familial deficiency of vitamin k dependent clotting factors

8/10/2019 Familial Deficiency of Vitamin k Dependent Clotting Factors

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ORIGINAL ARTICLE

Familial deficiency of vitamin K-dependent clotting factors

B. W. WESTON and P. E. MONAHAN

The Harold R. Roberts Comprehensive Hemophilia Treatment Center, and the Department of Pediatrics, Division of

Hematology-Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA

Summary.Combined deficiency of vitamin K-depen-dent clotting factors II, VII, IX and X (and proteinsC, S, and Z) is usually an acquired clinical problem,often resulting from liver disease, malabsorption, orwarfarin overdose. A rare inherited form of defectivec-carboxylation resulting in early onset of bleeding

was first described by McMillan and Roberts in 1966and subsequently has been termed vitamin K-depen-dent clotting factor deficiency (VKCFD). Biochem-ical and molecular studies identify two variants ofthis autosomal recessive disorder: VKCFD1, which isassociated with point mutations in the c-glutamylcar-boxylase gene (GGCX), and VKCFD2, which resultsfrom point mutations in the vitamin K epoxide

reductase gene (VKOR). Bleeding ranges in severityfrom mild to severe. Therapy includes high oral dosesof vitamin K for prophylaxis, usually resulting inpartial correction of factor deficiency, and episodicuse of plasma infusions or prothrombin complex con-centrate. Recent molecular studies have the potential

to further ourunderstanding of vitamin K metabolism,c-carboxylation, and the functional role this post-translational modification has for other proteins.The results may also provide potential targets formolecular therapeutics and pharmacogenetics.

Keywords: haemorrhage, polymorphisms, reductase,vitamin K, c-carboxylation

Introduction

Vitamin K-dependent clotting factor deficiency(VKCFD) is a rare autosomal recessive bleedingdisorder that often presents with severe haemorrhageduring infancy. The first case of VKCFD was reportedin 1966 and described a 3-month-old girl withmultiple bruises and haemorrhages [1]. She had noevidence of malabsorption, liver disease, or warfarinpoisoning. She was found to have a prothrombin timeof 95 s and a partial thromboplastin time of 305 s.These times corrected on mixing 1:1 with normalplasma, indicating factor deficiency rather than inhi-bition of coagulation. Her plasma showed


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K epoxide reductase (VKOR) in 2004 by reversegenetics and expression cloning [1517] greatlyadvanced our understanding of VKCFD, as well asthe metabolism of vitamin K and the biological rolesofc-carboxylation. Subsequent pedigree studies havelooked at missense mutations in each gene, resulting

in the subtype designations VKCFD1 and VKCFD2[18,19]. Common single nucleotide polymorphisms(SNPs) in these genes (particularly VKOR) andCYP2C9 (cytochrome p450 2C9) have been exam-ined in large populations of various ethnic back-grounds in relation to warfarin dosing [reviewed in20]. Recent work has also focused on drug develop-ment and potential molecular therapeutics using theknowledge gained by study of VKCFD, making thisrare coagulation disorder relevant in new ways.

Methods

All current publications in PubMed and other scien-tific databases were searched. Approximately, 300articles pertaining to the subject were reviewed indetail. Original studies published in the past 3 yearswere chosen for additional analysis. Polymorphismsin GGCX and VKOR were reviewed in standardgenome databases and registries. Selected investiga-tors working in this area were also contacted. Severalrecent reviews and perspectives are also recom-mended [2125].

Incidence, racial and ethnic predilectionVKCFD1 and VKCFD2 are extremely rare autoso-mal recessive disorders with fewer than 30 casesreported. Carrier incidence, racial distribution andethnic predilections are not known. Cases andpedigrees have been reported in Africa, Asia, Europeand North America. As mentioned previously [20],SNP frequencies in the GGCX and VKOR genes inseveral large population-based studies have beenreported, but obviously these rarely result in theclinical syndrome VKCFD.

Pathophysiology

Glutamate residues in coagulation factors II, VII, IXand X (and the anticoagulant factors proteins C, Sand Z) are carboxylated by GGCX into c-carboxyg-lutamate residues. Nine to 13 of these residues arefound in the amino-terminal region of the circulatingform of each of these proteins, constituting thec-carboxyglutamic acid-rich Gla domain. Full activ-ity of these factors (but not immunological recogni-tion) is provided by this post-translational

modification of the proteins in the endoplasmicreticulum. Once carboxylated, the proteins have acalcium-dependent conformation that allows bindingto phospholipids and/or endothelial cells.

Vitamin K in reduced form is required as acofactor by GGCX during the catalytic reaction:

Glutamic acid !GGCX

c carboxyglutamic acid

Cofactor Vitamin K reduced

Once vitamin K is oxidized to the epoxide form inthis reaction, the reduced form of vitamin K must beregenerated by the VKOR:

Vitamin K epoxide !VKOR

Vitamin K reduced

The primary target for warfarins action is VKOR,resultingin lower levels of the reduced form of vitaminK. This in turn leads to failure of carboxylation andtherefore to decreased function of coagulation factorsin patients treated with coumarin derivatives. Detailedreview of the vitaminK cycle and carboxylation can befound in several recent reviews [2123].

Genetics and molecular basis

These rare autosomal disorders arise from pointmutations in either the GGCX or VKOR genes; thesingle exception is a kindred with a 14 bp deletion inintron 1 of GGCX, which was determined toperhaps eliminate cis-acting elements regulating

GGCX expression [26]. Several compound hetero-zygous cases and pedigrees have been described forVKCFD1 [5,8]. The only mutation identified to dateleading to VKCFD2 is the homozygous mutation ofVKOR complex subunit 1 (VKORC1) nucleotide292C fiT; this mutation, identified in three distinctkindreds, results in amino acid change Arg98Trp[16,27].

Carriers are asymptomatic. As Ginsberg notes[23], the rarity of VKCFD and the fact that onlymissense mutations have been identified suggestembryonic lethality with complete deficiency of

either enzyme in humans; this is supported byobservations from the GGCX knockout mouse [24].

Clinical manifestations

The first case of VKCFD was described in an infantwith multiple bruises and haemorrhages [1], and sub-sequent case reports are often similar. Mucocutaneousbleeding may be prominent and neonatal umbilicalbleeding has been reported [1, 28]; hemarthrosis israrely described [28]. VKCFD often presents with

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intracranial haemorrhage in the neonate or early inlife, similar to haemorrhagic disease of the newbornresulting from acquired vitamin K deficiency[9,15,26,28]. A few patients have dysmorphic featuresvaguely resembling warfarin embryopathy, but this isa heterogeneous group. Some of the described patients

have also had developmental abnormalities and/orskeletal defects [8,10,11], and there appears to be ahigh incidence of fetal wastage [8,1012,29], althoughthe small numbers preclude a definitive statement.Milder cases with later onset of diagnosis have alsobeen reported [5,7]. The most detailed clinicaldescriptions, however, are found in the original casereport [1], with published follow-up reports manyyears later [2,3].

Vitamin K-dependent clotting factor deficiencypatients have markedly prolonged prothrombintime and activated partial thromboplastin timeresults that correct with plasma mix. Factors II,VII, IX and X activity levels show variably reducedvalues (though usually quite low) that partiallyimprove with vitamin K treatment of the patient.Proteins increased in vitamin Ks absence (PIVKA-II;undercarboxylated prothrombin) are increased,even following therapeutic correction with plasmainfusion. Although the PIVKA-II immunoassay ismore sensitive than vitamin K-dependent factoractivity levels, its limited specificity does not allowdifferentiation of VKCFD from some forms of liverdisease or other disorders resulting in vitamin Kdeficiency. Proteins C, S and Z activities are also

reduced; however, the propensity to thromboticevents seems to be much less common [9]. This isprimarily a bleeding diathesis, not a thrombophilicdisorder.

Diagnosis

Diagnosis of vitamin K deficiency rests on thepersistence of bleeding manifestations and reducedlevels of vitamin K-dependent coagulation and anti-coagulation factors. Warfarin ingestion, malabsorp-tion and liver disease must be ruled out [2]. Reduced

vitamin K levels due to antibiotic or anticonvulsanttherapy can also lead to bleeding in VKCFD patients,and additional treatment and monitoring may beindicated during infection or seizure therapy [28].

Genotyping for VKORC1 (5 kb) and GGCX(13 kb) is possible in several research laboratories[6,8,1317,27] and should be strongly consideredrather than allowing the patient to have multipleand/or severe bleeding episodes while not takingvitamin K. Point mutations have also greatly con-tributed to our understanding of both GGCX and

VKOR structure and function [3032]. Serumvitamin K and vitamin K epoxide levels also can bemeasured in research laboratories; vitamin K epoxideis normally undetectable in serum but is elevated inVKCFD2 following vitamin K supplementation [6].

Management

Administration of large doses of oral vitamin K (e.g.15 mg daily in adults) may partially correct the lowfactor assay results in severely affected patients toabout 1520% but may not prevent significantbleeding [24]. These partially corrected factoractivities approach the levels observed in mildercases of VKCFD [5,7]. In fact, massive parenteraldoses of vitamin K do not always correct factor II,VII, IX and X activities, and there is clear biochem-ical evidence that the molecules are not fullycarboxylated by such treatment [2,8]. Continueddaily treatment with high-dose oral vitamin K is,however, successful in preventing some bleedingcomplications [25, 79] and is generally recom-mended for these patients.

Plasma infusions for surgical procedures and overthaemorrhage are indicated, and VKCFD patientsoften require multiple doses. Alternatively, so-calledfour-factor prothrombin complex concentrates(PCCs), which contain factors II, VII, IX, and Xand proteins C and S in variable amounts [33] couldbe considered (several 3-factor PCCs with little or nofactor VII are marketed and would be expected to

have lower efficacy) [33]. Although these concen-trates have rarely been used in VKCFD in thepublished literature [8], they have been used effec-tively in rapidly reversing warfarin anticoagulationand offer a therapeutic option that includes patho-gen-inactivation steps and lower risk of volumeoverload with repeated dosing when compared withplasma.

Prognosis

Prenatal diagnosis is possible if both alleles are

sequenced and familial SNPs are defined. Prognosisof VKCFD can be guarded based on the propensityfor perinatal intracranial haemorrhage, which canresult in permanent neurological damage and devel-opmental disabilities [6,8]. Other cases, however,have been milder and have favourable outcomes overtime. Early intervention with appropriate treatmentand prevention modalities would probably improvethe prognosis, as with any coagulation disorder. Asnoted previously, factor levels partially improve withvitamin K therapy, and regular vitamin K dosing may

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maintain haemostasis, though not preventing allcomplications.

Conclusions

Future areas of potential clinical relevance resulting

from this work include prediction of warfarin doseusing SNPs in VKOR and other genes, design of newsmall molecule inhibitors of VKOR and GGCX, andfurther definition of defective carboxylation of non-haematological proteins.

Individuals with interests in the area

Darrel W. Stafford, Department of Biology andPathology, University of North Carolina at ChapelHill, Chapel Hill, NC, USA.

Harold Roberts, Department of Medicine, Univer-sity of North Carolina at Chapel Hill, Chapel Hill,NC, USA.

Johannes Oldenburg, Institute of ExperimentalHematology and Transfusion Medicine, Bonn,Germany.

Acknowledgements

The authors thank H. R. Roberts and D. W. Staffordfor their thoughtful comments on the manuscript.This work was supported by NIH NHLBI PO1-HL66973.

Disclosures

The authors stated that they had no interests whichmight be perceived as posing a conflict or bias.

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Links to organizations

The International Registry of Rare Bleeding Dis-orders (RBDs): http://www.rbdd.orghttp://www.rbdd.eu

CDC Universal Data Collection/Rare BleedingDisorders Working Group

Centers for Disease Control UDC Working Group:http://www.cdc.gov/ncbddd/hbd/surveillance.htm

FDA news release dated 17 September 2007: TheNanosphere Verigene Warfarin Metabolism NucleicAcid Test; FDAs Center for Drug Evaluationand Research Web site: http://www.fda.gov/cderand http://www.fda.gov/bhs/topics/NEWS/2007/New01701.html

World Federation of Hemophilia Registry ofClotting Factor Concentrates (includes ProthrombinComplex Concentrates available worldwide) http://www.wfh.org/2/docs/Publications/Treatment_Products/

Monographs/FF6_Registry_8th_2008.pdf

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