Evaluation of protein Z plasma level in beta-thalassemia major patients in Ahvaz city in Iran

Abstract

OBJECTIVES: Thrombotic episodes occurred frequently in beta-thalassemia major (BTM) patients, leading to hypercoagulability of plasma. Protein Z (PZ) is a vitamin-K-dependent anti-coagulation factor that plays a role in the human homeostatic process. The objective of the current study is to investigate the distribution pattern of PZ plasma concentrations between BTM patients and the normal population in Ahvaz city, the center of Khuzestan province, southwest of Iran.

MATERIAL and METHODS: Forty confirmed BTM patients and 40 healthy volunteers were evaluated for complete blood count (CBC) indices and PZ plasma levels. CBC samples were measured using an automated cell counter, and PZ was assayed with an immunoassay method. Statistical analysis was conducted using SPSS software. The ROC curve and binary logistic regression estimated the sensitivity, specificity, and Odd’s ratio for PZ measurement.

RESULTS: The mean±SD of the PZ plasma level in normal individuals was 1.68±0.63 µg/mL, and in BTM patients, it was 1.10±0.52 µg/mL. This shows a significant reduction of PZ in BTM patients statistically (CI= 0.99; p<0.001). Further, the mean±SD of the PZ plasma levels in BTM patients who received washed red blood cells was not significantly different from that of patients undergoing packed red blood cell therapy (CI= 0.95; p = 0.320). The area under the curve (AUC) for PZ was 0.759 (p = 0.00). The cut-off value= 1.4 µg/mL of the PZ plasma level had at least 70% sensitivity and specificity in BTM patients.

DISCUSSION: Several epidemiologic studies have shown thromboembolism episodes in BTM patients. In the current study, PZ was reduced significantly in BTMs.

CONCLUSION: We noticed that BTMs have lower plasma PZ concentration might be predisposed to BTM.

Key words： major beta-thalassemia; protein Z; thrombosis; immunoassay; anti-coagulation factor

Acknowledgements

We thank Shafa Hospital’s staffwho worked with us, and patients who were involved in this study.This work was performed under a grant from Ahvaz Jundishapur Universityof Medical Sciences.

Compliance with ethics guidelines

The authors declare no conflict of interest. All proceduresperformed in studies involving human participants were in accordancewith the ethical standards of the institutional and/or national researchcommittee and with the 1964 Helsinki declaration and its later amendmentsor comparable ethical standards.

References

1 Al-Shanqeeti A, van Hylckama Vlieg  A, Berntorp E ,  Rosendaal F R ,  Broze G J Jr  (2005). Protein Z and protein Z-dependent protease inhibitor.Determinants of levels and risk of venous thrombosis. Thromb Haemost, 93(3): 411–413

PMID

2 Alizadeh S, Bavarsad  M S, Dorgalaleh  A, Khatib Z K ,  Dargahi H ,  Nassiri N ,  Hamid F ,  Rahim F ,  Jaseb K ,  Saki N (2014). Frequency of beta-thalassemia or beta-hemoglobinopathycarriers simultaneously affected with alpha-thalassemia in Iran. Clin Lab, 60(6): 941–949

PMID

3 Borgna-Pignatti C, Rugolotto  S, De Stefano P ,  Piga A, Di Gregorio  F, Gamberini M R ,  Sabato V ,  Melevendi C ,  Cappellini M D ,  Verlato G  (1998). Survival and disease complications in thalassemia major. Ann N Y Acad Sci, 850(1): 227–231

PMID

4 Broze G J Jr ,  Miletich J P  (1984). Human Protein Z. J Clin Invest, 73(4): 933–938 160;

PMID

5 Cappellini M D ,  Robbiolo L ,  Bottasso B M ,  Coppola R ,  Fiorelli G ,  Mannucci A P  (2000). Venous thromboembolism and hypercoagulability in splenectomized patientswith thalassaemia intermedia. Br J Haematol, 111(2): 467–473

PMID

6 Cunningham M J ,  Macklin E A ,  Neufeld E J ,  Cohen A R , and the Thalassemia Clinical Research Network (2004). Complications of -thalassemia majorin North America. Blood, 104(1): 34–39 

PMID

7 Eldor A, Rachmilewitz  E A (2002). The hypercoagulable state in thalassemia. Blood, 99(1): 36–43160;

PMID

8 Elkhateeb M, Elmenshawy  I, Azzam H ,  Selim T ,  Abousamra N K ,  Elsharawy S  (2009). Plasma levels of protein Z and antiphospholipid protein antibodies in patientswith ischemic stroke. Egypt J Neurol PsychiatNeurosurg, 46(1): 11–17

9 Gillis S, Cappellini  M D, Goldfarb  A, Ciceri L ,  Fiorelli G ,  Rachmilewitz E A  (1999). Pulmonary thromboembolism in thalassemia intermedia patients. Haematologica, 84(10): 959–960

PMID

10 Gris J C, Quéré  I, Dechaud H ,  Mercier E ,  Pinçon C ,  Hoffet M ,  Vasse M ,  Marès P  (2002). High frequency of protein Z deficiency in patients withunexplained early fetal loss. Blood, 99(7): 2606–2608160;

PMID

11 Han X, Fiehler  R, Broze G J Jr  (2000). Characterization of the protein Z-dependent protease inhibitor. Blood, 96(9): 3049–3055

12 Han X, Huang  Z F, Fiehler  R, Broze G J Jr  (1999). The protein Z-dependent protease inhibitor is a serpin. Biochemistry, 38(34): 11073–11078 

PMID

13 Hassan T H, Elbehedy  R M, Youssef  D M, Amr  G E (2010). Protein C levels in beta-thalassemiamajor patients in the east Nile delta of Egypt. Hematol Oncol Stem Cell Ther, 3(2): 60–65 

PMID

14 Heeb M J, Paganini-Hill  A, Griffin J H ,  Fisher M  (2002). Low protein Z levels and risk of ischemic stroke: differences by diabetic status and gender. Blood Cells Mol Dis, 29(2): 139–144

PMID

15 Kemkes-Matthes B, Matthes  K J (1995). Protein Z deficiency: a new cause of bleeding tendency. Thromb Res, 79(1): 49–55

PMID

16 Kemkes-Matthes B, Nees  M, Kühnel G ,  Matzdorff A ,  Matthes K J (2002). Protein Z influences the prothrombotic phenotype inFactor V Leiden patients. Thromb Res, 106(4-5): 183–185 

PMID

17 Kuypers F A, de Jong  K (2004). The role of phosphatidylserine in recognition and removalof erythrocytes. Cell Mol Biol (Noisy-le-grand), 50(2): 147–158

PMID

18 Mendiratta S L ,  Mittal M ,  Naaz F, Singh  S, Anand S  (2017). Role of thalassemia screening in prevention and control of thalassemia-a5 year experience. Int J Reprod ContraceptObstet Gynecol, 5(9): 3107–3111

19 Michaeli J, Mittelman  M, Grisaru D ,  Rachmilewitz E A  (1992). Thromboembolic complications in beta thalassemia major. Acta Haematol, 87(1-2): 71–74

PMID

20 Miletich J P, Broze  G J J Jr (1987). Human plasma protein Z antigen: range in normal subjectsand effect of warfarin therapy. Blood, 69(6): 1580–1586

PMID

21 Moratelli S, De Sanctis  V, Gemmati D ,  Serino M L ,  Mari R, Gamberini  M R, Scapoli  G L (1998). Thrombotic risk in thalassemic patients. J Pediatr Endocrinol Metab, 11(Suppl 3): 915–921

PMID

22 Olivieri N F, Brittenham  G M (1997). Iron-chelating therapy and the treatment of thalassemia. Blood, 89(3): 739–761 

PMID

23 Pardos-Gea J, Ordi-Ros  J, Serrano S ,  Balada E ,  Nicolau I ,  Vilardell M  (2008). Protein Z levels and anti-protein Z antibodies in patients with arterial andvenous thrombosis. Thromb Res, 121(6): 727–734

PMID

24 Santacroce R, Sarno  M, Cappucci F ,  Sessa F ,  Colaizzo D ,  Brancaccio V ,  Grandone E ,  Margaglione M  (2006). Low protein Z levels and risk of occurrence of deep vein thrombosis. J Thromb Haemost, 4(11): 2417–2422

PMID

25 Schettini F, De Mattia  D, Arcamone G ,  Sabato V ,  Altomare M ,  Burattini M G ,  Fedele F ,  Compagnone A ,  Ciavarella G  (1987). Coagulation contact phase factors and inhibitors in -thalassemia major children. Pediatr Hematol Oncol, 4(3): 231–236

PMID

26 Singer S T, Kuypers  F A, Styles  L, Vichinsky E P ,  Foote D ,  Rosenfeld H  (2006). Pulmonary hypertension in thalassemia: association with platelet activation and hypercoagulablestate. Am J Hematol, 81(9): 670–675

PMID

27 Steinberg M H  (2001). Disorders of hemoglobin: genetics, pathophysiology, and clinical management. J R Soc Med, 94(11): 602–603

28 Vasse M, Guegan-Massardier  E, Borg J Y ,  Woimant F ,  Soria C  (2001). Frequency of protein Z deficiency in patients with ischaemic stroke. Lancet, 357(9260): 933–934 

PMID

29 Weatherall D J  (1976). Molecular pathology of the thalassemia disorders. West J Med, 124(5): 388–402 

PMID

30 Winichagoon P, Fucharoen  S, Wasi P  (1981). Increased circulating platelet aggregates in thalassaemia. Southeast Asian J Trop Med Public Health, 12(4): 556–560 

PMID

31 Yin Z F, Huang  Z F, Cui  J, Fiehler R ,  Lasky N ,  Ginsburg D ,  Broze G J Jr  (2000). Prothrombotic phenotype of protein Z deficiency. Proc Natl Acad Sci USA, 97(12): 6734–6738 

PMID