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Guerra JCC, Ferreira MR, Mendes CA, Aranda V, Kanayama R, Bacal NS, Pasternak J, Ferreira E
ORIGINAL ARTICLE
Prevalence of hereditary factors predisposing to thrombosis in 260 patients diagnosed as thrombosis and investigated at Hospital Israelita Albert Einstein, São Paulo, Brazil Prevalência de fatores hereditários que predispõem à trombose em 260 pacientes com diagnóstico de trombose e investigados no Hospital Israelita Albert Einstein, São Paulo, Brasil João Carlos de Campos Guerra1, Marden Rene Ferreira2, Claudio Albers Mendes3, Valdir Aranda4, Ruth Kanayama5, Nydia Strachman Bacal6, Jacyr Pasternak6, Euripedes Ferreira6
ABSTRACT Objective: To evaluate the prevalence of genetic polymorphism in coagulation factors in thromboembolic disease in patients with clinical suspicion of thrombosis. Methods: A retrospective case collection was performed searching all patients with clinical suspicion of thrombosis who were submitted to coagulation factor analysis at the Hospital Israelita Albert Einstein from November 2003 to April 2004. We included 260 patients, 118 male and 142 female, mean age of 46 years. Prothrombin mutation and Leiden V factor were evaluated with multiplex PCR. Protein C, S and lupus anticoagulant were studied in coagulation assays. Antithrombin III was studied by chromogenic assay. Anticardiolipin was evaluated through an immunoenzymatic method and homocysteine by an immunometric method. Results: Factor V Leiden was found in 22 cases (8.3 %), one homozygote and 21 heterozygotes. Prothrombin mutation was found in 18 cases (6.8%), one homozygote and 17 heterozygotes. Forty cases with genetic alteration showed 34 cases with thrombosis (85%), 29 venous thrombosis and 4 arterial thrombosis. One hundred and seven patients were tested for anticardiolipin antibodies: 21 were anticardiolipin antibody positives (19.6%), and 15 of them had IgG antibodies, 3 IgM and 3 IgA. Sixteen of the 21 patients had thrombosis, 11 venous thrombosis and 5 arterial thrombosis. Lupus anticoagulant was found in two patients, both with thrombosis. There was only one case of hyperhomocystinemia, with thrombosis. Protein C, protein S and antithrombin III deficiencies were found in 63 cases (12%). Out of 31 cases with thrombosis (49,2 %), 26 cases had venous thrombosis and 5 had arterial thrombosis. Conclusion: Thromboembolic disease is clearly associated with genetic factors but there is
consensus its cause is multifactorial. Genetic alterations, however, should be studied when there is clinical evidence of thrombosis, at least in young patients. Keywords: Thrombosis/genetics; Polymorphism (genetics); Blood coagulation factors; Thromboembolism
RESUMO Objetivo: Avaliar a prevalência de polimorfismo genético entre os fatores de coagulação na doença tromboembólica. Métodos: Foi feito um estudo retrospectivo de todos os pacientes com suspeitas clinicas de trombose que fizeram análise de fatores da coagulação entre novembro de 2003 e abril de 2004 no Hospital Israelita Albert Einstein. Foram estudados 260 pacientes, 118 do sexo masculino e 142 do sexo feminino, com idade média de 46 anos. Mutação de protrombina e fator V de Leiden foram avaliados por meio de PCR múltiplo. Proteínas C, S e o anticoagulante lúpico foram estudados em ensaios de coagulação; a antitrombina, por ensaio cromogênico e a anticardioliopina, através de método imunoenzimático; a homocisteína, por método imunométrico. Resultados: O fator V de Leiden foi encontrado em 22 casos (8,3%), um homozigoto e 21 heterozigotos. A mutação de protrombina ocorreu em 18 casos (6,8%), 1 homozigoto e 17 heterozigotos. Em 40 casos com alteração genética havia 34 com trombose (85%), sendo 24 com trombose venosa e 4 com trombose arterial. Cento e sete pacientes foram testados para anticorpos anticardiolipina: 21 apresentavam anticorpos anticardiolipina positivos (19,6%) e, destes, 15 tinham anticorpos IgG, 3 IgM e 3 IgA. Dezesseis dos 21 tinham trombose,
Study carried out at Hospital Israelita Albert Einstein, São Paulo (SP), Brazil. 1
Hematologist and Clinical Pathologist, Department of Clinical Pathology, Hospital Israelita Albert Einstein, São Paulo (SP), Brazil.
2
Graduate Student of Hematology, Department of Clinical Pathology, Hospital Israelita Albert Einstein, São Paulo (SP), Brazil.
3
Biomedical Scientist, Technical Laboratory Coordinator, Department of Clinical Pathology, Hospital Israelita Albert Einstein, São Paulo (SP), Brazil.
4
Biochemist. Laboratory Analyst, Department of Clinical Pathology, Hospital Israelita Albert Einstein, São Paulo (SP), Brazil.
5
Pharmacist. Laboratory Analyst, Department of Clinical Pathology, Hospital Israelita Albert Einstein, São Paulo (SP), Brazil.
6
Physican, Department of Clinical Pathology, Hospital Israelita Albert Einstein, São Paulo (SP), Brazil. Corresponding author: João Carlos de Campos Guerra - Av. Albert Einstein, 627 - Morumbi - CEP 05651-901 - São Paulo (SP), Brazil - Tel.: (5511) 3747-2430 - e-mail:
[email protected] Received on Jan 16, 2005 – Accepted on April 25, 2005
einstein. 2005; 3(2):106-109
Prevalence of hereditary factors predisposing to thrombosis in 260 patients diagnosed as thrombosis and investigated at Hospital Albert Einstein, Sao Paulo, Brazil
11 tromboss venosa e 5 trombose arterial. Fator anticoagulante lúpus lúpico foi encontrado em 2 pacientes, ambos com trombose. Houve apenas 1 caso de hiper-homocisteinemia com trombose. Proteínas C, S e deficiência de antitrombina foram encontradas em 63 casos (12%). Em 31 casos com trombose (49,2%), 26 tinham trombose venosa e 5, arterial. Conclusão: a doença tromboembólica se acha claramente associada a fatores genéticos, mas há consenso de que seja multifatorial. Contudo, as alterações genéticas devem ser estudadas quando há suspeita clínica de trombose, principalmente em pacientes jovens, sem outros fatores de risco ou em localização pouco usual. Descritores: Trombose/genética; Polimorfismo (genética); Fatores de coagulação sangüínea; Tromboembolismo
INTRODUCTION In the last decades hypercoagulability has been recognized as a precondition to thrombosis. Many congenital and acquired conditions have been found to explain many of the clinical cases of thrombosis(1-3). Thrombophylia has been defined as a predisposition to thrombosis, mostly caused due to genetic factors(1). Venous thrombosis is a common disease in the general population, and it can have many possible causes. It is possible to define one or more predisposing congenital or acquired factors (4) in most cases. Atherosclerosis and arterial diseases are common and important causes of mortality. Arterial thrombosis is a multifactorial process involving genetic and acquired factors and can be caused by endothelial, coagulation or fibrinolytic alterations(2-3, 5-7). Venous thromboembolism is an important clinical entity, affecting 1 in 1000 patients per year. In the US, 300,000 to 600,000 admissions per year and 50,000 deaths per year are caused by this clinical entity(8-9). Clinical presentation of thromboenbolism includes deep venous thrombosis in legs and pulmonary embolism(10-12). Other sites of thrombosis include retinal veins, mesenteric veins, upper limb veins, brain veins and superficial repetitive thrombophlebitis(4,13). Patients with congenital causes for thrombosis exhibit recurrent deep venous thrombosis in legs even at a young age(14-15). Roughly one third of these cases have a family history of similar episodes(1). Most of the genetic causes linked to thrombosis affect the coagulation protein C (1,2). Resistance to activated protein C is the most common inherited predisposition factor to thrombosis(2-3,16). This resistance is caused by a point mutation in the V factor gene, with a glycine replacing an arginine at position 506. This is one of the three sites where factor V cleavage by activated protein C occurs (3,13,16). This is a typical Caucasian mutation and its prevalence varies in different
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countries(4,16). In Scandinavia, the prevalence is 15% in the general population and 20-60% in patients with deep venous thrombosis(4,16), whereas, in Brazil, the prevalence in patients with deep venous thrombosis is 15%(13,16). The second most frequent mutation leading to venous thrombosis occurs on the prothrombin gene (G 20210A). This mutation occurs in 2% of the normal population and in 6-7% of patients with deep venous thrombosis – thus being a moderate risk factor for this condition(4,6). Other rare genetic mutations linked to venous thrombosis are deficiency of natural anticoagulants, protein S and antithrombin III. They are present in less than 1% of the normal population and together represent 5 to 10 % of individuals with deep venous thrombosis(1,3-4).
OBJECTIVE To evaluate the prevalence of genetic polymorphism in coagulation factors in thromboembolic disease. All patients with clinical evidence of thrombosis were submitted to factor V Leiden, prothrombin mutation, protein C protein S, and antithrombin III deficiency evaluations, lupus anticoagulant screen, anticardiolipin screen, and homocystein assay. METHODS A retrospective case collection was performed searching all patients who had been submitted to coagulation factor analysis at Hospital Israelita Albert Einstein, from November 2003 to April 2004. We included 260 patients, 118 male and 142 female, mean age of 46 years. Prothrombin mutation and factor V Leiden were evaluated with multiplex PCR. Protein C, protein S and lupus anticoagulant were detected using coagulation assays. Antithrombin III was studied by chromogenic assay, anticardiolipin by means of immunoenzymatic method and homocysteine through an immunometric method. Statistical analysis Categorical data are presented descriptively in absolute and relative frequency tables. Proportions between groups were compared using the Pearsons chi-square test or Fisher exact test when the chi-square test could not be used. All probabilities are two-tailed and p
