© 2007 Schattauer GmbH, Stuttgart
Theme Issue Editorial
Mechanisms of thrombophilia
Pablo García de Frutos
Department of Cell Death and Proliferation, Institute for Biomedical Research of Barcelona, IIBB-CSIC-IDIBAPS, Barcelona, Spain
T
he term thrombophilia describes the predisposition to ve-
nous thromboembolism and, under certain circumstances,
also an increased risk of arterial thrombosis. In a broad
sense, thrombophilia includes any inherited or acquired disorder
associated with an increased tendency to thrombosis. It was soon
realised that thrombotic events have a complex multifactorial
cause, usually a combination of genetic factors combined with
acquired haematological disorders. Besides, behavioural factors,
as diet or exercise, influence the incidence of thrombosis, mak-
ing it difficult to asses the risk of thrombosis in a given individ-
ual. In any case, inherited thrombophilia is one of the main deter-
minants of venous thromboembolism (VTE), and the presence of
inherited thrombophilic defects exposes carriers to increased
risks for VTE compared with non-carriers. The presence of her-
editary thrombophilia should be considered in patients with a
documented unexplained thrombotic episode or a positive
family history. There is no clear relationship between clinical
manifestations and the type of underlying thrombophilic defect.
Thus, diagnosis of inherited thrombophilia has to be established
on a laboratory basis.
The concept that thrombophilia could be associated with a
genetically determined hypercoagulable state was first proposed
already in 1965 after the discovery of an association of thrombo-
sis and antithrombin deficiency in a large family (1). Further
studies in this field have gone in parallel with a better under-
standing of the components of blood coagulation, and the natural
anticoagulant mechanisms essential in haemostasis, in particular
the activated protein C pathway. In turn, these studies have lead
to better therapies and protocols for the prophylactic control of
thrombosis (2). Since the seminal work on antithrombin, genetic
studies on thrombophilic families in combination with epidemi-
ological studies lead to the discovery of anticoagulant protein
deficits linked to thrombosis: protein C, protein S and antithrom-
bin. These deficiencies are generally caused by a series of del-
eterious mutations in the respective genes behaving as relatively
rare autosomal dominant genetic traits with a low or incomplete
penetrance. Still, very few cases of thrombosis could be ex-
plained by these mechanisms.
Correspondence to:
Pablo García de Frutos
Institute for Biomedical Research of Barcelona (IIBB-CSIC-IDIBAPS)
Roselló 161 p6, 08036 Barcelona, Spain
Tel.: +34 933632382, Fax: +34 933638301
E-mail: pgffat@iibb.csic.es
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This situation changed with the discovery of activated pro-
tein C (APC) resistance in 1993 and the mutation associated with
factor V Leiden (FV)Leiden, and, shortly afterwards, the discovery
of a mutation in the 3’ untranslated region of the prothrombin
gene associated with increased concentration of prothrombin in
plasma. Large epidemiological studies have confirmed that
these mutations are risk factors for thrombophilia and opened the
search for other thrombophilic traits (3). During the last decade,
several additional prothrombotic risk factors have been de-
scribed, including genetic variants and haplotypes associated
with qualitative or quantitative defects of coagulation factor in-
hibitors, increased levels or function of coagulation factors, de-
fects of the fibrinolytic system, altered platelet function, and hy-
perhomocysteinemia. At present, it is possible to identify an in-
herited predisposition to thrombosis in patients with such com-
plications in about 50% to 80% of cases, depending on the study
population. Nevertheless, despite the great number of mutations
or polymorphisms which have been added to the list of candidate
genetic traits implicated in thrombosis, the diagnosis of throm-
bophilia in most settings is still based on the “classical” param-
eters mentioned (4). In general, many of the genetic variants or
haplotypes that have been recently studied are relatively com-
mon in the general population. These variants have been shown
sometimes to be functional, i.e. they have an effect on the activ-
ity of the gene, but usually have only a minor impact on the
thrombotic risk. Most of them are not interesting for diagnostic
purposes, as they do not add significantly to the risk of thrombo-
sis. In any case, genetic studies have provided insights into spe-
cific mechanisms of the coagulation cascade,which lead to
thrombus formation as opposed to mechanisms of physiological
haemostasis.
The present set of articles in this Theme Issue are devoted to
novel aspects of the mechanisms linked to thrombophilia, and
nicely illustrate how the combination of biochemical and genetic
studies have provided a substantial advance in our field. The first
three articles discuss and summarise our knowledge about a can-
didate gene, each one found to be implicated in the risk of throm-
bosis. Mutations in the genes coding for factor V (F5) and pro-
Received August 13, 2007
Accepted August 13, 2007
Prepublished online August 18, 2007
doi:10.1160/TH07–08–0504
Thromb Haemost 2007; 98: 485–487
 Theme Issue Editorial
tein S (PROS1) are well established as risk factors for thrombo-
sis. Activated factor V is a cofactor of the prothrombinase com-
plex essential in the exponential phase of thrombin production,
but the discovery of factor V (FV)Leiden lead to the proposal of a
new anticoagulant role for FV. Mutations in FV lead to an alter-
ed haemostatic balance, but manifest either as thrombotic or
bleeding events. The article by Segers et al. (5) describes how
these functions are regulated and its implication in the aetiology
of thromboembolic disease. As mentioned by the authors, FV
variants are often found in combination with other prothrom-
botic factors in the same individual. Gene-gene interactions have
been observed among the two alleles in F5, and mutations in the
F5 gene as the FVLeiden could be combined with F5 haplotypes
with a minor effect, as the F5 R2, to increase the risk of thrombo-
sis. Besides these genetic interactions, acquired thrombotic traits
could affect specifically FV, such as anti-FV auto-antibodies.
A second chapter in this series focuses on PROS1, the gene
coding for the vitamin K-dependent anticoagulant protein S (6).
Protein S deficiency has always been the most difficult to study
among prothrombotic deficiencies, due to intrinsic difficulties
in its diagnosis (7). Difficulties derive in part from the presence
in plasma of two protein S pools, either as a free form, or in com-
plex with C4 binding protein (8, 9). Additionally, protein S has
no direct enzymatic activity, acting as a modulator of serine pro-
teases, either activating APC or directly inhibiting the prothrom-
binase complex, making it difficult to standardize an activity
assay in plasma and to establish normal ranges for protein S as-
says in the general population. Despite these limitations, recent
studies have raised the number of mutations associated with pro-
tein S deficiency (PSD) up to almost 200. Especially important
have been the finding of large deletions in PROS1 in families
were the initial genetic analysis was unable to find a causative
mutation (10). Besides, the careful analysis of the mechanism as-
sociated with PSD has provided a better understanding of the re-
lationship between the different kinds of PSD and the associated
risk of thrombosis. New evidence support the concept that quali-
tative or mild quantitative deficiencies of protein S could play a
role in thrombophilia, which could be important in certain popu-
lations (11).
While these two articles focus on new aspects of the classical
mechanisms of inherited thrombophilia, the following article in
the series by Hernández-Espinosa et al. focuses on the serpin
family of protease inhibitors and proposes new mechanisms
leading to thrombosis that go beyond the genetic inheritance of
deficiency (12). The atypical structure of serpins, the main direct
inhibitors of thrombin and other serine proteases in plasma,
makes this family of molecules especially sensitive to changes in
environmental parameters such as pH or temperature. The con-
comitant effect of environmental and structurally de-stabilizing
allelic variants could be the underlying cause of thrombosis as-
sociated with microbial infections. Furthermore, the described
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effect of certain drugs could also cause deficiency of haemos-
tatic serpins that may be explained by conformational mech-
anisms. Interestingly, one of the latest components added to the
natural anticoagulant pathways, the protein Z-dependent pro-
tease inhibitor (SERPINA10), belongs to the serpin family and it
is actively studied as a candidate gene in thrombophilia (13–15).
The article by Medina et al. reviews the interesting addition
of a potentially important new candidate gene in the field of
thrombosis (16). The discovery of a second protein C-binding
protein in the endothelial cell membrane after thrombomodulin
in 1995 added a new level of complexity to the APC anticoagu-
lant system (17). The endothelial protein C receptor (EPCR) has
been shown to have a major impact both in the activation and in
the anticoagulant activity of APC. During recent years, a wealth
of genetic data on the EPCR gene has supported its important
role in maintaining haemostasis (18–20). From these studies,
some of the polymorphisms and haplotypes found in the EPCR
gene emerge as possible factors affecting the risk of thrombosis
(21). The haplotypes in EPCR clearly correlate with the soluble
concentration of EPCR in plasma.
The last article in the present Theme Issue series studies a dif-
ferent aspect of the relationship between genetic variants and
thrombosis, in this case not as a causative mechanisms underly-
ing thrombosis. The article by Oldenburg et al. focuses on the ef-
fect of common genetic variants in the efficacy of the oral anti-
coagulant therapy (22). For some years it has been known that the
oral anticoagulants could have broad differences in their effect.
While some of the differences are clearly related to diet and other
behavioural factors, there was also a genetic component in these
differences, as was proved when genetic variants in the cytoch-
rome P450 CYP2C9 were shown to affect the efficacy of oral
anticoagulants. The discovery of the target enzyme for oral anti-
coagulants, VKORC1, and genetic studies determining the effect
of different haplotypes of the gene with the efficacy of oral anti-
coagulants has lead to the conclusion that VKORC1 is the most
important determinant of efficacy of the anticoagulant treatment
(23, 24). This discovery was important for establishing better
dosing schemes for patients on anticoagulation, and therefore
has had a direct consequence in clinical practice.
All the articles in the series are good examples of how genetic
studies have shown the way for a better understanding of throm-
bosis and how to treat it. Still, it is a matter of intense debate
under which circumstances genetic screening for thrombophilia
are useful in clinical practice, as it seems advisable that it should
be performed only in cases where such testing is likely to in-
fluence patient management, as it is clearly illustrated in the last
article of the series (22). Furthermore, the knowledge obtained
from the association of genetics and thrombotic disease has been
central in establishing our present paradigm of haemostasis and
its associated diseases.

References
1. Egeberg O. Inherited antithrombin deficiency
causing thrombophilia. Thromb Diath Haemorrh 1965;
13: 516–530.
2. Weitz JI. Emerging themes in the treatment of ve-
nous thromboembolism. Thromb Haemost 2006; 96:
239–241.
3. Reitsma PH, Rosendaal FR. Past and future of gen-
etic research in thrombosis. J Thromb Haemost 2007; 5
(Suppl 1): 264–269.
4. Mackie I, Cooper P, Kitchen S. Quality assurance
issues and interpretation of assays. Semin Hematol
2007; 44: 114–125.
5. Segers K, Dahlbäck B, Nicolaes GAF. Coagulation
factor V and thrombophilia: background and mech-
anisms. Thromb Haemost 2007; 98: 530-542.
6. García de Frutos P, Fuentes-Prior P, Hurtado B, et
al. Molecular basis of protein S deficiency. Thromb
Haemost 2007; 98: 543-556.
7. 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.
8. Giri TK, Linse S, Garcia de Frutos, et al. Structural
requirements of anticoagulant protein S for its binding
to the complement regulator C4b-binding protein. J
Biol Chem 2002; 277: 15099–15106.
9. Dahlback B. The tale of protein S and C4b-binding
protein, a story of affection. Thromb Haemost 2007;
98: 90–96.
10. Johansson AM, Hillarp A, Sall T, et al. Large dele-
tions of the PROS1 gene in a large fraction of mutation-
Downloaded from www.thrombosis-online.com on 2017-05-27 | IP: 54.191.40.80
For personal or educational use only. No other uses without permission. All rights reserved.
Theme Issue Editorial
negative patients with protein S deficiency. Thromb
Haemost 2005; 94: 951–957.
11. Adachi T. Protein S and congenital protein S defi-
ciency: the most frequent congenital thrombophilia in
Japanese. Curr Drug Targets 2005; 6: 585–592.
12. Hernández-Espinosa D, Ordóñez A, Vicente V, et al.
Factors with conformational effects on hemostatic ser-
pins: Implications in thrombosis. Thromb Haemost
2007; 98: 557-563.
13. Razzari C, Martinelli I, Bucciarelli P, et al. Poly-
morphisms of the protein Z-dependent protease in-
hibitor (ZPI) gene and the risk of venous thromboem-
bolism. Thromb Haemost 2006; 95: 909–910.
14. Folsom AR, Cushman M, Rasmussen-Torvik LJ, et
al. Prospective study of polymorphisms of the protein
Z-dependent protease inhibitor and risk of venous
thromboembolism. Thromb Haemost 2007; 97:
493–494.
15. Corral J, Gonzalez-Conejero R, Soria JM, et al. A
nonsense polymorphism in the protein Z-dependent
protease inhibitor increases the risk for venous throm-
bosis. Blood 2006; 108: 177–183.
16. Medina P, Navarro S, Estellés A, et al. Polymor-
phisms in the endothelial protein C receptor and throm-
bophilia. Thromb Haemost 2007; 98: 564-569.
17. Fukudome K, Esmon CT. Molecular cloning and
expression of murine and bovine endothelial cell pro-
tein C/activated protein C receptor (EPCR). The struc-
tural and functional conservation in human, bovine,
and murine EPCR. J Biol Chem 1995; 270: 5571–5577.
487
18. Medina P, Navarro S, Estelles A, et al. Influence of
the 4600A/G and 4678G/C polymorphisms in the en-
dothelial protein C receptor (EPCR) gene on the risk of
venous thromboembolism in carriers of factor V
Leiden. Thromb Haemost 2005; 94: 389–394.
19. Saposnik B, Reny JL, Gaussem 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.
20. Qu D, Wang Y, Song Y, et al. The Ser219-->Gly di-
morphism of the endothelial protein C receptor con-
tributes to the higher soluble protein levels observed in
individuals with the A3 haplotype. J Thromb Haemost
2006; 4: 229–235.
21. García de Frutos P. Genetic variants in the endothe-
lial protein C receptor gene: reaching significance.
Thromb Haemost 2005; 94: 233–234.
22. Oldenburg J, Bevans CG, Fregin A, et al. Current
Pharmacogenetic Developments in Oral Anticoagu-
lation Therapy: The Influence of Variant VKORC1 and
CYP2C9Alleles. Thromb Haemost 2007; 98: 570-578.
23. Geisen C, Watzka M, Sittinger K, et al. VKORC1
haplotypes and their impact on the inter-individual and
inter-ethnical variability of oral anticoagulation.
Thromb Haemost 2005; 94: 773–779.
24. Vecsler M, Loebstein R, Almog S, et al. Combined
genetic profiles of components and regulators of the
vitamin K-dependent gamma-carboxylation system af-
fect individual sensitivity to warfarin. Thromb Hae-
most 2006; 95: 205–211.