Apolipoprotein A-I (APOA1) Gene, Known Mutation
Clinical Information Discusses physiology, pathophysiology, and general clinical aspects, as they relate to a laboratory test
The systemic amyloidoses are a number of disorders of varying etiology characterized by extracellular protein deposition. The most common form is an acquired amyloidosis secondary to multiple myeloma or monoclonal gammopathy of unknown significance (MGUS) in which the amyloid is composed of immunoglobulin light chains. In addition to light chain amyloidosis, there are a number of acquired amyloidoses caused by the misfolding and precipitation of a wide variety of proteins. There are also hereditary forms of amyloidosis.
The hereditary amyloidoses comprise a group of autosomal dominant, late-onset diseases that show variable penetrance. A number of genes have been associated with hereditary forms of amyloidosis, including those that encode transthyretin, apolipoprotein A-I, apolipoprotein A-II, fibrinogen alpha chain, gelsolin, cystatin C, and lysozyme. Apolipoprotein A-I, apolipoprotein A-II, lysozyme, and fibrinogen alpha chain amyloidosis present as non-neuropathic systemic amyloidosis, with renal dysfunction being the most prevalent manifestation. Apolipoprotein A-I amyloidosis is also associated with additional organ system involvement, including clinical manifestations in the liver, heart, skin, and larynx. In addition, the G26R APOA1 mutation has been associated with a neuropathic presentation.
To date, at least 16 amyloidogenic mutations have been identified within the APOA1 gene. The majority of these are missense mutations, although deletion/insertion mutations have also been described. There is some evidence of genotype-phenotype correlations. Mutations that occur near the amino terminal portion of the protein are more often associated with hepatic and renal amyloidosis, while mutations occurring near the carboxyl terminal portion of the gene are more often associated with cardiac, cutaneous, and laryngeal amyloidosis. The majority of mutations reported to date occur at 1 of 2 hot spots spanning amino acid residues 50 through 93 and 170 through 178.
Mutations in the APOA1 gene have also been linked to familial hypoalphalipoproteinemia. Patients carrying 1 APOA1 mutation typically demonstrate reduced levels of high-density lipoprotein (HDL) cholesterol, which is associated with increased risk for coronary artery disease. Comparatively, the presence of 2 APOA1 mutations generally results in complete absence of HDL cholesterol and may include additional clinical features such as xanthomas or corneal opacities.
Due to the clinical overlap between the acquired and hereditary forms, it is imperative to determine the specific type of amyloidosis in order to provide an accurate prognosis and consider appropriate therapeutic interventions. Tissue-based, laser capture tandem mass spectrometry might serve as a useful test preceding gene sequencing to better characterize the etiology of the amyloidosis, particularly in cases that are not clear clinically.
It is important to note that this assay does not detect mutations associated with non-APOA1 forms of familial amyloidosis. Therefore, it is important to first test an affected family member to determine if APOA1 is involved and to document a specific mutation in the family before testing at risk individuals.
Testing of individuals at risk for apolipoprotein A-I (APOA1) gene-associated amyloidosis when a mutation has been identified in an affected family member
An interpretive report will be provided.
Cautions Discusses conditions that may cause diagnostic confusion, including improper specimen collection and handling, inappropriate test selection, and interfering substances
The identification of a disease-causing mutation in an affected family member is necessary before predictive testing for other family members can be offered. If a familial mutation has not been previously identified, order APO1S / Apolipoprotein A-I (APOA1) Gene, Full Gene Analysis.
Analysis is performed for the familial mutation(s) provided only. This assay does not rule out the presence of other mutations within this gene or within other genes that may be associated with familial amyloidosis
We strongly recommend that patients undergoing predictive testing receive genetic counseling both prior to testing and after results are available.
Predictive testing of an asymptomatic child is not recommended.
Test results should be interpreted in the context of clinical findings, family history, and other laboratory data. Any error in the diagnosis or in the pedigree provided to us, including false paternity, could lead to erroneous interpretation of results.
A previous bone marrow transplant from an allogenic donor will interfere with testing. Call Mayo Medical Laboratories at 800-533-1710 or 507-266-5700 for instructions for testing patients who have received a bone marrow transplant.
Reference Values Describes reference intervals and additional information for interpretation of test results. May include intervals based on age and sex when appropriate. Intervals are Mayo-derived, unless otherwise designated. If an interpretive report is provided, the reference value field will state this.
An interpretive report will be provided.
Clinical References Provides recommendations for further in-depth reading of a clinical nature
1. Eriksson M, Schonland S, Yumlu S, et al: Hereditary apolipoprotein AI-associated amyloidosis in surgical pathology specimens: identification of three novel mutations in the APOA1 gene. J Mol Diagn 2009;11(3):257-262
2. Benson MD: Ostertage revisited: The inherited systemic amyloidoses without neuropathy. Amyloid 2005:12(2):75-80
3. von Eckardstein A: Differential diagnosis of familial high density lipoprotein deficiency syndromes. Atherosclerosis 2006;186:231-239
4. Shiller SM, Dogan A, Highsmith WE: Laboratory methods for the diagnosis of hereditary amyloidoses. In Amyloidosis-Mechanisms and Prospects for Therapy. Edited by S Sarantseva. InTech 2011, pp 101-120