Characterization of Type 2N Von Willebrand Disease Mutations Using Ιn Vitro and Ιn Vivo Mouse Models

Introduction: Von Willebrand factor (VWF) is a multimeric glycoprotein that serves as the carrier for the essential coagulation cofactor, factor VIII (FVIII). Both plasma levels of VWF and its FVIII-binding ability can influence plasma levels of FVIII. Type 2N von Willebrand disease (VWD) is associated with a reduced binding affinity of VWF for FVIII, resulting in accelerated proteolysis and clearance of FVIII (plasma levels 5 – 30% of normal). Type 2N VWD is a recessive trait and patients are either homozygous or compound heterozygous for 2N alleles. We hypothesize that type 2N VWD mutations can alter the expression and FVIII-binding ability of VWF. In these studies, we characterize three type 2N VWD mutations in vitro and in a murine model. R854Q (20-30% FVIII) is the most common 2N allele and is associated with a mild phenotype, while R816W (<10% FVIII) is associated with a severe phenotype. The R763A mutation inhibits propeptide cleavage that likely sterically interferes with the FVIII-binding ability of VWF.

Methods: Type 2N VWD mutations were generated in the murine VWF cDNA. Heterologous VWF synthesis/secretion was characterized in vitro using HEK 293T cells and in vivo using hydrodynamic gene transfer of the murine VWF cDNA into VWF deficient mice. Binding of FVIII to type 2N variants was assessed in vitro using a solid phase binding assay and in vivo in VWF deficient mice by a FVIII chromogenic activity assay.

Results: In HEK 293 T cells, biosynthesis of type 2N VWD variants was not significantly different from wild type VWF while secretion of all type 2N VWD variants was decreased relative to wild type: R763A (66%, p=0.0043), R816W (53%, p=0.0004), R854Q (4%, p<0.0001). Immunofluorescent staining of transfected HEK 293 cells demonstrated impaired pseudo-Weibel Palade body formation for the R854Q variant. Western blot analysis under denaturing conditions demonstrated that approximately 50% of the secreted R763A protein remained attached to the propeptide. Multimeric profiles of plasma-derived type 2N VWD mutants were normal. In vitro binding of plasma-derived murine type 2N VWD mutants to recombinant human FVIII was reduced relative to wild type VWF: R763A (56%, p=0.0009), R816W (10%, p<0.0001), R854Q (46%, p=0.0002).

Type 2N VWD mutants were expressed alone or in a compound heterozygous state (R816W/R854Q) in VWF deficient mice. A trend of lower VWF:Ag levels were observed for type 2N VWD mutants relative to wild type (average 4.8 U/mL) after 14 days: R763A (35.7%), R816W (53.1%), R854Q (21.3%), except for compound heterozygous condition R816W/R854Q (103%).

Plasma levels of FVIII:C are significantly reduced in VWF deficient mice (15-20% of normal). We measured the ability of hydrodynamically expressed type 2N VWD mutants to stabilize endogenous FVIII:C in VWF deficient mice. Hepatic expression of wild type VWF stabilized endogenous plasma FVIII:C, resulting in a significant increase in FVIII:C after 14 days (7.7-fold increase above baseline, p=0.0002). For the type 2N VWD mutants, variable partial stabilization of endogenous FVIII:C was observed relative to baseline: R763A (4.7-fold increase, p=0.01), R816W (1.2-fold decrease, p=0.04), R816W/R854Q (4.8-fold increase, p<0.0001), R854Q (2.1-fold increase, p=0.06).

The correlation coefficient between VWF:Ag and FVIII:C was assessed for samples with VWF:Ag between 0.5-10 U/mL. Correlation between wild type VWF expression and FVIII:C was highly positive (r²=0.85, slope=189.5 ± 15.7, p<0.0001). Correlation between VWF:Ag and FVIII:C for mice expressing type 2N VWD mutants was variable: R763A (r²=0.89, slope=235.3 ± 18.15, p<0.0001), R816W (r²=0.591, slope=0.96 ± 2.8, p=0.7433), R816W/854Q (r²=0.72, slope=91.32 ± 10.64, p<0.0001) and R854Q (r²=0.705, slope=156.7 ± 24.4, p=0.0002). The slopes for R816W (p<0.0001) and R816W/R854Q (p=0.009) mutants were significantly different from wild type, suggesting impaired FVIII-stabilization in vivo.

Conclusion: Expression of the type 2N VWD severe mutant R816W or the compound heterozygous R816W/R854Q mutant can recapitulate type 2N VWD in a murine model. Type 2N VWD mutations are associated with impaired secretion of VWF and/or decreased binding and stabilization of endogenous FVIII.