Role of multimeric analysis of von Willebrand factor (VWF) in von Willebrand disease (VWD) diagnosis: Lessons from the PCM-EVW-ES Spanish project

Almudena Pérez-Rodríguez, Javier Batlle, Irene Corrales, Nina Borràs, Ángela Rodríguez-Trillo, Esther Lourés, Ana Rosa Cid, Santiago Bonanad, Noelia Cabrera, Andrés Moret, Rafael Parra, María Eva Mingot-Castellano, Nira Navarro, Carmen Altisent, Rocío Pérez-Montes, Shally Marcellini, Ana Moreto, Sonia Herrero, Inmaculada Soto, Nuria Fernández Mosteirín, Víctor Jiménez-Yuste, Nieves Alonso, Aurora de Andrés Jacob, Emilia Fontanes, Rosa Campos, María José Paloma, Nuria Bermejo, Rubén Berrueco, José Mateo, Karmele Arribalzaga, Pascual Marco, Ángeles Palomo, Nerea Castro Quismondo, Belén Iñigo, María Del Mar Nieto, Rosa Vidal, María Paz Martínez, Reyes Aguinaco, Maria Tenorio, María Ferreiro, Javier García-Frade, Ana María Rodríguez-Huerta, Jorge Cuesta, Ramón Rodríguez-González, Faustino García-Candel, Manuela Dobón, Carlos Aguilar, Fernando Batlle, Francisco Vidal, María Fernanda López-Fernández, Almudena Pérez-Rodríguez, Javier Batlle, Irene Corrales, Nina Borràs, Ángela Rodríguez-Trillo, Esther Lourés, Ana Rosa Cid, Santiago Bonanad, Noelia Cabrera, Andrés Moret, Rafael Parra, María Eva Mingot-Castellano, Nira Navarro, Carmen Altisent, Rocío Pérez-Montes, Shally Marcellini, Ana Moreto, Sonia Herrero, Inmaculada Soto, Nuria Fernández Mosteirín, Víctor Jiménez-Yuste, Nieves Alonso, Aurora de Andrés Jacob, Emilia Fontanes, Rosa Campos, María José Paloma, Nuria Bermejo, Rubén Berrueco, José Mateo, Karmele Arribalzaga, Pascual Marco, Ángeles Palomo, Nerea Castro Quismondo, Belén Iñigo, María Del Mar Nieto, Rosa Vidal, María Paz Martínez, Reyes Aguinaco, Maria Tenorio, María Ferreiro, Javier García-Frade, Ana María Rodríguez-Huerta, Jorge Cuesta, Ramón Rodríguez-González, Faustino García-Candel, Manuela Dobón, Carlos Aguilar, Fernando Batlle, Francisco Vidal, María Fernanda López-Fernández

Abstract

The multimeric analysis (MA) of plasma von Willebrand factor (VWF) evaluates structural integrity and helps in the diagnosis of von Willebrand disease (VWD). This assay is a matter of controversy, being considered by some investigators cumbersome and only slightly informative. The centralised study 'Molecular and Clinical Profile of von Willebrand Disease in Spain (PCM-EVW-ES)' has been carried out by including the phenotypic assessment and the genetic analysis by next generation sequencing (NGS) of the VWF gene (VWF). The aim of the present study was to evaluate the role of MA to the diagnosis of these patients and their potential discrepancies. Two hundred and seventy out of 480 patients centrally diagnosed with VWD had normal multimers, 168 had abnormal multimers and 42 a total absence of multimers. VWF MA was of great significance in the diagnosis of 83 patients (17.3%), it was also of help in the diagnosis achieved in 365 additional patients (76%) and was not informative in 32 cases (6.7%). With regard to discrepancies, 110 out of 480 (23%) patients centrally diagnosed with VWD presented some kind of discordance between VWF:RCo/VWF:Ag and/or VWF:CB/VWF:Ag ratios, multimeric study and/or genetic results. The VWF MA was key in the presence of novel mutations as well as in cases with phenotypic discrepancies. A comparison between the contribution of MA and VWF:CB showed a clearly higher contribution of the former in the diagnostic process. These data seem to reinforce the relevance of the VWF MA in VWD diagnosis, despite all its limitations.

Conflict of interest statement

The authors have declared that no competing interests exist. The funders provided support but did not have any additional role in study design, data collection and analysis, decision to publish, or preparation of the manuscript, as well as they do not alter our adherence to PLOS ONE policies on sharing data and materials. The only implication in the study of the funding organizations was to provide financial support for the development of the project (sample collection and shipment and for research materials). The Project “Molecular and Clinical Profile of VWD in Spain (PCM-EVW-ES) SPANISH REGISTRY” has been registered at www.clinicaltrials.gov Protocol Registration and Results System. (Study: Identifier: NCT02869074RE. Responsible Party Francisco Javier Batlle Fonrodona). Affiliation: Spanish Society on Thrombosis and Haemostasis (SETH). Last Public Release: 10/03/2017. The Banc de Sang i Teixits (Blood and Tissue Bank) is a public agency of the Catalan Department of Health. For more information you can visit the web page: https://www.bancsang.net/info-corporativa/en_missio/.

Figures

Fig 1. Evaluation of the contribution of…
Fig 1. Evaluation of the contribution of different laboratory steps in the diagnosis definition.
Four different successive laboratory assessment steps are considered. The progress in the diagnostic definition of the patients according to each step is shown. After the first and second steps, the multimeric analysis (MA) was of great significance in the diagnosis definition of 83 additional patients. Moreover, MA was in agreement with the diagnostic definition accomplished in steps 1 and 2 (179 patients). Finally, MA was also in agreement with the diagnostic definition achieved by molecular analysis in 186 additional patients. Thus, MA contributed to the diagnosis definition in a total of 448 (93.3%) patients.
Fig 2
Fig 2
Comparison between the diagnostic definition contribution of VWF:CB (in step “screening tests” [a]) and the multimeric analysis (MA) instead of VWF:CB first step, (step “screening tests” [b]). A greater degree of efficiency was observed for MA (50.4% versus 33.1% for VWF:CB).
Fig 3. Distribution of patients according to…
Fig 3. Distribution of patients according to their coincidence between ratios and multimeric analysis before genetic study and between multimeric analysis and mutation after genetic study.
Of 110 patients with some type of discrepancy, in 76 (48 + 28) the MA was in line with the molecular study while in 18 (14+4) patients there was not concordance. In the remaining 16, the similarity could not be demonstrated because the mutation found has not been described previously.
Fig 4. Multimeric analysis of von Willebrand…
Fig 4. Multimeric analysis of von Willebrand factor (VWF) in low-resolution SDS-agarose gels in patients with type 2A VWD and some discrepancy.
VWF from platelet lysate (NPt), plasmas of a normal subject (NP), patients with type 2A VWD and a patient with VWD type 2A (IIA) used as a control 2A are shown. (a-b): Patients with discrepancy between ratios and multimeric analysis; (c-d): Patients re-classified as type 2A on the basis of the genetic study.
Fig 5. Multimeric analysis of von Willebrand…
Fig 5. Multimeric analysis of von Willebrand factor (VWF) in low-resolution SDS-agarose gels in patients with type 2A/2M VWD and some discrepancy.
VWF from platelet lysate (NPt), plasmas of a normal subject (NP), patients with type 2A/2M VWD and a patient with VWD type 2A (IIA) used as a control 2A are shown. (a-c) Patients that showed discrepancy between ratios and multimeric analysis. In the case of the patients C30P012F07, C30P013F08 and C37P003F03 the mutations had not been described previously and the multimeric analysis (smeary) was of great significance to establish the diagnosis.

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