JOURNAL READING

Blood-Based Protein Changes in Childhood Are

Associated With Increased Risk for Later Psychotic
Disorder: Evidence from a Nested Case–Control
Study of the ALSPAC Longitudinal Birth Cohort

FAKULTAS KEDOKTERAN
UNIVERSITAS KRISTEN INDONESIA

PEMBIMBING:
dr. Sabar Parluhutan Siregar, Sp.KJ
Introduction
Introduction
• There is firm evidence that early identification and
treatment of patients with psychotic disorder (PD)
significantly improve their clinical outcome.1
• Blood-based precursors of the PD may offer the opportunity
to enhance predictive models and may provide important
clues for our understanding of pathophysiological cascades
which may later be expressed as psychosis or PD.
Introduction
• Recent review of blood biomarkers in the PD schizophrenia,
its pathophysiological mechanisms involves acute-phase
response, glucocorticoid receptor signaling, coagulation,
lipid and glucose metabolism4, inflammatory cytokines,
chemokines, and growth factors.5–9
• Several studies had demonstrated picture of enhanced
inflammatory before and during psychosis, but the basis of
these changes is not clear.10
Introduction
The aims of this study:
•To identify differential profiles which can be measured prior to the clinical onset of the
PD.
•To continue previous studies of the ALSPAC cohort, A prospective general population
cohort based in Bristol area in South West England have characterized subgroups of
subjects who developed PD and Psychotic Experiences (PEs) at age 18.14
•To discover a proteomic study on blood plasma samples at age 11 in order and find
underlying protein pathways in children with PD outcomes at age 18.
•To compare subjects who reported PEs at age 18 with matched control subjects without
PEs at age 18 as an verification study
Materials and Methods
Participants
• Participants are from ALSPAC (UK Avon Longitudinal Study
of Parents and Children) in cohort.
• They already agreed the written informed consent that
obtained before took the plasma samples.
• Ethical approval for the study was obtained from the
ALSPAC Ethics and Law Committee and the Local Research
Ethics Committees.
Materials and Methods
• Plasma samples: age 11 ALSPAC children with outcomes of
PD or PE at age 18

• Proteomic analysis: Thermo Scientific Q-Exactive mass

spectrometer, connected to a Dionex Ultimate 3000
(RSLCnano) chromatography system, and operated in data
dependent analysis (DDA) mode for label-free LC-MS/MS.
Descriptive Information for ALSPAC
Subjects
Statistical Analysis
• Only proteins present in >80% of samples in at least one
group were taken forward for quantification (n=181
proteins).

• A 5% false discovery rate (FDR) threshold was applied using

the “fdrtool” package.

• The demographic and clinical data were tested for

differences between case and control group using Fisher’s
Exact test.
RESULTS
Discovery Proteomic Analysis in PD
• 60 proteins out of 181 were significantly differentially
expressed between PD cases and controls (P < .05).
• 34 proteins (A2M, TNXB, IGHM, CLEC3B, BCHE, GSN, ECM1,
IGF2, C4BPB, CTBS, SERPINA7, VCAM1, LUM, GPLD1, HABP2,
IGHG3, SEPP1, CFH, SERPINF1, F5, F9, IGFBP3, F12, CFD, CFI,
LAMP2, CRTAC1, PCOLCE, AFM, PLG, COL6A3, C7, APOA2,
CD109) remained significant after FDR (False Discovery
Rate).
Pathway Analysis
• 60 significant proteins were uploaded to KEGG
for pathway analysis called “Complement and
Coagulation Cascade”.
• These proteins were analyzed on STRING algorithm
and found as subnetworks.
DISCUSSION
Discovery Proteomic Analysis in
PD
• 7 of 34 proteins (that remained significant after
FDR): A2M, APOA2, C4BPB, CLECB3, GPLD1, IGHM,
IGFBP3 have previously been implicated in blood-
based biomarker studies of patients diagnosed with
the PD schizophrenia.4
• So these proteins might have potential value to
predict the risk of PD.
• However it requires intensive and precise
identification and calibration.
 Differential Protein Expression in Psychotic Disorder

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Pathway Analysis
• 19 proteins involved in the process being differentially
expressed between groups.
• 3 decreased proteins: A2M, C4BPA, C4BPB
• 16 increased proteins: C1R, C1S, C6, C7, CFD, CFH, CFI, F12,
F13A1, F2, F5, F9, KLKB1, KNG1, PLG, SERPINF2
Pathway Analysis
• 6 of targeted proteins were implicated in
complement and coagulation: A2M, C4BPA, C4BPB,
CFH, PLG, VTN
• 2 in the immune system: IGHM and IGHG3
• 1 in Vitamin E binding: AFM
• 1 in synaptic elimination and myelination: GSN
• STRING network: regulation among coagulation and complement
proteins, with the average interactions per protein being.
Discussion
• Complement and coagulation cascade is the most significant
pathway implicated in plasma samples of schizophrenia patients,
and reported reduction of the expression of C4BPB.40
• Other blood-based proteomic studies of first-episode psychosis
support these findings.19,41,42
• Coagulation impairment has also been reported previously in
schizophrenia.4,43,44
• A recent study that observed therapy of schizophrenia patients
with chronic warfarin; showed remission of psychotic symptoms.45
• Complement system is linked functionally with inflammation46
and important functions of synaptic plasticity regulation in
brain.13,47–49
CONCLUSION
• The proteomic analysis has identified alterations in the
complement and coagulation process of plasma in
childhood from subjects who develop PD in early
adulthood.
• These changes are also present among subjects who go
on to develop PE in early adulthood.
• The findings may represent early changes associated
with a vulnerability to psychosis.
• The findings are indicative of the presence of a
pathophysiological process long before the development
of the disorder.
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THANK YOU
FOR YOUR
ATTENTION
CLINICAL APPRAISAL
1. Did the study address a clearly focused issue?
• Yes
• The study was conducted on a group of children who later
develop a PD as part of efforts to enhance predictive
models to allow the earliest identification of children who
may later develop psychosis.
2. Was the cohort recruited in an acceptable way?
• Yes
• The participants were recruited from the UK Avon
Longitudinal Study of Parents and Children (ALSPAC) cohort
who also participated in psychiatric assessment interviews
at age 18.
3. Was the exposure accurately measured to minimise bias?
• Yes
• Objective measurements were employed. PEs were
identified at 11 and 18 years through the face-to- face,
semi-structured Psychosis-Like Symptom (PLIKS)
interview. All subjects categorized at the interview as
having a PD met diagnostic criteria for PDs, given that
they had regular psychotic phenomena that were
causing them severe distress or substantially impaired
functioning.
4. Was the outcome accurately measured to minimise bias?
• Yes
• Researchers used a nested case-control study of the
ALSPC cohort and chose to assess all available plasma
samples from age 11 children with outcomes of PD or PE
at age 18. Available plasma samples from controls of
age-matched individuals were then randomly selected
to arrive at the sample size for each analysis.
5. (a) Have the authors identified all important confounding
factors?
• Yes
• It was based on a unique characterized cohort, but
reaserchers could not access an exactly similar age-
matched sample. Another potential weakness is that the
subjects investigated in the study were age 18 at the
time of last clinical assessment, therefore have not yet
gone through the full period of risk for developing a PD
5. (b) Have they taken account of the confounding factors in
the design and/or analysis?
• Yes
• The researchers obtained supportive complementary
data from the same cohort.
6. Was the follow up of subjects complete enough?
• Yes
• The researchers suggest robust identification of markers,
calibration of risk prediction models, and testing in
independent cohorts to predict the risk of and
contribute to future pathophysiological models for PD.
7. (a)What are the results of this study?
• Yes
• The study has identified alterations in the complement
and coagulation process. These changes are also that
the findings may represent early changes associated
with a vulnerability to psychosis
7. (b) How precise are the results?
• Yes
• The findings are indicative of the presence of a
pathophysiological process long before the development
of the disorder. The clarification of the roles of proteins
and processes will be obtained from future studies
which will test how baseline levels of these proteins in
subjects at ultra-high risk for PD relate to the varied
clinical outcomes.
8. Can the results be applied to the local population?
• Yes
• Blood-based profiles may be tested in larger population,
including the local population, for their value in
predicting later PD in early adulthood.
9. Do the results of this study fit with other available
evidence?
• Yes
• The findings of the study discovered significant support
from the plasma proteomic biomarker literature of
schizophrenia which has implicated the complement
and coagulation pathways very consistently.
10. What are the implications of this study for practice?
• Yes
• The study is the first to undertake a proteomic analysis
of plasma in childhood from subjects who develop PD in
early adulthood, and has enriched approaches
bioinformatics and could predict PD in early adulthood.