Download PDF
Thromb Haemost 2022; 122(08): 1326-1332
DOI: 10.1055/a-1738-1564
Coagulation and Fibrinolysis

Thrombotic Risk Determined by Protein C Receptor (PROCR) Variants among Middle-Aged and Older Adults: A Population-Based Cohort Study

Eric Manderstedt
1   Department of Environmental Science and Bioscience, Kristianstad University, Kristianstad, Sweden
,
Christer Halldén
1   Department of Environmental Science and Bioscience, Kristianstad University, Kristianstad, Sweden
,
Christina Lind-Halldén
1   Department of Environmental Science and Bioscience, Kristianstad University, Kristianstad, Sweden
,
Johan Elf
2   Department of Clinical Sciences, Skåne University Hospital, Lund University, Malmö, Sweden
,
Peter J. Svensson
2   Department of Clinical Sciences, Skåne University Hospital, Lund University, Malmö, Sweden
,
Gunnar Engström
2   Department of Clinical Sciences, Skåne University Hospital, Lund University, Malmö, Sweden
,
Olle Melander
2   Department of Clinical Sciences, Skåne University Hospital, Lund University, Malmö, Sweden
,
Aris Baras   *
3   Regeneron Genetics Center, Tarrytown, New York, United States
,
Luca A Lotta   *
3   Regeneron Genetics Center, Tarrytown, New York, United States
,
Bengt Zöller 
4   Center for Primary Health Care Research, Lund University and Region Skåne, Malmö, Sweden
,
for the Regeneron Genetics Center › Author Affiliations Funding This work was supported by a grant awarded to Dr. Bengt Zöller by ALF-funding from Region Skåne, Sparbanken Skåne, and by the Swedish Research Council.
› Further Information
Also available at
    Permissions and Reprints

Abstract

Background The protein C (PC) anticoagulant system has a key role in maintaining hemostatic balance. One missense (Ser219Gly) variant in the PC receptor (PROCR) was associated with venous thromboembolism (VTE) in genome-wide association studies.

Objectives This study aimed to determine the thrombotic risk of rare and common PROCR variants in a large population-based cohort of middle-aged and older adults.

Methods The exonic sequence of PROCR was analyzed for the Ser219Gly variant and other qualifying variants in 28,794 subjects (born 1923–1950, 60% women) without previous VTE, who participated in the Malmö Diet and Cancer study (1991–1996). Incidence of VTE was followed up until 2018. Qualifying variants were defined as loss-of-function or nonbenign (PolyPhen-2) missense variants with minor allele frequencies (MAFs) <0.1%.

Results Re-sequencing identified 36 PROCR variants in the study population (26,210 non-VTE exomes and 2,584 VTE exomes), 11 synonymous, 22 missense, and three loss-of-function variants. Kaplan–Meier analysis of the known Ser219Gly variant (rs867186) showed that homozygosity for this variant increased the risk of disease, whereas heterozygosity showed no effect. Cox multivariate regression analysis revealed an adjusted hazard ratio (HR) of 1.5 (95% confidence interval [CI]: 1.1–2.0). Fifteen rare variants were classified as qualifying and were included in collapsing analysis (burden test and SKAT-O). They did not contribute to risk. However, a Arg113Cys missense variant (rs146420040; MAF = 0.004) showed an increased VTE risk (HR = 1.3; 95% CI: 1.0–1.9).

Conclusion Homozygosity for the Ser219Gly variant and a previously identified functional PROCR variant (Arg113Cys) was associated with VTE. Other variants did not contribute to VTE.

Keywords

genetics - PROCR - protein C receptor - venous thromboembolism

Author Contributions

E.M., C.H., and B.Z. conceived and designed the study, analyzed and interpreted data, drafted the manuscript, and gave final approval of the submitted manuscript. All authors interpreted data, critically revised the manuscript for important intellectual content, and gave final approval of the submitted manuscript. Whole exome sequencing was performed by the Regeneron Genetics Center (see the Regeneron Genetics Center Banner Author List and Contribution Statements below). E.M., C.H., and B.Z. are the guarantors of this work and, as such, had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.


* A list of the Regeneron Genetics Center is provided in the [Supplementary Appendix].


Supplementary Material



Publication History

Received: 09 September 2021

Accepted: 10 January 2022

Accepted Manuscript online:
12 January 2022

Article published online:
23 February 2022

© 2022. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • References

  • 1 Dahlbäck B. Advances in understanding pathogenic mechanisms of thrombophilic disorders. Blood 2008; 112 (01) 19-27
    CrossrefPubMedSearch in Google Scholar
  • 2 Mohan Rao LV, Esmon CT, Pendurthi UR. Endothelial cell protein C receptor: a multiliganded and multifunctional receptor. Blood 2014; 124 (10) 1553-1562
    CrossrefPubMedSearch in Google Scholar
  • 3 Stearns-Kurosawa DJ, Kurosawa S, Mollica JS, Ferrell GL, Esmon CT. The endothelial cell protein C receptor augments protein C activation by the thrombin-thrombomodulin complex. Proc Natl Acad Sci U S A 1996; 93 (19) 10212-10216
    CrossrefPubMedSearch in Google Scholar
  • 4 Laszik Z, Mitro A, Taylor Jr FB, Ferrell G, Esmon CT. Human protein C receptor is present primarily on endothelium of large blood vessels: implications for the control of the protein C pathway. Circulation 1997; 96 (10) 3633-3640
    CrossrefPubMedSearch in Google Scholar
  • 5 Liaw PC, Neuenschwander PF, Smirnov MD, Esmon CT. Mechanisms by which soluble endothelial cell protein C receptor modulates protein C and activated protein C function. J Biol Chem 2000; 275 (08) 5447-5452
    CrossrefPubMedSearch in Google Scholar
  • 6 Navarro S, Medina P, Mira Y. et al. Haplotypes of the EPCR gene, prothrombin levels, and the risk of venous thrombosis in carriers of the prothrombin G20210A mutation. Haematologica 2008; 93 (06) 885-891
    CrossrefPubMedSearch in Google Scholar
  • 7 Uitte de Willige S, Van Marion V, Rosendaal FR, Vos HL, de Visser MCH, Bertina RM. Haplotypes of the EPCR gene, plasma sEPCR levels and the risk of deep venous thrombosis. J Thromb Haemost 2004; 2 (08) 1305-1310
    CrossrefPubMedSearch in Google Scholar
  • 8 Simioni P, Morboeuf O, Tognin G. et al. Soluble endothelial protein C receptor (sEPCR) levels and venous thromboembolism in carriers of two dysfunctional protein C variants. Thromb Res 2006; 117 (05) 523-528
    CrossrefPubMedSearch in Google Scholar
  • 9 Simmonds RE, Lane DA. Structural and functional implications of the intron/exon organization of the human endothelial cell protein C/activated protein C receptor (EPCR) gene: comparison with the structure of CD1/major histocompatibility complex alpha1 and alpha2 domains. Blood 1999; 94 (02) 632-641
    CrossrefPubMedSearch in Google Scholar
  • 10 Biguzzi E, Merati G, Liaw PCY. et al. A 23bp insertion in the endothelial protein C receptor (EPCR) gene impairs EPCR function. Thromb Haemost 2001; 86 (04) 945-948
    PubMedSearch in Google Scholar
  • 11 Biguzzi E, Gu JM, Merati G, Esmon NL, Esmon CT. Point mutations in the endothelial protein C receptor (EPCR) promoter. Thromb Haemost 2002; 87 (06) 1085-1086
    Thieme ConnectPubMedSearch in Google Scholar
  • 12 Medina P, Navarro S, Estellés A, España F. Polymorphisms in the endothelial protein C receptor gene and thrombophilia. Thromb Haemost 2007; 98 (03) 564-569
    Thieme ConnectPubMedSearch in Google Scholar
  • 13 Medina P, Navarro S, Estellés A. et al. Contribution of polymorphisms in the endothelial protein C receptor gene to soluble endothelial protein C receptor and circulating activated protein C levels, and thrombotic risk. Thromb Haemost 2004; 91 (05) 905-911
    Thieme ConnectPubMedSearch in Google Scholar
  • 14 Ireland H, Konstantoulas CJ, Cooper JA. et al. EPCR Ser219Gly: elevated sEPCR, prothrombin F1+2, risk for coronary heart disease, and increased sEPCR shedding in vitro. Atherosclerosis 2005; 183 (02) 283-292
    CrossrefPubMedSearch in Google Scholar
  • 15 Reiner AP, Carty CL, Jenny NS. et al. PROC, PROCR and PROS1 polymorphisms, plasma anticoagulant phenotypes, and risk of cardiovascular disease and mortality in older adults: the Cardiovascular Health Study. J Thromb Haemost 2008; 6 (10) 1625-1632
    CrossrefPubMedSearch in Google Scholar
  • 16 Qu D, Wang Y, Song Y, Esmon NL, Esmon CT. The Ser219–>Gly dimorphism of the endothelial protein C receptor contributes to the higher soluble protein levels observed in individuals with the A3 haplotype. J Thromb Haemost 2006; 4 (01) 229-235
    CrossrefPubMedSearch in Google Scholar
  • 17 Saposnik B, Lesteven E, Lokajczyk A, Esmon CT, Aiach M, Gandrille S. Alternative mRNA is favored by the A3 haplotype of the EPCR gene PROCR and generates a novel soluble form of EPCR in plasma. Blood 2008; 111 (07) 3442-3451
    CrossrefPubMedSearch in Google Scholar
  • 18 Dennis J, Johnson CY, Adediran AS. et al. The endothelial protein C receptor (PROCR) Ser219Gly variant and risk of common thrombotic disorders: a HuGE review and meta-analysis of evidence from observational studies. Blood 2012; 119 (10) 2392-2400
    CrossrefPubMedSearch in Google Scholar
  • 19 Lindström S, Wang L, Smith EN. et al; Million Veteran Program, CHARGE Hemostasis Working Group. Genomic and transcriptomic association studies identify 16 novel susceptibility loci for venous thromboembolism. Blood 2019; 134 (19) 1645-1657
    CrossrefPubMedSearch in Google Scholar
  • 20 Germain M, Saut N, Greliche N. et al. Genetics of venous thrombosis: insights from a new genome wide association study. PLoS One 2011; 6 (09) e25581
    CrossrefPubMedSearch in Google Scholar
  • 21 Wu C, Dwivedi DJ, Pepler L. et al. Targeted gene sequencing identifies variants in the protein C and endothelial protein C receptor genes in patients with unprovoked venous thromboembolism. Arterioscler Thromb Vasc Biol 2013; 33 (11) 2674-2681
    CrossrefPubMedSearch in Google Scholar
  • 22 Zöller B, Melander O, Svensson P, Engström G. Red cell distribution width and risk for venous thromboembolism: a population-based cohort study. Thromb Res 2014; 133 (03) 334-339
    CrossrefPubMedSearch in Google Scholar
  • 23 Melander O, Newton-Cheh C, Almgren P. et al. Novel and conventional biomarkers for prediction of incident cardiovascular events in the community. JAMA 2009; 302 (01) 49-57
    CrossrefPubMedSearch in Google Scholar
  • 24 Manderstedt E, Halldén C, Lind-Halldén C. et al; Regeneron Genetics Center*. Thrombotic risk determined by STAB 2 variants in a population-based cohort study. Circ Genom Precis Med 2021; 14 (05) e003449
    CrossrefPubMedSearch in Google Scholar
  • 25 Rosengren A, Fredén M, Hansson P-O, Wilhelmsen L, Wedel H, Eriksson H. Psychosocial factors and venous thromboembolism: a long-term follow-up study of Swedish men. J Thromb Haemost 2008; 6 (04) 558-564
    CrossrefPubMedSearch in Google Scholar
  • 26 Ludvigsson JF, Andersson E, Ekbom A. et al. External review and validation of the Swedish national inpatient register. BMC Public Health 2011; 11: 450
    CrossrefPubMedSearch in Google Scholar
  • 27 Williams RC, Knowler WC, Shuldiner AR. et al; Regeneron Genetics Center. Next generation sequencing and the classical HLA loci in full heritage Pima Indians of Arizona: defining the core HLA variation for North American Paleo-Indians. Hum Immunol 2019; 80 (12) 955-965
    CrossrefPubMedSearch in Google Scholar
  • 28 Wang K, Li M, Hakonarson H. ANNOVAR: functional annotation of genetic variants from high-throughput sequencing data. Nucleic Acids Res 2010; 38 (16) e164
    CrossrefPubMedSearch in Google Scholar
  • 29 Lee S, Emond MJ, Bamshad MJ. et al; NHLBI GO Exome Sequencing Project—ESP Lung Project Team. Optimal unified approach for rare-variant association testing with application to small-sample case-control whole-exome sequencing studies. Am J Hum Genet 2012; 91 (02) 224-237
    CrossrefPubMedSearch in Google Scholar
  • 30 Zöller B, Svensson PJ, Dahlbäck B, Lind-Hallden C, Hallden C, Elf J. Genetic risk factors for venous thromboembolism. Expert Rev Hematol 2020; 13 (09) 971-981
    CrossrefPubMedSearch in Google Scholar
  • 31 Zöller B, Melander O, Svensson PJ, Engström G. Factor V Leiden paradox in a middle-aged Swedish population: a prospective study. Vasc Med 2018; 23 (01) 52-59
    CrossrefPubMedSearch in Google Scholar
  • 32 Lander ES, Schork NJ. Genetic dissection of complex traits. Science 1994; 265 (5181): 2037-2048
    CrossrefPubMedSearch in Google Scholar