Mild hemophilia A resulting from Arg-to-Leu substitution in exon 26 of the factor VIII gene

Prenatal diagnosis of haemophilia

Haemophilia A is a severe bleeding disorder caused by a deficiency in clotting factor VIII (FVIII). It is an X-linked recessive bleeding disorder affecting one in 10,000 males. Prevalence of the haemophilia gene in the general population has increased recently due to advances in treatment, which has resulted in reproductive fitness among heamophiliacs. Patients suffering from this disease and their families are faced with problems relating to morbidity and mortality from the disease. These include a continual risk of uncontrolled bleeding, haemarthroses and subsequent arthropathy and above all, the genetic risk to progeny. Factor VIII gene is very large with 26 exons. Defects in this gene result in the deficiency of FVIII molecule. With the advent of recent advances in the molecular biology, it is possible to identify the multiple molecular defects such as point mutations, premature stop codons, deletions, and inversions etc in the FVIII gene in patients with haemophilia. Nowadays the use of polymerase chain reaction (PCR)-based linkage analysis and direct mutation detection in the chorionic villus sample obtained at 10-12 weeks of gestation has significantly improved the prenatal diagnosis of haemophilia.

Factor VIII C2 domain missense mutations exhibit defective trafficking of biologically functional proteins

The half-life of coagulation factor VIII (FVIII) in plasma is prolonged by noncovalent interaction with von Willebrand factor (vWF). Antibody inhibition data indicate that epitopes within the carboxyl terminus of the FVIII light chain play a role in vWF binding. Analysis of hemophilia A patient DNA samples have identified missense mutations within this carboxyl terminus of the FVIII light chain at amino acid 2307 in which arginine is replaced with either glutamine or leucine. Patients with these mutations have reduced FVIII activity proportional to reduced cross-reacting material in their plasma. It was hypothesized that the reduced levels of FVIII in plasma due to these mutations may be related to a defect in vWF binding with resultant plasma instability. Wild-type and mutant FVIII cDNA expression vectors were prepared and expressed in COS-1 monkey cells by transient DNA transfection. FVIII mutants R2307Q and R2307L were synthesized at equal rates compared to FVIII wild-type but had greater than 10-fold reduced accumulation of antigen and activity levels in the conditioned medium. An additional mutation, Y2305F, also displayed a similar defect in protein accumulation, whereas Y2332F was secreted similarly to wild-type. The specific activity of immunoaffinity purified R2307Q was mildly reduced compared to FVIII wild-type, whereas vWF binding properties were retained. Inhibition of intracellular cysteine proteases resulted in intracellular accumulation of R2307Q protein, suggesting that the mechanism leading to hemophilia A is related to a block in secretion and subsequent degradation within the secretory pathway rather than extracellular instability.

Molecular etiology of factor VIII deficiency in hemophilia A

Hemophilia is a common X-linked coagulation disorder due to deficiency of factor VIII. The factor VIII gene has been cloned in 1984 and a large number of mutations that cause hemophilia A have been identified in the last decade. The most common of the mutations is an inversion of factor VIII that accounts for nearly 45% of patients with severe hemophilia A. This review lists all the factor VIII mutations identified to date and briefly discusses their functional significance.

Haemophilia A: database of nucleotide substitutions, deletions, insertions and rearrangements of the factor VIII gene, second edition

A large number of different mutations in the factor VIII (F8) gene have been identified as a cause of haemophilia A. This compilation lists known single base-pair substitutions, deletions and insertions in the F8 gene and reviews the status of the inversional events which account for a substantial proportion of mutations causing severe haemophilia A.

Haemophilia A: database of nucleotide substitutions, deletions, insertions and rearrangements of the factor VIII gene, second edition

A large number of different mutations in the factor VIII (F8) gene have been identified as a cause of haemophilia A. This compilation lists known single base-pair substitutions, deletions and insertions in the F8 gene and reviews the status of the inversional events which account for a substantial proportion of mutations causing severe haemophilia A.

Mutations in haemophilia A

In the present study DNA from 281 unrelated haemophilia A patients including 15 inhibitor patients has been analysed by Southern blotting technique. Using various restriction enzymes, cloned factor VIII cDNA probes and genomic fragments we have identified 14 mutations. Six of the mutations are novel partial factor VIII gene deletions. One deletion affects exon 1, two deletions concern exon 6, another deletion, of which breakpoints are sequenced, takes part of exon 16 and two deletions affect exon 26. Besides the deletions, eight point mutations have been found at the TaqI restriction sites of exons 18, 24 and 26. Five C-->T mutations resulted in nonsense mutations, one in exon 18, one in exon 26 and three in exon 24. Two G-->A mutations caused a missense mutation in exon 24 leading to an arginine/glutamine exchange. Although two patients showed this mutation, their clinical phenotypes were different, possibly due to an additional unidentified sequence polymorphism. A G-->T mutation in exon 26 substituted the arginine with leucine. All deletions and seven of the point mutations are associated with severe disease with a detectable inhibitor in the patient with the TaqI-point mutation in exon 18. One of the G-->A mutations is associated with mild haemophilia but the patient also has developed an inhibitor. Amongst these mutations the origin of the mutation could be determined in four kindred, one of which showed maternal mosaicism.

Molecular characterization of mild-to-moderate hemophilia A: detection of the mutation in 25 of 29 patients by denaturing gradient gel electrophoresis

To date it has been difficult to characterize completely a genetic disorder, such as hemophilia A, in which the involved gene is large and unrelated affected individuals have different mutations, most of which are point mutations. Toward this end, we analyzed the DNA of 29 patients with mild-to-moderate hemophilia A in which the causative mutation is likely to be a missense mutation. Using computer analysis, we determined the melting properties of factor VIII gene sequences to design primer sets for PCR amplification and subsequent denaturing gradient gel electrophoresis (DGGE). A total of 45 primer sets was chosen to amplify 99% of the coding region of the gene and 41 of 50 splice junctions. To facilitate detection of point mutations, we mixed DNA from two male patients, and both homoduplexes and heteroduplexes were analyzed. With these 45 primer sets, 26 DNAs containing previously identified point mutations in the factor VIII gene were studied, and all 26 mutations were easily distinguishable from normal. After analyzing the 29 patients with unknown mutations, we identified the disease-producing mutation in 25 (86%). Two polymorphisms and two rare normal variants were also found. Therefore, DGGE after computer analysis is a powerful method for nearly complete characterization of disease-producing mutations and polymorphisms in large genes such as that for factor VIII.

Haemophilia A: database of nucleotide substitutions, deletions, insertions and rearrangements of the factor VIII gene

Mutations at the factor VIII gene locus causing Haemophilia A have now been identified in many patients from many ethnic groups. Earlier studies used biased methods which detected repetitive mutations at a few CG dinucleotides. More recently rapid gene scanning methods have uncovered an extreme diversity of mutations. Over 80 different point mutations, 6 insertions, 7 small deletions, and 60 large deletions have been characterised. Repetitive mutation has been proved for at least 16 CpG sites. All nonsense mutations cause severe disease. Most missense mutations appear to cause instability of the protein, but some are associated with production of dysfunctional factor VIII molecules, thereby localising functionally critical regions of the cofactor. Variable phenotype has been observed in association with three of the latter class of genotype. This catalogue of gene lesions in Haemophilia A will be updated annually.

The polymerase chain reaction: miracle or mirage? A critical review of its uses and limitations in diagnosis and research

Since publication of the polymerase chain reaction (PCR) technique in 1985 (Saiki et al. Science 1985; 230: 1350-1354), there has been an explosion of reports on its use in medicine and science. We critically review its use both as a diagnostic technique and as a research tool, and show the pathologist how to evaluate PCR data and how to avoid the pitfalls of overinterpretation. We discuss the value of PCR in the characterization of genetic defects, prenatal diagnosis, carrier testing, HLA typing, detecting micro-organisms, identifying activated oncogenes, and in the characterization of leukaemias and lymphomas, and summarize the main applications in biomedical research.

Clinical applications of the polymerase chain reaction

The polymerase chain reaction (PCR) is a technique that allows a million-fold, or greater, amplification of defined regions of DNA or RNA. It is potentially capable of detecting a single copy of a gene, present only once in 105 eukaryotic cells. This remarkable level of sensitivity has allowed the development of many diagnostic assays for human pathogens and disease states. These include: the detection of viral, bacterial and protozoal agents; diagnosis and genetic analysis of inherited diseases such as β-thalassaemia, sickle cell disease, haemophilia, Tay-Sachs disease and many others; diagnosis and analysis of neoplastic disorders such as, chronic myelogenous leukaemia (CML), acute lymphocytic lymphoma (ALL), follicular lymphomas and various other cancers, including the detection of activated oncogenes; prenatal and pre-implantation diagnosis; and the development of genetic risk prediction.

The PCR can greatly simplify diagnostic processes that were previously difficult to perform, particularly where the initial amounts of biological material were very limited. In other cases, PCR provides the only method available for detection and diagnosis. However, although simple in theory, the PCR technique remains, for routine clinical diagnostic purposes, currently in the domain of the specialist laboratory. This is because of its sensitivity to nucleic acid contamination from other sources that can cause misleading results. Procedures and precautions are being developed to minimize this problem and there is little doubt that, in many instances, the PCR will be the diagnostic method of choice within the next few years.

Characterization of mutations in the factor VIII gene by direct sequencing of amplified genomic DNA

In order to search for mutations resulting in hemophilia A that are not detectable by restriction analysis, three regions of the factor VIII gene were chosen for direct sequence analysis. Short segments of genomic DNA of 127 unrelated patients with hemophilia A were amplified by polymerase chain reaction. A total of 136,017 nucleotides were sequenced, and four mutations leading to the disease were found: a frameshift at codon 360 due to deletion of two nucleotides (GA), a nonsense codon 1705 due to a C----T transition, and two missense codons at positions 1699 and 1708. The first missense mutation (A----T) results in a Tyr----Phe substitution at a putative von Willebrand factor binding site. The second results in an Arg----Cys substitution at a thrombin cleavage site. In addition, we identified three rare sequence variants: a silent C----T transition at codon 34 which does not result in an amino acid change, a G----C change at codon 345 (Val----Leu), and an A----G change at the third nucleotide of intron 14. Direct sequence analysis of amplified DNA is a powerful but labor-intensive method of identifying mutations in large genes such as the human factor VIII gene.