As trombofilias na perda gestacional de repetição: uma revisão de prevalência e condutas / Thrombophilias in recurrent pregnancy loss: a review of prevalence and conduct

Objetivo: Discutir o papel das trombofilias na perda gestacional de repetição, com foco em prevalência/associação dessas patologias com perdas de repetição e seu tratamento, por meio de resultados de ensaios clínicos, revisões sistemáticas e metanálises. Métodos: Trata-se de uma revisão não sistemática de artigos publi- cados nas bases eletrônicas PubMed, Cochrane e SciELO nos últimos cinco anos, utilizando os seguintes descritores: "recurrent pregnancy loss", "recurrent abortion", "habitual abortion", "thrombophilia", "antiphospholipid syndrome" e "treatment". Resultados: A maioria dos estudos relatou forte associação entre os anticorpos antifosfolípides específicos e a síndrome do anticorpo antifosfolípide com perda gestacional de repetição. Mulheres portadoras da mutação do fator V de Leiden, mutação do gene da protrombina e deficiência de proteína S apresentaram alto risco de perda gestacional de repetição em uma grande revisão sistemática. Estudos recentes demonstraram taxas de prevalência das trombofilias hereditárias e da síndrome do anticorpo antifosfolípide, em mulheres com perda gestacional de repetição, semelhantes às da população em geral. Os estudos atuais endossam o uso da heparina associada à aspirina em mulheres com síndrome do anticorpo antifosfolípide, com aumento da taxa de nascidos vivos, mas sem diferença em re- lação às complicações obstétricas. Conclusão: Apesar de novos estudos demons- trarem que a prevalência das trombofilias hereditárias e adquiridas em mulheres com perda gestacional de repetição é semelhante à da população em geral, reco- menda-se a pesquisa rotineira de síndrome do anticorpo antifosfolípide nessas pacientes. O uso de aspirina em baixas doses associada à heparina é a intervenção farmacológica de primeira linha para a prevenção de perda gestacional de repeti- ção em pacientes com síndrome do anticorpo antifosfolípide.

Objective: To discuss the role of thrombophilias in recurrent pregnancy loss, focu- sing on the prevalence/association of these pathologies with recurrent abortion and treatment, through results of clinical trials, systematic reviews and meta-analyses. Methods: This is a non-systematic review of articles published in electronic databa- ses PubMed, Cochrane, SciELO in the last five years, using the following descriptors: "recurrent pregnancy loss", "recurrent abortion", "habitual abortion", "thrombophilia", "antiphospholipid syndrome", and "treatment". Results: Most studies have reported a strong association between specific antiphospholipid antibodies and antiphospho- lipid antibody syndrome with recurrent pregnancy loss. Women carrying the factor V Leiden mutation, prothrombin gene mutation, and protein S deficiency were shown to be at high risk of recurrent pregnancy loss in a large systematic review. Recent studies have shown prevalence rates of hereditary thrombophilias and antiphospholipid antibody syndrome, in women with re- current pregnancy loss, similar to those of the general po- pulation. Current studies endorse the use of heparin plus aspirin in women with antiphospholipid antibody syndrome, with an increase in live birth rate, but with no difference in obstetric complications. Conclusion: Although new studies demonstrate that the prevalence of hereditary and acquired thrombophilias in women with recurrent pregnancy loss is si- milar to that of the general population, routine investigation of antiphospholipid antibody syndrome in these patients is recommended. The use of low-dose aspirin plus heparin is the first-line pharmacological intervention for the prevention of recurrent pregnancy loss in patients with antiphospholipid antibody syndrome.

Genetic correlation between Prothrombin G20210A polymorphism and retinal vein occlusion risk

The aim of this study was to perform an updated meta-analysis to quantitatively investigate the association between G20210A polymorphism of Prothrombin gene and the risk of retinal vein occlusion (RVO), based on the available publications with inconsistent results. We utilized the Stata software to perform the heterogeneity test, association test, Begg's and Egger's tests, and sensitivity analysis. We searched three on-line databases (PubMed, Embase, and WOS) and obtained a total of 422 articles. Based on our selection criteria, 24 case-control studies were finally enrolled in this overall meta-analysis; a subgroup analysis by the factors ethnicity, control source, and RVO type was done. Through the association test of overall meta-analysis, we did not observe a significant difference between RVO cases and controls under the A vs G (allele) (z=1.49, P=0.137), A vs G (carrier) (z=1.42, P =0.155), GA vs GG (z=1.50, P=0.135), and GA+AA vs GG (z=1.50, P=0.135). Furthermore, we observed similar negative results in the association test of subgroup analysis (all P>0.05). Heterogeneity, Begg's, and Egger's tests excluded the presence of high heterogeneity and publication bias. Statistically stable results were observed in the sensitivity analyses. Based on integrated analysis of the current evidence, Prothrombin gene G20210A polymorphism is likely unrelated to the risk of RVO.

Potential Risk Factors Associated With Vascular Diseases in Patients Receiving Treatment for Hypertension

BACKGROUND: Currently, the hypertension (HTN) patients undergo appropriate medical treatment, and traditional risk factors are highly controlled. Therefore, potential risk factors of atherosclerotic vascular diseases (AVD) and venous thromboembolisms (VTE) in HTN should be reconsidered. We investigated thrombophilic genetic mutations and existing biomarkers for AVD or VTE in HTN patients receiving treatment. METHODS: A total of 183 patients were enrolled: AVD with HTN (group A, n=45), VTE with HTN (group B, n=62), and HTN patients without any vascular diseases (group C, n=76). The lipid profile, homocysteine (Hcy) levels, D-dimers, fibrinogen, antithrombin, lupus anticoagulant, and anti-cardiolipin antibody (aCL) were evaluated. Prothrombin G20210A, Factor V G1691A, and methylenetetrahydrofolate reductase (MTHFR) C677T and A1298C were analyzed. RESULTS: All patients revealed wild type prothrombin G20210A and Factor V G1691A polymorphisms. The frequency of MTHFR polymorphisms was 677CT (n=84, 45.9%); 677TT (n=46, 25.1%); 1298AC (n=46, 25.1%); and 1298CC (n=2, 1.1%). The MTHFR 677TT genotype tended to increase the odds ratio (OR) to AVD events in HTN patients (OR 2.648, confidence interval 0.982-7.143, P=0.05). The group A demonstrated significantly higher Hcy levels (P=0.009), fibrinogen (P=0.004), and platelet counts (P=0.04) than group C. Group B had significantly higher levels of D-dimers (P=0.0001), platelet count (P=0.0002), and aCL (P=0.02) frequency than group C. CONCLUSIONS: The MTHFR 677TT genotype and Hcy level could be potential risk factors associated with development of AVD in HTN patients receiving treatment. D-dimer and aCL might be useful to estimate the occurrence of VTE in them.

Lack of association between the prothrombin rs1799963 polymorphism and juvenile myoclonic epilepsy / Ausência de associação entre o polimorfismo G20210A (rs1799963) da protrombina e epilepsia mioclônica juvenil

Juvenile myoclonic epilepsy (JME) accounts for 26% of generalized idiopathic epileptic syndromes. The highest levels of thrombin activity are closely involved in the development of neurological diseases, including epilepsy. The prothrombin c.20210G>A (rs1799963) variation, which alters prothrombin mRNA stability, is associated with high plasma prothrombin levels. Objective : The present study was designed to investigate whether the SNP rs1799963 is a risk factor for JME in the northeastern Brazilian population. Results : The polymorphism was genotyped in 207 controls and 123 patients using polymerase chain reaction-restriction fragment length polymorphism method. No significant differences were observed in the genotype and allele frequencies of this polymorphism between cases and controls. Conclusion : These results present no evidence for an association of rs1799963 with JME. Further studies including other types of epilepsy are required to investigate the involvement of prothrombin gene in the genetic susceptibility to chronic seizure. .

Epilepsia mioclônica juvenil (EMJ) representa 26% das síndromes epilépticas idiopáticas generalizadas. Níveis elevados de atividade da trombina estão intimamente envolvidos no desenvolvimento de distúrbios neurológicos, incluindo epilepsia. A variante c.20210G>A (rs1799963) do gene de protrombina, que altera a estabilidade do RNAm, está associada com altos níveis de protrombina no plasma. Objetivo: Investigar se o SNP rs1799963 é um fator de risco para EMJ em uma amostra da população do nordeste brasileiro. Resultados : O polimorfismo foi genotipado em 123 pacientes e 207 controles usando a reação de polimerase em cadeia com restrição de polimorfismo. Não observamos diferença significativa nas frequências alélicas e genotípicas deste polimorfismo, entre as populações de pacientes e controle. Conclusão : Estes resultados não demonstram evidências para uma associação do polimorfismo rs1799963 com EMJ. Estudos posteriores, incluindo outros tipos de epilepsia, são necessários para investigar o envolvimento do gene protrombina na susceptibilidade genética a crises crônicas. .

Analysis of factor V Leiden and prothrombin mutations in patients with suspected thrombophilia in São Paulo state-Brazil / Análise da mutação no fator V de Leiden e na protrombina em pacientes do estado de São Paulo, Brasil

INTRODUCTION: Prothrombin (factor II) is a thrombin precursor, which induces fibrin formation. A mutation in the prothrombin gene (G20210A) has been described, which is directly associated with high prothrombin levels, hence thrombophilia. G1691A mutation in the factor V Leiden (FVL) gene occurs on exon 10, one of the main cleavage sites for protein C activation, resulting in protein alteration. OBJECTIVE: To identify and estimate the genotype frequency of the three possible genotypes and the frequency of the two existing alleles in the FVL and prothrombin genes in patients with suspected thrombophilia in the state of Sao Paulo. This study may provide more literature and reference data on the incidence of prothrombin genotypes among individuals in Brazil. MATERIAL AND METHODS: Analysis of point mutation by real time polymerase chain reaction (RT-PCR). RESULTS: We obtained a total of 100 individuals, from which 94% had the homozygous G genotype. Only 6% had heterozygous genotype and there was no individual with the homozygous genotype A for FVL gene. As to the prothrombin gene, the frequency was 97% for homozygous G genotype and 3% for the heterozygous genotype. There was no patient with the homozygous A genotype. CONCLUSION: This study demonstrated that the genotype identification of these genes is advisable for patients with suspected thrombophilia in this region.

INTRODUÇÃO: A protrombina (fator II) é a precursora da trombina, que induz a formação de fibrina. Foi descrita uma mutação no gene da protrombina (G20210A), associado diretamente a altos níveis de protrombina no sangue e, consequentemente, a trombofilia. A mutação G1691A no gene do fator V de Leiden (FLV) localiza-se no éxon 10, resultando na alteração da proteína, um dos principais sítios de clivagem para ativação da proteína C. OBJETIVOS: Identificar e estimar a frequência genotípica dos três possíveis genótipos, assim como estimar a frequência dos dois alelos existentes no gene do FLV e na protrombina em pacientes com suspeita de trombofilia no estado de São Paulo. Este estudo poderá fornecer mais dados para a literatura e para consulta da incidência dos genótipos da protrombina em indivíduos no Brasil. MATERIAL E MÉTODOS: Análise de mutação pontual por reação em cadeia da polimerase em tempo real (RT-PCR). RESULTADO: Obtivemos o número de 100 indivíduos e, desse total, 94% possuíam o genótipo para homozigoto G; apenas 6%, genótipo heterozigoto; nenhum indivíduo foi encontrado com genótipo homozigoto A no gene do FLV. No gene da protrombina, a frequência foi de 97% para o genótipo homozigoto G e 3% para o genoma heterozigoto; não foi encontrado nenhum indivíduo com o genoma homozigoto A. CONCLUSÃO: Este estudo mostrou que é recomendável a identificação do genótipo para esses genes em pacientes com suspeita de trombofilia nessa região.

Análise da mutação G20210A no gene da protrombina (fator II) em pacientes com suspeita de trombofilia no sul do Brasil / Analysis of prothrombin G20210A mutation (factor II) in patients with suspected trombophilia in Southern Brazil

INTRODUÇÃO: A protrombina (fator II) é uma proteína sanguínea sintetizada no fígado com a presença de vitamina K. É a precursora da trombina, que induz a formação de fibrina. Foi descrita uma mutação no gene da protrombina G20210A, associada diretamente a altos níveis de protrombina no sangue e, consequentemente, à trombofilia. Essa variante alélica consiste em mutação pontual, também chamada de polimorfismo de nucleotídeo simples (SNP), ocasionando a troca de uma guanina por uma adenina no nucleotídeo 20210, localizado em um sítio de clivagem do precursor do ácido ribonucleico mensageiro (mRNA). Essa troca caracteriza o alelo A e a ausência da mutação do alelo G. OBJETIVO: Quantificar o número de indivíduos homozigotos para alelo G, homozigotos para alelo A e heterozigotos, cujas amostras foram enviadas para o laboratório Genolab Análises Genéticas, abrangendo os estados do Paraná e Santa Catarina, no período de 1º de janeiro de 2009 a 10 de outubro de 2010. MÉTODOS: Análise de mutação pontual por reação em cadeia da polimerase em tempo real (RT-PCR). RESULTADOS: Obtivemos o número de 243 indivíduos e desse total 51,03% eram oriundos do estado do Paraná, enquanto 48,97%, oriundos do estado de Santa Catarina. Do total analisado, 88,89% possuíam o genótipo para homozigoto G, e nenhum indivíduo foi encontrado com mutação para homozigoto A. Apenas 11,11% possuíam genótipo heterozigoto. O estado de Santa Catarina apresentou frequência superior para genótipo heterozigoto em relação ao Paraná. CONCLUSÃO: Este estudo mostrou que é recomendável a identificação do genótipo para esse gene em pacientes com suspeita de trombofilia nos dois estados.

INTRODUCTION: Prothrombin (factor II) is a blood protein synthesized in the liver in the presence of vitamin K. It is a thrombin precursor, which induces fibrin formation. Prothrombin G20210A mutation and high prothrombin levels have been closely associated with thrombophilia. This allelic variant is a single mutation, also denominated single nucleotide polymorphism (SNP), in which guanine is replaced with adenine in the messenger ribonucleic acid (mRNA) cleavage of nucleotide 20210. The replacement is characterized by the presence of allele A and the absence of mutation in allele G. OBJECTIVE: To quantify the number of individuals homozygous for allele G, allele A and heterozygotes. The samples were collected in Paraná and Santa Catarina from January 1st, 2009 to October 10th, 2010 and were sent to Genolab Análises Genéticas. METHODS: Analysis of single mutation by polymerase chain reaction in real time (RT-PCR). RESULTS: From 243 individuals, 51.03% were from Paraná and 48.97% were from Santa Catarina. 88.89% individuals were homozygous for G genotype, none of them were homozygous for A. Only 11.11% were heterozygotes. Santa Catarina presented a higher frequency in heterozygous genotype in comparison with Paraná. CONCLUSION: This study showed that patients with suspected thrombophilia should undergo genotype identification in both states.

Genetic polymorphisms and cerebrovascular disease in children with sickle cell anemia from Rio de Janeiro, Brazil / Polimorfismos genéticos e doença cerebrovascular em crianças com anemia falciforme do Rio do Janeiro, Brasil

The aim of the present work was to examine possible genetic risk factors related to the occurrence of cerebrovascular disease (CVD) in Brazilian population, the frequency of βS-globin gene haplotypes and co-inheritance with α-thalassemia (-α3.7kb) and single nucleotide polymorphism of methylenetetrahydrofolate reductase (MTHFR-C677T), Factor V Leiden (FV-G1691A) and prothrombin (PT-G20210A) genes in children from Rio de Janeiro. Ninety four children with sickle cell anemia (SCA) were included, 24 patients with cerebrovascular involvement and 70 patients without CVD as control group. The mean age of children at the time of the cerebrovascular event was similar to the control group. The frequency of -α3.7kb thalassemia was similar in both groups (p=0.751). Children with Bantu/Atypical βS-globin gene haplotype presented 15 times more chance (OR=15.4 CI 95 percent 2.9-81.6) of CVD than the other βS-globin gene haplotypes. The C677T polymorphism of MTHFR gene was similar in both groups (p=0.085). No mutation in the FV Leiden or PT genes was found. A large study seems necessary to establish the role of these genetic polymorphisms in Brazilian miscegenated population.

Avaliar o papel da talassemia alfa (-α3.7kb), dos haplótipos da globina βS, e mutações nos genes da metileno-tetrahidrofolato redutase (MTHFR-C677T), fator V de Leiden (FV-G1691A) e protrombina (PT-G20210A) como fatores de risco para a doença cerebrovascular em pacientes com anemia falciforme. Foi realizado um estudo de caso controle com 94 crianças portadoras de anemia falciforme, 24 com doença cerebrovascular (DCV) e 70 sem DCV como grupo controle. A frequência de talassemia -α3.7kb foi semelhante em ambos os grupos (p=0,751). Crianças portadoras do haplótipo Bantu/Atípico da globina βS apresentam 15 vezes mais chances de desenvolverem DCV (OR=15,4 IC 95 por cento 2,9-81,6) do que os outros haplótipos. A frequência do polimorfismo MTHFR-C677T foi semelhante em ambos os grupos (p=0,085) e não foi observada mutação nos genes fator V e protrombina. Estudos com maior número de casos são necessários para esclarecer o papel desses polimorfismos genéticos na nossa população.

Variante protrombótica C677T del gen metilenotetrahidrofolato reductasa es un biomarcador molecular de fallas de implantación en mujeres chilenas sometidas a protocolos de reproducción asistida / Prothrombotic variant C677T at the methylenetetrahydrofolate reductase gene is a molecular biomarker of implantation failure in chilean women undergoing assisted reproductive protocols

Las fallas de implantación son consideradas una importante causa de infertilidad en mujeres sometidas a protocolos de Fecundación Asistida. Evidencia reciente sugiere que la presencia de variantes protrombóticas está asociada a diversos defectos obstétricos y falla reproductiva. Sin embargo, los resultados en diversas poblaciones son contradictorios. De acuerdo a esta evidencia, se evaluó la potencial asociación entre variantes protrombóticas y fallas de implantación en mujeres chilenas incluidas en protocolos de fecundación asistida. Un total de 180 mujeres, 80 pacientes sometidas a protocolos de reproducción asistida y 100 controles fueron incluidas en este estudio. La genotipificación molecular de variantes protrombóticas en genes candidatos fue realizada por PCR-RFLP. Observamos una paciente heterocigota para la variante F5 G1691A y ausencia total del polimorfismo F2 G20210A en pacientes y controles. La distribución genotípica y la distribución relativa de alelos del polimorfismo MTHFR C677T fueron significativamente diferentes entre pacientes y controles. Odds Ratio para fallas de implantación asociadas al genotipo homocigoto fue 2,78 (95 por ciento IC 1,147 - 6,755; p= 0,0199). En resumen, nuestros resultados sugieren que la variante MTHFR C677T constituye un biomarcador molecular de susceptibilidad a fallas de implantación población chilena.

Implantation failures are considered an important cause of infertility in women undergoing assisted reproductive protocols. Recent evidence suggests that the presence of prothrombotic variants is associated with obstetric defects and reproductive failure. However, results between several populations are contradictory. According this evidence, we evaluated the potential association between prothrombotic variants and implantation failure susceptibility in Chilean women undergoing Assisted Reproductive protocols. 180 women, 80 patients undergoing assisted reproductive protocols and 100 controls were included in this study. Molecular genotyping of prothrombotic variants in candidate genes was realized by PCR-RFLP. We observed one patient heterozygote for factor V G1691A variant, and total absence to prothrombin G20210A polymorphism in patients and controls. Genotype distribution and allelic frequencies of MTHFR C677T polymorphism were significantly different between patients and controls (p<0.05). Odss Ratio for implantation failure associated to homozygote genotype was 2.78 (95 percent IC 1.147 ¡ 6.755; p= 0.0199). In summary, our data suggest that the MTHFR C677T polymorphism constituted a molecular biomarker of implantation failure susceptibility in Chilean population.

Factor V Leiden and prothrombin G20210A gene mutations in women with a history of thrombosis during pregnancy relation to pregnancy outcomes for mother and fetus

To investigate the presence of factor V Leiden [FVL], and prothrombin gene mutations [PRT], protein C and protein S in pregnant women with a previous history of thromboembolism, and evaluate their impact on maternal and fetal outcomes. This study was carried out at Ain Shams University Hospital, Cairo, Egypt between January 2006 to March 2008. The study included 15 pregnant females without a history of thromboembolism [control group], and 25 pregnant females with a history of previous thromboembolism during pregnancy, and puerperium [patient group]. Identification of FVL and PRT mutations by real-time quantitative polymerase chain reaction, and estimation of protein C and S activity by functional clotting assay were performed. Regarding the control group; one patient had FVL mutation [6.6%], and one had decreased protein C activity [6.6%]. As regard the patient group 13/25 [52%] bad normal genotype, and 12/25 [48%] expressed abnormal genotype either FVL or PRT G20210A, or both. Also 3/25 [12%] patients had decreased protein C activity, and 2/25 [8%] had decreased protein S. The intrauterine growth retardation [IUGR] less than the tenth percentile was more in the patients group [48%] compared to the control group [33%], while there was no statistically significant difference between both groups on preeclampsia, placental abruption, abortion, or IUGR less than the fifth percentile. The FVL was not associated with any adverse outcomes, while the PRT mutation was significantly associated with IUGR less than the fifth percentile. The results of this study shows that good monitoring of fetal growth is mandatory for all carriers of the PRT gene mutation

Placental histomorphology in unexplained foetal loss with thrombophilia.

BACKGROUND & OBJECTIVES: Acquired and genetic thrombotic conditions, both organ and non organ specific, are associated with increased foetal wastage. This study was carried out to examine the placenta from women with abnormal pregnancies and a history of unexplained foetal loss, and to associate with maternal thrombophilia status. METHODS: Placentas from eight women with history of unexplained foetal loss were analyzed for histopathological characteristics. All the women were simultaneously screened for the common acquired and genetic thrombophilia markers i.e., lupus anticoagulants ( LA), IgG / IgM antibodies for anticardiolipin (ACA), beta2 glycoprotein 1 (beta2GPI) and annexin V, protein C (PC), protein S (PS), antithrombin III (AT III), factor V Leiden ( FVL) mutation, prothrombin (PT) gene G20210A, methylene tetrahydrofolate reductase (MTHFR) C 677T, endothelial protein C receptor (EPCR) 23 bp insertion and plasminogen activator inhibitor ( PAI-1 4G/5G) polymorphisms RESULTS: Six of eight women were positive for one or more thrombophilia markers. The placenta in all the cases except one, showed the characteristic features of infarct fibrin deposition and calcification. Among two women who were negative for thrombophilia, one showed clear evidence of thrombus in the placental sections while the other did not show any characteristic infarcts in the placental sections. INTERPRETATION & CONCLUSION: Our findings showed that the histopathological examination of the placentas confirmed thrombophilia as the aetiological cause of thrombosis in 6 of the 8 women. The presence of thrombus in a negative thrombophilia woman suggests yet unidentified thrombophilia markers or probably non-haemostatic factors causing thrombosis.

Venous thromboembolism: the intricacies.

Venous thromboembolism (VTE) has been a subject of great interest of late. Since Rudolph Virchow described the famous Virchow's triad in 1856, there have been rapid strides in the understanding of the pathogenesis and factors responsible for it. Discovery of various thrombophilic factors, both primary and acquired, in the last 40 years has revolutionized prognostication and management of this potentially life-threatening condition due to its associated complication of pulmonary thromboembolism. Detailed genetic mapping and linkage analyses have been underlining the fact that VTE is a multifactorial disorder and a complex one. There are many gene-gene and gene-environment interactions that alter and magnify the clinical picture in this disorder. Point in case is pregnancy, where the risk of VTE is 100-150 times increased in the presence of Factor V Leiden, prothrombin mutation (Prothrombin 20210A) and antithrombin deficiency. Risk of VTE associated with long-haul air flight has now been well recognized. Thrombotic events associated with antiphospholipid syndrome (APS) are 70% venous and 30% arterial. Deep venous thrombosis and pulmonary embolism are the most common venous events, though unusual cases of catastrophes due to central vein thrombosis like renal vein thrombosis and Budd-Chiari syndrome (catastrophic APS) may occur.

Down-Syndrome associated with MBL-deficiency, IgG-deficiency, vasculitis and mutated prothrombin / Síndrome de Down asociado a deficiencia de lectina de unión a manosa, deficiencia de IgG, vasculitis y mutación de la protrombina: Informe de un caso

The association of Down syndrome with mannose-binding lectin (MBL)-deficiency, recurrent infections and vasculitis has not been reponed. We repon a 30 year-old female with Down-syndrome associated with MBL-deficiency with the genotype LXA/HYD, IgG-deficiency, recurrent uro-genital infections, cutaneous vasculitis, G20.210A prothrombin mutation, deep venous thrombosis, and pulmonary embolism. MBL-deficiency in combination with IgG deficiency might have favored the development of recurrent uro-genital infections. Immunodeficiency might be also involved in the pathogenesis of cutaneous vasculitis. Deep venous thrombosis and pulmonary embolism were attributed to the genetically determined prothrombotic state and intake of oral contraceptives.

La asociación de síndrome de Down con deficiencia de lectina de unión a manosa, infecciones recurrentes y vasculitis no ha sido informada. Presentamos una mujer de 30 años de edad con síndrome de Down asociado a deficiencia de lectina de unión a mañosa, con el genotipo LXA/HYD, deficiencia de IgG, infecciones urogenitales recurrentes, vasculitis cutánea, mutación de protrombina G20.210A, trombosis venosa profunda y embolia pulmonar. La deficiencia de lectina de unión a manosa combinada con la deficiencia de IgG puede haber favorecido las infecciones urogenitales recurrentes. La inmunodeficiencia puede también tener relación con la patogenia de la vasculitis cutánea. La trombosis venosa profunda y la embolia pulmonar pueden deberse al estado protrombótico derivado de la mutación de protrombina y el uso de contraceptivos orales.

Saudi thrombosis and familial thrombophilia registry Design, rational, and preliminary results

To describe the Registry and report preliminary data for the prevalence of 5 prothrombotic gene mutations in the normal Saudi population. Blood from consenting healthy Saudi individuals and patients with venous thrombosis [VT] from different regions of the Kingdom was collected from November 2001 until July 2007. The extracted DNA of each sample was kept at -70°C until tested for 5 known prothrombotic factors using established methods. Only patients with confirmed VT were included. Data generated through direct interview were entered into the Saudi Thrombosis and Familial Thrombophilia [S-TAFT] Register. The consent and demographic data collection forms and the S-TAFT Register were developed using the SQL web based software. Nine hundred and two DNA samples of consenting healthy Saudi individuals were tested for factor V Leiden [FVL], prothrombin [PT] 20210 G>A, 5-10 methylenetetrahydrofolate reductase [MTHFR] 677 C>T, the 4G/5G polymorphism of Plasminogen activator inhibitor type 1 [PAI-1 4G/5G], and factor V HR2 [FVHR2] haplotype. The incidence of FVL among healthy subjects was 1.3%, PT 20210 G>A 0.7%, homozygous MTHFR 677C>T 2.45%, PAI 4G/4G 10.1%, and FVHR2 26.1%. Our preliminary data from healthy Saudi individuals suggest that the incidence of the 5 prothrombotic risk factors is lower than in most other populations, except for FVHR2

Protrombina mutante em indivíduos sob investigação de trombofilia / Mutant prothrombin in individuals under thrombophilia investigation

INTRODUÇÃO: A doença tromboembólica é bastante freqüente, com incidência anual na população de 1 caso por mil indivíduos. Os fatores de risco para trombose incluem condições hereditárias e adquiridas. Uma mutação de ponto no fator II da coagulação, a protrombina G20210A (PTCR), constitui o segundo defeito genético mais comum associado à predisposição para trombose ou trombofilia. No Brasil, o estudo desse fator de risco é relativamente recente e se dispõe de poucos dados na literatura especializada. OBJETIVO: Este trabalho teve como objetivo determinar a freqüência da PTCR em 285 indivíduos sob investigação de trombofilia na Fundação de Hematologia e Hemoterapia de Pernambuco (HEMOPE/PE). MATERIAL E MÉTODO: A técnica molecular utilizada foi a enzima de restrição/reação em cadeia da polimerase (RE/PCR), com primers específicos e a enzima Hind III. RESULTADOS: A freqüência encontrada da PTCR foi de 6 por cento em heterozigose. A presença da mutação foi semelhante em indivíduos com idades tanto inferiores quanto superiores a 45 anos. DISCUSSÃO: A presença da PTCR pode ter sido determinante para o surgimento dos quadros trombóticos, e a baixa mediana de idade do grupo estudado sugere que outras causas genéticas de trombofilia devem ser investigadas, pois a maioria dos trabalhos associa a presença de fator de risco genético a eventos trombóticos em indivíduos com idade inferior a 45 anos. CONCLUSÕES: Os resultados da pesquisa mostraram que a freqüência da PTCR na população estudada é semelhante à descrita na literatura científica para indivíduos selecionados com tromboembolismo e confirmam a importância do estudo molecular em diferentes faixas etárias.

BACKGROUND: Thromboembolic disease is very common, with a yearly incidence in the general population of approximately 1 case per a thousand individuals. The risk factors for thrombosis include both hereditary and acquired conditions. A point mutation in coagulation factor II, prothrombin G20210A (PTCR), constitutes the second most prevalent genetic defect associated with the predisposition to thrombosis or thrombophilia. In Brazil, the study of this risk factor is relatively recent and there is little available data in medical literature. OBJECTIVE: The aim of this study was to determine the frequency of PTCR in 285 individuals being investigated for thrombophilia at Fundação de Hematologia e Hemoterapia de Pernambuco (HEMOPE/PE). MATERIAL AND METHOD: The molecular biology technique used was restriction enzyme/polymerase chain reaction (RE/PCR), using specific primers and the Hind III enzyme. RESULTS: The frequency of PTCR was 6 percent in heterozygosis. The presence of the mutation was similar among individuals under and over 45 years old. DISCUSSION: The presence of PTCR may have been a relevant factor for the episodes of thrombosis, and the low median age of the group suggests that other genetic causes of thrombophilia must be investigated inasmuch as most publications associate the presence of genetic risk factor with thrombotic events in individuals under 45 years old. CONCLUSIONS: Our findings showed that the frequency of PTCR in the studied population is similar to the results published in medical literature for selected patients with thromboembolism and they confirm the importance of molecular testing at different age groups.

Factor VLeiden and Prothrombin G20210A Gene Polymorphisms in Patients with Coronary Artery Disease

PURPOSE: The precise molecular mechanisms culminating in coronary artery disease (CAD) are not well understood, despite a wealth of knowledge on predisposing risk factors and pathomechanisms. CAD and myocardial infarction (MI) are complex genetic diseases; neither the environment alone, nor a single gene, cause disease, rather, a mix of environmental and genetic factors lead to atherosclerosis of the coronary arteries. MATERIALS AND METHODS: In the present study, our aim was to investigate the roles of prothrombin G20210A mutation and Factor VLeiden mutation in atherosclerotic coronary artery disease. 287 subjects (106 control subjects, who were angiographically normal, and 181 angiographically documented coronary atherosclerotic patients who exhibited coronary artery narrowing to a degree of > or = 50%) were included in this study. The mutations were assessed with LightCycler Real-Time PCR mutation detection kits (Roche Diagnostics, GmbH, Germany). RESULTS: 6.6% of control subjects, and 6.1% of patients with (50% coronary artery narrowing were determined to have the Factor VLeiden heterozygote mutation. 6.6% of control subjects had the Prothrombin G20210A heterozygote mutation, while 7.7% of patients with (50% coronary artery narrowing had this mutation. The OR for Factor VLeiden was 1.52 (CI: 0.240-9.602) and for Prothrombin G20210A mutation, the OR was 1.415 (CI: 0.287-6.962). CONCLUSION: Although both the heterozygote Factor VLeiden and Prothrombin gene mutations were more frequent in patients with CAD than in control subjects, there was no statistical relationship found to exist between coronary artery disease and the Factor VLeiden and Prothrombin G20210A mutations.

Thrombophilic mutations and risk of retinal vein occlusion

PURPOSE: The association of retinal vein occlusion and hereditary thrombophilia abnormalities is not established, with controversial results in the literature. This study investigates the association between retinal vein occlusion and three thrombophilic mutations: factor V 1691A (factor V Leiden), prothrombin 20210A (PT 20210A) and homozygous methylenetetrahydrofolate reductase 677T (MTHFR 677TT). METHODS: 55 consecutive retinal vein occlusion patients and 55 controls matched by age, gender and race, were tested for the presence of the following mutations: factor V Leiden, PT 20210A and MTHFR 677TT. The frequencies of the three mutations in cases and controls were compared. RESULTS: Factor V Leiden was found in 3.6 percent of patients and in 0 percent of controls; PT 20210A was found in 1.8 percent of patients and 3.6 percent of controls, (matched-pair odds ratio, 0.5; 95 percent confidence interval, 0.04 to 5.51); MTHFR 677TT was found in 9 percent of patients and 9 percent of controls (matched-pair odds ratio, 1; 95 percent confidence interval, 0.92 to 3.45). Arterial hypertension was more frequent in patients than controls (matched-pair odds ratio, 3.4; 95 percent confidence interval, 1.25 to 9.21). CONCLUSIONS: This study suggests that thrombophilic mutations are not risk factors for RVO. Routine investigation of hereditary thrombophilia in these patients is not justified.

OBJETIVOS: A associação entre oclusão venosa retiniana e trombofilias hereditárias não está estabelecida, com resultados controversos na literatura. O presente estudo investiga a associação entre a oclusão venosa retiniana e três mutações trombofílicas: fator V 1691A (fator V Leiden), protrombina 20210A (PT 20210A) e mutação C677T do gene da metileno-tetra-hidro-folato redutase (MTHFR 677TT). MÉTODOS: Cinquenta e cinco pacientes portadores de oclusão venosa retiniana e 55 controles pareados por idade, sexo e raça foram testados para a presença das seguintes mutações: fator V Leiden, PT 20210A e MTHFR 677TT. As freqüências das três mutações em casos e controles foram comparadas. RESULTADOS: Fator V Leiden foi encontrado em 3,6 por cento dos pacientes e em 0 por cento dos controles; PT 20210A foi encontrada em 1.8 por cento dos pacientes e em 3,6 por cento dos controles, (odds ratio, 0,5; 95 por cento IC, 0,04 to 5,51); MTHFR 677TT foi encontrada em 9 por cento dos pacientes e em 9 por cento dos controles (odds ratio, 1; 95 por cento IC, 0,92 to 3,45). Hipertensão arterial foi encontrada mais freqüentemente em pacientes do que em controles (odds ratio, 3,4; 95 por cento IC, 1,25 to 9,21). CONCLUSÕES: O presente estudo sugere que mutações trombofílicas não são fatores de risco para oclusão venosa retiniana. A investigação rotineira para trombofilias hereditárias neste grupo de pacientes não é indicada.

Trombofilia primaria: 41 nuevos casos / Primary thrombophilias: 41 new cases

Se presentan 37 casos de trombosis, en su mayoría jóvenes, con antecedentes trombóticos familiares y con diagnóstico de trombofilia primaria o hereditaria además de cuatro familiares de primer grado de estos pacientes en los cuales se confirmó la portación familiar de trombofilia. La anamnesis reveló que el 82 por ciento presentó la primera trombosis antes de los 45 años; tuvo más de una trombosis en un 59 por ciento y tenía antecedentes familiares en 49 por ciento. Los defectos trombofílicos determinantes encontrados fueron: deficiencia de proteína S (27 por ciento); resistencia a proteína C activada por factor V Leiden (24,3 por ciento); deficiencia proteína C (21,6 por ciento) y antotrombina III (16,2 por ciento); mutación G20210 A del gen protrombina (8,1 por ciento). Entre los defectos adquiridos estudiados simultáneamente, un 27,2 por ciento de los casos presentaron anticoagulante lupico y ninguno hiperhomocisteína. La existencia de mas de un factor de riesgo trombofílico se observó en el 24.3 por ciento de los pacientes. En el estudio de los 4 parientes de primer grado se encontró factor V Leiden en uno; factor V Leiden mas anticoagulante lupico en uno y deficiencia proteína S en dos. El trabajo anterior publicado en 2004 motivó a los pacientes que no se hicieron el estudio a tomar conciencia de su situación y de la necesidad de controlarse, lo que demuestra la importancia de difundir esta patología aún poco conocida.

Eventos trombóticos em dois irmãos com trombofilia / Thrombotic events in two siblings with thrombophilia

Apresentaremos à seguir o caso clínico de dois irmãos com diferentes apresentações de fenômenos trombóticos, nos quais foi constatado a mutação da protrombina.

We describe the clinical case of two siblings with different presentations of thrombotic phenomena, in which prothrombin mutation was observed.

The clinical impact of MTHFR polymorphism on the vascular complications of sickle cell disease

Sickle cell disease (SCD) is one of the most common inherited diseases in the world and the patients present notorious clinical heterogeneity. It is known that patients with SCD present activation of the blood coagulation and fibrinolytic systems, especially during vaso-occlusive crises, but also during the steady state of the disease. We determined if the presence of the factor V gene G1691A mutation (factor V Leiden), the prothrombin gene G20210A variant, and methylenetetrahydrofolate reductase (MTHFR) C677T polymorphism may be risk factors for vascular complications in individuals with SCD. We studied 53 patients with SCD (60 percent being women), 29 with SS (sickle cell anemia; 28 years, range: 13-52 years) and 24 with SC (sickle-hemoglobin C disease; 38.5 years, range: 17-72 years) hemoglobinopathy. Factor V Leiden, MTHFR C677T polymorphism, and prothrombin G20210A variant were identified by PCR followed by further digestion of the PCR product with specific endonucleases. The following vascular complications were recorded: stroke, retinopathy, acute thoracic syndrome, and X-ray-documented avascular necrosis. Only one patient was heterozygous for factor V Leiden (1.8 percent) and there was no prothrombin G20210A variant. MTHFR 677TT polymorphism was detected in 1 patient (1.8 percent) and the heterozygous form 677TC was observed in 18 patients (34 percent, 9 with SS and 9 with SC disease), a prevalence similar to that reported by others. No association was detected between the presence of the MTHFR 677T allele and other genetic modulation factors, such as alpha-thalassemia, ß-globin gene haplotype and fetal hemoglobin. The presence of the MTHFR 677T allele was associated with the occurrence of vascular complications in SCD, although this association was not significant when each complication was considered separately. In conclusion, MTHFR C677T polymorphism might be a risk factor for vascular complications in SCD.