Influence of protein Z plasma level on thrombin generation assay

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Bérangère S Joly Bénédicte Sudrié-Arnaud Jeanne-Yvonne Borg Véronique Le Cam Duchez


Introduction: Protein Z (PZ) is a vitamin K-dependent factor, involved as a cofactor of PZ-dependent protease inhibitor (ZPI) that inhibits the activated factor X on phospholipid surface. A severe PZ deficiency could be associated with ischemic arterial diseases. The aim of this study was to evaluate the influence of PZ plasma levels on thrombin generation (TG) and to detect a hypercoagulable state in patients with PZ deficiency.

Patients and Methods: Young patients with personal history of arterial thrombosis and PZ deficiency were included. PZ concentrations were assessed using ELISA method. TG assay was performed using PPP containing 5 pM or 1 pM tissue factor and 4 μM phospholipids with and without thrombomodulin. Then, we focussed on the influence of successive overloads with purified PZ in two patients with PZ deficiency (Pat1PZdef and Pat2PZdef) and industrial PZ deficiency (IndPZdef).

Results: First, in 13 patients with PZ deficiency, none influence of PZ level was reported on TG assay parameters. Second, TG profiles performed on Pat1PZdef, Pat2PZdef and IndPZdef were close to the reference TG profile. In presence of TM, there was no difference in TG parameters according to PZ plasma levels. After each overload, real PZ plasma levels were underestimated; differences in standards of purified PZ between the two manufacturers might explain such results.

Conclusion: The absence of influence of PZ concentration on TG assay is reliable to the absence of well-demonstrated clinical consequences of PZ deficiency in arterial thrombosis. Clinical consequences of protein Z deficiency warranted further studies.

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JOLY, Bérangère S et al. Influence of protein Z plasma level on thrombin generation assay. Medical Research Archives, [S.l.], v. 4, n. 6, oct. 2016. ISSN 2375-1924. Available at: <>. Date accessed: 25 june 2024.
Protein Z, thrombin generation assay, protein Z deficiency
Research Articles


Prowse CV, Esnouf MP. The isolation of a new warfarin-sensitive

Broze GJ, Jr., Miletich JP. Human Protein Z. J Clin Invest 1984; 73:933-938.

Hojrup P, Jensen MS, Petersen TE. Amino acid sequence of bovine protein Z: a vitamin K-dependent serine protease homolog. FEBS Lett 1985; 184:333-338.

Ichinose A, Takeya H, Espling E, Iwanafa S, Kisiel W, Davie EW. Amino acid sequence of human protein Z, a vitamin K-dependent plasma glycoprotein. Biochem Biophys Res Commun 1990; 172:1139-1144.

Hogg PJ, Stenflo J. Interaction of vitamin K-dependent protein Z with thrombin. Consequences for the amidolytic activity of thrombin and the interaction of thrombin with phospholipid vesicles. J Biol Chem 1991; 266:10953-10958.

Hogg PJ, Stenflo J. Interaction of human protein Z with thrombin: evaluation of the species difference in the interaction between bovine and human protein Z and thrombin. Biochem Biophys Res Commun 1991; 178:801-807.

Sejima H, Hayashi T, Deyashiki Y, Nishioka J, Suzuki K. Primary structure of vitamin K-dependent human protein Z. Biochem Biophys Res Commun 1990; 171:661-668.

McDonald JF, Shah AM, Schwalbe RA, Kisiek W, Dahlbäck B, Nelsestuen GL. Comparison of naturally occurring vitamin K-dependent proteins: correlation of amino acid sequences and membrane binding properties suggests a membrane contact site. Biochemistry 1997; 36:5120-5127.

Han X, Fiehler R, Broze GJ, Jr. Isolation of a protein Z-dependent plasma protease inhibitor. Proc Natl Acad Sci USA 1998; 95:9250-9255.

Han X, Fiehler R, Broze GJ, Jr. Characterization of the protein Z-dependent protease inhibitor. Blood 2000; 96:3049-3055.

Broze GJ, Jr. Protein Z-dependent regulation of coagulation. Thromb Haemost 2001; 86:8-13.

Tabatabai A, Fiehler R, Broze GJ, Jr. Protein Z circulates in plasma in a complex with protein Z-dependent protease inhibitor. Thromb Haemost 2001; 85:655-660.

Yin ZF, Huang ZF, Cui J, Fiehler R, Lasky N, Ginsburg D et al. Prothrombotic phenotype of protein Z deficiency. Proc Natl Acad Sci USA. 2000; 97:6734-6738.

Kemkes-Matthes B, Matthes KJ. Protein Z deficiency: a new cause of bleeding tendency. Thromb Res 1995; 79:49-55.

Ravi S, Mauron T, Lammle B, Wuillemin WA. Protein Z in healthy human individuals and in patients with a bleeding tendency. Br J Haematol 1998; 102:1219-1223.

Gamba G, Bertolino G, Montani N, Spedini P, Balduini CL. Bleeding tendency of unknown origin and protein Z levels. Thromb Res 1998; 90:291-295.

Corral J, Gonzalez-Conejero R, Hernandez-Espinosa D, Vincete V. Protein Z/Z-dependent protease inhibitor (PZ/ZPI) anticoagulant system and thrombosis. Br J Haematol. 2007; 137:99-108.

Le Cam-Duchez V, Barbay V, Soria C, Borg JY. [Protein Z, polymorphisms in the protein Z gene and thrombosis]. Rev Med Interne 2010; 31:551-557.

Hemker HC, Giesen P, Al Dieri R, Regnault V, de Smedt E. Calibrated automated thrombin generation measurement in clotting plasma. Pathophysiol Haemost Thromb 2003; 33:4-15.

Hemker HC, Al Dieri R. Age-dependency of thrombin generation. Thromb Haemost 2006; 95:756-757.

Hemker HC, Al Dieri R, De Smedt E, Béguin S. Thrombin generation, a function test of the haemostatic-thrombotic system. Thromb Haemost 2006; 96:553-561.

Haidl H, Cimenti C, Leschnik B, Zach D, Muntean W. Age-dependency of thrombin generation measured by means of calibrated automated thrombography (CAT). Thromb Haemost 2006;95:772-775.

Gerotziafas GT, Depasse F, Busson J, Leflem L, Elalamy I, Samama MM. Towards a standardization of thrombin generation assessment: the influence of tissue factor, platelets and phospholipids concentration on the normal values of Thrombogram-Thrombinoscope assay. Thromb J 2005;3:16-27.

Dargaud Y, Trzeciak MC, Bordet JC, Ninet J, Negrier C. Use of calibrated automated thrombinography +/- thrombomodulin to recognise the prothrombotic phenotype. Thromb Haemost 2006; 96:562-567.

Dargaud Y, Luddington R, Gray E, Negrier C, Lecompte T, Petros S et al. Effect of standardization and normalization on imprecision of calibrated automated thrombography: an international multicentre study. Br J Haematol 2007; 139:303-309.

Dargaud Y, Luddington R, Gray E, Lecompte T, Siegemund T, Baglin T et al. Standardisation of thrombin generation test--which reference plasma for TGT? An international multicentre study. Thromb Res 2010; 125:353-356. doi: 10.1016/j.thromres.2009.11.012.

Dargaud Y, Wolberg AS, Luddington R, Ragnault V, Spronk H, Baglin T et al. Evaluation of a standardized protocol for thrombin generation measurement using the calibrated automated thrombogram: an international multicentre study. Thromb Res 2012; 130:929-934. doi: 10.1016/j.thromres.2012.07.017.

Hezard N, Bouaziz-Borgi L, Remy MG, Nguyen P. Utility of thrombin-generation assay in the screening of factor V G1691A (Leiden) and prothrombin G20210A mutations and protein S deficiency. Clin Chem 2006 ; 52:665-670.

Duchemin J, Pittet JL, Tartary M, Béguin S, Gaussem P, Alhenc-Gelas M et al. A new assay based on thrombin generation inhibition to detect both protein C and protein S deficiencies in plasma. Thromb Haemost 1994; 71:331-338.

Dielis AW, Castoldi E, Spronk HM, van Oerle R, Hamulyak K, Ten Cate H et al. Coagulation factors and the protein C system as determinants of thrombin generation in a normal population. J Thromb Haemost 2008; 6 :125-131.

Santacroce R, Sarno M, Cappucci F, Sessa F, Colaizzo D, Brancaccio V et al. Low protein Z levels and risk of occurrence of deep vein thrombosis. J Thromb Haemost 2006; 4:2417-2422.

Martinelli I, Razzari C, Biguzzi E, Bucciarelli P, Mannucci PM. Low levels of protein Z and the risk of venous thromboembolism. J Thromb Haemost 2005; 3:2817-2819.

Vasse M, Guegan-Massardier E, Borg JY, Woimant F, Soria C. Frequency of protein Z deficiency in patients with ischaemic stroke. Lancet 2001; 357:933-934.

Lopaciuk S, Bykowska K, Kwiecinski H, Czlonkowska A, Kuczynska-Zardzewialy A. Protein Z in young survivors of ischemic stroke. Thromb Haemost 2002; 88:536.

Fedi S, Sofi F, Brogi D, Tellini I, Cesari F, Sestini I et al. Low protein Z plasma levels are independently associated with acute coronary syndromes. Thromb Haemost 2003 ; 90 :1173-1178.

Le Cam-Duchez V, Soria C, Dit Sollier CB, Borg JY, Coudert M, Montalescot G et al. Rare genotypes of protein Z gene are a risk factor for premature myocardial infarction but not protein Z plasma level. Thromb Haemost 2009 ; 102:131-136. doi: 10.1160/TH09-01-0007.