International Journal of Hematology

, Volume 96, Issue 2, pp 200–213 | Cite as

AKT3, ANGPTL4, eNOS3, and VEGFA associations with high altitude sickness in Han and Tibetan Chinese at the Qinghai-Tibetan Plateau

  • Norman E. Buroker
  • Xue-Han Ning
  • Zhao-Nian Zhou
  • Kui Li
  • Wei-Jun Cen
  • Xiu-Feng Wu
  • Wei-Zhong Zhu
  • C. Ronald Scott
  • Shi-Han Chen
Original Article


Mountain sickness (MS) occurs among humans visiting or inhabiting high altitude environments. We conducted genetic analyses of the AKT3, ANGPTL4, eNOS3 and VEGFA genes in lowland (Han) and highland (Tibetan) Chinese. Ten single nucleotide polymorphisms (SNPs) were evaluated in Han and Tibetan patients with acute (A) and chronic (C) MS. We compared 74 patients with AMS to 79 Han unaffected with MS, as well as 48 CMS patients to 31 unaffected Tibetans. The ten SNPs studied are AKT3 (rs4590656, rs2291409), ANGPTL4 (rs1044250), eNOS3 (rs1007311, rs1799983) and VEGFA (rs79469752, rs13207351, rs28357093, rs1570360, rs3025039). Direct sequencing was used to identify individual genotypes for these SNPs. Hemoglobin (Hb), hematocrit (Hct), and red blood cell count (RBC) were found to be significantly associated with the AKT3 SNP (rs4590656), Hb was found to be associated with the eNOS3 SNP (rs1007311), and RBC was found to be significantly associated with the VEGFA SNP (rs1570360) in Tibetan patients with CMS. CMS patients were found to diverge significantly for both eNOS3 SNPs as measured by genetic distance (0.042, 0.047) and for the VEGFA SNP (rs28357093) with a genetic distance of 0.078 compared to their Tibetan control group. Heart rate (HR) was found to be significantly associated with the eNOS3 SNP (rs1799983) and arterial oxygen saturation of hemoglobin (SaO2) was found to be significantly associated with the VEGFA SNPs (rs13207351, rs1570360) in Han patients with AMS. The Han and Tibetan control groups were found to diverge significantly for the ANGPTL4 SNP and VEGFA SNP (rs28357093), as measured by genetic distances of 0.049 and 0.073, respectively. Seven of the SNPs from non-coding regions are found in the transcriptional factor response elements and their possible role in gene regulation was evaluated with regard to MS. AMS and CMS were found to be significantly associated with the four genes compared to their Han and Tibetan control groups, respectively, indicating that these nucleotide alterations have a physiological effect for the development of high altitude sickness.


Acute and chronic mountain sickness AKT3 ANGPTL4 eNOS3 VEGFA Transcriptional factors Response element 

Supplementary material

12185_2012_1117_MOESM1_ESM.doc (240 kb)
Supplementary material 1 (DOC 239 kb)


  1. 1.
    Hackett PH, Roach RC. High-altitude illness. N Engl J Med. 2001;345:107–14.PubMedCrossRefGoogle Scholar
  2. 2.
    Bartsch P, Bailey DM, Berger MM, Knauth M, Baumgartner RW. Acute mountain sickness: controversies and advances. High Alt Med Biol. 2004;5:110–24.PubMedCrossRefGoogle Scholar
  3. 3.
    Ning XH, Li SP. Health care at high altitude—self-care universal health book. Shanghai: Shanghai Science and Technology Publishing House; 2006. p. 66–8.Google Scholar
  4. 4.
    Monge C. Chronic mountain sickness. Physiol Rev. 1943;23:166–84.Google Scholar
  5. 5.
    Winslow RM, Monge CC. Hypoxia, polycythemia, and chronic mountain sickness. Baltimore: Johns Hopkins University Press; 1987.Google Scholar
  6. 6.
    Moore LG. Human genetic adaptation to high altitude. High Alt Med Biol. 2001;2:257–79.PubMedCrossRefGoogle Scholar
  7. 7.
    Wu TY, Li WS, Wei LY, et al. A preliminary studies on the diagnosis of chronic mountain sickness in Tibetan populations. Matsumoto: Press Committee of the 3rd World congress on Mountain Medicine and High Altitude Physiology; 1998.Google Scholar
  8. 8.
    Leon-Velarde F, McCullough RG, McCullough RE, Reeves JT. Proposal for scoring severity in chronic mountain sickness (CMS). Background and conclusions of the CMS Working Group. Adv Exp Med Biol. 2003;543:339–54.PubMedCrossRefGoogle Scholar
  9. 9.
    Ainslie PN, Ogoh S. Regulation of cerebral blood flow in mammals during chronic hypoxia: a matter of balance. Exp Physiol. 2010;95:251–62.PubMedCrossRefGoogle Scholar
  10. 10.
    Gassmann M, Soliz J. Erythropoietin modulates the neural control of hypoxic ventilation. Cellular and molecular life sciences. CMLS. 2009;66:3575–82.PubMedCrossRefGoogle Scholar
  11. 11.
    West JB. The physiologic basis of high-altitude diseases. Ann Intern Med. 2004;141:789–800.PubMedGoogle Scholar
  12. 12.
    Strohl KP. Lessons in hypoxic adaptation from high-altitude populations. Sleep Breath. 2008;12:115–21.PubMedCrossRefGoogle Scholar
  13. 13.
    Wilson MH, Newman S, Imray CH. The cerebral effects of ascent to high altitudes. Lancet Neurol. 2009;8:175–91.PubMedCrossRefGoogle Scholar
  14. 14.
    Su B, Xiao C, Deka R, Seielstad MT, Kangwanpong D, Xiao J, Lu D, Underhill P, Cavalli-Sforza L, Chakraborty R, et al. Y chromosome haplotypes reveal prehistorical migrations to the Himalayas. Hum Genet. 2000;107:582–90.PubMedCrossRefGoogle Scholar
  15. 15.
    Torroni A, Miller JA, Moore LG, Zamudio S, Zhuang J, Droma T, Wallace DC. Mitochondrial DNA analysis in Tibet: implications for the origin of the Tibetan population and its adaptation to high altitude. Am J Phys Anthropol. 1994;93:189–99.PubMedCrossRefGoogle Scholar
  16. 16.
    Du R, Xiao C, Cavalli-Sforza LL. Genetic distances between Chinese populations calculated on gene frequencies of 38 loci. Sci China C Life Sci. 1997;40:613–21.PubMedCrossRefGoogle Scholar
  17. 17.
    Maloney J, Wang D, Duncan T, Voelkel N, Ruoss S. Plasma vascular endothelial growth factor in acute mountain sickness. Chest. 2000;118:47–52.PubMedCrossRefGoogle Scholar
  18. 18.
    Dorward DA, Thompson AA, Baillie JK, MacDougall M, Hirani N. Change in plasma vascular endothelial growth factor during onset and recovery from acute mountain sickness. Respir Med. 2007;101:587–94.PubMedCrossRefGoogle Scholar
  19. 19.
    Walter R, Maggiorini M, Scherrer U, Contesse J, Reinhart WH. Effects of high-altitude exposure on vascular endothelial growth factor levels in man. Eur J Appl Physiol. 2001;85:113–7.PubMedCrossRefGoogle Scholar
  20. 20.
    Stobdan T, Karar J, Pasha MA. High altitude adaptation: genetic perspectives. High Alt Med Biol. 2008;9:140–7.PubMedCrossRefGoogle Scholar
  21. 21.
    Bigham A, Bauchet M, Pinto D, Mao X, Akey JM, Mei R, Scherer SW, Julian CG, Wilson MJ, Lopez Herraez D, et al. Identifying signatures of natural selection in Tibetan and Andean populations using dense genome scan data. PLoS Genet 2010; 6:1–14.Google Scholar
  22. 22.
    Yi X, Liang Y, Huerta-Sanchez E, Jin X, Cuo ZX, Pool JE, Xu X, Jiang H, Vinckenbosch N, Korneliussen TS, et al. Sequencing of 50 human exomes reveals adaptation to high altitude. Science. 2010;329:75–8.PubMedCrossRefGoogle Scholar
  23. 23.
    Rupert JL, Koehle MS. Evidence for a genetic basis for altitude-related illness. High Alt Med Biol. 2006;7:150–67.PubMedCrossRefGoogle Scholar
  24. 24.
    Buroker NE, Ning XH, Zhou ZN, Li K, Cen WJ, Wu XF, Ge M, Fan LP, Zhu WZ, Portman MA, et al. Genetic associations with mountain sickness in Han and Tibetan residents at the Qinghai-Tibetan Plateau. Clin Chim Acta. 2010;411:1466–73.PubMedCrossRefGoogle Scholar
  25. 25.
    Buroker NE, Ning XH, Zhou ZN, Li K, Cen WJ, Wu XF, Zhu WZ, Scott CR, Chen SH. EPAS1 and EGLN1 associations with high altitude sickness in Han and Tibetan Chinese at the Qinghai-Tibetan Plateau. Blood Cells Mol Dis 2012;49 (in press).Google Scholar
  26. 26.
    Droma Y, Hanaoka M, Ota M, Katsuyama Y, Koizumi T, Fujimoto K, Kobayashi T, Kubo K. Positive association of the endothelial nitric oxide synthase gene polymorphisms with high-altitude pulmonary edema. Circulation. 2002;106:826–30.PubMedCrossRefGoogle Scholar
  27. 27.
    Hanaoka M, Droma Y, Ota M, Ito M, Katsuyama Y, Kubo K. Polymorphisms of human vascular endothelial growth factor gene in high-altitude pulmonary oedema susceptible subjects. Respirology. 2009;14:46–52.PubMedCrossRefGoogle Scholar
  28. 28.
    Hackett PH, Oelz O (1992). The diagnoses accord with the Lake Louise scoring system. In: Sutton GC JR, Houston CS, editors. Hypoxia and mountain sickness. New York: Pergamon Press, pp. 327–330.Google Scholar
  29. 29.
    Schneider S, Roessli D, Excoffier L. Arlequin ver. 2.000: A software for population genetics data analysis. 2.000 Edition. Geneva; 2000.Google Scholar
  30. 30.
    Nei M, Roychoudhury AK. Sampling variances of heterozygosity and genetic distance. Genetics. 1974;76:379–90.PubMedGoogle Scholar
  31. 31.
    Holsinger KE, Weir BS. Genetics in geographically structured populations: defining, estimating and interpreting F(ST). Nat Rev Genet. 2009;10:639–50.PubMedCrossRefGoogle Scholar
  32. 32.
    Ding K, Zhou K, He F, Shen Y. LDA–a java-based linkage disequilibrium analyzer. Bioinformatics. 2003;19:2147–8.PubMedCrossRefGoogle Scholar
  33. 33.
    Weir BS. Genetic data analysis: methods for discrete population genetic data. Sunderland: Sinauer Associates; 1990.Google Scholar
  34. 34.
    Bryne JC, Valen E, Tang MH, Marstrand T, Winther O, da Piedade I, Krogh A, Lenhard B, Sandelin A. JASPAR, the open access database of transcription factor-binding profiles: new content and tools in the 2008 update. Nucleic Acids Res. 2008;36:D102–6.PubMedCrossRefGoogle Scholar
  35. 35.
    Sandelin A, Alkema W, Engstrom P, Wasserman WW, Lenhard B. JASPAR: an open-access database for eukaryotic transcription factor binding profiles. Nucleic Acids Res. 2004;32:D91–4.PubMedCrossRefGoogle Scholar
  36. 36.
    Sandelin A, Wasserman WW, Lenhard B. ConSite: web-based prediction of regulatory elements using cross-species comparison. Nucleic Acids Res. 2004;32:W249–52.PubMedCrossRefGoogle Scholar
  37. 37.
    Nowak DG, Woolard J, Amin EM, Konopatskaya O, Saleem MA, Churchill AJ, Ladomery MR, Harper SJ, Bates DO. Expression of pro- and anti-angiogenic isoforms of VEGF is differentially regulated by splicing and growth factors. J Cell Sci. 2008;121:3487–95.PubMedCrossRefGoogle Scholar
  38. 38.
    Woolard J, Bevan HS, Harper SJ, Bates DO. Molecular diversity of VEGF-A as a regulator of its biological activity. Microcirculation. 2009;16:572–92.PubMedCrossRefGoogle Scholar
  39. 39.
    Simonson TS, Yang Y, Huff CD, Yun H, Qin G, Witherspoon DJ, Bai Z, Lorenzo FR, Xing J, Jorde LB, et al. Genetic evidence for high-altitude adaptation in Tibet. Science. 2010;329:72–5.PubMedCrossRefGoogle Scholar
  40. 40.
    Appenzeller O, Minko T, Pozharov V, Bonfichi M, Malcovati L, Gamboa J, Bernardi L. Gene expression in the Andes; relevance to neurology at sea level. J Neurol Sci. 2003;207:37–41.PubMedCrossRefGoogle Scholar
  41. 41.
    Patitucci M, Lugrin D, Pages G. Angiogenic/lymphangiogenic factors and adaptation to extreme altitudes during an expedition to Mount Everest. Acta Physiol. 2009;196:259–65.CrossRefGoogle Scholar
  42. 42.
    Gao W, Gao Y, Zhang G, Song L, Sun B, Shi J. Hypoxia-induced expression of HIF-1alpha and its target genes in umbilical venous endothelial cells of Tibetans and immigrant Han. Comp Biochem Physiol Toxicol Pharmacol. 2005;141:93–100.CrossRefGoogle Scholar
  43. 43.
    Appenzeller O, Minko T, Qualls C, Pozharov V, Gamboa J, Gamboa A, Wang Y. Gene expression, autonomic function and chronic hypoxia: lessons from the Andes. Clinical Auton Res. 2006;16:217–22.CrossRefGoogle Scholar
  44. 44.
    Dai J, Rabie AB. VEGF: an essential mediator of both angiogenesis and endochondral ossification. J Dent Res. 2007;86:937–50.PubMedCrossRefGoogle Scholar
  45. 45.
    Harper SJ, Bates DO. VEGF-A splicing: the key to anti-angiogenic therapeutics? Nat Rev Cancer. 2008;8:880–7.PubMedCrossRefGoogle Scholar
  46. 46.
    Xu J, Dou T, Liu C, Fu M, Huang Y, Gu S, Zhou Y, Xie Y. The evolution of alternative splicing exons in vascular endothelial growth factor A. Gene. 2011;487:143–50.PubMedCrossRefGoogle Scholar
  47. 47.
    Holmes DI, Zachary I. The vascular endothelial growth factor (VEGF) family: angiogenic factors in health and disease. Genome Biol. 2005;6:209.PubMedCrossRefGoogle Scholar
  48. 48.
    Ding H, Liu Q, Hua M, Ding M, Du H, Zhang W, Li Z, Zhang J. Polymorphisms of hypoxia-related genes in subjects susceptible to acute mountain sickness. Respiration. 2011;81:236–41.PubMedCrossRefGoogle Scholar
  49. 49.
    Bader AG, Kang S, Zhao L, Vogt PK. Oncogenic PI3K deregulates transcription and translation. Nat Rev Cancer. 2005;5:921–9.PubMedCrossRefGoogle Scholar
  50. 50.
    Karar J, Maity A. PI3K/AKT/mTOR pathway in angiogenesis. Front Mol Neurosci. 2011;4:51.PubMedCrossRefGoogle Scholar
  51. 51.
    Testa JR, Bellacosa A. AKT plays a central role in tumorigenesis. Proc Natl Acad Sci USA. 2001;98:10983–5.PubMedCrossRefGoogle Scholar
  52. 52.
    Wang P, Koehle MS, Rupert JL. Genotype at the missense G894T polymorphism (Glu298Asp) in the NOS3 gene is associated with susceptibility to acute mountain sickness. High Alt Med Biol. 2009;10:261–7.PubMedCrossRefGoogle Scholar
  53. 53.
    Sawada T, Kishimoto T, Osaki Y, Okamoto M, Tahara A, Kaetu A, Kurosawa Y, Kotani K. Relation of the Glu298Asp polymorphism of the nitric oxide synthase gene to hypertension and serum cholesterol in Japanese workers. Prev Med. 2008;47:167–71.PubMedCrossRefGoogle Scholar
  54. 54.
    Srivastava K, Narang R, Sreenivas V, Das S, Das N. Association of eNOS Glu298Asp gene polymorphism with essential hypertension in Asian Indians. Clin Chim Acta. 2008;387:80–3.PubMedCrossRefGoogle Scholar
  55. 55.
    Lichtenstein L, Berbee JF, van Dijk SJ, van Dijk KW, Bensadoun A, Kema IP, Voshol PJ, Muller M, Rensen PC, Kersten S. Angptl4 upregulates cholesterol synthesis in liver via inhibition of LPL- and HL-dependent hepatic cholesterol uptake. Arterioscler Thromb Vasc Biol. 2007;27:2420–7.PubMedCrossRefGoogle Scholar
  56. 56.
    Yu X, Burgess SC, Ge H, Wong KK, Nassem RH, Garry DJ, Sherry AD, Malloy CR, Berger JP, Li C. Inhibition of cardiac lipoprotein utilization by transgenic overexpression of Angptl4 in the heart. Proc Natl Acad Sci USA. 2005;102:1767–72.PubMedCrossRefGoogle Scholar
  57. 57.
    Le Jan S, Amy C, Cazes A, Monnot C, Lamande N, Favier J, Philippe J, Sibony M, Gasc JM, Corvol P, et al. Angiopoietin-like 4 is a proangiogenic factor produced during ischemia and in conventional renal cell carcinoma. Am J Pathol. 2003;162:1521–8.PubMedCrossRefGoogle Scholar
  58. 58.
    Smart-Halajko MC, Robciuc MR, Cooper JA, Jauhiainen M, Kumari M, Kivimaki M, Khaw KT, Boekholdt SM, Wareham NJ, Gaunt TR, et al. The relationship between plasma angiopoietin-like protein 4 levels, angiopoietin-like protein 4 genotype, and coronary heart disease risk. Arterioscler Thromb Vasc Biol. 2010;30:2277–82.PubMedCrossRefGoogle Scholar
  59. 59.
    Wang X, Tomso DJ, Liu X, Bell DA. Single nucleotide polymorphism in transcriptional regulatory regions and expression of environmentally responsive genes. Toxicol Appl Pharmacol. 2005;207:84–90.PubMedCrossRefGoogle Scholar
  60. 60.
    Naqvi A, Hoffman TA, DeRicco J, Kumar A, Kim CS, Jung SB, Yamamori T, Kim YR, Mehdi F, Kumar S, et al. A single-nucleotide variation in a p53-binding site affects nutrient-sensitive human SIRT1 expression. Hum Mol Genet. 2010;19:4123–33.PubMedCrossRefGoogle Scholar

Copyright information

© The Japanese Society of Hematology 2012

Authors and Affiliations

  • Norman E. Buroker
    • 1
  • Xue-Han Ning
    • 2
  • Zhao-Nian Zhou
    • 3
  • Kui Li
    • 4
  • Wei-Jun Cen
    • 4
  • Xiu-Feng Wu
    • 3
  • Wei-Zhong Zhu
    • 3
  • C. Ronald Scott
    • 1
  • Shi-Han Chen
    • 1
  1. 1.Department of PediatricsUniversity of WashingtonSeattleUSA
  2. 2.Division of CardiologySeattle Children’s Hospital, Institute, FoundationSeattleUSA
  3. 3.Laboratory of Hypoxia Physiology, Shanghai Institutes for Biological SciencesChinese Academy of SciencesShanghaiChina
  4. 4.Lhasa People HospitalLhasaChina

Personalised recommendations