Background and Methods: Association studies using unrelated individuals cannot detect intergenerational genetic effects contributing to disease. To detect these effects, we improve the extended maternal-fetal genotype (EMFG) incompatibility test to estimate any combination of maternal effects, offspring effects, and their interactions at polymorphic loci or multiple SNPs, using any size pedigrees. We explore the advantages of using extended pedigrees rather than nuclear families. We apply our methods to schizophrenia pedigrees to investigate whether the previously associated mother-daughter HLA-B matching is a genuine risk or the result of bias. Results: Simulations demonstrate that using the EMFG test with extended pedigrees increases power and precision, while partitioning extended pedigrees into nuclear families can underestimate intergenerational effects. Application to actual data demonstrates that mother-daughter HLA-B matching remains a schizophrenia risk factor. Furthermore, ascertainment and mate selection biases cannot by themselves explain the observed HLA-B matching and schizophrenia association. Conclusions: Our results demonstrate the power of the EMFG test to examine intergenerational genetic effects, highlight the importance of pedigree rather than case/control or case-mother/control-mother designs, illustrate that pedigrees provide a means to examine alternative, non-causal mechanisms, and they strongly support the hypothesis that HLA-B matching is causally involved in the etiology of schizophrenia in females.
© 2011 S. Karger AG, Basel
- Family-based association
- Maternal-fetal genotype test
- Extended maternal-fetal genotype test
- Genotype interactions
- Complex disease
- Olfactory deficits
- Major histocompatibility complex
- Hindorff LA, Sethupathy P, Junkins HA, Ramos EM, Mehta JP, Collins FS, Manolio TA: Potential etiologic and functional implications of genome-wide association loci for human diseases and traits. Proc Natl Acad Sci USA 2009;106:9362–9367.
- Visscher PM, Hill WG, Wray NR: Heritability in the genomics era – concepts and misconceptions. Nat Rev Genet 2008;9:255–266.
- Manolio TA, Collins FS, Cox NJ, Goldstein DB, Hindorff LA, Hunter DJ, McCarthy MI, Ramos EM, Cardon LR, Chakravarti A, Cho JH, Guttmacher AE, Kong A, Kruglyak L, Mardis E, Rotimi CN, Slatkin M, Valle D, Whittemore AS, Boehnke M, Clark AG, Eichler EE, Gibson G, Haines JL, Mackay TF, McCarroll SA, Visscher PM: Finding the missing heritability of complex diseases. Nature 2009;461:747–753.
- Maher B: Personal genomes: the case of the missing heritability. Nature 2008;456:18–21.
- Eichler EE, Flint J, Gibson G, Kong A, Leal SM, Moore JH, Nadeau JH: Missing heritability and strategies for finding the underlying causes of complex disease. Nat Rev Genet 2010;11:446–450.
- Zhou J, Pelka S, Lange K, Palmer CGS, Sinsheimer JS: Dissecting prenatal, postnatal, and inherited effects: ART and design. Genet Epidemiol 2011;35:437–446.
- Chen JB, Zheng HT, Wilson ML: Likelihood ratio tests for maternal and fetal genetic effects on obstetric complications. Genet Epidemiol 2009;33:526–538.
- Childs EJ, Palmer CGS, Lange K, Sinsheimer JS: Modeling maternal-offspring gene-gene interactions: the extended-MFG test. Genet Epidemiol 2010;34:512–521.
- Cordell HJ: Properties of case/pseudocontrol analysis for genetic association studies: effects of recombination/ascertainment, and multiple affected offspring. Genet Epidemiol 2004;26:186–205.
- Cordell HJ: Estimation and testing of gene-environment interactions in family-based association studies. Genomics 2009;93:5–9.
- Cordell HJ, Barratt BJ, Clayton DG: Case/pseudocontrol analysis in genetic association studies: a unified framework for detection of genotype and haplotype associations, gene-gene and gene-environment interactions, and parent-of-origin effects. Genet Epidemiol 2004;26:167–185.
- Cordell HJ, Clayton DG: Genetic epidemiology 3 – genetic association studies. Lancet 2005;366:1121–1131.
- Gjessing HK, Lie RT: Case-parent triads: estimating single- and double-dose effects of fetal and maternal disease gene haplotypes. Ann Hum Genet 2006;70:382–396.
- Hsieh HJ, Palmer CGS, Harney S, Newton JL, Wordsworth P, Brown MA, Sinsheimer JS: The v-MFG test: investigating maternal, offspring and maternal-fetal genetic incompatibility effects on disease and viability. Genet Epidemiol 2006;30:333–347.
- Hsieh HJ, Palmer CGS, Sinsheimer JS: Allowing for missing data at highly polymorphic genes when testing for maternal, offspring and maternal-fetal genotype incompatibility effects. Hum Hered 2006;62:165–174.
- Kraft P, Hsieh HJ, Cordell HJ, Sinsheimer J: A conditional-on-exchangeable-parental-genotypes likelihood that remains unbiased at the causal locus under multiple-affected-sibling ascertainment. Genet Epidemiol 2005;29:87–90.
- Kraft P, Palmer CGS, Woodward AJ, Turunen JA, Minassian S, Paunio T, Lonnqvist J, Peltonen L, Sinsheimer JS: RHD maternal-fetal genotype incompatibility and schizophrenia: extending the MFG test to include multiple siblings and birth order. Eur J Hum Genet 2004;12:192–198.
- Li S, Lu Q, Fu W, Romero R, Cui Y: A regularized regression approach for dissecting genetic conflicts that increase disease risk in pregnancy. Stat Appl Genet Mol Biol 2009;8:Article 45.
- Minassian SL, Palmer CGS, Sinsheimer JS: An exact maternal-fetal genotype incompatibility (MFG) test. Genet Epidemiol 2005;28:83–95.
- Minassian SL, Palmer CGS, Turunen JA, Paunio T, Lonnqvist J, Peltonen L, Woodward JA, Sinsheimer JS: Incorporating serotypes into family based association studies using the MFG test. Ann Hum Genet 2006;70:541–553.
- Parimi N, Tromp G, Kuivaniemi H, Nien JK, Gomez R, Romero R, Goddard KA: Analytical approaches to detect maternal/fetal genotype incompatibilities that increase risk of pre-eclampsia. BMC Med Genet 2008;9:60.
- Sinsheimer JS, Elston RC, Fu WJ: Gene-gene interaction in maternal and perinatal research. J Biomed Biotechnol 2010;2010:853612.
- Sinsheimer JS, Palmer CGS, Woodward JA: Detecting genotype combinations that increase risk for disease: the maternal-fetal genotype incompatibility test. Genet Epidemiol 2003;24:1–13.
- Weinberg CR, Wilcox AJ, Lie RT: A log-linear approach to case-parent-triad data: assessing effects of disease genes that act either directly or through maternal effects and that may be subject to parental imprinting. Am J Hum Genet 1998;62:969–978.
- McGuffin P, Gottesman II: Risk factors for schizophrenia. N Engl J Med 1999;341:370–371.
- Wray NR, Visscher PM: Narrowing the boundaries of the genetic architecture of schizophrenia. Schizophr Bull 2010;36:14–23.
- Cannon M, Jones PB, Murray RM: Obstetric complications and schizophrenia: historical and meta-analytic review. Am J Psychiatry 2002;159:1080–1092.
- Cannon TD, Rosso IM, Hollister JM, Bearden CE, Sanchez LE, Hadley T: A prospective cohort study of genetic and perinatal influences in the etiology of schizophrenia. Schizophr Bull 2000;26:351–366.
- Dalman C, Allebeck P, Cullberg J, Grunewald C, Koster M: Obstetric complications and the risk of schizophrenia – a longitudinal study of a national birth cohort. Arch Gen Psychiatry 1999;56:234–240.
- Geddes JR, Verdoux H, Takei N, Lawrie SM, Bovet P, Eagles JM, Heun R, McCreadie RG, McNeil TF, O’Callaghan E, Stober G, Willinger U, Murray RM: Schizophrenia and complications of pregnancy and labor: an individual patient data meta-analysis. Schizophr Bull 1999;25:413–423.
- Kendell RE, Juszczak E, Cole SK: Obstetric complications and schizophrenia: a case control study based on standardised obstetric records. Br J Psychiatry 1996;168:556–561.
- Nicodemus KK, Marenco S, Batten AJ, Vakkalanka R, Egan MF, Straub RE, Weinberger DR: Serious obstetric complications interact with hypoxia-regulated/vascular-expression genes to influence schizophrenia risk. Mol Psychiatry 2008;13:873–877.
- Rifkin L, Lewis S, Jones P, Toone B, Murray R: Low birth weight and schizophrenia. Br J Psychiatry 1994;165:357–362.
- Palmer CGS, Hsieh HJ, Reed EF, Lonnqvist J, Peltonen L, Woodward JA, Sinsheimer JS: HLA-B maternal-fetal genotype matching increases risk of schizophrenia. Am J Hum Genet 2006;79:710–715.
- Palmer CG: Evidence for maternal-fetal genotype incompatibility as a risk factor for schizophrenia. J Biomed Biotechnol 2010;2010:576318.
- Brewer WJ, Wood SJ, Pantelis C, Berger GE, Copolov DL, McGorry PD: Olfactory sensitivity through the course of psychosis: relationships to olfactory identification, symptomatology and the schizophrenia odour. Psychiatry Res 2007;149:97–104.
- Cumming AG, Matthews NL, Park S: Olfactory identification and preference in bipolar disorder and schizophrenia. Eur Arch Psychiatry Clin Neurosci 2011;261:251–259.
- Ishizuka K, Tajinda K, Colantuoni C, Morita M, Winicki J, Le C, Lin S, Schretlen D, Sawa A, Cascella NG: Negative symptoms of schizophrenia correlate with impairment on the University of Pennsylvania smell identification test. Neurosci Res 2010;66:106–110.
- Kopala LC, Good KP, Morrison K, Bassett AS, Alda M, Honer WG: Impaired olfactory identification in relatives of patients with familial schizophrenia. Am J Psychiatry 2001;158:1286–1290.
- Moberg PJ, Agrin R, Gur RE, Gur RC, Turetsky BI, Doty RL: Olfactory dysfunction in schizophrenia: a qualitative and quantitative review. Neuropsychopharmacology 1999;21:325–340.
- Strauss GP, Allen DN, Ross SA, Duke LA, Schwartz J: Olfactory hedonic judgment in patients with deficit syndrome schizophrenia. Schizophr Bull 2010;36:860–868.
- Turetsky BI, Kohler CG, Gur RE, Moberg PJ: Olfactory physiological impairment in first-degree relatives of schizophrenia patients. Schizophr Res 2008;102:220–229.
- Santos PSC, Schinemann JA, Gabardo J, Bicalho MD: New evidence that the MHC influences odor perception in humans: a study with 58 Southern Brazilian students. Horm Behav 2005;47:384–388.
- Wedekind C, Furi S: Body odour preferences in men and women: do they aim for specific MHC combinations or simply heterozygosity? Proc Biol Sci 1997;264:1471–1479.
- Wedekind C, Seebeck T, Bettens F, Paepke AJ: MHC-dependent mate preferences in humans. Proc Biol Sci 1995;260:245–249.
- Havlicek J, Roberts SC: MHC-correlated mate choice in humans: a review. Psychoneuroendocrinology 2009;34:497–512.
- Jacob S, McClintock MK, Zelano B, Ober C: Paternally inherited HLA alleles are associated with women’s choice of male odor. Nat Genet 2002;30:175–179.
- Lie HC, Simmons LW, Rhodes G: Genetic dissimilarity, genetic diversity, and mate preferences in humans. Evol Hum Behav 2010;31:48–58.
- Roberts SC, Gosling LM, Carter V, Petrie M: MHC-correlated odour preferences in humans and the use of oral contraceptives. Proc Biol Sci 2008;275:2715–2722.
- Thornhill R, Gangestad SW, Miller R, Scheyd G, McCollough JK, Franklin M: Major histocompatibility complex genes, symmetry, and body scent attractiveness in men and women. Behav Ecol 2003;14:668–678.
- Derti A, Cenik C, Kraft P, Roth FP: Absence of evidence for MHC-dependent mate selection within hapmap populations. PLoS Genet 2010;6:e1000925.
- Ekelund J, Hovatta I, Parker A, Paunio T, Varilo T, Martin R, Suhonen J, Ellonen P, Chan GY, Sinsheimer JS, Sobel E, Juvonen H, Arajarvi R, Partonen T, Suvisaari J, Lonnqvist J, Meyer J, Peltonen L: Chromosome 1 loci in Finnish schizophrenia families. Hum Mol Genet 2001;10:1611–1617.
- Ekelund J, Lichtermann D, Hovatta I, Ellonen P, Suvisaari J, Terwilliger JD, Juvonen H, Varilo T, Arajarvi R, Kokko-Sahin ML, Lonnqvist J, Peltonen L: Genome-wide scan for schizophrenia in the Finnish population: evidence for a locus on chromosome 7q22. Hum Mol Genet 2000;9:1049–1057.
- Hovatta I, Varilo T, Suvisaari J, Terwilliger JD, Ollikainen V, Arajarvi R, Juvonen H, Kokko-Sahin ML, Vaisanen L, Mannila H, Lonnqvist J, Peltonen L: A genomewide screen for schizophrenia genes in an isolated Finnish subpopulation, suggesting multiple susceptibility loci. Am J Hum Genet 1999;65:1114–1124.
- Paunio T, Ekelund J, Varilo T, Parker A, Hovatta I, Turunen JA, Rinard K, Foti A, Terwilliger JD, Juvonen H, Suvisaari J, Arajarvi R, Suokas J, Partonen T, Lonnqvist J, Meyer J, Peltonen L: Genome-wide scan in a nationwide study sample of schizophrenia families in Finland reveals susceptibility loci on chromosomes 2q and 5q. Hum Mol Genet 2001;10:3037–3048.
- American Psychiatric Association Task Force on DSM-IV: Diagnostic and Statistical Manual of Mental Disorders: DSM-IV, ed 4. Washington, DC, American Psychiatric Association, 1994.
- Blin N, Stafford DW: A general method for isolation of high molecular weight DNA from eukaryotes. Nucleic Acids Res 1976;3:2303–2308.
- Lange K, Sinsheimer JS: The pedigree trimming problem. Hum Hered 2004;58:108–111.
- Lange K, Cantor R, Horvath S, Perola M, Sabatti C, et al: MENDEL version 4.0: a complete package for the exact genetic analysis of discrete traits in pedigree and population data sets. Am J Hum Genet 2001;69 (suppl):504.
- Sobel E, Papp JC, Lange K: Detection and integration of genotyping errors in statistical genetics. Am J Hum Genet 2002;70:496–508.
- Zhou JJ, Lange K, Papp JC, Sinsheimer JS: A heterozygote-homozygote test of Hardy-Weinberg equilibrium. Eur J Hum Genet 2009;17:1495–1500.
- Lange K: Mathematical and Statistical Methods for Genetic Analysis, ed 2. New York, Springer, 2002.
- Clayton D: A generalization of the transmission/disequilibrium test for uncertain-haplotype transmission. Am J Hum Genet 1999;65:1170–1177.
- Ober C, Hyslop T, Elias S, Weitkamp LR, Hauck WW: Human leukocyte antigen matching and fetal loss: results of a 10 year prospective study. Hum Reprod 1998;13:33–38.
- Lange K, Sinsheimer JS, Sobel E: Association testing with Mendel. Genet Epidemiol 2005;29:36–50.
- Schreuder GMT, Hurley CK, Marsh SGE, Lau M, Maiers M, Kollman C, Noreen HJ: The HLA dictionary 2001: a summary of HLA-A, -B, -C, -DRB1/3/4/5 and -DQB1 alleles and their association with serologically defined HLA-A, -B, -C, -DR and -DQ antigens. Eur J Immunogenet 2001;28:565–596.
- Sinsheimer JS, McKenzie CA, Keavney B, Lange K: SNPs and snails and puppy dogs’ tails: analysis of SNP haplotype data using the gamete competition model. Ann Hum Genet 2001;65:483–490.
- Nunes SOV, Borelli SD, Matsuo T, Watanabe MAE, Itano EN: The association of the HLA in patients with schizophrenia, schizoaffective disorder, and in their biological relatives. Schizophr Res 2005;76:195–198.
- Nelis M ET, Magi R, Zimprich F, Zimprich A, Toncheva D, Karachanak S, Piskackova T, Balascak I, Peltonen L, Jakkula E, Rehnstrom K, Lathrop M, Heath S, Galan P, Schreiber S, Meitinger T, Pfeufer A, Wichmann HE, Melegh B, Polgar N, Toniolo D, Gasparini P, D’Adamo P, Klovins J, Nikitina-Zake L, Kucinskas V, Kasnauskiene J, Lubinski J, Debniak T, Limborska S, Khrunin A, Estivill X, Rabionet R, Marsal S, Julia A, Antonarakis SE, Deutsch S, Borel C, Attar H, Gagnebin M, Macek M, Krawczak M, Remm M, Metspalu A: Genetic structure of Europeans: a view from the North-East. PLoS One 2009;4:e5472.
- Tian C KR, Nassir R, Lee A, Villoslada P, Klareskog L, Hammarstrom L, Garchon HJ, Pulver AE, Ransom M, Gregersen PK, Seldin MF: European population genetic substructure: further definition of ancestry informative markers for distinguishing among diverse European ethnic groups. Mol Med 2009;15:371–383.
- Vatten LJ, Skjaerven R: Offspring sex and pregnancy outcome by length of gestation. Early Hum Dev 2004;76:47–54.
- Beydoun H, Saftlas AF: Association of human leucocyte antigen sharing with recurrent spontaneous abortions. Tissue Antigens 2005;65:123–135.
- Bolis PF, Bianchi MM, Lafianza A, Franchi M, Belvedere MC: Immunogenetic aspects of preeclampsia. Biol Res Pregnancy Perinatol 1987;8:42–45.
- Fujisawa S: HLA antigens-antibodies system and its association with severe toxemia of pregnancy. Nippon Sanka Fujinka Gakkai Zasshi 1985;37:124–130.
- Moghraby JS, Tamim H, Anacan V, Al Khalaf H, Moghraby SA: HLA sharing among couples appears unrelated to idiopathic recurrent fetal loss in Saudi Arabia. Hum Reprod 2010;25:1900–1905.
- Ober C: HLA and pregnancy: the paradox of the fetal allograft. Am J Hum Genet 1998;62:1–5.
- Ober CL, Martin AO, Simpson JL, Hauck WW, Amos DB, Kostyu DD, Fotino M, Allen FH: Shared HLA antigens and reproductive performance among Hutterites. Am J Hum Genet 1983;35:994–1004.
- Schneider K, Knutson F, Tamsen L, Sjoberg O: HLA antigen sharing in preeclampsia. Gynecol Obstet Invest 1994;37:87–90.
- Unander AM, Olding LB: Habitual abortion: parental sharing of HLA antigens, absence of maternal blocking antibody, and suppression of maternal lymphocytes. Am J Reprod Immunol 1983;4:171–178.
- Astolfi P, Cuccia M, Caruso C, Favoino B, Fazzari M, Mantovani V, Lulli P, Illeni MT, Martinetti M: Sharing at the major histocompatibility complex affects the secondary sex ratio in differing ways. Hum Hered 1996;46:155–165.
- Brunori ID, Battini L, Simonelli M, Clemente F, Brunori E, Mariotti ML, Genazzani AR: Increased HLA-DR homozygosity associated with pre-eclampsia. Hum Reprod 2000;15:1807–1812.
- Cowan LD, Hudson L, Bobele G, Chancellor I, Baker J: Maternal-fetal HLA sharing and risk of newborn encephalopathy and seizures: a pilot study. J Child Neurol 1994;9:173–177.
- Larizza D, Martinetti M, Dugoujon JM, Tinelli C, Calcaterra V, Cuccia M, Salvaneschi L, Severi F: Parental GM and HLA genotypes and reduced birth weight in patients with Turner’s syndrome. J Pediatr Endocrinol Metab 2002;15:1183–1190.
- Montgomery GW, Zhu G, Hottenga JJ, Duffy DL, Heath AC, Boomsma DI, Martin NG, Visscher PM: HLA and genomewide allele sharing in dizygotic twins. Am J Hum Genet 2006;79:1052–1058.
- Ober C, Simpson JL, Ward M, Radvany RM, Andersen R, Elias S, Sabbagha R: Prenatal effects of maternal-fetal HLA compatibility. Am J Reprod Immunol Microbiol 1987;15:141–149.
- Reznikoff-Etievant MF, Bonneau JC, Alcalay D, Cavelier B, Toure C, Lobet R, Netter A: HLA antigen-sharing in couples with repeated spontaneous abortions and the birthweight of babies in successful pregnancies. Am J Reprod Immunol 1991;25:25–27.
- Verp MS, Sibul M, Billstrand C, Belen G, Hsu M, Ober C: Maternal-fetal histocompatibility in intrauterine growth retarded and normal weight babies. Am J Reprod Immunol 1993;29:195–198.
- Zollner S, Wen XQ, Hanchard NA, Herbert MA, Ober C, Pritchard JK: Evidence for extensive transmission distortion in the human genome. Am J Hum Genet 2004;74:62–72.
- Buka SL, Tsuang MT, Lipsitt LP: Pregnancy/delivery complications and psychiatric diagnosis. A prospective study. Arch Gen Psychiatry 1993;50:151–156.
- Brown AS, Susser ES, Butler PD, Andrews RR, Kaufmann CA, Gorman JM: Neurobiological plausibility of prenatal nutritional deprivation as a risk factor for schizophrenia. J Nerv Ment Dis 1996;184:71–85.
- Hulshoff HE, Hoek HW, Susser E, Brown AS, Dingemans A, Schnack HG, van Haren NEM, Ramos LMP, Gispen-de Wied CC, Kahn RS: Prenatal exposure to famine and brain morphology in schizophrenia. Am J Psychiatry 2000;157:1170–1172.
- St Clair D, Xu MQ, Wang P, Yu YQ, Fang YR, Zhang F, Zheng XY, Gu NF, Feng GY, Sham P, He L: Rates of adult schizophrenia following prenatal exposure to the Chinese famine of 1959–1961. JAMA 2005;294:557–562.
- Susser ES, Lin SP: Schizophrenia after prenatal exposure to the Dutch Hunger Winter of 1944–1945. Arch Gen Psychiatry 1992;49:983–988.
- Xu MQ, Sun WS, Liu BX, Feng GY, Yu L, Yang L, He G, Sham P, Susser E, St Clair D, He L: Prenatal malnutrition and adult schizophrenia: further evidence from the 1959–1961 Chinese famine. Schizophr Bull 2009;35:568–576.
- Cudihy D, Lee RV: The pathophysiology of pre-eclampsia: current clinical concepts. J Obstet Gynaecol 2009;29:576–582.
- Hanson DR, Gottesman II: Theories of schizophrenia: a genetic-inflammatory-vascular synthesis. BMC Med Genet 2005;6:7.
- Huleihel M, Golan H, Hallak M: Intrauterine infection/inflammation during pregnancy and offspring brain damages: possible mechanisms involved. Reprod Biol Endocrinol 2004;2:17.
Christina Palmer, PhD
UCLA Semel Institute
760 Westwood Plaza, Room 47-422, Los Angeles, CA 90095 (USA)
Tel. +1 310 794 4796, E-Mail email@example.com
Janet Sinsheimer, PhD
UCLA Gonda Center
695 Charles E. Young Drive South, 5357-C
Los Angeles, CA 90095 (USA)
Tel. +1 310 825 8002, E-Mail firstname.lastname@example.org
C.G.S. Palmer and J.S. Sinsheimer contributed equally to this work.
Received: June 2, 2011
Accepted after revision: August 23, 2011
Published online: October 15, 2011
Number of Print Pages : 12
Number of Figures : 1, Number of Tables : 5, Number of References : 97
Human Heredity (International Journal of Human and Medical Genetics)
Vol. 72, No. 3, Year 2011 (Cover Date: November 2011)
Journal Editor: Devoto M. (Philadelphia, Pa./Rome)
ISSN: 0001-5652 (Print), eISSN: 1423-0062 (Online)
For additional information: http://www.karger.com/HHE
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