithrombin deficiency. Thromb Haemost 2013; 111:249-57. [PMID: 24196373 DOI: 10.1160/th13-05-0402] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2013] [Accepted: 09/27/2013] [Indexed: 11/05/2022]
Abstract
Mutations in the antithrombin (AT) gene can impair the capacity of AT to bind heparin (AT deficiency type IIHBS), its target proteases such as thrombin (type IIRS), or both (type IIPE). Type II AT deficiencies are almost exclusively caused by missense mutations, whereas type I AT deficiency can originate from missense or null mutations. In a retrospective cohort study, we investigated the impact of the type of mutation and type of AT deficiency on the manifestation of thromboembolic events in 377 patients with hereditary AT deficiencies (133 from our own cohort, 244 reported in the literature). Carriers of missense mutations showed a lower risk of venous thromboembolism (VTE) than those of null mutations (adjusted hazard ratio [HR] 0.39, 95% confidence interval [CI] 0.27-0.58, p<0.001), and the risk of VTE was significantly decreased among patients with type IIHBS AT deficiency compared to patients with other types of AT deficiency (HR 0.23, 95%CI 0.13-0.41, p<0.001). The risk of pulmonary embolism complicating deep-vein thrombosis was lower in all type II AT deficiencies compared to type I AT deficiency (relative risk 0.69, 95%CI 0.56-0.84). By contrast, the risk of arterial thromboembolism tended to be higher in carriers of missense mutations than in those with null mutations (HR 6.08-fold, 95%CI 0.74-49.81, p=0.093) and was 5.9-fold increased (95%CI 1.22-28.62, p=0.028) in type IIHBS versus other types of AT deficiency. Our data indicate that the type of inherited AT defect modulates not only the risk of thromboembolism but also the localisation and encourage further studies to unravel this phenomenon.
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Affiliation(s)
- Beate Luxembourg
- Beate Luxembourg, MD, Institute of Transfusion Medicine and Immunohaematology, Department of Molecular Haemostaseology, DRK Blood Donor Service Baden-Württemberg - Hessen, Sandhofstr. 1, 60528 Frankfurt a.M., Germany, Tel.: +49 69 6782 353, Fax: +49 69 6782 346, E-mail:
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27
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Ding Q, Wang M, Xu G, Ye X, Xi X, Yu T, Wang X, Wang H. Molecular basis and thrombotic manifestations of antithrombin deficiency in 15 unrelated Chinese patients. Thromb Res 2013; 132:367-73. [PMID: 23932013 DOI: 10.1016/j.thromres.2013.07.013] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Revised: 06/24/2013] [Accepted: 07/10/2013] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Antithrombin (AT) deficiency is associated with an increasing risk of thrombosis. MATERIALS AND METHODS 15 unrelated patients with AT deficiency defined by thrombophilic assays were recruited and detailed clinical information about patients, focusing on the personal and family history of thromboembolism (TE), were recorded. Mutation analysis was performed by direct sequencing of an AT gene (SERPINC1) in the patients and their family members. RESULTS A total of 15 heterozygous causative mutations, each being identified in one family, were identified. Five mutations (33.3%) were reported here for the first time, including three null mutations (Ser36X, Lys70X and Try307X) and two missense mutations (Phe123Cys and Leu340Phe) probably impairing the structural integrity and stability of protein based on the AT structural analysis. Of the 15 patients, 33.3% (5/15) had additional risk factors and only one patient presented with additional genetic alteration causing an early onset of thrombosis. Fourteen patients (93.9%) suffered from multisite recurrent thrombotic episodes after a first episode of thrombosis. 93.3% of the patients experienced deep vein thrombosis (DVT) and 40.0% presented with mesenteric venous thrombosis (MVT). In addition, both venous and arterial thrombosis was present in two unrelated patients. 51.0% subjects with AT deficiency in the 15 unrelated pedigrees experienced TE events. CONCLUSIONS Prophylactic anticoagulation may be suggested in AT-deficient patients to avoid the recurrent and multisite thrombosis. The association of primary MVT and AT deficiency is highlighted.
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Affiliation(s)
- Qiulan Ding
- Department of Laboratory Medicine, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
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28
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Águila S, Martínez-Martínez I, Collado M, Llamas P, Antón AI, Martínez-Redondo C, Padilla J, Miñano A, de la Morena-Barrio ME, Garcia-Avello Á, Vicente V, Corral J. Compound heterozygosity involving Antithrombin Cambridge II (p.Ala416Ser) in antithrombin deficiency. Thromb Haemost 2013; 109:556-8. [PMID: 23329010 DOI: 10.1160/th12-09-0707] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2012] [Accepted: 11/27/2012] [Indexed: 11/05/2022]
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Recurrent arterial thrombosis associated with the antithrombin basel variant and elevated lipoprotein(a) plasma level in an adolescent patient. J Pediatr Hematol Oncol 2012; 34:276-9. [PMID: 22134617 DOI: 10.1097/mph.0b013e3182331ecd] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Both myocardial infarction and ischemic stroke are rare in the young. Yet a 15-year-old male patient suffered a myocardial infarction and later an ischemic stroke despite uninterrupted antiplatelet therapy. His medical history involved the surgical correction of an incomplete atrioventricular canal defect at the age of 13 years. No cardiovascular risk factors other than elevated lipoprotein(a) level could be identified. His antithrombin (AT) activity was decreased and DNA sequence analysis revealed heterozygosity for AT Basel (p.Pro41Leu), a variant with impaired heparin binding. This report supports a possible additional pathophysiological role for AT Basel and elevated lipoprotein(a) level in arterial thrombogenesis.
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30
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Castaldo G, Cerbone AM, Guida A, Tandurella I, Ingino R, Tufano A, Ceglia C, Di Minno MND, Ruocco AL, Di Minno G. Molecular analysis and genotype-phenotype correlation in patients with antithrombin deficiency from Southern Italy. Thromb Haemost 2012; 107:673-80. [PMID: 22398878 DOI: 10.1160/th11-09-0671] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2011] [Accepted: 12/27/2011] [Indexed: 12/19/2022]
Abstract
We sequenced the SERPINC1 gene in 26 patients (11 males) with antithrombin (AT) deficiency (22 type I, 4 type II), belonging to 18 unrelated families from Southern Italy. Heterozygous mutations were identified in 15/18 (83.3%) families. Of them, eight were novel mutations, each being identified in one family. Seven clearly cause impaired protein synthesis (four frameshift, one non-stop, one splicing and one 21bp deletion). One, present in a single patient, is a missense mutation thought to be causative because: a) it is absent in 100 chromosomes from controls; b) it involves a highly conserved amino acid, whose change is predicted to impair AT activity; c) no other mutation is present in the propositus. Severe mutations (i.e. nonsense, frameshift, deletions) were invariably identified in type I patients. In type II patients, 3/4 were missense mutations; the fourth leads to a 19 nucleotides shift in the stop codon. In addition to the type of mutation, the co-existence of other predisposing factors in most patients helps explain the severity of the present type I cases (age at first event, recurrence during prophylaxis). In the five families in which there was more than one member affected, the same genotype and a concordant clinical expression of the disease were found. We conclude that the molecular bases of AT deficiency in Southern Italy are different as compared to other geographic areas, and that molecular analysis and the study of the effect of the mutation may help predict the clinical expression of the disease.
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Affiliation(s)
- G Castaldo
- CEINGE-Biotecnologie Avanzate, Naples, Italy
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31
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Antithrombin Cambridge II(A384S) mutation frequency and antithrombin activity levels in 120 of deep venous thrombosis and 150 of cerebral infarction patients in a single center in Southern China. Blood Coagul Fibrinolysis 2011; 21:588-91. [PMID: 20683322 DOI: 10.1097/mbc.0b013e32833dbe68] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Antithrombin Cambridge II(A384S) mutation shows a relatively high frequency in western population. Some studies suggest that the mutation is an independent genetic risk factor both for deep vein thrombosis (DVT) and for arterial thrombosis, but whether the mutation has racial difference or has a general significance for thrombophilia remains unclear. In this study we performed an analysis of the prevalence of the mutation in Chinese southern population; Also, the antithrombin activity levels were evaluated in each investigated individual. The studies included 120 patients with DVT, 150 patients with cerebral infarction, and 110 controls. The mutation was detected using polymerase chain reaction/PvuII restrictive fragment length polymorphism procedures. Antithrombin activity assay was done using chromogenic substrate method. The results showed that no antithrombin Cambridge II mutation was detected in all three groups (DVT, cerebral infarction and controls), the incidence was 0/380. Plasma antithrombin activity was 91.37% +/- 16.15% in the DVT patients and 102.68% +/- 13.10% in the controls; the antithrombin activity was significantly reduced in the DVT group (P < 0.0001). In DVT patients, eight cases were identified as primary antithrombin deficiency, accounting for an incidence of 6.7%. No significant difference was found for antithrombin activity between cerebral infarction group and controls. These results suggest that antithrombin Cambridge II mutation has a racial difference, and may not be a valuable risk factor of thrombophilia in Asian population, and antithrombin deficiency remains a major genetic risk factor for DVT patients in China.
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32
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Muszbek L, Bereczky Z, Kovács B, Komáromi I. Antithrombin deficiency and its laboratory diagnosis. Clin Chem Lab Med 2010; 48 Suppl 1:S67-78. [PMID: 21062218 DOI: 10.1515/cclm.2010.368] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Antithrombin (AT) belongs to the serpin family and is a key regulator of the coagulation system. AT inhibits active clotting factors, particularly thrombin and factor Xa; its absence is incompatible with life. This review gives an overview of the protein and gene structure of AT, and attempts to explain how glucosaminoglycans, such as heparin and heparan sulfate accelerate the inhibitory reaction that is accompanied by drastic conformational change. Hypotheses on the regulation of blood coagulation by AT in physiological conditions are discussed. Epidemiology of inherited thrombophilia caused by AT deficiency and its molecular genetic background with genotype-phenotype correlations are summarized. The importance of the classification of AT deficiencies and the phenotypic differences of various subtypes are emphasized. The causes of acquired AT deficiency are also included in the review. Particular attention is devoted to the laboratory diagnosis of AT deficiency. The assay principles of functional first line laboratory tests and tests required for classification are discussed critically, and test results expected in various AT deficiency subtypes are summarized. The reader is provided with a clinically oriented algorithm for the correct diagnosis and classification of AT deficiency, which could be useful in the practice of routine diagnosis of thrombophilia.
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Affiliation(s)
- László Muszbek
- Clinical Research Center, University of Debrecen, Medical and Health Science Center, Debrecen, Hungary.
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