Molecular Genetic Screening in Patients With ACE Inhibitor/Angiotensin Receptor Blocker-Induced Angioedema to Explore the Role of Hereditary Angioedema Genes

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  • Carina M. Mathey
  • Carlo Maj
  • Annika B. Scheer
  • Julia Fazaal
  • Bettina Wedi
  • Dorothea Wieczorek
  • Philipp M. Amann
  • Harald Löffler
  • Lukas Koch
  • Clemens Schöffl
  • Heinrich Dickel
  • Nomun Ganjuur
  • Thorsten Hornung
  • Susann Forkel
  • Jens Greve
  • Gerda Wurpts
  • Pär Hallberg
  • Anette Bygum
  • Malgorzata Karawajczyk
  • Michael Steffens
  • Julia Stingl
  • Per Hoffmann
  • Stefanie Heilmann-Heimbach
  • Elisabeth Mangold
  • Kerstin U. Ludwig
  • Eva R. Rasmussen
  • Mia Wadelius
  • Bernhardt Sachs
  • Markus M. Nöthen
  • Andreas J. Forstner

Angioedema is a relatively rare but potentially life-threatening adverse reaction to angiotensin-converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARBs). As with hereditary forms of angioedema (HAE), this adverse reaction is mediated by bradykinin. Research suggests that ACEi/ARB-induced angioedema has a multifactorial etiology. In addition, recent case reports suggest that some ACEi/ARB-induced angioedema patients may carry pathogenic HAE variants. The aim of the present study was to investigate the possible association between ACEi/ARB-induced angioedema and HAE genes via systematic molecular genetic screening in a large cohort of ACEi/ARB-induced angioedema cases. Targeted re-sequencing of five HAE-associated genes (SERPING1, F12, PLG, ANGPT1, and KNG1) was performed in 212 ACEi/ARB-induced angioedema patients recruited in Germany/Austria, Sweden, and Denmark, and in 352 controls from a German cohort. Among patients, none of the identified variants represented a known pathogenic variant for HAE. Moreover, no significant association with ACEi/ARB-induced angioedema was found for any of the identified common [minor allele frequency (MAF) >5%] or rare (MAF < 5%) variants. However, several non-significant trends suggestive of possible protective effects were observed. The lowest p-value for an individual variant was found in PLG (rs4252129, p.R523W, p = 0.057, p.adjust > 0.999, Fisher’s exact test). Variant p.R523W was found exclusively in controls and has previously been associated with decreased levels of plasminogen, a precursor of plasmin which is part of a pathway directly involved in bradykinin production. In addition, rare, potentially functional variants (MAF < 5%, Phred-scaled combined annotation dependent depletion score >10) showed a nominally significant enrichment in controls both: 1) across all five genes; and 2) in the F12 gene alone. However, these results did not withstand correction for multiple testing. In conclusion, our results suggest that HAE-associated mutations are, at best, a rare cause of ACEi/ARB-induced angioedema. Furthermore, we were unable to identify a significant association between ACEi/ARB-induced angioedema and other variants in the investigated genes. Further studies with larger sample sizes are warranted to draw more definite conclusions concerning variants with limited effect sizes, including protective variants.

OriginalsprogEngelsk
Artikelnummer914376
TidsskriftFrontiers in Genetics
Vol/bind13
Antal sider11
ISSN1664-8021
DOI
StatusUdgivet - 2022

Bibliografisk note

Funding Information:
This work was funded by in-house resources of both the Federal Institute for Drugs and Medical Devices (BfArM) and the Institute of Human Genetics, University Hospital of Bonn (V-17454/68502/2017-2020 and V2021.5/68502/2022-2024). The research was supported by the Swedish Research Council (Medicine 521-2011-2440, 521-2014-3370 and 2018-03307), Swedish Heart and Lung Foundation (20120557, 20140291, and 20170711), Selander’s Foundation, Thureus’ Foundation, and Clinical Research Support Avtal om Läkarutbildning och Forskning at Uppsala University. KL received support by the German Research Council (LU 1944/3-1).

Publisher Copyright:
Copyright © 2022 Mathey, Maj, Scheer, Fazaal, Wedi, Wieczorek, Amann, Löffler, Koch, Schöffl, Dickel, Ganjuur, Hornung, Forkel, Greve, Wurpts, Hallberg, Bygum, Von Buchwald, Karawajczyk, Steffens, Stingl, Hoffmann, Heilmann-Heimbach, Mangold, Ludwig, Rasmussen, Wadelius, Sachs, Nöthen and Forstner.

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