Association of the transthyretin variant V122I with polyneuropathy among individuals of African ancestry

Hereditary transthyretin-mediated (hATTR) amyloidosis is an underdiagnosed, progressively debilitating disease caused by mutations in the transthyretin (TTR) gene. V122I, a common pathogenic TTR mutation, is found in 3-4% of individuals of African ancestry in the United States and has been associated with cardiomyopathy and heart failure. To better understand the phenotypic consequences of carrying V122I, we conducted a phenome-wide association study scanning 427 ICD diagnosis codes in UK Biobank participants of African ancestry (n=6062). Significant associations were tested for replication in the Penn Medicine Biobank (n=5737) and the Million Veteran Program (n=82,382). V122I was significantly associated with polyneuropathy in the UK Biobank (odds ratio [OR]=6.4, 95% confidence interval [CI] 2.6-15.6, p=4.2x10(-5)), which was replicated in the Penn Medicine Biobank (OR=1.6, 95% CI 1.2-2.4, p=6.0x10(-3)) and Million Veteran Program (OR=1.5, 95% CI 1.2-1.8, p=1.8x10(-4)). Polyneuropathy prevalence among V122I carriers was 2.1%, 9.0%, and 4.8% in the UK Biobank, Penn Medicine Biobank, and Million Veteran Program, respectively. The cumulative incidence of common hATTR amyloidosis manifestations (carpal tunnel syndrome, polyneuropathy, cardiomyopathy, heart failure) was significantly enriched in V122I carriers compared with non-carriers (HR=2.8, 95% CI 1.7-4.5, p=2.6x10(-5)) in the UK Biobank, with 37.4% of V122I carriers having at least one of these manifestations by age 75. Our findings show that V122I carriers are at increased risk of polyneuropathy. These results also emphasize the underdiagnosis of disease in V122I carriers with a significant proportion of subjects showing phenotypic changes consistent with hATTR amyloidosis. Greater understanding of the manifestations associated with V122I is critical for earlier diagnosis and treatment.