Polymorphisms in the endothelial protein C receptor gene and thrombophilia

Summary

The protein C anticoagulant pathway plays a crucial role as a regulator of the blood clotting cascade. Protein C is activated on the vascular endothelial cell membrane by the thrombin-thrombomodulin complex. Once formed, activated protein C (APC) down-regulates thrombin formation by inactivating factors (F)Va and FVIIIa. Endothelial protein C receptor (EPCR) is able to bind protein C and increase the rate of protein C activation. Normal APC generation depends on the precise assemblage, on the surface of endothelial cells, of thrombin, thrombomodulin, protein C and EPCR.Therefore, any change in the efficiency of this assemblage may cause reduced/increased APC generation and modify the risk of thrombosis. This review highlights the different mutations/polymorphisms reported in the EPCR gene and their association with the risk of thrombosis.

Keywords

Coagulation inhibitors - deep vein thrombosis - inherited coagulation disorders - polymorphisms - protein C/S pathway

• References

• 1 Stenflo J, Ferlund P. Aminoacid sequence of the heavy chain of bovine protein C. J Biol Chem 1982; 257: 12180-12190.
• 2 Esmon CT. The role of protein C and thrombomodulin in the regulation of blood coagulation. J Biol Chem 1989; 264: 4743-4746.
• 3 Walker FJ. Regulation of activated protein C by protein S. The role of phospholipids in factor Va inactivation. J Biol Chem 1981; 256: 11128-11131.
• 4 Fulcher CA, Gardiner JE, Griffin JH. et al. Proteolytic inactivation of human factor VIII procoagulant protein by activated human protein C and its analogy with Factor V. Blood 1984; 63: 486-489.
• 5 España F, Griffin JH. Determination of functional and antigen protein C inhibitor and its complexes with activated protein C in plasma by ELISA‘s. Thromb Res 1989; 55: 671-682.
• 6 Tabernero D, España F, Vicente V. et al. Protein C inhibitor and other components of the protein C pathway in patients with acute deep vein thrombosis during heparin treatment. Thromb Haemost 1990; 63: 380-382.
• 7 Vicente V, España F, Tabernero D. et al. Evidence of activation of the protein C pathway during acute vascular damage induced by Mediterranean spotted fever. Blood 1991; 78: 416-422.
• 8 Laszik Z, Mitro A, Taylor Jr FB. et al. Human protein C receptor is present primarily on endothelial of large vessels: implications in the control of the protein C pathway. Circulation 1987; 96: 3633-3640.
• 9 Stearns-Kurosawa DJ, Kurosawa S, Mollica JS. et al. The endothelial cell protein C receptor augments protein C activation by the thrombin-thrombomodulin complex. Proc Natl Acad Sci USA 1996; 93: 10212-1026.
• 10 Nakabayashi T, Mizukami K, Naitoh S. et al. Protein C Sapporo (protein C Glu→Lys): a heterozygous missense mutation in the Gla domain provides new insight into the interaction between protein C and endothelial protein C receptor. Thromb Haemost 2005; 94: 942-950.
• 11 Griffin JH, Evatt B, Zimmerman TS. et al. Deficiency of protein C in congenital thrombotic disease. J Clin Invest 1981; 68: 1370-1373.
• 12 Bertina RM, Broekmans AW, van der Linden IK. et al. Protein C deficiency in a Dutch family with thrombotic disease. Thromb Haemost 1982; 48: 1-5.
• 13 Estellés A, García-Plaza I, Dasí A. et al. Severe inherited "homozygous" protein C deficiency in a newborn infant. Thromb Haemost 1984; 52: 53-56.
• 14 Schwartz HP, Fischer M, Hopmeier P. et al. Plasma protein S deficiency in familial thrombotic disease. Blood 1984; 64: 1297-1300.
• 15 Comp PC, Nixon RR, Cooper MR. et al. Familial protein S deficiency is associated with recurrent thrombosis. J Clin Invest 1984; 74: 2082-2088.
• 16 Engesser L, Broekmans AW, Briet E. et al. Hereditary protein S deficiency: clinical manifestations. Ann Intern Med 1987; 106: 677-682.
• 17 España F, Vayá A, Mira Y. et al. Low level of circulating activated protein C is a risk factor for venous thrombosis. Thromb Haemost 2001; 86: 1368-1373.
• 18 Zorio E, Navarro S, Medina P. et al. Circulating activated protein C is reduced in young survivors of myocardial infarction and inversely correlates with the severity of coronary lesions. J Thromb Haemost 2006; 4: 1530-1536.
• 19 Fukudome K, Esmon CT. Identification, cloning and regulation of a novel endothelial cell protein C/activated protein C receptor. J Biol Chem 1994; 269: 26486-26491.
• 20 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 α1 and α2 domains. Blood 1999; 94: 632-641.
• 21 Hayashi T, Nakamura H, Okada A. et al. Organization and chromosomal localization of the human endothelial protein C receptor gene. Gene 1999; 238: 367-373.
• 22 Rance JB, Follows GA, Cockerill PN. et al. Regulation of the human endothelial cell protein C receptor gene promoter by multiple Sp1 binding sites. Blood 2003; 101: 4393-4401.
• 23 Mollica LR, Crawley JTB, Liu K. et al. Role of a 5’-enhancer in the transcriptional regulation of the human endothelial cell protein C receptor gene. Blood 2006; 108: 1251-1259.
• 24 Maruyama I, Bell CE, Majerus PW. Thrombomodulin is found on endothelium of arteries, veins, capillaries, and lymphatics, and on syncytiotrophoblast of human placenta. J Cell Biol 1985; 101: 363-371.
• 25 Fukudome K, Ye X, Tsuneyoshi N. et al. Activation mechanism of anticoagulant protein C in large blood vessels involving the endothelial cell protein C receptor. J Exp Med 1998; 187: 1029-1035.
• 26 Ghosh S, Pendurthi UR, Steinoe A. et al. Endothelial cell protein C receptor acts as a cellular receptor for factor VIIa on endothelium. J Biol Chem 2007; 282: 11849-11857.
• 27 Kurosawa S, Stearns-Kurosawa DJ, Hidari N. et al. Identification of functional endothelial protein C receptor in human plasma. J Clin Invest 1997; 100: 411-418.
• 28 Xu J, Qu D, Esmon NL. et al. Metalloproteolytic release of endothelial protein C receptor. J Biol Chem 2000; 275: 6038-6044.
• 29 Qu D, Wang Y, Esmon NL. et al. Regulated endothelial protein C receptor shedding is mediated by tumor necrosis factor-α converting enzyme/ADAM17. J Thromb Haemost 2007; 5: 395-402.
• 30 Kurosawa S, Stearns-Kurosawa DJ, Carson CW. et al. Plasma levels of endothelial cell protein C receptor are elevated in patients with sepsis and systemic lupus erythematosus: lack of correlation with thrombomodulin suggests involvement of different pathological processes. Blood 1998; 91: 725-727.
• 31 Regan LM, Stearns-Kurosawa DJ, Kurosawa S. et al. The endothelial cell protein C receptor. Inhibition of activated protein C anticoagulant function without modulation of reaction with proteinase inhibitors. J Biol Chem 1996; 271: 17499-17503.
• 32 Liaw PCY, Neuenschwander PF, Smirnov MD. et al. Mechanisms by which soluble endothelial cell protein C receptor modulates protein C and activated protein C function. J Biol Chem 2000; 275: 5447-5452.
• 33 Kurosawa S, Esmon CT, Stearns-Kurosawa DJ. The soluble endothelial protein C receptor binds to activated neutrophils: involvement of proteinase-3 and CD11b/CD18. J Immunol 2000; 165: 4697-4703.
• 34 Mosnier LO, Zlokovic BV, Griffin JH. The cytoprotective protein C pathway. Blood 2007; 109: 3161-3172.
• 35 Esmon CT. The endothelial cell protein C receptor. Thromb Haemost 2000; 83: 639-643.
• 36 Van de Wouwer M, Collen D, Conway EM. Thrombomodulin- protein C-EPCR system integrated to regulate coagulation and inflammation. Arterioscler Thromb Vasc Biol 2004; 24: 1374-1383.
• 37 Gu JM, Katsuura Y, Ferrell GL. et al. Endotoxin and thrombin elevate rodent endothelial cell protein C receptor mRNA levels and increase receptor shedding in vivo. Blood 2000; 95: 1687-1693.
• 38 Taylor Jr FB, Stearns-Kurosawa DJ, Kurosawa S. et al. The endothelial cell protein C receptor aids in host defense against Escherichia coli sepsis. Blood 2000; 95: 1680-1686.
• 39 Taylor Jr FB, Peer GT, Lockhart MS. et al. Endothelial cell protein C receptor plays an important role in protein C activation in vivo. Blood 2001; 97: 1685-1688.
• 40 Gu JM, Crawley JT, Ferrell G. et al. Disruption of the endothelial cell protein C receptor gene in mice causes placental thrombosis and early embryonic lethality. J Biol Chem 2002; 277: 43335-43343.
• 41 Castellino FJ, Liang Z, Volkir SP. Mice with a severe deficiency of the endothelial protein C receptor gene develop, survive, and reproduce normally, and do not present with enhanced arterial thrombosis after challenge. Thromb Haemost 2002; 88: 462-472.
• 42 Li W, Zheng X, Gu J. et al. Overexpressing endothelial cell protein C receptor alters the hemostatic balance and protects mice from endotoxin. J Thromb Haemost 2005; 3: 1351-1359.
• 43 Hurtado V, Montes R, Gris JC. et al. Autoantibodies against EPCR are found in antiphospholipid syndrome and are a risk factor for fetal death. Blood 2004; 10: 1369-1374.
• 44 Montes R, Hurtado V, Alonso A. et al. Autoantibodies against the endothelial receptor of protein C are associated with acute myocardial infarction in young women. J Thromb Haemost 2005; 3: 1454-1458.
• 45 Galligan L, Livingstone W, Volkov Y. et al. Characterization of protein C receptor expression in monocytes. Br J Haematol 2001; 115: 408-414.
• 46 Sturn DH, Kaneider NC, Feistritzer C. et al. Expression and function of the endothelial protein C receptor in human neutrophils. Blood 2003; 102: 1499-1505.
• 47 Cheng T, Liu D, Griffin JH. et al. Activated protein C blocks p53-mediated apoptosis in ischemic human brain endothelium and is neuroprotective. Nat Med 2003; 9: 338-342.
• 48 Crawley JT, Gu JM, Ferrell G. et al. Disruption of endothelial cell protein C/activated protein C receptor (EPCR) during mouse embryo development. Thromb Haemost 2002; 88: 259-266.
• 49 Balazs AB, Fabian AJ, Esmon CT. et al. Endothelial protein C receptor (CD201) explicitly identifies hematopoietic stem cells in murine bone marrow. Blood 2006; 107: 2317-2321.
• 50 Bretschneider E, Uzonyi B, Weber AA. et al. Human vascular smooth muscle cells express functionally active endothelial cell protein C receptor. Circ Res 2007; 100: 255-262.
• 51 Esmon CT. Role of the coagulation inhibitors in inflammation. Thromb Haemost 2001; 86: 51-56.
• 52 España F, Medina P, Navarro S. et al. The multifunctional protein C system. Curr Med Chem Cardiovasc Hematol Agents 2005; 3: 119-131.
• 53 Brueckmann M, Horn S, Lang S. et al. Recombinant human activated protein C upregulates cyclooxygenase- 2 expression in endothelial cells via binding to endothelial cell protein C receptor and activation of protease-activated receptor-1. Thromb Haemost 2005; 93: 743-750.
• 54 Riewald M, Petrovan RJ, Donner A. Activation of endothelial cell protease activated receptor 1 by the protein C pathway. Science 2002; 296: 1880-1882.
• 55 Mosnier LO, Griffin JH. Inhibition of staurosporine- induced apoptosis of endothelial cells by activated protein C requires protease-activated receptor-1 and endothelial cell protein C receptor. Biochem J 2003; 373: 65-70.
• 56 Guo H, Liu D, Gelbard H. et al. Activated protein C prevents neuronal apoptosis via protease activated receptors 1 and 3. Neuron 2004; 41: 563-572.
• 57 Feistritzer C, Schuepbach RA, Mosnier LO. et al. Protective signalling by activated protein C is mechanistically linked to protein C activation on endothelial cells. J Biol Chem 2006; 281: 20077-20084.
• 58 Bae JS, Yang L, Rezaie AR. Receptors of the protein C activation and activated protein C signaling pathways are colocalized in lipid rafts of endothelial cells. Proc Natl Acad Sci USA 2007; 104: 2867-2872.
• 59 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: 945-948.
• 60 von Depka M, Czwalinna A, Eisert R. et al. Prevalence of a 23bp insertion in exon 3 of the endothelial cell protein C receptor gene in venous thrombophilia. Thromb Haemost 2001; 86: 1360-1362.
• 61 Poort SR, Vos HL, Rosendaal FR. et al. The endothelial protein C receptor (EPCR) 23 bp insert mutation and the risk of venous thrombosis. Thromb Haemost 2002; 88: 160-162.
• 62 Merati G, Biguzzi E, Oganesyan N. et al. A 23bp insertion in the endothelial protein C receptor (EPCR) gene in patients with myocardial infarction and deep vein thrombosis. Thromb Haemost 1999; Suppl: 507.
• 63 Akar N, Gökdemir R, Akar E. et al. Endothelial cell protein C/activated protein C receptor gene exon III, 23 bp insertion mutation in Turkish pediatric thrombotic patients. Thromb Haemost 2001; Suppl: Abstract.
• 64 Galligan L, Livingstone WJ, Mynett-Johnson L. et al. Prevalence of a 23bp endothelial protein C receptor gene insertion in the Irish population. Thromb Haemost 2001; Suppl: Abstract.
• 65 Grossmann R, Schwender S, Geisen U. et al. CBS 844ins68, MTHFR TT677 and EPCR 4031ins23 genotypes in patients with deep-vein thrombosis. Thromb Res 2002; 107: 13-15.
• 66 Van de Water NS, French JK, McDowell J. et al. The endothelial protein C receptor (EPCR) 23bp insert in patients with myocardial infarction. Thromb Haemost 2001; 85: 749-751.
• 67 Franchi F, Biguzzi E, Cetin I. et al. Mutations in the thrombomodulin and endothelial protein C receptor genes in women with late fetal loss. Brit J Haematol 2001; 114: 641-646.
• 68 Biguzzi E, Gu JM, Merati G. et al. Point mutations in the endothelial protein C receptor (EPCR) promoter. Thromb Haemost 2002; 87: 1085-1086.
• 69 Hermida J, Hurtado V, Villegas-Méndez A. et al. Identification and characterization of a natural R96C EPCR variant. J Thromb Haemost 2003; 1: 1850-1852.
• 70 Saposnik B, Reny JL, Gausem P. et al. A haplotype of the EPCR gene is associated with increased plasma levels of sEPCR and is a candidate risk factor for thrombosis. Blood 2004; 103: 1311-1318.
• 71 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: 905-911.
• 72 Uitte de Willige S, van Marion V, Rosendaal FR. et al. Haplotypes of the EPCR gene, plasma sEPCR levels and the risk of deep venous thrombosis. J Thromb Haemost 2004; 2: 1305-1310.
• 73 Medina P, Navarro S, Estellés A. et al. Influence of the 4600A/G and 4678G/C polymorphisms in the endothelial protein C receptor (EPCR) gene on the risk of venous thromboembolism in carriers of the factor V Leiden mutation. Thromb Haemost 2005; 94: 389-395.
• 74 España F, Zuazu I, Vicente V. et al. Quantification of circulating activated protein C in human plasma by immunoassays. Enzyme levels are proportional to total protein C levels. Thromb Haemost 1996; 75: 56-61.
• 75 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: 283-292.
• 76 Qu D, Wang Y, Song Y. et al. 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: 229-235.
• 77 Seligshon U, Zivelin A. Thrombophilia as a multigenic disorder. Thromb Haemost 1997; 78: 297-301.
• 78 Zoller B, García de Frutos P, Hillarp A. et al. Thrombophilia as a multigenic disease. Haematologica 1999; 84: 59-70.
• 79 Rosendaal FR. Venous thrombosis: a multicausal disease. Lancet 1999; 353: 1167-1173.
• 80 Aznar J, Vayá A, Estellés A. et al. Risk of venous thrombosis in carriers of the prothrombin G20210A variant and factor V Leiden and their interaction with oral contraceptives. Haematologica 2000; 85: 1271-1276.
• 81 Tirado I, Mateo J, Soria JM. et al. Contribution of prothrombin 20210A allele and factor V Leiden mutation to thrombosis risk in thrombophilic families with other hemostatic deficiencies. Haematologica 2001; 86: 1200-1208.
• 82 García de Frutos P. Genetic variants in the endothelial protein C receptor gene: reaching significance. Thromb Haemost 2005; 94: 233-234.