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Cystic fibrosis and thrombophilic mutations

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Lecture "Cystic fibrosis and thrombophilic mutations", that I had during optional subject Reproductive medicine and reproductive genetics on 2nd Medical Faculty of Charles University in Prague on 3rd …

Lecture "Cystic fibrosis and thrombophilic mutations", that I had during optional subject Reproductive medicine and reproductive genetics on 2nd Medical Faculty of Charles University in Prague on 3rd May 2011.

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  • 1. Molecular genetics in reproductive medicine Cystic fibrosis Thrombofilic mutations MUDr. Marek Turnovec 3 rd May 2011 Lecture for optional subject Reproductive medicine and reproductive genetics 2 nd Medical Faculty of Charles University, Prague
  • 2. Genotype × fenotype relation fenotype genotype environment
  • 3. Genes vs. environment Monogenic disorders Multifactorial disorders Infectious diseases
  • 4. Cystic fibrosis
    • severe disorder with the most severe symptoms in respiratory and gastrointestinal system
    • 5. autosomal recesive
    • 6. most common of „rare diseases“
    • 7. cause by CFTR gene mutations
    • 8. >1800 known mutations and variants (see www.genet.sickkids.on.ca)
  • 9. History I Typical symptoms were observed also in middle-ages... „ Wehe dem Kind, das beim Kuß auf die Stirn salzig schmekt, er ist verhext und muss bald sterbe“ „ Woe is the child who tastes salty from a kiss on the brow, for he is cursed, and soon must die...“ (18 th century)
  • 10. History II
    • 19th century – Carl von Rokitanski – meconium peritonitis
    • 11. 1905 – Karl Landsteiner – meconium ileus
    • 12. 1936 – Guido Fanconi – relation between celiac disease, bronchiectasis and cystic fibrosis of pancreas
  • 13. History III
    • 1938 – Dorothy Andersen – „cystic fibrosis of pancreas“, pancreatic substitution
    • 14. 1952 – Paul di Sant' Agnese – imbalance of electrolytes in sweat
    • 15. 1988 – Tsui, Riordan, Collins, et al. – F508del
    • 16. 1989 – Tsui, Kerem, Riordan, Rommens et al. – CFTR gene sequence and cloning
  • 17. CFTR gene nad its product 7 chromosome, q31.2 116 907 253-117 095 955 bp ≈ 189 kb 24 exons cystic fibrosis transmembrane conductance regulator
  • 18. CFTR protein
    • ion channel for chloride anions and thiocyanate (=rhodanide)
    • 19. epithelial cells – mostly in lungs, liver, pancreas, reproductive systém and sweat glands
    • 20. ATP dependent channel, it regulates other channels (např. ENaC)
    • 21. impairment of balance among electrolytes (Cl – , Na + ) and water in cytoplasma and in lumen of glands
  • 22. Typy mutací genu CFTR
  • 23. „ Anyone who reviews the literature on CF and isn't confused, is confused.“ Efraim Racker, 1985
  • 24. Incidence
    • Czech Republic in text books – 1:2736 , it means, that each each one of 26 persons is carrier
    • 25. incidence in Czech Republic decreases thanks to prenatal diagnosis
    • 26. highest in Europe: Ireland
    • 27. Hispanic: 1:9000, Asian: 1:32000, Afroamericans: 1:15000
  • 28. Inheritance
  • 29. Mutations in CFTR gene
    • F508del – most common (70 % in Czech)
    • 30. differences even accross the Europe
    • 31. Other most common in Czech population: CFTRdele2,3(21kb), G551D, N1303K, G542X, 2143delT
    • 32. ethnic specific mutations:
      • „Slavonic“ mutation: CFTRdele2,3(21kb), 2143delT, 4374+1 G>A
      • 33. „Celtic“ mutation: G551D
      • 34. Anglo-saxons: R117H, I507del
      • 35. Mediterranean: N1303K
  • 36. Abnormal function of CFTR protein
    • viscous mucus -> in airways, gastrointestinal nad reproductive tract
    • 37. severe respiratory infections
    • 38. pancreatic insuficiency -> malnutrition, diarrhoea, CF related diabetes, cysts
    • 39. diagnosis:
      • clinical symptoms, sweat test
      • 40. newborn screening of CF
      • 41. molecular-genetic confirmation of two severe CFTR gene mutations
  • 42. Source: Wikipedia
  • 43. Fertility in CF males
    • 97-98 % of males with CF is infertile
    • 44. congenital bilateral absence of vas deference (CBAVD) – in typical and atypical forms of CF
    • 45. diagnosis: andrologic examination, spermiogram, MG examination
    • 46. solution: ART (acquirement of sperms – TESE, MESE, artifical insemination, IVF, ICSI and embryotransfer)
  • 47. Fertility in CF females
    • increased viscosity of cervical mucus
    • 48. irregular menstrual cycle, amenorrhea
    • 49. solution: ART (artifical insemination), improvement of nutrition, adequate therapy of CF complications
  • 50. Preconception care
    • carrier of CF mutation – always examine his/her partner
    • 51. in case of both parnters are carriers -> prenatal or preimplantation diagnosis
    • 52. it is common to investigate other relatives for disclosure of other carriers and for eventual care
  • 53. Prenatal diagnosis
    • chorionic villus sampling (CVS)
      • 12 th -14 th week
      • 54. karyotype
      • 55. molecular-genetic examination of CFTR gene
      • 56. risk of mother cells contamination (confirmation by examination of cultivated cells)
    • amniocentesis (AMC)
      • 16 th -23 th week
      • 57. karyotype
      • 58. molecular-genetic examination of CFTR gene
    • risk of procedure: 0,5-1 %
  • 59. Preimplantation diagnosis (PGD)
    • in pairs with risk >25 %
    • 60. IVF/ICSI
    • 61. sampling of blastomere / polar body
    • 62. genotype assessment
      • haplotype analysis
      • 63. direct molecular-genetic diagnosis
      • 64. WGA + NGS
    • embryotransfer / cryopreservation
  • 65. Thrombofilic mutations
  • 66. Definitions
    • Thrombophilia = hypercoagulability
      • propensity to development of thrombosis
      • 67. imbalance of coagulation and anticoagulation, impaired fibrinolysis
      • 68. incidence: 1:1000 – 1:100 000 (differs with age)
    • Thrombosis
      • formation of blood clot (thrombus) in blood vessel
  • 69. Causes of thrombosis – Virchow's triad
    • hypercoagulability
    • 70. haemodynamic changes (stasis, turbulence)
    • 71. endothelial dysfunction
    source: Wikimedia Commons
  • 72. Types of thrombosis
    • Venous thrombosis
      • venostasis
      • 73. hypercoagulation
    • Arterial thrombosis
      • dysfunction of endotel (atherosclerosis)
  • 74. Risk factors Acquired Inherited
  • 75. Acquired (non-hereditary) risk factors
    • trauma, surgery, immobilization, infection
    • 76. contraceceptives and hormonal substitution
    • 77. smoking, age
    • 78. renal insufficiency, heart diseases, malignant diseases
    • 79. pregnancy and postpartum period (puerperium)
    • 80. antiphospholipid antibodies (SLE, lymphomas)
    • 81. activated protein C resistence (APCR)
    • 82. hyperhomocysteinemia
  • 83. Hereditary risk factors
    • Antithrombin deficiency
    • 84. APC resistance due to the Factor V variants (Leiden, Cambridge...)
    • 85. Factor II (prothrombin) variants
    • 86. Hyperhomocysteinemia ( MTHFR variants)
    • 87. Deficiency of protein C , protein S or other anticoagulant factors
  • 88. Complications in pregnancy
    • D eep v ein t hrombosis (DVT) -> pulmonary embolia
    • 89. Recurrent pregnancy loss (mostly in II nd and III rd trimester)
    • 90. I ntra u terine g rowth r etardation (IUGR)
    • 91. Preeclampsia/eclampsia
    • 92. HELLP syndrome ( he molytic anemia, elevated l iver enzymes, l ow p latelet)
    • 93. Placental thrombosis -> inadequate perfusion -> placental abruption, infarction
  • 94. Source: Wikipedia
  • 95. Factor V
    • Activated FV is cofactor of activated FX in prothrombin conversion to thrombin
    • 96. F5 gene on 1 chromosome (1q23)
    • 97. Variants/mutations (13):
      • FV Leiden – most known variant
      • 98. FV Cambridge, FV Honk Kong, G1091C, A4070G...
    Source: RCSB – Protein Databank
  • 99. FV Leiden
    • Arg506Gln, R506Q, G1691A
    • 100. Prevalence: about 5 % in Caucasian, lower in Hispanic, rare in Asian descents
    • 101. In 20 % of patients with deep venous thrombosis
    • 102. Cleavage site for aPC -> 10 × slower inactivation of FVa
    • 103. Increased aPC resistency (in 90-95 %)
    • 104. First described by Bertina et al. 1994 from Netherlands
  • 105. FV Leiden - consequences
    • heterozygotes: 5-10 × risk of DVT
    • 106. homozygotes: 50-100 × risk of DVT
    • 107. Lower risk of intrapartum bleeding -> evolutionary advantage (Lindqvist et al. 1998)
  • 108. Factor II - prothrombin
    • prothrombin -> thrombin
    • 109. 11p11-11p12, G20210A
    • 110. increased synthesis of thrombin (>130 %)
    • 111. incidence: 2 % Caucasian (ethnic differences)
    • 112. 6 % of patients with DVT
    • 113. 2-3 × risk of DVT
  • 114. MTHFR
    • m ethylene t etra h ydro f olate r eductase
    • 115. MTHFR gene on 11p36.3-11p36.4
    • 116. many mutations/polymorphisms (>10)
    • 117. most common: C677T, A1298C
    • 118. termolabile form of enzyme -> lower activity (30 % in homozygotes, 65 % in heterozygotes) -> increased level of homocysteine
    • 119. prevalence of C677T in Czech population:
      • heterozygotes: 40 %, homozygotes: 15 % (other Europe: 7.5 %)
  • 120. Hyperhomocysteinemia
    • concentration >18,5 mmol/L
    • 121. endothel damage
    • 122. increased risk of DVT (18,5-20 mmol/L – 2.5 × , >20 mmol/L – 4 ×)
    • 123. increased risk of atherosclerosis (coronary blood vessels, brain)
    • 124. carcinogenesis
    • 125. NTD
  • 126.
      Protein C deficiency
    • Hereditary
      • rare (1:5000 ?)
      • 127. in homozygous form: purpura fulminans in newborns – haemorrhage, sepsis, necrosis, disseminated intravascular coagulation (DIC)
    • Acquired
      • autoimmune – antibodies agains protein C
  • 128. Recommendations in pregnancy
    • Exhaustive personal history (deep vein thrombosis, thromboembolism)
    • 129. Exhaustive gynecological/obstetric history – concentrate on course of previous pregnancy (or pregnancies) and their complications
    • 130. Family history
    • 131. Increased PAPP-A level
    • 132. Testing of all risk factors (but not testing all pregnant women!)
    • 133. According the results: observation , prophylaxis
  • 134. Indications for genetic testing
    • Personal medical history (anamnesis)
      • recurrent pregnancy loss (habitual abortions)
      • 135. deep vein thrombosis
      • 136. thromboembolism
    • Family history
      • recurrent pregnancy loss
      • 137. thrombophilia mutations already detected in family
  • 138. Prophylaxis
    • FV, FII
      • prevention of DVT in risk conditions (surgery)
      • 139. contraindication of hormonal contraception or hormonal replacement therapy
      • 140. acetylsalicylic acid before concetpion and in I st trimester (max 70 mg/day), LMWH in III rd trimester
      • 141. lifelong anticoagulation therapy in symptomatic patients
    • MTHFR
      • Acidum folicum, B vitamines (B12) – at least in I st trimester – also prevents NTD
  • 142. Don't blame genetics for everything...