Fourteen Percent of Healthy African Americans Participating In the Zimmerman Program for the Molecular and Clinical Biology of VWD (ZPMCB VWD) Are Heterozygous for the VWF Gene Mutation H817Q Associated with Type 2N Von Willebrand Disease

Abstract 239

Von Willebrand disease (VWD) is a common hereditary bleeding disorder caused by reduced concentration or abnormal structure/function of von Willebrand Factor (VWF). Most published studies of normal VWF have been carried out in European or North American subjects without regard to racial differences. In the process of studying healthy controls in the Zimmerman Program for the Molecular and Clinical Biology of VWD (ZPMCB-VWD), we identified a common polymorphism (D1472H) in the VWF A1-domain in African Americans that affects the measurement of VWF function by ristocetin cofactor (VWF:RCo) but does not appear associated with increased bleeding risk. We therefore explored whether other polymorphisms or mutations were identified more frequently in African Americans. VWF sequencing was performed on 191 healthy controls including 66 that were self-identified as African American. European Bleeding Score was obtained and normal in all healthy subjects. Among the African Americans, 9 individuals were heterozygous for the reported type 2N H817Q mutation and one was homozygous. Factor VIII binding to VWF (VWF:F8B) was determined with a standard FVIII binding assay using the subject's plasma VWF and recombinant FVIII. The VWF:F8B was significantly reduced in H817Q heterozygotes when compared to 10 healthy study subjects without the H817Q mutation (65 ± 11 versus 108 ± 11, p=0.003). The VWF:F8B was further reduced to 37 using the plasma VWF from the homozygous H817Q subject. However, the observed VWF:F8B in these individuals with H817Q are still considerably higher that that observed in patients enrolled in ZPMCB-VWD that are either homozygous or compound heterozygous with the common R854Q type 2N VWD (VWF:F8B < 13). Of the 116 self-identified Caucasian healthy subjects, none had the H817Q mutation, but 3 were heterozygous for the R854Q mutation; their mean plasma VWF:F8B was reduced to 51. While the homozygous R854Q patients had reduced plasma FVIII levels (mean FVIII=24 IU/dL), none of the sequenced healthy control subjects had plasma FVIII levels below 53 IU/dL, Some have advocated FVIII/VWF:Ag ratios as a screen for type 2N VWD. The subject with homozygous H817Q had only a mildly reduced FVIII/VWF:Ag ratio (0.59), while the heterozygous H817Q were not reduced (mean=0.90), thereby demonstrating that the VWF:F8B assay has greater sensitivity for type 2N VWF binding defects than the FVIII/VWF:Ag ratio. Since the previously reported A1-domain D1472H polymorphism was common in African Americans, we explored the prevalence of this polymorphism in the healthy subjects with the H817Q mutation. All H817Q heterozygous subjects were either homozygous (4) or heterozygous (5) for the D1472H polymorphism. The one individual who was H817Q homozygous was also D1472H homozygous, suggesting that there may be an extended haplotype present in African Americans. In summary, an H817Q type 2N mutation is commonly found in healthy African American subjects with an allele frequency of 0.083, predicting that approximately 7 in 1,000 African Americans would be homozygous for the H817Q type 2N mutation. Our data, and the rarity of diagnosis of type 2N VWD in African Americans suggests that while mutation H817Q may interfere with the interaction of FVIII with VWF, this mutation appears to confer little or no clinical symptoms.