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Alshehri FS, Bashmeil AA, Alamar IA, Alouda SK. The natural anticoagulant protein S; hemostatic functions and deficiency. Platelets 2024; 35:2337907. [PMID: 38602463 DOI: 10.1080/09537104.2024.2337907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 03/27/2024] [Indexed: 04/12/2024]
Abstract
Protein S (PS) is a vital endogenous anticoagulant. It plays a crucial role in regulating coagulation by acting as a cofactor for the activated protein C (APC) and tissue factor pathway inhibitor (TFPI) pathways. Additionally, it possesses direct anticoagulant properties by impeding the intrinsic tenase and prothrombinase complexes. Protein S oversees the coagulation process in both the initiation and propagation stages through these roles. The significance of protein S in regulating blood clotting can be inferred from the significant correlation between deficits in protein S and an elevated susceptibility to venous thrombosis. This is likely because activated protein C and tissue factor pathway inhibitor exhibit low efficacy as anticoagulants when no cofactors exist. The precise biochemical mechanisms underlying the roles of protein S cofactors have yet to be fully elucidated. Nevertheless, recent scientific breakthroughs have significantly enhanced comprehension findings for these functions. The diagnosis of protein S deficiency, both from a technical and genetic standpoint, is still a subject of debate due to the complex structural characteristics of the condition. This paper will provide an in-depth review of the molecular structure of protein S and its hemostatic effects. Furthermore, we shall address the insufficiency of protein S and its methods of diagnosis and treatment.
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Affiliation(s)
- Fahad S Alshehri
- Pathology and Clinical Laboratory Medicine Department, Haematology Division, King Faisal Medical City for Southern Region, Abha, Saudi Arabia
- Pathology and Clinical Laboratory Medicine Department, Haematology Division, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Abdullah A Bashmeil
- Pathology and Clinical Laboratory Medicine Department, Haematology Division, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Ibrahim A Alamar
- Pathology and Clinical Laboratory Medicine Department, Haematology Division, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Sarah K Alouda
- College of Applied Medical Science, Clinical Laboratory Department, King Saud University, Riyadh, Saudi Arabia
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Puri S, Grover AK, Narula AK, Choudhry PN, Gupta AP. Atypical presentation of pulmonary embolism and deep vein thrombosis due to protein S deficiency in a young female with chest pain. THE EGYPTIAN JOURNAL OF INTERNAL MEDICINE 2022. [DOI: 10.1186/s43162-022-00124-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
AbstractVenous thromboembolism has many risk factors including protein S deficiency, which poses a significant diagnostic challenge as it presents with atypical complaints. A treatable yet potentially fatal condition, acute pulmonary embolism, is currently third most common cause of cardiovascular death. Clinicians should include pulmonary embolism as differential diagnosis in young adults with atypical symptoms with 2 D ECHO findings of the dilated right atrium, right ventricle, and elevated pulmonary artery pressure, and diagnosis is confirmed by computed tomography pulmonary angiography (CTPA). Anticoagulants including NOACs should be initiated promptly to improve the outcome for patients.
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Kacar M, Bhatt M. A Case of a Pediatric Patient With Protein S Heerlen Polymorphism and Deep Venous Thrombosis. J Pediatr Hematol Oncol 2022; 44:e442-e443. [PMID: 34486549 DOI: 10.1097/mph.0000000000002299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 07/16/2021] [Indexed: 11/25/2022]
Abstract
Hereditary protein S (PS) deficiency is a rare autosomal dominant disorder with increased risk of venous thromboembolism. The PS Heerlen polymorphism at codon 501 of the PROS1 gene is considered a variant of uncertain significance. It has since been shown that PS Heerlen has a reduced half-life, resulting in reduced levels of free PS. We report a case of an adolescent female with May Thurner syndrome and heterozygous PS Heerlen mutation resulting in a mild PS deficiency and venous thromboembolism. With this nonmodifiable risk factor, the patient received prolonged anticoagulation with strong consideration for lifelong prophylaxis.
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Affiliation(s)
- Marija Kacar
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
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4
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Vorobev AV, Bitsadze VO, Khizroeva JK, Potapkina SA, Makatsariya NA, Rizzo G, Di Renzo GC, Blinov DV, Pankratyeva LL, Tsibizova VI. Neonatal thrombosis: risk factors and principles of prophylaxis. OBSTETRICS, GYNECOLOGY AND REPRODUCTION 2021. [DOI: 10.17749/2313-7347/ob.gyn.rep.2021.233] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Data analysis on the pathogenesis and risk factors of neonatal thrombosis was carried out. The main risk factor of any neonatal thrombosis is central catheter installment, but other maternal, fetal and neonatal factors should be taken into consideration. We discuss the epidemiology of neonatal thrombosis and the main features of the hemostasis system in newborns, the most significant risk factors, including genetic and acquired thrombophilia. We consider the von Willebrand factor activity and ADAMTS-13 (a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13) level in the development of neonatal thrombotic microangiopathy. Finally, we discuss the basic principles of prevented neonatal thrombosis by using low molecular weight heparins.
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Affiliation(s)
| | | | | | | | | | - G. Rizzo
- Sechenov University; University of Rome Tor Vergata
| | - G. C. Di Renzo
- Sechenov University; Center for Prenatal and Reproductive Medicine, University of Perugia
| | - D. V. Blinov
- Institute for Preventive and Social Medicine; Lapino Clinic Hospital, MD Medical Group
| | - L. L. Pankratyeva
- Vorokhobov City Clinical Hospital № 67, Moscow Healthcare Department; Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology, Health Ministry of Russian Federation
| | - V. I. Tsibizova
- Almazov National Medical Research Centre, Health Ministry of Russian Federation
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Clinical Profile and Long-Term Outcome in Neonatal Cerebral Sinus Venous Thrombosis. Pediatr Neurol 2021; 121:20-25. [PMID: 34126318 DOI: 10.1016/j.pediatrneurol.2021.05.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 04/20/2021] [Accepted: 05/01/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Neonatal cerebral sinus venous thrombosis (CSVT) causes high morbidity and mortality. Factors associated with either favorable or unfavorable long-term outcomes have not been clearly established. This study aimed to determine the factors involved in long-term neurological outcomes in patients with neonatal CSVT. METHODS This was a retrospective cohort study of patients with neonatal CSVT at a single institution. Clinical factors associated with long-term neurological outcomes were examined. RESULTS A total of 67 patients met study inclusion criteria for radiologically confirmed neonatal CSVT. The mean patient follow-up duration was four years (range one week to 16 years, median six years). We observed a favorable neurological outcome defined by a pediatric stroke outcome measures (PSOM) score of 0 to 0.5 in 26 (53%) of osurviving patients at follow-up. An unfavorable neurological outcome as defined by PSOM score >0.5 was observed in 23 survivors (47%). Death was reported in 18 (27%) patients, of which 10 patients died due to direct complications of CSVT. Congential heart disease and genetic disease were associated with significantly increased odds for all-cause death. Cardiorespiratory failure and altered mental status during the initial neurological examination were significantly associated with increased odds of death due to CSVT. Among surviving patients, higher PSOM scores were associated with premature birth (i.e., gestational age < 37 weeks), traumatic birth, site of thrombosis in the straight sinus, site of thrombosis in the internal cerebral veins, and hemorrhagic infarct. In contrast, lower PSOM scores were associated with a normal neurological examination at presentation, thrombosis in only superficial sinuses, and hemorrhage without infarct. There was no statistically significant association between the type and duration of CSVT treatment. CONCLUSIONS The major factors influencing outcome of neonates following CSVT included comorbid medical conditions, abnormal neurological examination at presentation, location of venous thrombosis, and type of cerebral injury. These results can help guide further studies in neonatal CSVT aiming to decrease morbidity and mortality with the goal of improving long-term neurological outcomes.
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Juhl D, Kuta P, Shneyder M, Wünsche F, Nowak-Göttl U. Two Novel Variants in the Protein S Gene PROS1 Are Associated with Protein S Deficiency and Thrombophilia. Acta Haematol 2020; 144:222-226. [PMID: 32653888 DOI: 10.1159/000508525] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 05/07/2020] [Indexed: 11/19/2022]
Abstract
Protein S (PS) is an important anticoagulant. Its main function is to act as a non-enzymatical cofactor of activated protein C. PS deficiency is defined as low plasma levels of PS and/or loss of function associated with variable risk of venous thromboembolism (VTE). We report 2 novel variants in the PS gene (PROS1) which are associated with PS deficiency and severe thrombophilic diathesis in 2 patients. Patient 1 suffered from 3 VTE events, including a spontaneous VTE at the age of 19. Patient 2 suffered from 2 provoked VTE events. In both patients decreased plasma levels of PS antigen as well as decreased PS activity were found. Gene sequencing results showed a heterozygous deletion of 8 base pairs (c.938_945delTAAAATTT, p.Leu313Serfs13*) in exon 9 of the PROS1 gene in patient 1 and a missense variant (c.1613C>T, p.Ser538Phe) in patient 2. Due to the clinically proven history of recurrent VTE events in both patients, genetic testing of first-degree relatives is discussed.
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Affiliation(s)
- David Juhl
- Institute of Clinical Chemistry, University Hospital of Schleswig-Holstein, Lübeck/Kiel, Germany,
- Institute of Transfusion Medicine, University Hospital of Schleswig-Holstein, Lübeck, Germany,
| | - Piotr Kuta
- Institute of Clinical Chemistry, University Hospital of Schleswig-Holstein, Lübeck/Kiel, Germany
| | - Maria Shneyder
- Institute of Clinical Chemistry, University Hospital of Schleswig-Holstein, Lübeck/Kiel, Germany
| | - Falko Wünsche
- Medizinisches Versorgungszentrum Dr. Eberhard und Partner, Dortmund, Germany
| | - Ulrike Nowak-Göttl
- Institute of Clinical Chemistry, University Hospital of Schleswig-Holstein, Lübeck/Kiel, Germany
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Kayemba-Kay's S. Spontaneous neonatal renal vein thrombosis, a known pathology without clear management guidelines: An overview. Int J Pediatr Adolesc Med 2020; 7:31-35. [PMID: 32373700 PMCID: PMC7193072 DOI: 10.1016/j.ijpam.2019.07.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 06/12/2019] [Accepted: 07/02/2019] [Indexed: 04/18/2023]
Abstract
Renal vein thrombosis (RVT) was first described in 1837 by Rayer. Although tremendous progress has been achieved in the comprehension of its pathophysiology, its management remains controversial over 20 decades later. Therapeutic modalities vary from supportive measures alone to the utilization of thrombolytic agents whose protocols are derived from adult medicine. This review aims to show how difficult the treatment of RVT still is, especially with regard to the prognosis. The majority of affected neonates end with various renal complications (renal atrophy, dysfunction, hypertension, etc.). Like others, we suggest that simple unilateral RVT be managed conservatively, while thrombolytic agents may be attempted in unilateral RVT with extension to VCI and in bilateral RVT. Further studies are needed to reach appropriate consensual guidelines.
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Affiliation(s)
- S. Kayemba-Kay's
- Paediatrics and Neonatal Medicine Department, Centre Hospitalier du Valais Romand, Sion, Switzerland
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8
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Reconstructive complications of thrombophilia and keloid scarring: free flap surgery in a patient with mild protein S deficiency. Br J Oral Maxillofac Surg 2019; 57:1173. [PMID: 31629548 DOI: 10.1016/j.bjoms.2019.08.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 08/20/2019] [Indexed: 11/21/2022]
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9
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Fearon A, Pearcy P, Venkataraman S, Shah P. Protein S Deficiency and Arterial Thromboembolism: A Case Report and Review of the Literature. J Hematol 2019; 8:37-39. [PMID: 32300440 PMCID: PMC7153672 DOI: 10.14740/jh478] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 02/15/2019] [Indexed: 02/06/2023] Open
Abstract
Protein S (PS) deficiency is associated with a well documented risk of venous thromboembolism. However, the relation between PS deficiency itself to arterial thrombotic events (ATEs) is not clearly established. In our case, we report an ATE in a patient with a documented novel PROS1 mutation and a family history of PS deficiency. Other etiologies for arterial thrombosis were excluded. The role of precise diagnosis with levels of PS and documentation for mutational analysis are discussed. We highlight the problems with diagnosis in previously reported cases with arterial thrombotic events and discuss the potential for treatment with antiplatelet therapy in a subset of patients with PS deficiency.
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Affiliation(s)
- Amber Fearon
- Rosalind Franklin Chicago Medical School, 3333 Green Bay Rd., North Chicago, IL, USA
| | - Paige Pearcy
- Rosalind Franklin Chicago Medical School, 3333 Green Bay Rd., North Chicago, IL, USA
| | | | - Prabodh Shah
- Little Company of Mary Hospital, 2800 W. 95th St., Evergreen Park, IL, USA
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deVeber G, Kirkham F, Shannon K, Brandão L, Sträter R, Kenet G, Clausnizer H, Moharir M, Kausch M, Askalan R, MacGregor D, Stoll M, Torge A, Dlamini N, Ganesan V, Prengler M, Singh J, Nowak-Göttl U. Recurrent stroke: the role of thrombophilia in a large international pediatric stroke population. Haematologica 2019; 104:1676-1681. [PMID: 30679327 PMCID: PMC6669164 DOI: 10.3324/haematol.2018.211433] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 01/22/2019] [Indexed: 12/04/2022] Open
Abstract
Risk factors for arterial ischemic stroke in children include vasculopathy and prothrombotic risk factors but their relative importance to recurrent stroke is uncertain. Data on recurrent stroke from databases held in Canada (Toronto), Germany (Kiel-Lübeck/Münster), and the UK (London/Southampton) were pooled. Data were available from 894 patients aged 1 month to 18 years at first stroke (median age, 6 years) with a median follow-up of 35 months. Among these 894 patients, 160 (17.9%) had a recurrence between 1 day and 136 months after the first stroke (median, 3.1 months). Among 288 children with vasculopathy, recurrence was significantly more common [hazard ratio (HR) 2.5, 95% confidence interval (95% CI) 1.92-3.5] compared to the rate in children without vasculopathy. Adjusting for vasculopathy, isolated antithrombin deficiency (HR 3.9; 95% CI: 1.4-10.9), isolated elevated lipoprotein (a) (HR 2.3; 95% CI: 1.3-4.1), and the presence of more than one prothrombotic risk factor (HR 1.9; 95% CI: 1.12-3.2) were independently associated with an increased risk of recurrence. Recurrence rates calculated per 100 person-years were 10 (95% CI: 3-24) for antithrombin deficiency, 6 (95% CI: 4-9) for elevated lipoprotein (a), and 13 (95% CI: 7-20) for the presence of more than one prothrombotic risk factor. Identifying children at increased risk of a second stroke is important in order to intensify measures aimed at preventing such recurrences.
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Affiliation(s)
| | - Fenella Kirkham
- Developmental Neurosciences Programme, UCL Great Ormond Street Institute of Child Health, London, UK.,University Hospital Southampton, UK
| | | | | | - Ronald Sträter
- Department of Paediatric Haematology/Oncology, University of Münster, Münster, Germany
| | - Gili Kenet
- Pediatric Coagulation Service, National Hemophilia Centre and Institute of Thrombosis and Hemostasis Sheba Medical Center, Tel-Hashomer, Israel
| | - Hartmut Clausnizer
- Institute of Clinical Chemistry, University Hospital Kiel-Lübeck, Kiel, Germany
| | | | - Martina Kausch
- Institute of Clinical Chemistry, University Hospital Kiel-Lübeck, Kiel, Germany
| | | | | | - Monika Stoll
- Department of Genetic Epidemiology, University of Münster, Münster, Germany
| | - Antje Torge
- Institute of Clinical Chemistry, University Hospital Kiel-Lübeck, Kiel, Germany
| | | | - Vijeja Ganesan
- Developmental Neurosciences Programme, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Mara Prengler
- Developmental Neurosciences Programme, UCL Great Ormond Street Institute of Child Health, London, UK
| | | | - Ulrike Nowak-Göttl
- Department of Paediatric Haematology/Oncology, University of Münster, Münster, Germany .,Institute of Clinical Chemistry, University Hospital Kiel-Lübeck, Kiel, Germany
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11
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Venous thromboembolism associated with protein S deficiency due to Arg451* mutation in PROS1 gene: a case report and a literature review. J Genet 2018; 96:1047-1051. [PMID: 29321366 DOI: 10.1007/s12041-017-0865-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Protein S (PS) is a vitaminK-dependent glycoproteinwhich plays an important role in the regulation of blood coagulation. PS deficiency has been found in 1.5-7% of thrombophilic patients. Here, we report the first Polish case with PS deficiency caused by the p.Arg451* in the PROS1 gene detected in a 21-year-old man with trauma-induced venous thromboembolism. To our knowledge, we provided the review of all the available data on this mutation (a total of 56 cases). The proband, his mother and his sister were screened for thrombophilia. To elucidate genetic background of PS deficiency, all PROS1 genes were subjected to direct sequencing. The free PS levels were 35% in the proband, 21% in the proband's mother and 28% in the proband's sister and their PS total levels were 37.1, 47.5 and 55.1%, respectively. Type I PS deficiency was diagnosed. In all patients, genetic analysis revealed the presence of heterozygous nonsense mutation (c.1351C>T; p.Arg451*) located in exon 12 of PROS1 gene. This mutation interrupts the reading frame by premature termination codon at position 451 and may lead to the production of truncated protein. The present case combined with the review of the literature suggests that p.Arg451* in the PROS1 gene mainly leads to clinically evident thrombosis following trauma, surgery or serious comorbidities especially malignancy.
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12
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Schultz C, Doran R. Pulmonary Emboli and Deep Venous Thrombosis during Adolescence. J Pediatr Health Care 2018; 32:298-301. [PMID: 29290408 DOI: 10.1016/j.pedhc.2017.09.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Revised: 09/03/2017] [Accepted: 09/20/2017] [Indexed: 10/18/2022]
Abstract
Pulmonary emboli (PE) and deep venous thrombus (DVT) are two conditions considered to affect primarily adults. These conditions, however, can and do affect neonates, toddlers, school-age children, and adolescents. Factors contributing to the development of PE and DVT are often associated with genetic mutations in Antithrombin III, Protein C, and Protein S. This article presents a primary care case study of an adolescent who was diagnosed with and underwent treatment for bilateral PE and a DVT, and reviews the underlying primary genetic mutations, diagnostic workup, and management of his clinical condition.
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13
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Abstract
Venous thrombosis (VTE) in children is gaining increased awareness and apart from underlying medical conditions, recently reported systematic reviews on pediatric VTE (70% provoked) have shown significant associations between thrombosis and presence of inherited thrombophilic risk factors (IT), such as protein C-, protein S- and antithrombin deficiency, mutations of factor 5 (F5: rs6025) and factor 2 (F2: rs1799963), even more pronounced when combined IT were involved. Although we have learned more about the pathophysiology of VTE with the increased discovery of IT evidence is still lacking as to whether IT influence the clinical outcome in pediatric VTE. It still remains controversial as to whether children with VTE or offspring from thrombosis-prone families benefit from IT screening. Thus, IT testing in children should be individualized. If the decision "pro screening" is discussed as an appropriate option in adolescents with unprovoked VTE and in children with a positive family history for VTE screening should be performed in a specialized coagulation unit for acquired or inherited and prothrombotic defects based on the individual population background. Apart from the laboratory assessment for the presence/absence of lupus anticoagulants and antiphospholipid antibodies screening should be performed beyond the acute VTE onset and after withdrawal of anticoagulant medication possibly influencing laboratory results.
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Affiliation(s)
- Ulrike Nowak-Göttl
- Thrombosis and Hemostasis Unit, Department of Clinical Chemistry, Univ. Hospital of Kiel, Germany.
| | - Heleen van Ommen
- Department of Pediatric Hematology, Sophia Children's Hospital Erasmus MC, Rotterdam, The Netherlands
| | - Gili Kenet
- The Israel National Hemophilia Centre, Sheba Medical Centre, Tel-Hashomer, The Sackler Medical School, Tel Aviv University, Israel
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Abstract
Paediatric venous thromboembolism (VTE) is a rare disorder but a rising incidence has been observed in recent years, due to improved VTE diagnosis and increased use of central venous catheters in the treatment of severe diseases. Risk assessment strategies are well established for adult patients, however, similar guidelines for paediatric patients are largely lacking. Several risk prediction tools have been reported in recent literature, which make use of established risk factors to assess VTE risk in paediatric subgroups, such as hospitalised children, cancer-diagnosed children and paediatric trauma patients. Although these models suffer several limitations regarding their study size and heterogeneous selection of predictor variables, they offer potential for improving the thromboprophylaxis management in these children. Here, we give an overview on recently reported risk prediction models for paediatric VTE.
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Affiliation(s)
- Frank Rühle
- Department of Genetic Epidemiology, Institute of Human Genetics, University of Münster, Münster, Germany
| | - Monika Stoll
- Department of Genetic Epidemiology, Institute of Human Genetics, University of Münster, Münster, Germany.,Department of Biochemistry, Genetic Epidemiology and Statistical Genetics, CARIM School for Cardiovascular Diseases, Maastricht Centre for Systems Biology (MaCSBio), Maastricht University, Maastricht, The Netherlands
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15
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Kenet G, Limperger V, Shneyder M, Nowak-Göttl U. Risk factors for symptomatic venous and arterial thromboembolism in newborns, children and adolescents - What did we learn within the last 20years? Blood Cells Mol Dis 2016; 67:18-22. [PMID: 28010922 DOI: 10.1016/j.bcmd.2016.12.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Accepted: 12/12/2016] [Indexed: 01/23/2023]
Abstract
Venous thrombosis (VTE) in children is increasingly diagnosed, as advanced medical care has increased treatment intensity of hospitalized pediatric patients. The aim of this review was to summarize the data available and to discuss the controversial issue of thrombophilia screening in the light of the pediatric data available. Follow-up data for VTE recurrence in children suggest a recurrence rate between 3% (neonates) and 21% in individuals with unprovoked VTE. Apart from underlying medical conditions, recently reported systematic reviews on pediatric VTE (70% provoked) have shown significant associations between thrombosis and presence of protein C-, protein S- and antithrombin deficiency, factor 5 (F5: rs6025), factor 2 (F2: rs1799963), even more pronounced when combined inherited thrombophilias [IT] were involved. The F2 mutation, protein C-, protein S-, and antithrombin deficiency did also play a significant role at VTE recurrence. Although we have learned more about the pathophysiology of VTE with the increased discovery of IT evidence is still lacking as to whether IT influence the clinical outcome in pediatric VTE. It still remains controversial as to whether children with VTE or offspring from thrombosis-prone families benefit from IT screening. Thus, IT testing in children should be individualized.
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Affiliation(s)
- Gili Kenet
- The Israel National Hemophilia Centre, Sheba Medical Centre, Tel-Hashomer, The Sackler Medical School, Tel Aviv University, Israel
| | - Verena Limperger
- Thrombosis and Hemostasis Unit, Department of Clinical Chemistry, Univ. Hospital of Kiel, Germany
| | - Maria Shneyder
- Thrombosis and Hemostasis Unit, Department of Clinical Chemistry, Univ. Hospital of Lübeck, Germany
| | - Ulrike Nowak-Göttl
- Thrombosis and Hemostasis Unit, Department of Clinical Chemistry, Univ. Hospital of Kiel, Germany; Thrombosis and Hemostasis Unit, Department of Clinical Chemistry, Univ. Hospital of Lübeck, Germany.
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16
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Nagler A. The Neglected Role of Hematologic Disorders in Pulmonary Embolism. JOURNAL OF CARDIOVASCULAR EMERGENCIES 2016. [DOI: 10.1515/jce-2016-0026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Arnon Nagler
- Division of Hematology, Sackler Faculty of Medicine, University of Tel Aviv, Israel
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Impact of high risk thrombophilia status on recurrence among children and adults with VTE: An observational multicenter cohort study. Blood Cells Mol Dis 2016; 62:24-31. [PMID: 27838551 DOI: 10.1016/j.bcmd.2016.10.024] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Accepted: 10/30/2016] [Indexed: 12/20/2022]
Abstract
BACKGROUND Antithrombin [AT]-, protein C [PC]- or protein S [PS]-deficiency [D] constitutes a major risk factor for venous thromboembolism [VTE]. Primary study objective was to evaluate if the clinical presentation at first VTE onset differs between children and adults and to compare the individual recurrence risk among patients with respect to age at onset and their thrombophilia status ATD, PCD or PSD. METHODS/PATIENTS/RESULTS In 137 of 688 consecutively enrolled pediatric and adult VTE patients we calculated the absolute risk of VTE recurrence and event-free-survival adjusted for thrombophilia and positive family VTE history. At first VTE children manifested i) with a lower rate of pulmonary embolism, ii) a higher rate of cerebral vascular events or multiple VTEs, and iii) showed a higher proportion of unprovoked VTE compared to adolescents and adults. Adult patients reported more often a positive VTE history compared to younger study participants. The adjusted odds of recurrence in adults was 2.05 compared to children. CONCLUSION At disease manifestation children and adults differ with respect to i) thrombotic locations, ii) percentage of unprovoked versus provoked VTE, and iii) different rates of positive VTE family histories. Furthermore, adults showed a two-fold increase risk of VTE recurrence compared to children.
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Limperger V, Kenet G, Goldenberg NA, Heller C, Holzhauer S, Junker R, Klostermeier UC, Knoefler R, Kurnik K, Krümpel A, Mesters R, Stach M, Young G, Nowak-Göttl U. Impact of high-risk thrombophilia status on recurrence among children with a first non-central-venous-catheter-associated VTE: an observational multicentre cohort study. Br J Haematol 2016; 175:133-40. [PMID: 27329967 DOI: 10.1111/bjh.14192] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Accepted: 04/15/2016] [Indexed: 11/30/2022]
Abstract
Deficiency of antithrombin (AT), protein C (PC) or protein S (PS) constitutes a major risk factor for venous thromboembolism (VTE). Individuals at high risk for recurrence who benefit from screening need to be identified. The primary study objective was to determine the individual recurrence risk among children with a first non-central-venous-catheter-associated VTE with respect to their thrombophilia status and to evaluate if the clinical presentation at first VTE onset differs between children with AT, PC or PS deficiency versus no thrombophilia. We calculated the absolute risk of VTE recurrence and event-free-survival adjusted for thrombophilia, age, sex and positive family VTE history in 161 consecutively enrolled paediatric VTE patients. The presence of a deficiency relative to no thrombophilia was evaluated as a potential predictor of recurrence. Predictors for recurrence were AT deficiency (hazard ratio/95% CI: 6·5/2·46-17·2) and female gender (2·6/1·1-6·35). The annual recurrence rates (95% CIs) were 5·4% (2·6-10) in AT-deficient children, 1·3% (0·3-3·8) in patients with PC deficiency, 0·7% (0·08-2·4) in the PS-deficient cohort and 0·9% (0·4-1·8) in patients with no thrombophilia. Positive family VTE history or combined thrombophilias did not predict recurrence. Given the overall annual incidence rate of recurrence of 1·5% we suggest screening for AT deficiency in children with VTE.
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Affiliation(s)
- Verena Limperger
- Institute of Clinical Chemistry, University Hospital Kiel, Kiel, Germany
| | - Gili Kenet
- Thrombosis Unit, National Haemophilia Centre, Tel Hashomer and the Sackler Medical School, Tel Aviv University, Tel Aviv, Israel
| | - Neil A Goldenberg
- All Children's Hospital Johns Hopkins Medicine and All Children's Research Institute, St. Petersburg, FL, USA.,Division of Hematology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Susanne Holzhauer
- Department of Paediatric Haematology/Oncology, Charité, Berlin, Germany
| | - Ralf Junker
- Institute of Clinical Chemistry, University Hospital Kiel, Kiel, Germany
| | | | - Ralf Knoefler
- Department of Paediatric Haemostaseology, Dresden, Germany
| | - Karin Kurnik
- Department of Paediatrics, University Children Hospital Munich, Munich, Germany
| | - Anne Krümpel
- Department of Paediatric Haematology/Oncology, University Children Hospital Münster, Münster, Germany
| | - Rolf Mesters
- Department of Medicine/Haematology & Oncology, Univ. Hospital Münster, Münster, Germany
| | - Michael Stach
- IT Service Centre, University Hospital of Münster, Münster, Germany
| | - Guy Young
- Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Ulrike Nowak-Göttl
- Institute of Clinical Chemistry, University Hospital Kiel, Kiel, Germany. .,Department of Paediatric Haematology/Oncology, University Children Hospital Münster, Münster, Germany.
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19
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Kurnik K, Bidlingmaier C, Hütker S, Olivieri M. [Haemostatic disorders in children]. Hamostaseologie 2016; 36:109-25. [PMID: 26988657 DOI: 10.5482/hamo-15-04-0016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Accepted: 03/04/2016] [Indexed: 12/28/2022] Open
Abstract
Haemorrhagic and thrombotic events occur in both children and adults. The underlying causes are congenital or acquired disorders. In contrast to haemorrhagic disorders, inherited thrombotic disorders nearly exclusively in association with additional external risk factors lead to thrombotic events predominantly during the newborn period and adolescence. It is necessary to be aware of age-specific properties of coagulation in order to correctly interpret clinical and laboratory findings and to provide optimal care for children with haemorrhagic and thrombotic complications.
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Affiliation(s)
- Karin Kurnik
- Priv.-Doz. Dr. med. Karin Kurnik, Kinderklinik im Dr. von Haunerschen Kinderspital Klinikum der Universität München, Lindwurmstr. 4, 80337 München,
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20
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Age-specific onset and distribution of the natural anticoagulant deficiency in pediatric thromboembolism. Pediatr Res 2016; 79:81-6. [PMID: 26372516 DOI: 10.1038/pr.2015.180] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Accepted: 06/29/2015] [Indexed: 12/21/2022]
Abstract
BACKGROUND The early diagnosis of inherited thrombophilia in children is challenging because of the rarity and hemostatic maturation. METHODS We explored protein C (PC), protein S (PS), and antithrombin (AT) deficiencies in 306 thromboembolic patients aged ≤20 y using the screening of plasma activity and genetic analysis. RESULTS Reduced activities were determined in 122 patients (40%). Low PC patients were most frequently found in the lowest age group (0-2 y, 45%), while low PS or low AT patients were found in the highest age group (16-20 y; PS: 30% and AT: 20%). Genetic study was completed in 62 patients having no other causes of thromboembolism. Mutations were determined in 18 patients (8 PC, 8 PS, and 2 AT genes). Six of eight patients with PC gene mutation were found in age 0-2 y (75%), while six of eight patients with PS gene mutation were in 7-20 y. Two AT gene-mutated patients were older than 4 y. Four PC-deficient and two PS-deficient patients carried compound heterozygous mutations. All but one PC gene-mutated patient suffered from intracranial thromboembolism, while PS/AT gene-mutated patients mostly developed extracranial venous thromboembolism. CONCLUSION Stroke in low PC infants and deep vein thrombosis in low PS/AT school age children could be targeted for genetic screening of pediatric thrombophilias.
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