Download PDF
Thromb Haemost 2010; 104(03): 618-625
DOI: 10.1160/TH10-02-0113
New Technologies, Diagnostic Tools and Drugs
Schattauer GmbH

Low cut-off values increase diagnostic performance of protein S assays

René Mulder
1   Department of Laboratory Medicine, University Medical Centre Groningen, University of Groningen, the Netherlands
2   Division of Haemostasis and Thrombosis, Department of Haematology, University Medical Centre Groningen, University of Groningen, the Netherlands
,
Min Ki ten Kate
2   Division of Haemostasis and Thrombosis, Department of Haematology, University Medical Centre Groningen, University of Groningen, the Netherlands
,
Hanneke C. Kluin-Nelemans
2   Division of Haemostasis and Thrombosis, Department of Haematology, University Medical Centre Groningen, University of Groningen, the Netherlands
,
André B. Mulder
1   Department of Laboratory Medicine, University Medical Centre Groningen, University of Groningen, the Netherlands
› Author Affiliations
Further Information

Publication History

Received: 12 February 2010

Accepted after minor revision: 15 April 2010

Publication Date:
23 November 2017 (online)

Also available at
    Permissions and Reprints

Summary

Conflicting data have been reported on the accuracy of protein S (PS) assays for detection of hereditary PS deficiency. In this study we assessed the diagnostic performance of two total PS antigen assays, four free PS assays and three PS activity assays in a group of 28 heterozygous carriers of mutations in PROS1 and 165 control subjects. Several control groups were formed, one of healthy volunteers and – because PS levels are influenced by oral contraception and pregnancy, and assays measuring PS activity may be influenced by the presence of the factor V Leiden mutation -, we also investigated the influences of these factors. All nine PS assays detected significantly reduced PS levels in subjects with a PROS1 mutation. Eight out of nine PS assays showed a 100% sensitivity and 100% specificity to detect heterozygous carriers of mutations in PROS1 with values far below the lower limit of the reference values obtained from healthy volunteers. Low specificities were found in subjects with a factor V Leiden mutation and in pregnant women. At lower cutoff levels, equal to the highest PS value found in heterozygous carriers of mutations in PROS1, the specificity considerably increased in these subjects. When using low cut-off levels equal to the highest PS value found in heterozygous carriers of mutations in PROS1, ensuring 100% sensitivity, the specificity in all study groups increases considerably, by which misclassification can be maximally avoided.

Keywords

Protein S assays - low cut-off values - diagnostic performance - protein S deficiency - PROS1 mutation
 

  • References

  • 1 Walker FJ. Regulation of activated protein C by a new protein. A possible function for bovine protein S. J Biol Chem 1980; 255: 5521-5524.
    PubMedGoogle Scholar
  • 2 Walker FJ. Regulation of activated protein C by protein S. The role of phospholipid in factor Va inactivation. J Biol Chem 1981; 256: 11128-11131.
    PubMedGoogle Scholar
  • 3 Walker FJ, Chavin SI, Fay PJ. Inactivation of factor VIII by activated protein C and protein S. Arch Biochem Biophys 1987; 252: 322-328.
    CrossrefPubMedGoogle Scholar
  • 4 Dahlback B. The tale of protein S and C4b-binding protein, a story of affection. Thromb Haemost 2007; 98: 90-96.
    Article in Thieme ConnectPubMedGoogle Scholar
  • 5 Dykes AC, Walker ID, McMahon AD. et al. A study of Protein S antigen levels in 3788 healthy volunteers: influence of age, sex and hormone use, and estimate for prevalence of deficiency state. Br J Haematol 2001; 113: 636-641.
    CrossrefPubMedGoogle Scholar
  • 6 Seligsohn U, Lubetsky A. Genetic susceptibility to venous thrombosis. N Engl J Med 2001; 344: 1222-1231.
    CrossrefPubMedGoogle Scholar
  • 7 Schattner A, Kasher I, Berrebi A. Causes and outcome of deep-vein thrombosis in otherwise-healthy patients under 50 years. QJM 1997; 90: 283-287.
    CrossrefPubMedGoogle Scholar
  • 8 Pabinger I, Brucker S, Kyrle PA. et al. Hereditary deficiency of antithrombin III, protein C and protein S: prevalence in patients with a history of venous thrombosis and criteria for rational patient screening. Blood Coagul Fibrinolysis 1992; 3: 547-553.
    CrossrefPubMedGoogle Scholar
  • 9 Heijboer H, Brandjes DP, Buller HR. et al. Deficiencies of coagulation-inhibiting and fibrinolytic proteins in outpatients with deep-vein thrombosis. N Engl J Med 1990; 323: 1512-1516.
    CrossrefPubMedGoogle Scholar
  • 10 Gladson CL, Scharrer I, Hach V. et al. The frequency of type I heterozygous protein S and protein C deficiency in 141 unrelated young patients with venous thrombosis. Thromb Haemost 1988; 59: 18-22.
    Article in Thieme ConnectPubMedGoogle Scholar
  • 11 Borgel D, Duchemin J, Alhenc-Gelas M. et al. Molecular basis for protein S hereditary deficiency: genetic defects observed in 118 patients with type I and type IIa deficiencies. The French Network on Molecular Abnormalities Responsible for Protein C and Protein S Deficiencies. J Lab Clin Med 1996; 128: 218-227.
    CrossrefPubMedGoogle Scholar
  • 12 Faioni EM, Valsecchi C, Palla A. et al. Free protein S deficiency is a risk factor for venous thrombosis. Thromb Haemost 1997; 78: 1343-1346.
    Article in Thieme ConnectPubMedGoogle Scholar
  • 13 Makris M, Leach M, Beauchamp NJ. et al. Genetic analysis, phenotypic diagnosis, and risk of venous thrombosis in families with inherited deficiencies of protein S. Blood 2000; 95: 1935-1941.
    PubMedGoogle Scholar
  • 14 Martinelli I, Mannucci PM, De Stefano V. et al. Different risks of thrombosis in four coagulation defects associated with inherited thrombophilia: a study of 150 families. Blood 1998; 92: 2353-2358.
    PubMedGoogle Scholar
  • 15 Simmonds RE, Ireland H, Lane DA. et al. Clarification of the risk for venous thrombosis associated with hereditary protein S deficiency by investigation of a large kindred with a characterized gene defect. Ann Intern Med 1998; 128: 8-14.
    CrossrefPubMedGoogle Scholar
  • 16 Lijfering WM, Mulder R, ten Kate MK. et al. Clinical relevance of decreased free protein S levels. Results from a retrospective family cohort study involving 1143 relatives. Blood 2009; 113: 1225-1230.
    CrossrefPubMedGoogle Scholar
  • 17 Brouwer JL, Veeger NJ, van der Schaaf W. et al. Difference in absolute risk of venous and arterial thrombosis between familial protein S deficiency type I and type III. Results from a family cohort study to assess the clinical impact of a laboratory test-based classification. Br J Haematol 2005; 128: 703-710.
    CrossrefPubMedGoogle Scholar
  • 18 Boerger LM, Morris PC, Thurnau GR. et al. Oral contraceptives and gender affect protein S status. Blood 1987; 69: 692-694.
    PubMedGoogle Scholar
  • 19 Comp PC, Thurnau GR, Welsh J. et al. Functional and immunologic protein S levels are decreased during pregnancy. Blood 1986; 68: 881-885.
    PubMedGoogle Scholar
  • 20 Henkens CMA, Bom VJJ, Van der Schaaf W. et al. Plasma-Levels of Protein-S, Protein-C, and Factor-X – Effects of Sex, Hormonal State and Age. Thromb Haemost 1995; 74: 1271-1275.
    Article in Thieme ConnectPubMedGoogle Scholar
  • 21 Malm J, Laurell M, Dahlback B. Changes in the plasma levels of vitamin K-dependent proteins C and S and of C4b-binding protein during pregnancy and oral contraception. Br J Haematol 1988; 68: 437-443.
    CrossrefPubMedGoogle Scholar
  • 22 Said JM, Ignjatovic V, Monagle PT. et al. Altered reference ranges for protein C and protein S during early pregnancy: Implications for the diagnosis of protein C and protein S deficiency during pregnancy. Thromb Haemost 2010; 103: 984-988.
    Article in Thieme ConnectPubMedGoogle Scholar
  • 23 Szecsi PB, Jorgensen M, Klajnbard A. et al. Haemostatic reference intervals in pregnancy. Thromb Haemost 2010; 103: 718-727.
    Article in Thieme ConnectPubMedGoogle Scholar
  • 24 Faioni EM, Franchi F, Asti D. et al. Resistance to activated protein C in nine thrombophilic families: interference in a protein S functional assay. Thromb Haemost 1993; 70: 1067-1071.
    Article in Thieme ConnectPubMedGoogle Scholar
  • 25 Faioni EM, Boyer-Neumann C, Franchi F. et al. Another protein S functional assay is sensitive to resistance to activated protein C. Thromb Haemost 1994; 72: 648.
    Article in Thieme ConnectPubMedGoogle Scholar
  • 26 Ten Kate MK, Platteel M, Mulder R. et al. PROS1 analysis in 87 pedigrees with hereditary protein S deficiency demonstrates striking genotype-phenotype associations. Hum Mutat 2008; 29: 939-947.
    CrossrefPubMedGoogle Scholar
  • 27 Sanders Sevall J. Factor V Leiden genotyping using real-time fluorescent polymerase chain reaction. Mol Cell Probes 2000; 14: 249-253.
    CrossrefPubMedGoogle Scholar
  • 28 Hubbard AR. Standardisation of protein S in plasma: calibration of the 1st International Standard. Thromb Haemost 1997; 78: 1237-1241.
    Article in Thieme ConnectPubMedGoogle Scholar
  • 29 Goodwin AJ, Rosendaal FR, Kottke-Marchant K. et al. A review of the technical, diagnostic, and epidemiologic considerations for protein S assays. Arch Pathol Lab Med 2002; 126: 1349-1366.
    CrossrefPubMedGoogle Scholar
  • 30 Boyer-Neumann C, Bertina RM, Tripodi A. et al. Comparison of functional assays for protein S: European collaborative study of patients with congenital and acquired deficiency. Thromb Haemost 1993; 70: 946-950.
    Article in Thieme ConnectPubMedGoogle Scholar
  • 31 Tans G, Curvers J, Middeldorp S. et al. A randomized cross-over study on the effects of levonorgestrel- and desogestrel-containing oral contraceptives on the anticoagulant pathways. Thromb Haemost 2000; 84: 15-21.
    Article in Thieme ConnectPubMedGoogle Scholar
  • 32 Almasy L, Soria JM, Souto JC. et al. A quantitative trait locus influencing free plasma protein S levels on human chromosome 1q: results from the Genetic Analysis of Idiopathic Thrombophilia (GAIT) project. Arterioscler Thromb Vasc Biol 2003; 23: 508-511.
    CrossrefPubMedGoogle Scholar
  • 33 Persson KE, Hillarp A, Dahlback B. Analytical considerations for free protein S as-says in protein S deficiency. Thromb Haemost 2001; 86: 1144-1147.
    Article in Thieme ConnectPubMedGoogle Scholar
  • 34 Sakkinen PA, Cushman M, Psaty BM. et al. Correlates of antithrombin, protein C, protein S, and TFPI in a healthy elderly cohort. Thromb Haemost 1998; 80: 134-139.
    Article in Thieme ConnectPubMedGoogle Scholar
  • 35 Lowe GD, Rumley A, Woodward M. et al. Epidemiology of coagulation factors, inhibitors and activation markers: the Third Glasgow MONICA Survey. I. Illustrative reference ranges by age, sex and hormone use. Br J Haematol 1997; 97: 775-784.
    CrossrefPubMedGoogle Scholar
  • 36 Favaloro EJ, Soltani S, McDonald J. et al. Laboratory identification of familial thrombophilia: do the pitfalls exceed the benefits? A reassessment of ABO-blood group, gender, age, and other laboratory parameters on the potential influence on a diagnosis of protein C, protein S, and antithrombin deficiency and the potential high risk of a false positive diagnosis. Lab Hematol 2005; 11: 174-184.
    CrossrefPubMedGoogle Scholar
  • 37 Favaloro EJ. Learning from peer assessment: the role of the external quality assurance multilaboratory thrombophilia test process. Semin Thromb Hemost 2005; 31: 85-89.
    Article in Thieme ConnectPubMedGoogle Scholar
  • 38 Favaloro EJ, Bonar R, Sioufi J. et al. Multilaboratory testing of thrombophilia: current and past practice in Australasia as assessed through the Royal College of Path-ologists of Australasia Quality Assurance Program for Hematology. Semin Thromb Hemost 2005; 31: 49-58.
    Article in Thieme ConnectPubMedGoogle Scholar
  • 39 Jennings I, Kitchen S, Woods TA. et al. Multilaboratory testing in thrombophilia through the United Kingdom National External Quality Assessment Scheme (Blood Coagulation) Quality Assurance Program. Semin Thromb Hemost 2005; 31: 66-72.
    Article in Thieme ConnectPubMedGoogle Scholar
  • 40 Meijer P, Kluft C, Haverkate F. et al. The long-term within- and between-laboratory variability for assay of antithrombin, and proteins C and S: results derived from the external quality assessment program for thrombophilia screening of the ECAT Foundation. J Thromb Haemost 2003; 1: 748-753.
    CrossrefPubMedGoogle Scholar
  • 41 Meijer P, Haverkate F. External quality assessment and the laboratory diagnosis of thrombophilia. Semin Thromb Hemost 2005; 31: 59-65.
    Article in Thieme ConnectPubMedGoogle Scholar
  • 42 Meijer P, Haverkate F, Kluft C. Performance goals for the laboratory testing of antithrombin, protein C and protein S. Thromb Haemost 2006; 96: 584-589.
    Article in Thieme ConnectPubMedGoogle Scholar
  • 43 Florell SR, Rodgers GM. 3rd. Utilization of testing for activated protein C resistance in a reference laboratory. Am J Clin Pathol 1996; 106: 248-252.
    CrossrefPubMedGoogle Scholar
  • 44 Johnston AM, Aboud M, Morel-Kopp MC. et al. Use of a functional assay to diagnose protein S deficiency; inappropriate testing yields equivocal results. Intern Med J 2007; 37: 409-411.
    CrossrefPubMedGoogle Scholar