Antithrombin III Deficiency 

  • Author: James L Harper, MD; Chief Editor: Robert J Arceci, MD, PhD   more...
 
Updated: Aug 1, 2011
 

Background

Antithrombin III (ATIII) is a potent inhibitor of the coagulation cascade. It is a nonvitamin K-dependent protease that inhibits coagulation by lysing thrombin and factor Xa. Antithrombin III activity is markedly potentiated by heparin; potentiation of its activity is the principle mechanism by which both heparin and low molecular weight heparin result in anticoagulation.

Congenital antithrombin III deficiency is an autosomal dominant disorder in which an individual inherits one copy of a defective gene. This condition leads to increased risk of venous and arterial thrombosis, with an onset of clinical manifestations typically appearing in young adulthood. This form is commonly diagnosed during childhood by screening after an affected family member has been identified or after a child has had a thrombotic event.

Severe congenital antithrombin III deficiency, in which the individual inherits 2 defective genes, is a rare autosomal recessive condition associated with increased thrombogenesis, typically noted in the neonatal period or early infancy. This condition is rarely compatible with life. Most neonates have heterozygous antithrombin III deficiency.

Acquired antithrombin III deficiency is a deficiency of antithrombin primarily due to consumption. It is observed in situations in which activation of the coagulation system is inappropriate. Common conditions that result in acquired antithrombin III deficiency include disseminated intravascular coagulation (DIC), microangiopathic hemolytic anemias due to endothelial damage (ie, hemolytic-uremic syndrome), and venoocclusive disease (VOD) in patients undergoing bone marrow transplantation.

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Pathophysiology

See the image below.

Antithrombin (AT) sites of action. Antithrombin (AT) sites of action.

Heterozygous antithrombin III deficiency results in venous thrombosis, most commonly starting in the third decade of life.

The defect is autosomal dominant, and several different genetic abnormalities have been identified in separate kindreds. The defects are most often translational or postprocessing errors that result in decreased functional antithrombin III.

Two types of antithrombin III deficiency have been described. Type I is a simple deficiency of the enzyme, and both antigen and activity levels are similarly low. Type II results in reduced enzyme activity. Numerous discrete point mutations of the antithrombin gene have been identified.[1, 2] The type I deficiency is the most common phenotype.

Two defects, wibble and wobble, have been characterized as resulting in substitutions of a single amino acid at the beginning of the beta sheet of the peptide. Substitutions that result in polar amino acids in this location result in decreased activity and survival of the enzyme (Wibble), whereas others cause amino acid substitutions and result in less severe decreases. Clinically, the Wibble gene is associated with a greater risk of thrombosis early in life (second decade).

Other regions of the gene (eg, the "shutter" region) are also associated with clinically significant thrombosis. The shutter region of the antithrombin protein is centrally located near the "A" B sheet and facilitates opening and closing of the enzyme's active site. These examples are all part of the conformational diseases that may occur in all SERPIN class enzymes (see Alpha-1 Antitrypsin Deficiency).

Acquired deficiencies are commonly due to increased coagulation secondary to endothelial injury or the presence of antiphospholipid (AP) antibodies (eg, lupus anticoagulant). In both of these situations, antithrombin III is consumed at increased rates because of excessive activation of the coagulation pathway. Other reported mechanisms of acquired antithrombin III deficiency include chronic liver disease, with resultant synthetic failure, and protein loss due to ascites or nephrotic syndrome.

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Epidemiology

Race

Congenital antithrombin III deficiency is recognized in all racial and ethnic groups.

Sex

No sex-related difference is noted in terms of the prevalence of congenital antithrombin III deficiency. Women of childbearing age are of special concern. Antithrombin III deficiency, like other congenital procoagulant defects, may contribute to an increased risk of spontaneous abortions. Particularly in cases of fetal or umbilical thrombosis as the cause of the miscarriage, consider antithrombin III deficiency, along with protein C or protein S deficiency and AP antibody syndrome.

Oral contraceptives (OCs) contain large doses of estrogen, which is a stimulator of coagulation. Women who are antithrombin III–deficient heterozygotes are at an increased risk of thrombosis when taking OCs.

Parents of newborns who have a thrombotic event are at increased risk of having a procoagulant disorder themselves. These individuals should be referred for further assessment of their own risk factors.

Age

Patients who are homozygotes often present in the neonatal period; individuals who are heterozygotes may remain asymptomatic well into middle age. A thrombotic challenge, such as placement of a central venous catheter or other vascular catheter, frequently unmask heterozygotes. Individuals who have multiple catheter-related thrombotic events, or life/organ threatening events with no other risk factor, should be evaluated for an underlying procoagulant condition.

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Contributor Information and Disclosures
Author

James L Harper, MD  Associate Professor, Department of Pediatrics, Division of Hematology/Oncology and Bone Marrow Transplantation, Associate Chairman for Education, Department of Pediatrics, University of Nebraska Medical Center; Assistant Clinical Professor, Department of Pediatrics, Creighton University School of Medicine; Director, Continuing Medical Education, Children's Memorial Hospital; Pediatric Director, Nebraska Regional Hemophilia Treatment Center

James L Harper, MD is a member of the following medical societies: American Academy of Pediatrics, American Association for Cancer Research, American Federation for Clinical Research, American Society of Hematology, American Society of Pediatric Hematology/Oncology, Council on Medical Student Education in Pediatrics, and Hemophilia and Thrombosis Research Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Gary R Jones, MD  Associate Medical Director, Clinical Development, Berlex Laboratories

Gary R Jones, MD is a member of the following medical societies: American Academy of Pediatrics, American Society of Pediatric Hematology/Oncology, and Western Society for Pediatric Research

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Gary D Crouch, MD  Program Director of Pediatric Hematology-Oncology Fellowship, Department of Pediatrics, Associate Professor, Uniformed Services University of the Health Sciences

Gary D Crouch, MD is a member of the following medical societies: American Academy of Pediatrics and American Society of Hematology

Disclosure: Nothing to disclose.

David Pallares, MD  Clinical Assistant Professor, Department of Pediatrics, Division of Allergy and Immunology, University of Louisville School of Medicine

David Pallares, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology

Disclosure: Nothing to disclose.

Chief Editor

Robert J Arceci, MD, PhD  King Fahd Professor of Pediatric Oncology, Professor of Pediatrics, Oncology and the Cellular and Molecular Medicine Graduate Program, Kimmel Comprehensive Cancer Center at Johns Hopkins University School of Medicine

Robert J Arceci, MD, PhD is a member of the following medical societies: American Association for Cancer Research, American Association for the Advancement of Science, American Pediatric Society, American Society of Hematology, and American Society of Pediatric Hematology/Oncology

Disclosure: Nothing to disclose.

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