JOURNAL OF COAGULATION DISORDERS REVIEW ARTICLE

Clinical Perspective of Congenital Vitamin K-Dependent

Coagulation Factor Deficiency
Amir A Kuperman1,2 and Benjamin Brenner1
Affiliations: 1Thrombosis and Hemostasis Unit, Institute of Hematology, Rambam Medical Center, and Bruce Rappaport Faculty of Medicine, Technion, Haifa,
Israel and 2Pediatric Hematology, Western Galilee Hospital, Naharriya, Israel

A B S T R A C T

The ‘‘vitamin K system’’ requires the normal function of two enzymes: c-glutamyl carboxylase and vitamin K epoxide reductase enzyme
complex (VKORC1). Heritable enzymatic dysfunction of the c-glutamyl carboxylase or the VKOR complex results in the secretion of poorly
carboxylated vitamin K-dependent proteins that play a role in coagulation. The following review focuses on the clinical perspectives of VKCFD
(vitamin K-dependent coagulation factors deficient) I and II, which have received increasing interest lately, and provides a brief explanation
about the pathogenesis of the disease. Laboratory assays used for diagnosis are discussed, and management in various clinical settings is
reviewed.

Keywords: vitamin K-dependent coagulation factors deficiency (VKCFD), c-glutamyl carboxylase (GGCX), vitamin K epoxide reductase
(VKOR)

Correspondence: Benjamin Brenner, Thrombosis and Hemostasis Unit, Institute of Hematology, Rambam Medical Center, and Bruce
Rappaport Faculty of Medicine, Technion, Haifa, Israel. Tel: (972)-4-8543520; Fax: (972)-4-8543886; e-mail: b_brenner@rambam.health.gov.il

ABOUT THE DISEASE
All vitamin K-dependent coagulation factors, FII, FVII, FIX,
and FX, require c-carboxylation of glutamic acid residues at
their Gla (c-carboxyglutamic acid) domains to enable binding
of calcium and attach to phospholipid membranes. The c-
carboxylation is catalyzed by hepatic c-glutamyl carboxylase,
which requires reduced vitamin K (KH2) as a cofactor. During
the c-carboxylation reaction, KH2 is converted to vitamin K
epoxide (KO), which is recycled to KH2 by the vitamin K
epoxide reductase enzyme complex (VKORC1) [1]. Heritable
dysfunction of c-glutamyl carboxylase or of the VKOR
complex results in the secretion of poorly carboxylated
vitamin K-dependent coagulation factors, as well as non-
functional proteins C, S, and Z and the skeletal proteins
osteocalcin and matrix Gla protein.
A rare inherited form of combined deficiency of the vitamin
K-dependent coagulation factors (VKCFD) has been reported
to date as an autosomal recessive disorder in 21 kindreds
worldwide [2–22], and has received increasing interest lately
[23]. The first case of VKCFD was described in 1966 in an
infant girl who exhibited significant bleeding from the first
week of life [2]. The proband was found to have low or
undetectable levels of factors II, VII, IX, and X, with no
evidence of hepatic disease or malabsorption. Clotting factor
levels were normal in both parents.
The two genes known to be involved in the familial
combined deficiency of vitamin K-dependent coagulation
factors are the gene encoding for c-glutamyl carboxylase
(GGCX), which is located on chromosome 2p12 [24], and the
gene encoding for vitamin K epoxide reductase (VKORC1),
which is located on chromosome 16p11.2 [25, 26]. Mutations
in the GGCX gene cause a disease termed vitamin K-
dependent coagulation defect (VKCFD) type I, first demon-
strated in Devon Rex cats [27], and mutations in the VKORC1
gene cause a disease termed VKCFD type II. Diagnosis
requires differentiation from acquired forms of the disorder
that can be caused by low dietary intake of vitamin K,
intestinal malabsorption of vitamin K, liver or renal dysfunc-
tion, or treatment with coumarin.
The genetic diagnosis of a single family with combined
vitamin K-dependent clotting factor deficiency finally led to
the identification and molecular characterization of VKORC1
[18, 25]. Mutations within VKORC1 have been shown to cause
a coumarin-resistant phenotype, and a single nucleotide
polymorphism (SNP) within the VKORC1 promoter region
has been identified as a major pharmacodynamic determinant
of coumarin dose [28–30]. That is the basis for the
development of an algorithm integrating gene polymorph-
isms (VKORC1, CYP2C9) with some demographic informa-
tion and clinical variables, which will provide a valuable tool
in the care of patients using coumarin [31, 32].
To investigate the importance of c-glutamyl carboxylation
for the function of the Gla-containing proteins, mice were
generated completely lacking c-carboxylase activity by gene
targeting [30]. Heterozygous mice carrying a null mutation at
the GGCX gene exhibit normal development and survival with
no evidence of hemorrhage and normal functional activity of
the vitamin K-dependent coagulation factors. Owing to

JCD 2009; 000:(000). Month 2009 1 www.slm-hematology.com

Journal of Coagulation Disorders
embryonic lethality, only half of the GGCX–/– mice embryos
developed to term. All delivered homozygous c-carboxylase-
deficient mice succumbed to massive intra-abdominal
hemorrhage shortly after birth [33].
CLINICAL PRESENTATION
The clinical symptoms of VKCFD may vary, although they
correlate with clotting factor levels [18]. Severely affected
individuals may present at birth with spontaneous intracranial
hemorrhage or umbilical stump bleeding that can lead to a
fatal outcome [16–18], or later on in infancy and childhood
with spontaneous hemarthrosis and retroperitoneal, soft
tissue, or gastrointestinal bleeds. Hemorrhagic manifesta-
tions in childhood often present when the child has infections
and is treated with antibiotics, which may result in decreased
vitamin K production by endogenous gut bacteria. Older
patients may present with easy bruising and mucocutaneous
or post-surgical bleeding [4, 8, 13]. Severe bleeding is usually
associated with low factor levels below 5 U/dL. The phenotype
of the affected individuals may be more severe if there is
concomitant acquired vitamin K deficiency, and a milder
phenotype may be seen in patients treated with therapeutic
doses of vitamin K. The routine administration of vitamin K
in neonates may delay the diagnosis of VKCFD.
Severely affected children may show skeletal abnormalities
such as nasal hypoplasia, distal digital hypoplasia, epiphyseal
stippling, and mild conductive hearing loss [11, 15]. Mental
retardation has also been reported [14]. These abnormalities
resemble warfarin embryopathy, and are attributed to the
non-functional osteocalcin and matrix Gla protein.
The first mutation in the GGCX gene was identified in four
affected members of an Arab family with combined deficiency
of all vitamin K-dependent procoagulants and anticoagulants
[16]. The clinical presentation was bleeding tendency with
skin ecchymoses, starting soon after birth, and central
nervous system (CNS) bleeding was diagnosed at the age of
6 weeks. The prothrombin time (PT) and the activated partial
thromboplastin time (aPTT) were long, and no response to
1 mg of vitamin K was observed. Weekly treatment with
subcutaneous vitamin K (10 mg) was successful in preventing
bleeding episodes during a follow-up of several years [16].
Another mechanism by which a phenocopy of the warfarin
embryopathy due to a disorder of embryonic vitamin K
metabolism is produced by maternal vitamin K deficiency
[34]. Three unrelated infants presented with radiographic
punctate calcifications, nasal hypoplasia, and spinal abnorm-
alities. Additional anomalies included cupped ears in two
patients and one each with Dandy–Walker malformation with
hydrocephaly, congenital cataracts, and peripheral pulmonary
artery stenosis. The mothers of these three infants had chronic
intestinal malabsorption because of celiac disease, short bowel
syndrome, and the third mother had jejuno-ileal bypass.
Although protein S and protein C levels are low in VKCFD,
there are no reports of venous or arterial thrombosis. Thus,
the pendulum is clearly in the bleeding area, in resemblance
to vitamin K deficiency.
JCD 2009; 000:(000). Month 2009
Recently, a second phenotype associated with mutations in
GGCX has been discovered. While searching for candidate
genes in patients exhibiting a pseudoxanthoma elasticum-like
phenotype without mutations in the ABCC6 gene, Vanakker et
al [35] recognized as a common characteristic reduced levels
of vitamin K-dependent coagulation factors. Therefore, they
screened VKORC1 and GGCX for mutations and found
mutations in the GGCX gene in six out of seven patients
with this phenotype. In one case, a homozygous missense
mutation could be detected (p.Trp439Ser, c.1506 G.C),
while three patients showed compound heterozygous muta-
tions (p.Q374X, c.1149C.T; p.G537Y, c.1339G.T p.Q374X,
c.1149C.T; p.G537Y, c.1339G.T p.F299S, c.924T.C;
p.G558R, c.1700G.A) and two cases a single mutant allele
(p.Arg476Cys, c.1454C.T). The correlation between muta-
tions in GGCX and the observed PXE phenotype is still not
completely understood. In a first hypothesis, Vanakker et al
[35] speculate on insufficiently carboxylated osteocalcin and
matrix Gla protein, two important inhibitors of calcification,
which also need post-translational c carboxylation for full
biological activity. Therefore, the observed calcification and
subsequent fragmentation of elastic fibers responsible for the
PXE phenotype might result from inactive osteocalcin and
matrix Gla protein, unable to maintain calcium homoeos-
tasis. As a PXE phenotype is not observed in all patients
suffering from VKCFD1, a digenic inheritance including a
second unknown gene is most likely.
PHENOTYPE ANALYSIS
There is a wide phenotypic variation in all reported patients
with VKCFD. The clinical presentation of affected individuals
is usually mucocutaneous or intracranial bleeding, with or
without dysmorphic features, skeletal defects, or develop-
mental abnormalities. Propensity to thrombotic events is
theoretical and has not yet been reported. Laboratory
evaluation reveals normal platelet count, with markedly
prolonged PT and aPTT, which correct with normal plasma
mix. Vitamin K-dependent coagulation and anticoagulation
factor levels are reduced. Normal fasting serum KH2 allows
exclusion of acquired vitamin K deficiency or warfarin
exposure. After excluding other causes of vitamin K
deficiency, such as liver disease, malabsorption, and the
ingestion of several drugs (e.g., warfarin, anticonvulsants,
and antibiotics), genotyping for VORC1 and GGCX is
considered. The two genetic variants of this autosomal
recessive disorder share the same clinical phenotype, but
may be distinguished by measuring serum vitamin K epoxide.
Elevated levels are supportive for VKCFD type 2. Molecular
studies confirmed that carriers are asymptomatic.
GENETICS AND MOLECULAR BASIS
VKCFD arises from point mutations in the GGCX or VKOR
genes. As mentioned before, the gene for VKCFD type 1 that
encodes for GGCX was mapped to locus 2p12 (OMIM
#277450). A mutation in the GGCX gene (Leu394Arg) was
first identified in four affected members of an Arab family
[16]. Since then, several other mutations in the GGCX gene
2 www.slm-hematology.com

Table 1. Management of Patients with Vitamin K-Dependent Clotting Factor Deficiency
Reference Indication
[39] Prophylaxis
[16, 44] Minor bleeding
[9, 16, 39] Active bleeding, before surgical procedures
[38] Active bleeding, before surgical procedures
sc, subcutaneous; iv, intravenous; FFP, fresh frozen plasma; PCC, prothrombin complex concentrate.
have been reported: Trp501Ser [17], Arg485Pro [19], and
Asp31Asn+Trp157Arg+Thr591Lys [21]. The gene for VKCFD
type 2 that encodes for VKORC1 was mapped to locus 16p11.2
(OMIM #607473). There is only a single mutation that was
found in two unrelated index patients with VKCFD 2 and their
affected sibs, which was a homozygous mutation of the
VKORC1 nucleotide 292CRT, resulting in amino acid change
Arg98 to Trp [22, 26]. The rarity of the disease and the fact
that all mutations identified are missense mutations suggest
that complete deficiency is incompatible with life in humans,
as was shown in mice [36].
LABORATORY ANALYSIS
The routine administration of vitamin K1 to newborns may
present difficulties in establishing the diagnosis of VKCFD in
neonates. As discussed earlier, before genotyping for VORC1
and GGCX is performed, other differential diagnoses for
vitamin K deficiency should be ruled out. Those diagnoses
consist of liver disease, malabsorption, and ingestion of
warfarin, anticonvulsants, or antibiotics. Serum warfarin
assays may sometimes be necessary to exclude factitious
warfarin ingestion. It should be remembered that there are
cases of VKCFD with mild reduction in vitamin K-dependent
coagulation factors, which may also complicate the diagnosis
[18].
Prenatal diagnosis, although possible, is not indicated in
these disorders. The disease can be medically controlled with
no need for pregnancy termination, and no intrauterine
therapy is needed. PT and aPTT measured after birth can be
used as a screening test in suspected cases. No cases of
prenatal diagnosis have been published.
PRINCIPLES OF TREATMENT
Naturally, information on management of patients with
VKCFD is limited to case reports (Table 1). Most patients
with VKCFD show partial or complete improvement in
clotting factor activity, normalization of the PT and aPTT,
and resolution of bleeding symptoms with oral or parenteral
vitamin K1 [8, 11, 15, 16, 18, 37, 38]. In other cases, however,
vitamin K was ineffective [4, 9, 10]. No clear correlation exists
between responsiveness to vitamin K and clinical severity, or
with the molecular defect. Treatment with oral vitamin K is
therefore indicated in all patients at diagnosis, and should be
started as soon as possible [38]. In patients who show
insufficient response, there is limited experience of weekly
parenteral vitamin K1 (10 mg) [16, 39]. Caution is advised in
situations where vitamin K requirements rise and the risk of
www.slm-hematology.com
Congenital vitamin K-dependent coagulation factor deficiency
Dose Mode of administration Agent
10 mg/week Oral Vitamin K
10 mg sc/iv Vitamin K
15 cc/kg iv FFP
25–50 units/kg iv PCC
bleeding is higher, such as pregnancy with antiepileptic
medications without folic acid supplementation, the perinatal
period, infections, antibiotic treatment, and malabsorption.
In patients who have responded poorly to vitamin K1 and
require surgical procedures or have acute bleeding, factor
replacement is necessary. There is limited experience with the
use of fresh frozen plasma (FFP) in the treatment of acute
bleeding [9, 16, 38, 40]. The agent of choice is the virally
inactivated FFP product. Therapy should be monitored using
the PT or FVII activity assay because FVII has the shortest
half-life of all VKDCFs. As VKDCFD is a natural model that
resembles anticoagulation, there are lessons that can be
drawn. Prothrombin complex concentrates have been used
effectively in reversing warfarin anticoagulation and offer a
therapeutic option. These agents are an alternative to FFP
[41], but have been associated with thrombosis and
disseminated intravascular coagulopathy (DIC), and therefore
should be used with caution in some patients [42]. However,
in case of the need for rapid increase in clotting factor levels
due to severe bleeding or surgical procedure, use of the
prothrombin complex can be considered after proper
assessment of safety issues. A recently published report on
effective hemostasis during minor surgery in a case of
VKDCFD with the use of recombinant factor VIIa sheds light
on a new treatment options for these patients [43].
There is a single case report of treating a pregnancy
progressing to term in a patient with severe VKCFD managed
with oral vitamin K1 (15 mg) daily throughout pregnancy.
After delivery, bleeding from an episiotomy wound required
FFP [38].
In conclusion, VKCFD is an example of a rare disease, in
which elucidation of its molecular basis has led to the
understanding of much more common practical issues of
coumadin resistance and sensitivity.
Disclosure: The authors declare no conflict of interest.
REFERENCES
1. Furie B, Bochard BA, Furie BC. Vitamin K-dependent biosynthesis of
gamma-carboxyglutamic acid. Blood. 1999;93:1798–1808.
2. Mcmillan CW, Roberts HR. Congenital combined deficiency of coagula-
tion factors II, VII, IX and X. N Engl J Med.. 1966;274:1313–1315.
3. Fischer M, Zweymuller E. Kongenitaler Mangel der faktoren II, VII und X.
Zeitschr Kinderheikunde. 1966;95:309–323.
4. Johnson CA, Chung KS, Mcgrath KM, Bean PE, Roberts HR.
Characterization of a variant prothrombin in a patient congenitally
deficient in factors II, VII, IX and X. Br J Haematol. 1980;44:461–469.
5. Mickleson KN, Whyte G. Severe deficiency of vitamin K dependent
coagulation factors in an infant. NZ Med J. 1979;90:291–292.
3 JCD 2009; 000:(000). Month 2009
Journal of Coagulation Disorders
6. Thomas A, Stirling D. Four factor deficiency. Blood Coagul Fibrinolysis.
2003;14(Suppl 1):S55–S57.
7. Puetz J, Knutsen A, Bouhasin J. Congenital deficiency of vitamin K-
dependent coagulation factors associated with central nervous system
anomalies. Thromb Haemost. 2004;91:819–821.
8. Goldsmith GH Jr, Pence RE, Ratnhoff OD, Adelstein DJ, Furie B. Studies
on a family with combined functional deficiencies of vitamin K-
dependent coagulation factors. J Clin Invest. 1982;69:1253–1260.
9. Vincente V, Maia R, Alberca I, Tamagnini GPT, Lopez Borrasca A.
Congenital deficiency of vitamin K-dependent coagulation factors and
protein C. Thromb Haemost. 1984;51:343–346.
10. Ekelund H, Lindeberg L, Wranne L. Combined deficiency of coagulation
factors II, VII, IX and X: a case of probable congenital origin. Pediatr
Hematol Oncol. 1986;3:187–193.
11. Pauli RM, Lian JB, Mosher DF, Suttie JW. Association of congenital
deficiency of multiple vitamin K-dependent coagulation factors and the
phenotype of warfarin embryopathy: clues to the mechanism of
teratogenicity of coumarin derivates. Am J Hum Genet. 1987;41:566–583.
12. Leonar CO. Vitamin K responsive bleeding disorder: a genocopy of the
warfarin embryopathy. Proc Greenwood Genetic Center. 1988;7:165–166.
13. Pechlaner C, Vogel W, Erhart R, Pumpel E, Kunz F. A new case of
combined deficiency of vitamin K-dependent coagulation factors. Thromb
Haemost. 1992;68:617.
14. Ghosh K, Shetty S, Mohanty D. Inherited deficiency of multiple vitamin
K-dependent coagulation factors and coagulation Inhibitors presenting
as haemorrhagic diathesis, mental retardation and growth retardation.
Am J Hematol. 1996;52:67.
15. Boneh A, Bar-Ziv J. Hereditary deficiency of vitamin K-dependent
coagulation factors with skeletal abnormalities. Am J Med Genet. 1996;
65:241–243.
16. Brenner B, Sánchez-Vega B, Wu SM, Lanir N, Stafford DW, Solera J. A
missense mutation in gamma-glutamyl carboxylase gene causes com-
bined deficiency of all vitamin K-dependent blood coagulation factors.
Blood. 1998;92:4554–4559.
17. Spronk HM, Farah RA, Buchanan GR, Vermeer C, Soute BA. Novel
mutation in the gamma-glutamyl carboxylase gene resulting in
congenital combined of all vitamin K-dependent blood coagulation
factors. Blood. 2000;96:3650–3652.
18. Oldenburg J, von Bredelow B, Fregin A, et al. Congenital deficiency of
vitamin K-dependent coagulation factors in two families presents as a
genetic defect of the vitamin K–epoxide–reductase-complex. Thromb
Haemost. 2000;84:937–941.
19. Rost S, Fregin A, Koch D, Compes M, Muller CR, Oldenburg J.
Compound heterozygous mutations in the gamma-glutamyl carboxylase
gene cause combined deficiency of all vitamin K-dependent blood
coagulation factors. Br J Haematol. 2004;126:546–549.
20. Bhattacharyya J, Dutta P, Mishra P, et al. Congenital vitamin K-dependent
coagulation factor deficiency: a case report. Blood Coagul Fibrinolysis. 2005;
16:525–527.
21. Darghouth D, Hallgren KW, Shtofman RL, et al. Compound hetero-
zygosity of novel missense mutations in the gamma-glutamyl-carboxylase
gene causes hereditary combined vitamin K-dependent coagulation factor
deficiency. Blood. 2006;108:1925–1931.
22. Marchetti G, Caruso P, Lunghi B, et al. Vitamin K-induced modification
of coagulation phenotype in VKORC1 homozygous deficiency. J Thromb
Haemost. 2008;6:797–803.
23. Brenner B, Kuperman AA, Watzka M, Oldenburg J. Vitamin K-dependent
coagulation factors deficiency. Semin Thromb Hemost. 2009;35(4)439–46.
24. Kuo WL, Stafford DW, Cruces J, Gray J, Solera J. Chromosomal
localization of the gamma-glutamyl carboxylase gene at 2p12. Genomics.
1995;25:746–748.
25. Fregin A, Rost S, Woltz W, Krebsova A, Muller CR, Oldenburg J.
Homozygosity mapping of a second gene locus for hereditary combined
deficiency of vitamin K-dependent clotting factors to the centromeric
region of chromosome 16. Blood. 2002;100:3229–3232.
26. Rost S, Fregin A, Ivaskevicius V, et al. Mutations in VKORC1 cause
warfarin resistance and multiple coagulation factor deficiency type 2.
Nature. 2004;427:537–541.
27. Soute BAM, Ulrich MMW, Watson ADJ, et al. Congenital deficiency of all
vitamin K-dependent blood coagulation factors due to a defective vitamin
JCD 2009; 000:(000). Month 2009
K-dependent carboxylase in Devon Rex cats. Thromb Haemost. 1992;68:
521–525.
28. Rieder MJ, Reiner AP, Gage BF, et al. Effect of VKORC1 haplotypes on
transcriptional regulation and warfarin dose. N Engl J Med. 2005;352:
2285–2293.
29. Yuan HY, Chen JJ, Lee MT, et al. A novel functional VKORC1 promoter
polymorphism is associated with inter-individual and inter-ethnic
differences in warfarin sensitivity. Hum Mol Genet. 2005;14:1745–1751.
30. Schwartz UI, Ritchie MD, Bradford Y, et al. Genetic determinants of
response to warfarin during initial anticoagulation. N Engl J Med. 2008;
358:999–1008.
31. Lippi G, Franchini M, Favaloro EJ. Pharmacogenetics of vitamin K
antagonists: useful or hype? Clin Chem Lab Med. 2009;47:503–515.
32. Yang L, Ge W, Yu F, Zhu H. Impact of VKORC1 gene polymorphism on
interindividual and interethnic warfarin dosage requirement. A systematic
review and meta analysis. Thromb Res. 2009 Nov 24 [Epub ahead of print].
33. Zhu A, Sun H, Raymond R, et al. Fatal hemorrhage in mice lacking c-
glutamyl carboxylase. Blood. 2007;109:5270–5275.
34. Menger H, Lin AE, Toriello HV, Bernert G, Spranger JW. Vitamin K
deficiency embryopathy: a phenocopy of the warfarin embryopathy due to
a disorder of embryonic vitamin K metabolism. Am J Med Genet. 1997;72:
129–134.
35. Vanakker OM, Martin L, Gheduzzi D, et al. Pseudoxanthoma elasticum-
like phenotype with cutis laxa and multiple coagulation factor deficiency
represents a separate genetic entity. J Invest Dermatol. 2007;127:581–587.
36. Zhang B, Ginsburg D. Familial multiple coagulation factor deficiencies:
new biologic insight from rare genetic bleeding disorders. J Thromb
Haemost. 2004;2:1564–1572.
37. Mousallem M, Spronk HM, Sacy R, Hakime N, Soute BA. Congenital
combined deficiencies of all vitamin K-dependent coagulation factors.
Thromb Haemost. 2001;86:1334–1336.
38. McMahon MJ, James AH. Combined deficiency of factors II, VII, IX, and X
(Borgschulte–Grigsby deficiency) in pregnancy. Obstet Gynecol. 2001;97:
808–809.
39. Chu PH, Huang TY, Williams J, Stafford DW. Purified vitamin K epoxide
reductase alone is sufficient for conversion of vitamin K epoxide to
vitamin K and vitamin K to vitamin KH2. Proc Natl Acad Sci USA. 2006;103:
19308–19313.
40. Bolton-Maggs PH, Perry DJ, Chalmers EA. The rare coagulation
disorders—review with guidelines for management from the United
Kingdom Haemophilia Centre Doctors’ Organization. Hemophilia. 2004;
10:593–628.
41. Scott LJ. Prothrombin complex concentrate (Beriplex P/N). Drugs. 2009;
69(14)1977–1984.
42. Kohler M. Thrombogenicity of prothrombin complex concentrates.
Thromb Res. 1999;95:S13–S17.
43. Lapecorella M, Napolitano M, Bernardi F, et al. Effective hemostasis
during minor surgery in a case of hereditary combined deficiency of
vitamin K-dependent clotting factors. Clin Appl Thromb Hemost. 2009 Jan 13
[Epub ahead of print].
44. Rost S, Fregin A, Hünerberg M, Bevans CG, Müller CR, Oldenburg J. Site-
directed mutagenesis of coumarin-type anticoagulant-sensitive VKORC1:
evidence that highly conserved amino acids define structural require-
ments for enzymatic activity and inhibition by warfarin. Thromb Haemost.
2005;94:780–786.
4 www.slm-hematology.com