Patrizia Vergura

Gain of function gene mutations and venous thromboembolism: Distinct roles in different clinical settings

Objective: To calculate the prevalence of common gain of function gene mutations in patients with different clinical manifestations of venous thromboembolism. Design and setting: Case–control study in two hospitals in Italy. Participants: 387 patients with venous thromboembolism and 286 controls. Main measures: Factor V (FV) Leiden, factor II (FII) A20210 and JAK2 V617F mutations. Results: Among patients with deep vein thrombosis in one leg, 23 (20.9%) carried FV Leiden and FII A20210 mutations. Similar figures were observed in patients with cerebral vein thrombosis (CVT; n = 9; 20.0%) and in patients presenting with splanchnic vein thrombosis (SVT; n = 26; 18.7%). A lower prevalence was obtained in patients with retinal vein thrombosis (n = 11; 11.8%). The JAK2 F617 mutant allele was found in 27 (21.1%) patients with SVT, but in none of the patients presenting with a thrombotic event from different districts. 13 of the 27 JAK2 V617F-positive subjects with SVT were previously known to have a myeloproliferative disease (MPD). Three other patients had a diagnosis of MPD after the occurrence of the thrombotic event. Conclusion: Carriership of FV Leiden or FII A20210 mutations identifies an at-risk condition for venous thrombosis in the lower extremities, SVT or CVT. In patients with SVT, screening for the JAK2 V617F mutation may be useful in recognising patients who should be carefully observed for the subsequent development of overt MPD. Thus, genetic tests may play a different role, various clinical manifestations of venous thromboembolism being associated with distinct risk profiles.

Hyperhomocysteinaemia in chronic liver diseases: role of disease stage, vitamin status and methylenetetrahydrofolate reductase genetics

Abstract: Background/Aims: The liver plays a key role in sulphur aminoacid metabolism hence, homocysteine metabolism may be impaired in chronic liver diseases. The aim of this study was to investigate, in patients affected by chronic liver diseases, (1) the prevalence of hyperhomocysteinaemia and (2) the role of its determinants such as the stage and the aetiology of disease, vitamin status, genetic documented alterations (methylenetetrahydrofolate reductase deficiency) and presence/absence of documented malignant evolution (hepatocellular carcinoma).

Risk of obstetric and thromboembolic complications in family members of women with previous adverse obstetric outcomes carrying common inherited thombophilias.

Summary.  Background: Factor (F)V Leiden and the prothrombin 20210A mutation (PTm) are associated with the occurrence of obstetric complications, including pregnancy‐related venous thromboembolism (VTE). It is not known whether family members of women with FV Leiden or PTm and previous obstetric complications have a higher risk of VTE or adverse obstetric outcomes. Methods: A retrospective family study including 563 relatives of 177 women with previous adverse outcomes carrying FV Leiden or PTm, referred between April 1993 and June 2010. A history of obstetric complications and VTE was obtained. Prevalence of VTE and obstetric complications in relatives with and without inherited thrombophilias was compared. Adjusted odd ratios (OR) and 95% confidence intervals (CI) were calculated using logistic regression models that controlled for predictors (age, FV Leiden and PTm). Results: Relatives carrying FV Leiden had a significant and independent risk for obstetric complications (OR: 1.98, 95% CI 1.03–3.83); this risk was not observed in the presence of PTm (OR: 1.03, 95% CI 0.46–2.32). The presence of FV Leiden or PTm in heterozygosis was significantly and independently associated with the occurrence of VTE (OR: 5.2, 95% CI: 1.70–15.91). Severe thrombophilias were strong risk factors for VTE (OR: 23.2, 95% CI: 6.0–89.85). Male gender was a significant and independent risk factor for VTE (OR: 3.49, 95% CI: 1.51–8.05). The risk did not change when relatives of women with a previous pregnancy‐related VTE were excluded (OR: 3.49, 95% CI: 1.51–8.05). Conclusions: Knowledge of thrombophilia status may help to better define the obstetric and thromboembolic risks in asymptomatic family members of women who suffered from obstetric complications.

The JAK2 rs12343867 CC genotype frequently occurs in patients with splanchnic venous thrombosis without the JAK2V617F mutation: a retrospective study

(617V>F) mutation. Blood 2007; 110: 485–9. 6 Melillo L, Tieghi A, Candoni A, Radaelli F, Ciancia R, Specchia G, Martino B, Scalzulli PR, Latagliata R, Palmieri F, Usala E, Valente D, Valvano MR, Cedrone M, Comitini G, Martinelli V, Cascavilla N, Gugliotta L. Outcome of 122 pregnancies in essential thrombocythemia patients: a report from the Italian registry. Am J Hematol 2009; 84: 636–40. 7 Gangat N, Wolanskyj AP, Schwager S, Tefferi A. Predictors of pregnancy outcome in essential thrombocythemia: a single institution study of 63 pregnancies. Eur J Haematol 2009; 82: 350–3. 8 Tefferi A, Passamonti F. Essential thrombocythemia and pregnancy: observations from recent studies and management recommendations. Am J Hematol 2009; 84: 629–30. 9 Harrison C. Pregnancy and its management in the Philadelphia negative myeloproliferative diseases. Br J Haematol 2005; 129: 293–306. 10 CLASP (Collaborative Low-dose Aspirin Study in Pregnancy) Collaborative Group. CLASP: a randomised trial of low-dose aspirin for the prevention and treatment of pre-eclampsia among 9364 pregnant women. Lancet 1994; 343: 619–29. 11 Niittyvuopio R, Juvonen E, Kaaja R, Oksanen K, Hallman H, Timonen T, Ruutu T. Pregnancy in essential thrombocythaemia: experience with 40 pregnancies. Eur J Haematol 2004; 73: 431–6. 12 Falanga A, Marchetti M, Vignoli A, Balducci D, Russo L, Guerini V, Barbui T. V617F JAK-2 mutation in patients with essential thrombocythemia: relation to platelet, granulocyte, and plasma hemostatic and inflammatory molecules. Exp Hematol 2007; 35: 702–11. 13 Arellano-Rodrigo E, Alvarez-Larran A, Reverter JC, Villamor N, Colomer D, Cervantes F. Increased platelet and leukocyte activation as contributing mechanisms for thrombosis in essential thrombocythemia and correlation with the JAK2 mutational status.Haematologica 2006; 91: 169–75. 14 PassamontiF,RumiE,PietraD,DellaPortaMG,BoveriE,PascuttoC, VanelliL,ArcainiL,Burcheri S,MalcovatiL,LazzarinoM,CazzolaM. Relation between JAK2 (V617F) mutation status, granulocyte activation, and constitutive mobilization of CD34+ cells into peripheral blood in myeloproliferative disorders. Blood 2006; 107: 3676–82. 15 Erez O, Gotsch F, Mazaki-Tovi S, Vaisbuch E, Kusanovic JP, Kim CJ, Chaiworapongsa T, Hoppensteadt D, Fareed J, Than NG, NhanChang CL, Yeo L, Pacora P, MazorM, Hassan SS, Mittal P, Romero R. Evidence of maternal platelet activation, excessive thrombin generation, and high amniotic fluid tissue factor immunoreactivity and functional activity in patients with fetal death. JMatern Fetal Neonatal Med. 2009; 22: 672–87. 913457925 [pii] 10.1080/14767050902853117. 16 Lok CA, Jebbink J, Nieuwland R, Faas MM, Boer K, Sturk A, van der Post JA. Leukocyte activation and circulating leukocyte-derived microparticles in preeclampsia. Am J Reprod Immunol 2009; 61: 346– 59. AJI701 [pii] 10.1111/j.1600-0897.2009.00701.x. 17 FalangaA,MarchettiM, Vignoli A, Balducci D, Barbui T. Leukocyteplatelet interaction in patients with essential thrombocythemia and polycythemia vera. Exp Hematol. 2005; 33: 523–30. 18 Vaughan JE, Walsh SW, Ford GD. Thromboxane mediates neutrophil superoxide production in pregnancy. Am J Obstet Gynecol 2006; 195: 1415–20. S0002-9378(06)00297-3 [pii] 10.1016/j.ajog.2006.02.053.

Impact of common thrombophilias and JAK2 V617F on pregnancy outcomes in unselected Italian women.

Summary.  Background: Although an association between thrombophilias and adverse pregnancy outcome has been shown, the influence of the most common inherited thrombophilias and the somatic mutation JAK2 V617F in determining an adverse outcome is questioned. Objectives: We examined the contribution of the factor V Leiden (FVL), the prothrombin G20210A (PTm) and the somatic JAK2 V617F mutations to adverse pregnancy outcome in an unselected cohort of pregnant women. Patients/methods: During the study period, 5345 pregnant women were admitted to the 14 hospitals of the five provinces of the Campania region (Italy). Of these, 3097 samples were investigated and obstetric history collected. The presence of the FVL, PTm, and JAK2 V617F mutation was prospectively determined by polymerase chain reaction followed by TaqMan SNP genotyping assays. Results and conclusions: We identified 119 (3.8%) women that carried FVL and 138 (4.4%) with the PTm. Only 4 (0.1%) women carried both mutations. Only one woman tested positive for the JAK2 V617F somatic mutation. The prevalence of a previous history of an adverse pregnancy outcome was similar in women with common thrombophilias as compared to those without. In the current pregnancy, there was no association of any of the genetic markers considered with any of the adverse outcomes investigated. Carriership of FVL or PTm showed a positive trend with delivery of a small for gestational age newborn (OR: 1.5, 95% CI: 0.9–2.5). Pregnancy outcomes in asymptomatic women with inherited thrombophilias are often uneventful. Therefore, in women at low‐risk of an adverse pregnancy, neither screening for common thrombophilias nor administration of routine thromboprophylaxis are warranted.

Sex modulation of the occurrence of jak2 v617f mutation in patients with splanchnic venous thrombosis.

BACKGROUND The JAK2 V617F mutation is an independent risk factor for MPN and SVT. Gender-related differences in MPN distribution have been reported and, recently, variability in the JAK2 V617F allele burden between sexes has been suggested. We wondered whether gender would modulate the role of the JAK2 V617F mutation as susceptibility risk factor for SVT. MATERIALS AND METHODS In 180 patients presenting with SVT, medical history was collected. The presence of the JAK2 V617F mutation and 46/1 haplotype was determined by polymerase chain reaction followed by TaqMan SNP genotyping assays. RESULTS Among patients with SVT, 43 (23.9%; 95%-CI: 18.2-30.7) carried the JAK2 V617F mutation. The JAK2 V617F mutation was found more frequently in women (29/95: 30.5%; 95%-CI: 22.1-40.4) than in men (14/85: 16.5%; 95%-CI: 10.0-25.9; OR: 2.2; 95%-CI: 1.1-4.5). The distribution of 46/1 haplotype frequencies did not differ significantly between men and women. In women carrying the rs12343867 CC genotype, the frequency observed for the occurrence of the V617F mutation was significantly higher than that observed in those not carrying (60.0% [95% CI: 31.2-83.3] vs. 26.8% [95% CI: 18.4-37.4]; OR: 4.1; 95%-CI: 1.1-14.9). In men, a similar prevalence was found among carriers of the rs12343867 CC genotype (16.7% [95% CI: 3.5-46.0]) and in non carriers (16.4% [95% CI: 9.3-27.2]). The V617F allele burden was unrelated to clinical characteristics and significantly higher in carriers of the rs12343867 CC genotype. CONCLUSIONS Present findings suggest that, in patients presenting with SVT, the JAK2 V617F mutation is frequently found in women and, possibly by interacting with the 46/1 haplotype, may represent a gender-related susceptibility allele for SVT.

Venous thrombosis in oral contraceptive users and the presence of the JAK2 V617F mutation

Venous thrombosis in oral contraceptive users and the presence of the JAK2 V617F mutation -

The haplotype M2 within the ANXA5 gene is independently associated with the occurrence of deep venous thrombosis

The haplotype M2 within the ANXA5 gene is independently associated with the occurrence of deep venous thrombosis -

Pregnancy-related venous thrombosis: comparison between spontaneous and ART conception in an Italian cohort.

Objective To evaluate in an Italian cohort the incidence of venous thromboembolic events (VTE) in pregnancies after assisted reproductive technologies (ART). Setting Thrombosis and Haemostasis Unit at I.R.C.C.S. ‘Casa Sollievo della Sofferenza’, S. Giovanni Rotondo. Participants A prospective cohort of 998 women advised to undergo ART was referred by local fertility clinics from April 2002 to July 2011. Follow-up information was obtained during the check-up and/or by phone interviews. In a cohort of women who consecutively gave birth (n=3339) after spontaneous conception in our Institution, information on the diagnoses of pregnancy-related venous thromboses was obtained by linkage to a patient administrative register. Primary and secondary outcome measures We calculated the incidence of VTE and superficial venous thrombosis in successful ART cycles and compared it with that of the general population conceiving spontaneously. Results Overall, 684 ART cycles were carried out by 234 women, who achieved a clinical pregnancy; in case of more than one successful cycle, only the first pregnancy was considered. Three vein thromboses (two VTE and one superficial vein thrombosis) were recorded. An antithrombotic prophylaxis with LMWH alone or combined with low-dose aspirin was prescribed in 23/234 (9.8%) women. In the reference cohort of 3339 women, a total of 11 vein thromboses were observed: six VTE and five SVT. The two-tailed Fisher exact test showed a trend towards statistical significance (p: 0.06, OR: 3.9, 95% CI 0.87 to 15.3). After the exclusion of superficial thromboses in both the groups, we found that the incidence of VTE in our population of women who had undergone ART was 2/234 pregnancies (8.5 ‰), whereas that in our reference population was 6/3339 (1.8 ‰) (p: 0.09). Conclusions Our data show a slightly higher incidence of vein thromboses in pregnancies after ART than in those after natural conception.

Venous thromboembolism in assisted reproductive technologies: comparison between unsuccessful versus successful cycles in an Italian cohort

Pregnancies after assisted reproductive technologies (ART) have been associated with an increased risk of venous thromboembolism (VTE). On the contrary, the magnitude of this risk in unsuccessful ART cycles (not resulting in a clinical pregnancy) has not yet been clearly defined. In this study, we evaluated the incidence of VTE in unsuccessful cycles and compared it with that recorded in successful cycles in the same study population. From a cohort of 998 women consecutively referred by local Fertility Clinics to our Atherosclerosis and Thrombosis Unit (April 2002–July 2011), we identified and included women with at least one cycle of ovarian stimulation and a negative history for VTE. Overall, 661 women undergone 1518 unsuccessful and 318 successful cycles of ovarian stimulation, respectively, were analysed. VTE events occurred in 2/1518 (1.3‰) unsuccessful cycles compared with 3/318 (9.4‰) successful cycles, (Two-tailed Fisher exact test, p = 0.04, OR 0.14, 95% CI 0.02–1.02). Both cases observed in unsuccessful cycles were isolated pulmonary embolism occurred after OHSS; no antithrombotic prophylaxis had been prescribed. At logistic regression analysis, the occurrence of successful cycle and BMI were significantly and independently associated with the occurrence of VTE with an OR of 13.94 (95% CI 1.41–137.45) and 1.23 (95% CI 1.01–1.49), respectively. VTE incidence is significantly lower in unsuccessful cycles as compared to that of successful ones. However, although rare, thrombotic risk during ovarian stimulation cannot be excluded and, when it occurs, can be life-threatening. Therefore, particular attention should be paid to these women, independently of ART outcome.