1、Advanced age is a risk for venous thromboembolism(VTE)All VTEBlood,110,3097-3101,2007among residents of Olmsted County,Minnesota,from 1966 to 1990PEDVT aloneMaleFemaleIncidence rates of VTE increase dramatically at about age 55,and,by age 80,are nearly 1 in 100 per year,approximately 1000-fold highe
2、r than for those aged 45 or younger.Risk factors for venous thromboembolismN Engl J Med,358,1037-52,2008Acquired factors Reduced mobility Advanced age Cancer Acute medical illness Major surgery Trauma Spinal cord injury Pregnancy and postpartum period Polycythemia vera Antiphospholipid antibody synd
3、rome Oral contraceptives Hormone-replacement therapy Heparins Chemotherapy Obesity Central venous catheterization Immobilizer or castHereditary factors Antithrombin deficiency Protein C deficiency Protein S deficiency Factor V Leiden Prothrombin gene mutationThrombo-modulinendotheliumEPCRPCPSprothro
4、mbinFVa FXaFVaFVIIIaHSPGthrombinAPCProtein C/protein S systemProteoglycansulfatesystemHeparan sulfateFVi FVIIIi IIa ATAnticoagulant Systems on EndotheliumCaucasianJapaneseFactor V LeidenProthrombin G20210ADeficiencies of protein C,protein S,antithrombinLow frequencyvariationDeficiencies of protein C
5、,protein S,antithrombinVery raremutationGenetic risk factors for venous thromboembolismProtein S K196ETokyoGeneral population,Suita study at NCVCVTE patients:Sub-group of Blood Coagulation Abnormality Study GroupSuita,OsakaNCVC,Osaka UNagoya UJichi Med UKeio UnivKyoto Pref Med UAbout 170 Japanese VT
6、E patientsCase-control study for more than 3,500 individuals from a general population randomly selected from Suita city residentsKimura et al.,Blood,2006VTE1392011600.06932903321736390.0502.1790.336ProSerMajor homoHeteroMinor homoTotalMAFMajor homoHeteroMinor homoTotalMAF 2PMajor alleleMinor allele
7、General population(Suita study)152901610.0283501149036500.0200.9870.320AlaThr1461321610.053358566036510.00975.464T6169301600.4031468168649736510.3673.4020.1834G5GADAMTS13P475SPLG A620TPS K196E6375231610.3761513165148636500.3590.3720.830TCPAI-1 4G/5GMAF:minor allele frequencyCase-control association
8、studyusing Japanese VTE patientsProtein S K196E as a Risk for VTE Populationbased-control n(%)Geno-types VTEgroup n(%)Protein SK196E(Protein STokushima)KKKEEETotalKKKE+EEtotal3585(98.2)66(1.8)0(0.0)3651(100.0)3585(98.2)66(1.8)3651(100.0)2=75.464,P0.0001 2=41.807,P0.0001 OR=5.58(95%CI 2.90-9.46)146(9
9、0.7)13(8.1)2(1.2)161(100.0)146(90.7)15(9.3)161(100.0)OR:odds ratio,CI:confidence intervalA missense mutation causing Lys196 to be replaced by Glu is located within the 2nd EGF-like domain.This mutation was referred to as protein S Tokushima.The odds ratio of the mutant E allele for VTE was 5.Other g
10、enetic factorsSex hormone-bindingAbout 170 Japanese VTE patientsFactor V Leiden66 heterozygotes/3,651 individualsNumber of Mutation CarriersIt is present in the second EGF-like domain of protein S.PROC K193del at the 6th residue from the C-terminus in the light chain,Blood,2006Heterozygosity:1.Gende
11、r and age dependency of plasma protein S levelsMinor alleleAllele freq.We have sequenced the entire coding regions of 3 genes in all 173 DNA samples obtained from Japanese VTE patients without any consideration of their activities and antigen levels.Sakata et al,JTH 2004Onset age of initial VTE GlaE
12、GF-like 1-4Sex hormone-binding globulin635 aaProtein S K196EProtein S TokushimaLys196Glu PS K196E mutation has been identified in Japanese DVT patients in 1993 by two independent groups.This mutation was referred to as protein S Tokushima.It is present in the second EGF-like domain of protein S.In v
13、itro study showed that this mutant exhibits the loss of the APC cofactor activity and the prothrombinase inhibitory activity.Yamazaki et al,1993,Shigekiyo et al,1993,Hayashi et al,1994TokyoNagoya U3 hetero/182 individualsHeterozygosity:1.65%Allele freq.:0.82%Kyushu U 5 hetero/304 individualsHeterozy
14、gosity:1.64%Allele freq.:0.82%Natl Cardio Vasc Ctr at Suita66 heterozygotes/3,651 individualsHeterozygosity:1.81%Allele freq.:0.90%HeterozygotesN=34Wild-typesN=1,828Staclot Protein S(Diagnostica Stago)Protein S activity in wild-type and K196E heterozygous individuals71.9+/-17.6%87.9+/-19.8%Protein S
15、 activityP0.0001Kimura et al.,JTH,4,2010-2013,2006only found in Japanese populationnonsynonymousGender and age dependency of plasma protein S levels,Blood,2006,Blood,2006Advanced ageMAF:minor allele frequencyAntiphospholipid antibody syndromeusing Japanese VTE patientsProteoglycanDeletion,at least 1
16、07 kbA missense mutation causing Lys196 to be replaced by Glu is located within the 2nd EGF-like domain.nonsynonymousAcquired factorsProthrombin G20210A4 hetero,normal PC amidolytic activity with reduced anticoagulant activityFactor V LeidenMAF:minor allele frequencyA missense mutation causing Lys19
17、6 to be replaced by Glu is located within the 2nd EGF-like domain.Geographical distribution of PROS1 K196E mutationFirst onset age mean+/-SDGenetic risk factors for venous thromboembolismAcquired factors influencing plasma protein S activityGender and age dependency of plasma protein S levelsSakata
18、et al,JTH 2004Men N=1252Women N=14383040506070801401201008060Protein S activity(%)Age band Age Gender Pregnancy Oral contraceptives Anticoagulant drugs DIC Liver diseases Kidney disease1.PROS1 K196E mutation is a genetic risk factor for venous thromboembolism(VTE)in Japanese.2.A missense mutation ca
19、using Lys196 to be replaced by Glu is located within the 2nd EGF-like domain.3.The odds ratio of the mutant E allele for VTE was 5.58.4.Individuals heterozygous for the mutant E-allele had lower(mean 16%)plasma protein S activity than wildtype subjects.PROS1 K196EKimura et al.,Blood,2006,Kimura et a
20、l.,JTH 2006,Miyata et al.,IJH 20065.The allelic frequency of the E allele was 0.9%.We estimated a total of as many as 10,000 Japanese as homozygotes.6.A substantial proportion of the Japanese population carries the PROS1 E allele and is at risk of developing VTE.7.Therefore,individuals with the PROS
21、1 E allele should avoid environmental risk factors known to be associated with VTE.PROS1 K196E,cont.Kimura et al.,Blood,2006,Kimura et al.,JTH 2006,Miyata et al.,IJH 2006CaucasianJapaneseFactor V LeidenProthrombin G20210ADeficiencies of protein C,protein S,antithrombinLow frequencyvariationDeficienc
22、ies of protein C,protein S,antithrombinVery raremutationGenetic risk factors for venous thromboembolismProtein S K196EWe have sequenced the entire coding regions of 3 genes in all 173 DNA samples obtained from Japanese VTE patients without any consideration of their activities and antigen levels.ABI
23、 3730 DNA AnalyzerQuestionPrevalence of nonsynonymous mutations in PROS1,PROC,and SERPINC1(antithrombin)in the Japanese VTE patientsNumber of Mutation Carriers55 out of 173 VTE patients(32%)carried nonsynonymous mutations SERPINC1145PROS1 24PROC12Including one patient with PROS1 gene deletionnonsyno
24、nymous mutationsMissense,Nonsense,Frame-shift,Splice-site,Inframe deletionPS K196E mutation as a modifierR221WV339MV339MR271WK193delK196EK196EK196EK196EK196ENoYesNoYesunavailable4025553957PROCPROS1Family historyOnset age of initial VTE5UTRpromotercentromereD3S3619D3S3634Chromosome 3Large PROS1 delet
25、ionin 1 out of 163 VTE patients347111321568912141015PROS1Deletion,at least 107 kbYin et al.,Thromb Haemost 2007;98:783-789A large PROS1 deletion was found in one VTE patient who showed 16%PS activity and did not have point mutations in PROS1.Comparison of first onset age of VTE events between mutati
26、on carriers and non-carriers55*44.7+/-16.511852.6+/-16.1NumberP=0.0031CarriersNon-carriersFirst onset age mean+/-SD*Five had mutations in both PROS1 and PROC.Two were homozygotes for PROS1 K196E.One was a compound heterozygote for PROS1 K196E/R101C.Recurrent mutations found in Japanese VTE patientsP
27、ROS1 K196E in the 2nd EGF-like domain 2 homo,13 hetero,reduced PS activity with normal PS antigenPROC K193del at the 6th residue from the C-terminus in the light chain 4 hetero,normal PC amidolytic activity with reduced anticoagulant activityPROC V339M in the catalytic 4 hetero,reduced PC amidolytic
28、 activityonly found in Japanese populationonly found in Japanese populationSERPINC114Other genetic factors5PROS1 24PROC12VTEGenetic risk factorsEnvironmental risk factorsObesity,Cancer,Immobilization,Hospitalization,Surgery,PregnancyCLOTKyoto Pref Med UAllele freq.PROS1 K196E,cont.Geographical distr
29、ibution of PROS1 K196E mutationYoshihiro KOKUBO,Toshiyuki SAKATA,Satoshi TAKESHITA,Hitonobu TOMOIKEbased-controlGeographical distribution of PROS1 K196E mutationAntithrombin deficiency2 homo,13 hetero,reduced PS activity with normal PS antigenMajor alleleAntithrombin deficiencyAcute medical illnessH
30、eterozygotesSakata et al,JTH 2004based-controlSakata et al,JTH 2004,Blood,200666 heterozygotes/3,651 individualsusing Japanese VTE patientsTong YIN,Rina KIMURA,Koichi KOKAME,Shigenori HONDA,Yongchol SHIN,Ms.Factor V LeidenKimura et al.Risk factors for venous thromboembolismN Engl J Med,358,1037-52,2
31、008Acquired factors Reduced mobility Advanced age Cancer Acute medical illness Major surgery Trauma Spinal cord injury Pregnancy and postpartum period Polycythemia vera Antiphospholipid antibody syndrome Oral contraceptives Hormone-replacement therapy Heparins Chemotherapy Obesity Central venous cat
32、heterization Immobilizer or castHereditary factors Antithrombin deficiency Protein C deficiency Protein S deficiency Factor V Leiden Prothrombin gene mutationAcknowledgementsNatl Cardiovascular Ctr Res Inst Drs.Tong YIN,Rina KIMURA,Koichi KOKAME,Shigenori HONDA,Yongchol SHIN,Ms.Junko ISHIKAWA,Yukiko SATO The Study Group of Blood Coagulation Abnormality on Measures for Intractable DiseasesDrs.Tomio KAWASAKI,Hajime TSUJI,Seiji MADOIWA,Yoichi SAKATA,Tetsuhito KOJIMA,Mitsuru MURATA,Yasuo IKEDANatl Cardiovascular Ctr Hospital Drs.Yoshihiro KOKUBO,Toshiyuki SAKATA,Satoshi TAKESHITA,Hitonobu TOMOIKE
