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DOI: 10.1055/s-0037-1613862
Intermediate and Severe Hyperhomocysteinemia with Thrombosis: A Study of Genetic Determinants
This work was supported by grants from the Danish Heart Foundation (98-1-5-74A-22579) and the Institute for Experimental Clinical Research, University of Aarhus. The excellent technical assistance of Mie Madsen, Jette Jensen, and the staff of the Coagulation Laboratory is gratefully acknowledged.Publication History
Received
14 September 1999
Accepted after resubmission
14 December 1999
Publication Date:
08 December 2017 (online)
![](https://www.thieme-connect.de/media/10.1055-s-00035024/200004/lookinside/thumbnails/10-1055-s-0037-1613862-1.jpg)
Summary
Hyperhomocysteinemia is an independent risk factor for cardiovascular disease. In search of genetic factors causing elevated levels of total homocysteine in plasma (tHcy), we investigated a cohort of consecutively identified, unrelated thrombosis patients (n = 28) having intermediate or severe hyperhomocysteinemia (30 µmol/l<tHcy ≤100 µmol/l, and tHcy >100 µmol/l, respectively). The methylenetetrahydrofolate reductase (MTHFR) 677C→T genotype, and the complete cystathionine β-synthase (CBS) genotype was determined in all patients. We found that the MTHFR T/T genotype was strongly correlated with intermediate hyperhomocysteinemia, being present in 73.9 % of those cases (17 of 23). In three of five patients with severe hyperhomocysteinemia, compound heterozygosity for CBS mutations was detected. Among the mutations, two novel missense mutations: 1265C→T (S422L) and 1397C→T (S466L) were detected. The phenotype in those patients was quite mild, thromboembolism apart. This indicates that a search for CBS mutations in patients with severe hyperhomocysteinemia is important to ensure the detection of a possible CBS deficiency, thus enabling treatment. Co-existence of the MTHFR T/T genotype and the common CBS 844ins68 variant was significantly higher among patients (10.7%) as compared to controls (1.2%), indicating that this genotype combination is a thrombotic risk factor (P <0.05). In a few patients, hyperhomocysteinemia could not be explained by this genetic approach, suggesting that other genetic risk factors were implicated.
Abbreviations: MTHFR, methylenetetrahydrofolate reductase; CBS, cystathionine β-synthase; tHcy, total homocysteine in plasma.
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References
- 1 Boers GHJ, Smals AHG, Trijbels FJM, Fowler B, Bakkeren JAJM, Schoonerwald HC, Kleijer WJ, Kloppenborg PWC. Heterozygosity for homocystinuria in premature peripheral and cerebral occlusive arterial disease. N Engl J Med 1985; 313: 709-15.
- 2 Graham IM, Daly LE, Refsum HM, Robinson K, Brattstrom LE, Ueland PM, Palmareis RJ, Boers GHJ, Sheahan RG, Israelsson B, Uiterwaal CS, Meleady R, Mcmaster D, Verhoef P, Witteman J, Rubba P, Bellet H, Wautrecht JC, Devalk HW, Luis ACS, Parrot-Roulaud FM, Tan KS, Higgins I, Garcon D, Medrano MJ, Candito M, Evans AE, Andria G. Plasma homocysteine as a risk factor for vascular disease: The European concerted action project. JAMA 1997; 277: 1775-81.
- 3 den Heijer M, Koster T, Blom HJ, Bos GMJ, Briët E, Reitsma PH, Vandenbroucke JP, Rosendaal FR. Hyperhomocysteinemia as a risk factor for deep-vein thrombosis. N Engl J Med 1996; 334: 759-62.
- 4 Simioni P, Prandoni P, Burlina A, Tormene D, Sardella C, Ferrari V, Benedetti L, Girolami A. Hyperhomocysteinemia and deep-vein thrombosis –A case-control study. Thromb Haemost 1997; 76: 883-6.
- 5 Ubbink JB, Vermaak WJ, van der Merwe A, Becker PJ. Vitamin B12, vitamin B6, and folate nutritional status in men with hyperhomocysteinemia. Am J Clin Nutr 1993; 57: 47-53.
- 6 Frosst P, Blom HJ, Milos R, Goyette P, Sheppard CA, Matthews RG, Boers GJH, den Heijer M, Kluijtmans LAJ, van den Heuvel LP, Rozen R. A candidate genetic risk factor for vascular disease: A common mutation in methylenetetrahydrofolate reductase. Nat Genet 1995; 10: 111-3.
- 7 Kozich V, Kraus JP. Screening for mutations by expressing patient cDNA segments in E. coli: homocystinuria due to cystathionine beta-synthase deficiency. Hum Mutat 1992; 01: 113-23.
- 8 Leclerc D, Campeau E, Goyette P, Adjalla CE, Christensen B, Ross M, Eydoux P, Rosenblatt DS, Rozen R, Gravel RA. Human methionine synthase: cDNA cloning and identification of mutations in patients of the cblG complementation group of folate/cobalamin disorders. Hum Mol Genet 1997; 05: 1867-74.
- 9 Jacques PF, Bostom AG, Williams RR, Ellison RC, Eckfeldt JH, Rosenberg IH, Selhub J, Rozen R. Relation between folate status, a common mutation in methylenetetrahydrofolate reductase, and plasma homocysteine concentrations. Circulation 1996; 93: 7-9.
- 10 Verhoef P, Kok FJ, Kluijtmans LAJ, Blom HJ, Refsum H, Ueland PM, Kruyssen DACM. The 677C→T mutation in the methylenetetrahydrofolate reductase gene: Associations with plasma total homocysteine levels and risk of coronary atherosclerotic disease. Atherosclerosis 1997; 132: 105-13.
- 11 Brattstrom L, Wilcken DE, Ohrvik J, Brudin L. Common methylenetetrahydrofolate reductase gene mutation leads to hyperhomocysteinemia but not to vascular disease: the result of a meta-analysis. Circulation 1998; 98: 2520-6.
- 12 Guttormsen AB, Ueland PM, Nesthus I, Nygard O, Schneede J, Vollset SE, Refsum H. Determinants and vitamin responsiveness of intermediate hyperhomocysteinemia (≥40 µmol/liter) –The Hordaland homocysteine study. J Clin Invest 1996; 98: 2174-83.
- 13 Kang SS, Wong PWK, Malinow MR. Hyperhomocyst(e)inemia as a risk factor for occlusive vascular disease. Annu Rev Nutr 1992; 12: 279-98.
- 14 Mudd SH, Finkelstein JD, Irreverre F, Laster L. Homocystinuria: an enzymatic defect. Science 1964; 143: 1443-5.
- 15 Mudd SH, Levy HL, Skovby F. Disorders of transsulfuration. In: The metabolic and molecular bases of inherited disease. Scriver CR, Beaudet AL, Sly WS, Valle D. eds. New York: McGraw-Hill; 1995: 1279-327.
- 16 Gaustadnes M, Ingerslev J, Rüdiger N. Prevalence of congenital homocystinuria in Denmark. N Engl J Med 1999; 340: 1513 (Letter).
- 17 Naughten ER, Yap S, Mayne PD. Newborn screening for homocystinuria: Irish and world experience. Eur J Pediatr 1998; 157: S84-7.
- 18 Gaustadnes M, Rüdiger N, Møller J, Rasmussen K, Larsen TB, Ingerslev J. Thrombophilic predisposition in stroke and venous thromboembolism in Danish patients. Blood Coag Fibrinol 1999; 10: 251-9.
- 19 Møller J, Rasmussen K. Homocysteine in plasma: Stabilization of blood samples with fluoride. Clin Chem 1995; 41: 758-9.
- 20 Rasmussen K. Solid-phase sample extraction for rapid determination of methylmalonic acid in serum and urine by a stable-isotope dilution method. Clin Chem 1989; 35: 260-4.
- 21 Gaustadnes M, Kluijtmans LAJ, Kudsk OJensen, Rasmussen K, Heil SG, Kraus JP, Blom HJ, Ingerslev J, Rüdiger N. Detection of a novel deletion in the cystathionine beta- synthase gene using an improved genomic DNA based method. FEBS Letters 1998; 431: 175-9.
- 22 Gaustadnes M, Rüdiger N, Ingerslev J. The 20210 A allele of the prothrombin gene is not a risk factor for juvenile stroke in the Danish population. Blood Coag Fibrinol 1998; 09: 663-4 (Letter).
- 23 Rasmussen K, Møller J, Lyngbak M, Holm AMPedersen, Dybkjær L. Age- and gender-specific reference intervals for total homocysteine and methylmalonic acid in plasma before and after vitamin supplementation. Clin Chem 1996; 42: 630-6.
- 24 Sebastio G, Sperandeo MP, Panico M, de Franchis R, Kraus JP, Andria G. The molecular basis of homocystinuria due to cystathionine beta-synthase deficiency in Italian families, and report of four novel mutations. Am J Hum Genet 1995; 56: 1324-33.
- 25 Kluijtmans LAJ, Boers GHJ, Stevens EMB, Renier WO, Kraus JP, Trijbels FJM, van den Heuvel LPWJ, Blom HJ. Defective cystathionine betasynthase regulation by S-adenosylmethionine in a partially pyridoxine responsive homocystinuria patient. J Clin Invest 1996; 98: 285-9.
- 26 de Franchis R, Kozich V, McInnes RR, Kraus JP. Identical genotypes in siblings with different homocystinuric phenotypes: identification of three mutations in cystathionine beta-synthase using an improved bacterial expression system. Hum Mol Genet 1994; 03: 1103-8.
- 27 Kraus JP, Le K, Swaroop M, Ohura T, Tahara T, Rosenberg LE, Roper MD, Kozich V. Human cystathionine beta-synthase cDNA: sequence, alternative splicing and expression in cultured cells. Hum Mol Genet 1993; 02: 1633-8.
- 28 de Stefano V, Dekou V, Nicaud V, Chasse JF, London J, Stansbie D, Humphries SE, Gudnason V. Linkage disequilibrium at the cystathionine beta synthase (CBS) locus and the association between genetic variation at the CBS locus and plasma levels of homocysteine. The Ears II Group. Ann Hum Genet 1998; 62: 481-90.
- 29 Kim CE, Gallagher PM, Guttormsen AB, Refsum H, Ueland PM, Ose L, Folling I, Whitehead AS, Tsai MY, Kruger WD. Functional modeling of vitamin responsiveness in yeast: a common pyridoxine-responsive cystathionine beta-synthase mutation in homocystinuria. Hum Mol Genet 1998; 06: 2213-21.
- 30 Kluijtmans LA, Boers GH, Kraus JP, van den Heuvel LP, Cruysberg JR, Trijbels FJ, Blom HJ. The molecular basis of cystathionine beta-synthase deficiency in Dutch patients with homocystinuria: effect of CBS genotype on biochemical and clinical phenotype and on response to treatment. Am J Hum Genet 1999; 65: 59-67.
- 31 Mudd SH, Skovby F, Levy HL, Pettigrew KD, Wilcken B, Pyeritz RE, Andria G, Boers GHJ, Bromberg IL, Cerone R, Fowler B, Grobe H, Schmidt H, Schweitzer L. The natural history of homocystinuria due to cystathionine beta-synthase deficiency. Am J Hum Genet 1985; 37: 1-31.
- 32 Kraus JP, Janosik M, Kozich V, Mandell R, Shih VE, Sperandeo MP, Sebastio G, de Franchis R, Andria G, Kluijtmans LAJ, Blom HJ, Boers GHJ, Gordon RB, Kamoun P, Tsai MY, Kruger WD, Koch HG, Ohura T, Gaustadnes M. Cystathionine beta-synthase mutations in homocystinuria. Hum Mutat 1999; 13: 362-75.
- 33 Shih VE, Fringer JM, Mandell R, Kraus JP, Berry GT, Heidenreich RA, Korson MS, Levy HL, Ramesh V. A missense mutation (1278T) in the cystathionine beta- synthase gene prevalent in pyridoxine-responsive homocystinuria, and associated with mild clinical phenotype. Am J Hum Genet 1995; 57: 34-9.
- 34 Tsai MY, Welge BG, Hanson NQ, Bignell MK, Vessey J, Schwichtenberg K, Yang F, Bullemer FE, Rasmussen R, Graham KJ. Genetic causes of mild hyperhomocysteinemia in patients with premature occlusive coronary artery diseases. Atherosclerosis 1999; 143: 163-70.
- 35 Kluijtmans LAJ, Boers GHJ, Trijbels FJM, van Lith-Zanders HMA, van den Heuvel LPWJ, Blom HJ. A common 844INS68 insertion variant in the cystathionine beta-synthase gene. Biochem Mol Med 1998; 62: 23-5.
- 36 Franco R, Maffei F, Lourenco D, Piccinato C, Morelli V, Thomazini I, Zago M. The frequency of 844ins68 mutation in the cystathionine betasynthase gene is not increased in patients with venous thrombosis. Haematologica 1998; 83: 1006-8.
- 37 Sperandeo MP, de Franchis R, Andria G, Sebastio G. A 68-bp insertion found in a homocystinuric patient is a common variant and is skipped by alternative splicing of the cystathionine beta-synthase mRNA. Am J Hum Genet 1996; 59: 1391-3.
- 38 van der Put NMJ, van der Molen EF, Kluijtmans LAJ, Heil SG, Trijbels JMF, Eskes TKAB, van Oppenraaij-Emmerzaal D, Banerjee R, Blom HJ. Sequence analysis of the coding region of human methionine synthase: Relevance to hyperhomocysteinaemia in neural-tube defects and vascular disease. Q J Med 1997; 90: 511-7.
- 39 Morita H, Kurihara H, Sugiyama T, Hamada C, Kurihara Y, Shindo T, Oh-hashi Y, Yazaki Y. Polymorphism of the methionine synthase gene: association with homocysteine metabolism and late-onset vascular diseases in the Japanese population. Arterioscler Thromb Vasc Biol 1999; 19: 298-302.