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Pérez-Rodríguez A, Batlle J, Pinto JC, Corrales I, Borràs N, Garcia-Martínez I, Cid AR, Bonanad S, Parra R, Mingot-Castellano ME, Navarro N, Altisent C, Pérez-Montes R, Moretó A, Herrero S, Soto I, Mosteirín NF, Jiménez-Yuste V, Jacob ADA, Fontanes E, Mateo J, Quismondo NC, Batlle F, Vidal F, López-Fernández MF. Type 2N VWD: Conclusions from the Spanish PCM-EVW-ES project. Haemophilia 2021; 27:1007-1021. [PMID: 34494337 DOI: 10.1111/hae.14405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 08/17/2021] [Accepted: 08/22/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Type 2N von Willebrand disease (VWD) is characterized by a decreased affinity of von Willebrand factor (VWF) for factor VIII (FVIII). Abnormal binding of FVIII to VWF (VWF:FVIIIB), results in low FVIII plasma levels, which can lead to a misdiagnosis of mild haemophilia A. Accurate diagnosis of type 2N VWD is essential for appropriate genetic counselling and therapy. This disease can be distinguished from haemophilia A by in vitro assays (measurement VWF:FVIIIB activity) and/or genetic analysis. AIM To identify the current challenges in the diagnosis and treatment of this type of VWD and provide an in-depth description of the phenotypes and mutations identified. RESULTS Twenty-eight patients had at least one type 2N mutation, and 13 of these had a type 2N mutation combined with other variations. Three type 2N mutations were detected: p.Arg816Trp, p.Arg854Gln, and p.Arg763Ser. Two of these are the most frequently described mutations worldwide. This mutational spectrum differs from the broad spectrum seen in neighbouring France, where at least eight distinct 2N mutations have been found. In the PCM-EVW-ES cohort, 11 asymptomatic type 2N carriers with borderline FVIII plasma levels would probably have been excluded if the evaluation had been based on clinical and laboratory data only. Likewise, three patients with a severe phenotype would have been classified as homozygous for a 2N mutation if only the phenotype study had been performed. CONCLUSION The high detection yield and affordability of next-generation sequencing support the use of this technology as a first-line diagnostic tool in this setting.
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Affiliation(s)
| | - Javier Batlle
- Complexo Hospitalario Universitario A Coruña, INIBIC, A Coruña, Spain
| | - Joana Costa Pinto
- Complexo Hospitalario Universitario A Coruña, INIBIC, A Coruña, Spain
| | - Irene Corrales
- Haematology Service, Banc de Sang i Teixits (BST), Barcelona, Spain.,Vall d'Hebron Institut de Recerca, Universitat Autònoma de Barcelona (VHIR-UAB), Barcelona, Spain
| | - Nina Borràs
- Haematology Service, Banc de Sang i Teixits (BST), Barcelona, Spain.,Vall d'Hebron Institut de Recerca, Universitat Autònoma de Barcelona (VHIR-UAB), Barcelona, Spain
| | - Iris Garcia-Martínez
- Haematology Service, Banc de Sang i Teixits (BST), Barcelona, Spain.,Vall d'Hebron Institut de Recerca, Universitat Autònoma de Barcelona (VHIR-UAB), Barcelona, Spain
| | - Ana Rosa Cid
- Haematology Service, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Santiago Bonanad
- Haematology Service, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Rafael Parra
- Vall d'Hebron Institut de Recerca, Universitat Autònoma de Barcelona (VHIR-UAB), Barcelona, Spain.,Haematology Service, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | | | - Nira Navarro
- Haematology Service, Hospital Universitario Dr. Negrín, Las Palmas de Gran Canaria, Spain
| | - Carmen Altisent
- Haematology Service, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Rocío Pérez-Montes
- Haematology Service, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Ana Moretó
- Haematology Service, Hospital Universitario Cruces, Barakaldo, Spain
| | - Sonia Herrero
- Haematology Service, Hospital Universitario de Guadalajara, Guadalajara, Spain
| | - Inmaculada Soto
- Haematology Service, Hospital Universitario Central de Asturias, Oviedo, Spain
| | | | | | - Aurora de Andrés Jacob
- Haematology Service, Complexo Hospitalario Universitario Santiago de Compostela, Santiago, Spain
| | - Emilia Fontanes
- Haematology Service, Hospital Universitario Lucus Augusti, Lugo, Spain
| | - José Mateo
- Haematology Service, Hospital Sta Creu i St Pau, Barcelona, Spain
| | | | - Fernando Batlle
- Haematology Service, Lapisoft Projects S.A., A Coruña, Spain
| | - Francisco Vidal
- Haematology Service, Banc de Sang i Teixits (BST), Barcelona, Spain.,Vall d'Hebron Institut de Recerca, Universitat Autònoma de Barcelona (VHIR-UAB), Barcelona, Spain.,Haematology Service, CIBER de Enfermedades Cardiovasculares (CIBERCV)
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- Complexo Hospitalario Universitario A Coruña, INIBIC, A Coruña, Spain
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Borràs N, Batlle J, Pérez-Rodríguez A, López-Fernández MF, Rodríguez-Trillo Á, Lourés E, Cid AR, Bonanad S, Cabrera N, Moret A, Parra R, Mingot-Castellano ME, Balda I, Altisent C, Pérez-Montes R, Fisac RM, Iruín G, Herrero S, Soto I, de Rueda B, Jiménez-Yuste V, Alonso N, Vilariño D, Arija O, Campos R, Paloma MJ, Bermejo N, Berrueco R, Mateo J, Arribalzaga K, Marco P, Palomo Á, Sarmiento L, Iñigo B, Nieto MDM, Vidal R, Martínez MP, Aguinaco R, César JM, Ferreiro M, García-Frade J, Rodríguez-Huerta AM, Cuesta J, Rodríguez-González R, García-Candel F, Cornudella R, Aguilar C, Vidal F, Corrales I. Molecular and clinical profile of von Willebrand disease in Spain (PCM-EVW-ES): comprehensive genetic analysis by next-generation sequencing of 480 patients. Haematologica 2017; 102:2005-2014. [PMID: 28971901 PMCID: PMC5709099 DOI: 10.3324/haematol.2017.168765] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 09/20/2017] [Indexed: 01/10/2023] Open
Abstract
Molecular diagnosis of patients with von Willebrand disease is pending in most populations due to the complexity and high cost of conventional molecular analyses. The need for molecular and clinical characterization of von Willebrand disease in Spain prompted the creation of a multicenter project (PCM-EVW-ES) that resulted in the largest prospective cohort study of patients with all types of von Willebrand disease. Molecular analysis of relevant regions of the VWF, including intronic and promoter regions, was achieved in the 556 individuals recruited via the development of a simple, innovative, relatively low-cost protocol based on microfluidic technology and next-generation sequencing. A total of 704 variants (237 different) were identified along VWF, 155 of which had not been previously recorded in the international mutation database. The potential pathogenic effect of these variants was assessed by in silico analysis. Furthermore, four short tandem repeats were analyzed in order to evaluate the ancestral origin of recurrent mutations. The outcome of genetic analysis allowed for the reclassification of 110 patients, identification of 37 asymptomatic carriers (important for genetic counseling) and re-inclusion of 43 patients previously excluded by phenotyping results. In total, 480 patients were definitively diagnosed. Candidate mutations were identified in all patients except 13 type 1 von Willebrand disease, yielding a high genotype-phenotype correlation. Our data reinforce the capital importance and usefulness of genetics in von Willebrand disease diagnostics. The progressive implementation of molecular study as the first-line test for routine diagnosis of this condition will lead to increasingly more personalized and effective care for this patient population.
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Affiliation(s)
- Nina Borràs
- Banc de Sang i Teixits, Barcelona, Spain
- Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona (VHIR-UAB), Spain
| | - Javier Batlle
- Complexo Hospitalario Universitario A Coruña, INIBIC, Spain
| | | | | | | | - Esther Lourés
- Complexo Hospitalario Universitario A Coruña, INIBIC, Spain
| | - Ana Rosa Cid
- Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | | | - Noelia Cabrera
- Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Andrés Moret
- Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Rafael Parra
- Banc de Sang i Teixits, Barcelona, Spain
- Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | | | - Ignacia Balda
- Hospital Universitario Dr. Negrín, Las Palmas de Gran Canaria, Spain
| | | | | | | | - Gemma Iruín
- Hospital Universitario Cruces, Barakaldo, Spain
| | | | | | | | | | | | - Dolores Vilariño
- Complejo Hospitalario Universitario Santiago de Compostela, Spain
| | - Olga Arija
- Hospital Universitario Lucus Augusti, Lugo, Spain
| | | | | | | | | | - José Mateo
- Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Rosa Cornudella
- Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
| | | | - Francisco Vidal
- Banc de Sang i Teixits, Barcelona, Spain
- Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona (VHIR-UAB), Spain
- CIBER de Enfermedades Cardiovasculares, Spain
| | - Irene Corrales
- Banc de Sang i Teixits, Barcelona, Spain
- Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona (VHIR-UAB), Spain
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Yee A, Oleskie AN, Dosey AM, Kretz CA, Gildersleeve RD, Dutta S, Su M, Ginsburg D, Skiniotis G. Visualization of an N-terminal fragment of von Willebrand factor in complex with factor VIII. Blood 2015; 126:939-42. [PMID: 26065653 DOI: 10.1182/blood-2015-04-641696] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Accepted: 05/27/2015] [Indexed: 11/20/2022] Open
Abstract
Binding to the von Willebrand factor (VWF) D'D3 domains protects factor VIII (FVIII) from rapid clearance. We performed single-particle electron microscopy (EM) analysis of negatively stained specimens to examine the architecture of D'D3 alone and in complex with FVIII. The D'D3 dimer ([D'D3]2) comprises 2 antiparallel D3 monomers with flexibly attached protrusions of D'. FVIII-VWF association is primarily established between the FVIII C1 domain and the VWF D' domain, whereas weaker interactions appear to be mediated between both FVIII C domains and the VWF D3 core. Modeling the FVIII structure into the three-dimensional EM reconstructions of [D'D3]2-FVIII ternary and quaternary complexes indicates conformational rearrangements of the FVIII C domains compared with their disposition in the unbound state. These results illustrate the cooperative plasticity between VWF and FVIII that coordinate their high-affinity interaction.
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Yee A, Gildersleeve RD, Gu S, Kretz CA, McGee BM, Carr KM, Pipe SW, Ginsburg D. A von Willebrand factor fragment containing the D'D3 domains is sufficient to stabilize coagulation factor VIII in mice. Blood 2014; 124:445-52. [PMID: 24850761 DOI: 10.1182/blood-2013-11-540534] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Plasma factor VIII (FVIII) and von Willebrand factor (VWF) circulate together as a complex. We identify VWF fragments sufficient for FVIII stabilization in vivo and show that hepatic expression of the VWF D'D3 domains (S764-P1247), either as a monomer or a dimer, is sufficient to raise FVIII levels in Vwf(-/-) mice from a baseline of ∼5% to 10%, to ∼50% to 100%. These results demonstrate that a fragment containing only ∼20% of the VWF sequence is sufficient to support FVIII stability in vivo. Expression of the VWF D'D3 fragment fused at its C terminus to the Fc segment of immunoglobulin G1 results in markedly enhanced survival in the circulation (t1/2 > 7 days), concomitant with elevated plasma FVIII levels (>25% at 7 days) in Vwf(-/-) mice. Although the VWF D'D3-Fc chimera also exhibits markedly prolonged survival when transfused into FVIII-deficient mice, the cotransfused FVIII is rapidly cleared. Kinetic binding studies show that VWF propeptide processing of VWF D'D3 fragments is required for optimal FVIII affinity. The reduced affinity of VWF D'D3 and VWF D'D3-Fc for FVIII suggests that the shortened FVIII survival in FVIII-deficient mice transfused with FVIII and VWF D'D3/D'D3-Fc is due to ineffective competition of these fragments with endogenous VWF for FVIII binding.
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Abstract
Quantitative and/or qualitative deficiency of von Willebrand factor (vWF) is associated with the most common inherited bleeding disease von Willebrand disease (vWD). vWD is a complex disease with clinical and genetic heterogeneity. Incomplete penetrance and variable expression due to genetic and environmental factors contribute to its complexity. vWD also has a complex molecular pathogenesis. Some vWF gene mutations are associated with the affected vWF biosynthesis and multimerization, whereas others are associated with increased clearance and functional impairment. Moreover, in addition to a particular mutation, type O blood may result in the more severe phenotype. The present review aimed to provide a summary of the current literature on the molecular genetics of vWD. Conflict of interest:None declared.
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Affiliation(s)
- Ergül Berber
- İstanbul Arel University, Department of Molecular Biology and Genetics, İstanbul, Turkey
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Gupta M, Lillicrap D, Stain AM, Friedman KD, Carcao MD. Therapeutic consequences for misdiagnosis of type 2N von Willebrand disease. Pediatr Blood Cancer 2011; 57:1081-3. [PMID: 21425451 DOI: 10.1002/pbc.23120] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2011] [Accepted: 02/14/2011] [Indexed: 11/06/2022]
Abstract
Patients presenting with a low FVIII:C and with normal VWF levels are usually presumed to have hemophilia (males) or be carriers for hemophilia (females). Some of these patients may instead have VWD:2N. Such patients if misdiagnosed are likely to suffer from insufficiently treated bleeds. We report 2 males and 1 female who presented with a low FVIII:C (1-21%) and minimally reduced/normal VWF and were assumed to have, or be a carrier for, hemophilia A. Eventually all were found to have VWD:2N. Prior to the correct diagnosis the males had been treated with rFVIII with poor responses and ultimately adverse clinical consequences.
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Affiliation(s)
- Madhu Gupta
- Division of Hematology/Oncology, Hospital for Sick Children, Toronto, Ontario, Canada
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Veyradier A, Fressinaud E, Goudemand J. Compound heterozygosity or heterozygosity with two mutations in cis on the same allele? A rebuttal to the letter to the Editors: Koessler et al. Von Willebrand disease caused by compound heterozygosity for p.R854Q and p.R760C: diagnostic and therapeutic implications. Haemophilia 2011; 17: e240-2. Haemophilia 2011; 17:e832-e833. [PMID: 21489050 DOI: 10.1111/j.1365-2516.2011.02531.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
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LANNOY N, ABINET I, BOSMANS A, LAMBERT C, VERMYLEN C, HERMANS C. Computational and molecular approaches for predicting unreported causal missense mutations in Belgian patients with haemophilia A. Haemophilia 2011; 18:e331-9. [DOI: 10.1111/j.1365-2516.2011.02640.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Enayat MS, Guilliatt AM, Short PE, Rastegar-Lari G, Jazebi M, Ravonbod S, Ala F, Chapman OG, Hill FGH. A novel alanine or threonine 789 to proline mutation causing type 2N von Willebrand's disease when inherited homozygously or heterozygously with arginine 854 to glutamine mutation. Haemophilia 2011; 16:966-9. [PMID: 20491956 DOI: 10.1111/j.1365-2516.2010.02271.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Abstract
Weibel-Palade bodies (WPBs) are elongated secretory organelles specific to endothelial cells that contain von Willebrand factor (VWF) and a variety of other proteins that contribute to inflammation, angiogenesis, and tissue repair. The remarkable architecture of WPBs is because of the unique properties of their major constituent VWF. VWF is stored inside WPBs as tubules, but on its release, forms strikingly long strings that arrest bleeding by recruiting blood platelets to sites of vascular injury. In recent years considerable progress has been made regarding the molecular events that underlie the packaging of VWF multimers into tubules and the processes leading to the formation of elongated WPBs. Mechanisms directing the conversion of tightly packaged VWF tubules into VWF strings on the surface of endothelial cells are starting to be unraveled. Several modes of exocytosis have now been described for WPBs, emphasizing the plasticity of these organelles. WPB exocytosis plays a role in the pathophysiology and treatment of von Willebrand disease and may have impact on common hematologic and cardiovascular disorders. This review summarizes the major advances made on the biogenesis and exocytosis of WPBs and places these recent discoveries in the context of von Willebrand disease.
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KOESSLER J, WITZ E, PLASS A, SOMMER C, STEIGERWALD U, WALTER U, HETERICH S. Von Willebrand disease caused by compound heterozygosity for p.r854q and p.r760c: diagnostic and therapeutic implications. Haemophilia 2010; 17:e240-2. [DOI: 10.1111/j.1365-2516.2010.02384.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Abstract
The common autosomally inherited mucocutaneous bleeding disorder, von Willebrand disease (VWD) results from quantitative or qualitative defects in plasma von Willebrand factor (VWF). Mutation can affect VWF quantity or its functions mediating platelet adhesion and aggregation at sites of vascular damage and carrying pro-coagulant factor VIII (FVIII). Phenotype and genotype analysis in patients with the three VWD types has aided understanding of VWF structure and function. Investigation of patients with specific disease types has identified mutations in up to 70% of type 1 and 100% of type 3 VWD cases. Missense mutations predominate in type 1 VWD and act through mechanisms including rapid clearance and intracellular retention. Many mutations are incompletely penetrant and attributing pathogenicity is challenging. Other factors including blood group O contribute to low VWF level. Missense mutations affecting platelet- or FVIII-binding through a number of mechanisms are responsible for the four type 2 subtypes; 2A, 2B, 2M and 2N. In contrast, mutations resulting in a lack of VWF expression predominate in recessive type 3 VWD. This review explores the genetic basis of each VWD type, relating mutations identified to disease mechanism. Additionally, utility of genetic analysis within the different disease types is explored.
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Schneppenheim R, Budde U. Von-Willebrand-Faktor und ADAMTS13. Hamostaseologie 2010. [DOI: 10.1007/978-3-642-01544-1_24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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van den Biggelaar M, Meijer AB, Voorberg J, Mertens K. Intracellular cotrafficking of factor VIII and von Willebrand factor type 2N variants to storage organelles. Blood 2009; 113:3102-9. [PMID: 19088379 DOI: 10.1182/blood-2008-05-159699] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Weibel-Palade bodies (WPBs) are the endothelial storage organelles that are formed upon von Willebrand factor (VWF) expression. Apart from VWF, WPBs contain a variety of hemostatic and inflammatory proteins. Some of these are thought to be targeted to WPBs by directly interacting with VWF in the secretory pathway. Previous studies have demonstrated that coexpression of factor VIII (FVIII) with VWF results in costorage of both proteins. However, whether cotrafficking is driven by intracellular FVIII-VWF assembly has remained unclear. We now have addressed this issue using recombinant VWF type 2N variants that are known to display reduced FVIII binding in the circulation. Binding studies using purified fluorescent FVIII and VWF type 2N variants revealed FVIII binding defects varying from moderate (Arg854Gln, Cys1060Arg) to severe (Arg763Gly, Thr791Met, Arg816Trp). Upon expression in HEK293 cells, all VWF variants induced formation of WPB-like organelles that were able to recruit P-selectin, as well as FVIII. WPBs containing FVIII did not display their typical elongated shape, suggesting that FVIII affects the organization of VWF tubules therein. The finding that VWF type 2N variants are still capable of cotargeting FVIII to storage granules implies that trafficking of WPB cargo proteins does not necessarily require high-affinity assembly with VWF.
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KEENEY S, BOWEN D, CUMMING A, ENAYAT S, GOODEVE A, HILL M. The molecular analysis of von Willebrand disease: a guideline from the UK Haemophilia Centre Doctors’ Organisation Haemophilia Genetics Laboratory Network. Haemophilia 2008; 14:1099-111. [DOI: 10.1111/j.1365-2516.2008.01813.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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