Instability of PRV-1 mRNA: a factor to be considered in PRV-1 quantification for the diagnosis of polycythemia vera.

High expression of PRV-1 mRNA in granulocytes has been proposed as a new diagnostic marker for polycythemia vera. We used real-time reverse transcription polymerase chain reaction (RT-PCR) to measure the levels of PRV-1 mRNA, GAPDH mRNA and 18S rRNA in granulocytes obtained from blood samples processed 2, 24 and 48 hours after collection and observed a significant decrease of PRV-1 levels after 24 and 48 hours. The instability of PRV-1 mRNA may affect the diagnostic value of the PRV-1 test in blood samples stored for extended periods.

Possible primary familial and congenital polycythemia locus at 7q22.1-7q22.2.

Primary familial and congenital polycythemia (PFCP), inherited as an autosomal dominant trait, has been reported to be associated with mutations in the gene encoding the erythropoietin receptor (EpoR). The clinical features include the presence of isolated erythrocytosis, low erythropoietin (Epo) levels, normal hemoglobin-oxygen dissociation curve, hypersensitivity of erythroid progenitors to exogenous Epo in vitro and no progression to leukemia or myelodysplastic syndrome. Less than 15% of PFCP families have an identifiable EPOR mutation. Abnormalities of other genes are therefore likely responsible for the phenotype of the majority PFCP patients. In this study we report a family segregating PFCP with an autosomal dominant pattern of inheritance, where 7 of 14 members of the family were affected in four generations. This family was studied previously and an EPOR mutation was ruled out by sequencing and by genetic means. Here, we confirmed by linkage analysis that the disease phenotype was not linked to the Epo and EPOR genes. We then performed a genomewide screen with 410 polymorphic markers at average spacing 7.67 cM to locate the chromosomal region responsible for PFCP. We identified a region in 7q22.1-7q22.2 with a suggestive LOD score of 1.84, from our data this is the most likely location of a candidate region responsible for PFCP in this family.

Mutations of von Hippel-Lindau tumor-suppressor gene and congenital polycythemia.

The von Hippel-Lindau (pVHL) protein plays an important role in hypoxia sensing. It binds to the hydroxylated hypoxia-inducible factor 1 alpha (HIF-1 alpha) and serves as a recognition component of an E3-ubiquitin ligase complex. In hypoxia or secondary to a mutated VHL gene, the nondegraded HIF-1 alpha forms a heterodimer with HIF-beta and leads to increased transcription of hypoxia-inducible genes, including erythropoietin (EPO). The autosomal dominant cancer-predisposition von Hippel-Lindau (VHL) syndrome is due to inheritance of a single mutated allele of VHL. In contrast, we recently showed that homozygous germline 598C-->T VHL mutation leads to Chuvash polycythemia (CP). We subsequently found VHL mutations in three unrelated individuals unaffected with CP, one of whom was compound heterozygous for the 598C-->T mutation and another VHL mutation. We now report seven additional polycythemic patients with VHL mutations in both alleles. Two Danish siblings and another American boy were homozygous for the VHL 598C-->T mutation. Three unrelated white Americans were compound heterozygotes for 598C-->T and another VHL mutation, 562C-->G in two and 574C-->T in the third. Additionally, a Croatian boy was homozygous for a 571C-->G VHL mutation, the first example of homozygous VHL germline mutation causing polycythemia, other than the VHL 598C-->T mutation. We have not observed VHL syndrome-associated tumors in polycythemic subjects or their heterozygous relatives; however, this will need to be evaluated by longitudinal studies. Over all, we found that up to half of the consecutive patients with apparent congenital polycythemia and increased serum Epo we have examined have mutations of both VHL alleles. Those findings, along with reports of CP, underscore that VHL mutations are the most frequent cause of congenital polycythemia and define a new class of polycythemic disorder, polycythemias due to augmented hypoxia sensing.

Mutations in the VHL gene in sporadic apparently congenital polycythemia.

The congenital polycythemic disorders with elevated erythropoietin (Epo) have been until recently an enigma, and abnormality in the hypoxia-sensing pathway has been hypothesized as a possible mechanism. The tumor suppressor von Hippel-Lindau (VHL) participates in the hypoxia-sensing pathway, as it binds to the proline-hydroxylated form of the hypoxia-inducible factor 1alpha (HIF-1alpha) and mediates its ubiquitination and proteosomal degradation. The loss of VHL function may result in the accumulation of HIF-1alpha and overproduction of HIF-1 downstream target genes including Epo. VHL syndrome is an autosomal dominant disorder predisposing to the development of tumors, due to inherited mutations in the VHL gene. Some rare patients with VHL syndrome have polycythemia, which has been attributed to Epo production by a tumor. It was recently found that homozygosity for the VHL Arg200Trp mutation is the cause of Chuvash polycythemia, an autosomal recessive polycythemic disorder characterized by elevated serum Epo and hypersensitivity of erythroid cells to Epo. We evaluated the role of VHL in 8 children with a history of polycythemia and an elevated serum Epo level and found 3 different germline VHL mutations in 4 of them. One child was homozygous for the Arg200Trp VHL mutation, and another compound heterozygous for the Arg200Trp and the Val130Leu mutations. Two children (siblings) were heterozygous for an Asp126Tyr mutation, one of them fulfilling some criteria of VHL syndrome. We propose that mutations of the VHL gene represent an important cause of pediatric sporadic polycythemias with an inappropriately high serum Epo concentration.

Search for genetic determinants of individual variability of the erythropoietin response to high altitude.

There is marked variability in the erythropoietin (Epo) and erythrocytic response to extreme high altitude among mountain dwellers, as well as to hypoxic training among athletes, at least in part because of the variation in the erythropoietic response to hypoxia. We hypothesized that this may be genetically determined. Forty-eight athletes were exposed to 24 h of simulated altitude to 2,800 m in a hypobaric chamber. Serum Epo concentrations were determined at baseline and after 24 h. The Epo responses ranged from -41 to 433% of baseline values after 24 h at simulated altitude. The association of the Epo response to hypoxia with the EPO gene and eight genes involved in Epo regulation utilizing 16 polymorphic dinucleotide repeats was examined. Initial analysis showed a possible association between the EPO gene (marker D7S477) and the increase of the Epo level (P = 0.018). We then tested the possibility that sequence abnormalities in the 3' and 5' hypoxia response elements (3' HRE) and (5' HRE) of the EPO gene could explain the differences in Epo response. We found a 3434 C --> T polymorphism in the 3' HRE sequence. However, this polymorphism showed no correlation with the differences in Epo levels. Further, when we analyzed two additional markers flanking the EPO gene by less than 0.3 cM, we found no association of the allelic variants at these loci with the Epo hypoxic response. In conclusion, we could find not convincing association between markers tightly linked to EPO or eight genes involved in Epo regulation and Epo differential responses to hypoxia.

Congenital disorder of oxygen sensing: association of the homozygous Chuvash polycythemia VHL mutation with thrombosis and vascular abnormalities but not tumors.

Adaptation to hypoxia is critical for survival and regulates multiple processes, including erythropoiesis and vasculogenesis. Chuvash polycythemia is a hypoxia-sensing disorder characterized by homozygous mutation (598C>T) of von Hippel-Lindau gene (VHL), a negative regulator of hypoxia sensing. Although endemic to the Chuvash population of Russia, this mutation occurs worldwide and originates from a single ancient event. That VHL 598C>T homozygosity causes elevated normoxic levels of the transcription factor hypoxia inducible factor-1alpha (HIF-1alpha), serum erythropoietin and hemoglobin is known, but the disease phenotype has not been documented in a controlled manner. In this matched cohort study, VHL 598C>T homozygosity was associated with vertebral hemangiomas, varicose veins, lower blood pressures, and elevated serum vascular endothelial growth factor (VEGF) concentrations (P <.0005), as well as premature mortality related to cerebral vascular events and peripheral thrombosis. Spinocerebellar hemangioblastomas, renal carcinomas, and pheochromocytomas typical of classical VHL syndrome were not found, suggesting that overexpression of HIF-1alpha and VEGF is not sufficient for tumorigenesis. Although hemoglobin-adjusted serum erythropoietin concentrations were approximately 10-fold higher in VHL 598C>T homozygotes than in controls, erythropoietin response to hypoxia was identical. Thus, Chuvash polycythemia is a distinct VHL syndrome manifested by thrombosis, vascular abnormalities, and intact hypoxic regulation despite increased basal expression of hypoxia-regulated genes.

The worldwide distribution of the VHL 598C>T mutation indicates a single founding event.

The first congenital defect of hypoxia-sensing homozygosity for VHL 598C>T mutation was recently identified in Chuvash polycythemia. Subsequently, we found this mutation in 11 unrelated individuals of diverse ethnic backgrounds. To address the question of whether the VHL 598C>T substitution occurred in a single founder or resulted from recurrent mutational events in human evolution, we performed haplotype analysis of 8 polymorphic markers covering 340 kb spanning the VHL gene on 101 subjects bearing the VHL 598C>T mutation, including 72 homozygotes (61 Chuvash and 11 non-Chuvash) and 29 heterozygotes (11 Chuvash and 18 non-Chuvash), and 447 healthy unrelated individuals from Chuvash and other ethnic groups. The differences in allele frequencies for each of the 8 markers between 447 healthy controls (598C) and 101 subjects bearing the 598T allele (P < 10(-7)) showed strong linkage disequilibrium. Haplotype analysis indicated a founder effect. We conclude that the VHL 598C>T mutation, the most common defect of congenital polycythemia yet found, was spread from a single founder 1,000 to 62,000 years ago.