Carbohydrate deficiency of the factor VIII/von Willebrand factor Protein in von Willebrand's disease variants

Historical perspective and future directions in platelet research

Platelets are a remarkable mammalian adaptation that are required for human survival by virtue of their ability to prevent and arrest bleeding. Ironically, however, in the past century, the platelets' hemostatic activity became maladaptive for the increasingly large percentage of individuals who develop age-dependent progressive atherosclerosis. As a result, platelets also make a major contribution to ischemic thrombotic vascular disease, the leading cause of death worldwide. In this brief review, I provide historical descriptions of a highly selected group of topics to provide a framework for understanding our current knowledge and the trends that are likely to continue into the future of platelet research. For convenience, I separate the eras of platelet research into the "Descriptive Period" extending from ~1880-1960 and the "Mechanistic Period" encompassing the past ~50 years since 1960. We currently are reaching yet another inflection point, as there is a major shift from a focus on traditional biochemistry and cell and molecular biology to an era of single molecule biophysics, single cell biology, single cell molecular biology, structural biology, computational simulations, and the high-throughput, data-dense techniques collectively named with the "omics postfix". Given the progress made in understanding, diagnosing, and treating many rare and common platelet disorders during the past 50 years, I think it appropriate to consider it a Golden Age of Platelet Research and to recognize all of the investigators who have made important contributions to this remarkable achievement..

Expression of terminal alpha2-6-linked sialic acid on von Willebrand factor specifically enhances proteolysis by ADAMTS13

von Willebrand factor (VWF) multimeric composition is regulated in plasma by ADAMTS13. VWF deglycosylation enhances proteolysis by ADAMTS13. In this study, the role of terminal sialic acid residues on VWF glycans in mediating proteolysis by ADAMTS13 was investigated. Quantification and distribution of VWF sialylation was examined by sequential digestion and high-performance liquid chromatography analysis. Total sialic acid expression on VWF was 167nmol/mg, of which the majority (80.1%) was present on N-linked glycan chains. Enzymatic desialylation of VWF by alpha2-3,6,8,9 neuraminidase (Neu-VWF) markedly impaired ADAMTS13-mediated VWF proteolysis. Neu-VWF collagen binding activity was reduced to 50% (+/- 14%) by ADAMTS13, compared with 11% (+/- 7%) for untreated VWF. Despite this, Neu-VWF exhibited increased susceptibility to other proteases, including trypsin, chymotrypsin, and cathepsin B. VWF expressing different blood groups exhibit altered ADAMTS13 proteolysis rates (O > or = B > A > or = AB). However, ABO blood group regulation of ADAMTS13 proteolysis was ablated on VWF desialylation, as both Neu-O-VWF and Neu-AB-VWF were cleaved by ADAMTS13 at identical rates. These novel data show that sialic acid protects VWF against proteolysis by serine and cysteine proteases but specifically enhances susceptibility to ADAMTS13 proteolysis. Quantitative variation in VWF sialylation therefore represents a key determinant of VWF multimeric composition and, as such, may be of pathophysiologic significance.

Oligosaccharide structures of von Willebrand factor and their potential role in von Willebrand disease

Oligosaccharides make up approximately 20% of the mass of VWF and although their structures are well established, their functional role remains unclear. Modification of the VWF oligosaccharide structures has been shown to result in increased plasma clearance of the protein. A mutation which alters cell type-specific expression of the Galgt2 glycosyltransferase gene in the RIIIS/J mouse results in an autosomal dominant partial quantitative deficiency of VWF. Increased plasma clearance of VWF has been demonstrated in some individuals with a partial quantitative deficiency of the protein and it is possible that variation in VWF glycosylation may contribute towards this. ABH antigens occur within the oligosaccharide component of VWF and may account for the variation in plasma VWF:Ag levels observed between individuals of different ABO blood groups. The structures and functional roles of the oligosaccharide side chains of VWF and possible pathogenetic mechanisms by which they may contribute towards VWD are reviewed in this article.

Sialyltransferase ST3Gal-IV operates as a dominant modifier of hemostasis by concealing asialoglycoprotein receptor ligands

A number of poorly characterized genetic modifiers contribute to the extensive variability of von Willebrand disease, the most prevalent bleeding disorder in humans. We find that a genetic lesion inactivating the murine ST3Gal-IV sialyltransferase causes a bleeding disorder associated with an autosomal dominant reduction in plasma von Willebrand factor (VWF) and an autosomal recessive thrombocytopenia. Although both ST3Gal-IV and ST6Gal-I sialyltransferases mask galactose linkages implicated as asialoglycoprotein receptor ligands, only ST3Gal-IV deficiency promotes asialoglycoprotein clearance mechanisms with a reduction in plasma levels of VWF and platelets. Exposed galactose on VWF was also found in a subpopulation of humans with abnormally low VWF levels. Oligosaccharide branch-specific sialylation by the ST3Gal-IV sialyltransferase is required to sustain the physiologic half-life of murine hemostatic components and may be an important modifier of plasma VWF level in humans.

Evolution and classification of cystine knot-containing hormones and related extracellular signaling molecules

The cystine knot three-dimensional structure is found in many extracellular molecules and is conserved among divergent species. The identification of proteins with a cystine knot structure is difficult by commonly used pairwise alignments because the sequence homology among these proteins is low. Taking advantage of complete genome sequences in diverse organisms, we used a complementary approach of pattern searches and pairwise alignments to screen the predicted protein sequences of five model species (human, fly, worm, slime mold, and yeast) and retrieved proteins with low sequence homology but containing a typical cystine knot signature. Sequence comparison between proteins known to have a cystine knot three-dimensional structure (transforming growth factor-beta, glycoprotein hormone, and platelet-derived growth factor subfamily members) identified new crucial amino acid residues (two hydrophilic amino acid residues flanking cysteine 5 of the cystine knot). In addition to the well known members of the cystine knot superfamily, novel subfamilies of proteins (mucins, norrie disease protein, von Willebrand factor, bone morphogenetic protein antagonists, and slit-like proteins) were identified as putative cystine knot-containing proteins. Phylogenetic analysis revealed the ancient evolution of these proteins and the relationship between hormones [e.g. transforming growth factor-beta (TGFbeta)] and extracellular matrix proteins (e.g. mucins). They are absent in the unicellular yeast genome but present in nematode, fly, and higher species, indicating that the cystine knot structure evolved in extracellular signaling molecules of multicellular organisms. All data retrieved by this study can be viewed at http://hormone.stanford.edu/.

Carbohydrate analysis of human von Willebrand factor with horseradish peroxidase-conjugated lectins

Human von Willebrand factor (vWF) immobilized on a polyvinylidene difluoride membrane was subjected to binding assay with a series of horseradish peroxidase-conjugated lectins. The protein was reactive with concanavalin A, Ricinus communis agglutinin 120, wheat germ agglutinin and Ulex europaeus agglutinin I (UEA-I) but not with peanut agglutinin before sialidase treatment. These reactivities were consistent with the major oligosaccharide structure reported except for UEA-I. The reactivity with UEA-I was greatly decreased after digestion of the protein with either alpha-L-fucosidase or peptide-N-glycosidase F, but no significant decrease was observed after mild alkaline treatment or delipidation. vWF and UEA-I have been independently used as a good marker for human endothelial cells. Our results indicate that vWF itself contains UEA-I reactive sugar chains in its Asn-linked oligosaccharides.

Platelet adhesion and prevention at blood-polymer interface

It has been proposed that adsorbed glycoproteins such as fibrinogen and gamma-globulin induce platelet adhesion at blood-polymer interfaces. The importance of oligosaccharide groups in the glycoproteins proved to be responsible for platelet adhesion and aggregation via possible complex formation. Several studies have provided evidence that the proposed mechanism was involved in platelet adhesion on polymer surfaces. To minimize or prevent platelet adhesion on polymers, prostaglandins (PGs), potent inhibitors of platelet aggregation and PG-heparin (HEP) conjugate, were combined with polymers via physical dispersion or chemical immobilization on the surfaces. Albumin-HEP conjugate-adsorbed surfaces also showed significant reduction of platelet adhesion.

The physiology and pathophysiology of the factor VIII complex

The factor VIII complex consists of two noncovalently linked proteins: von Willebrand factor (VWF) and factor VIII (FVIII). VWF plays an important role in primary hemostasis by mediating the adherence of blood platelets to the damaged vessel wall. A review of the literature on VWF is given with regard to its physicochemical properties and mode of action. FVIII acts as a cofactor in the factor Xa-generating enzyme complex of the intrinsic coagulation cascade. Starting with the recently published primary structure of FVIII, the literature is reviewed for structural information on FVIII. Also, an effort is made to characterize the interaction of FVIII with VWF and to discuss the possible physiological significance of FVIII-VWF complex formation. Interaction of FVIII with the clotting factors of the intrinsic pathway of coagulation is described in detail. Hemophilia and von Willebrand's disease (VWD) are both congenital bleeding disorders affecting a great many people. The different variants of these diseases are described with some reference to therapy and detection.

Inhibition of disulfide bonding of von Willebrand protein by monensin results in small, functionally defective multimers

The biosynthesis of von Willebrand protein by human endothelial cells was impaired by the presence of the carboxylic ionophore monensin. Several processing steps that have been localized to the Golgi apparatus were affected in a dose-dependent manner, including carbohydrate processing, dimer multimerization, and precursor cleavage. Since multimerization was more susceptible to the ionophore than was precursor cleavage, it appears that these processing steps are separate events. As expected, dimer formation, which occurs in the rough endoplasmic reticulum, was unaffected by monensin. Thus, at high concentrations of monensin, only dimer molecules were produced and secreted. The observed inhibition of multimer formation and precursor cleavage were not likely the result of incomplete carbohydrate processing, since inhibition of complex carbohydrate formation by swainsonine did not interfere with the other processing steps. Monensin also affected the capacity of endothelial cells to store von Willebrand protein, as the ratio of secreted to cell-associated protein increased dramatically in the presence of monensin, and the processed forms could not be found in the treated cells. The low molecular weight multimers produced in the presence of monensin did not incorporate in the endothelial cells' extracellular matrix nor did they bind to the matrix of human foreskin fibroblasts. In summary, the presence of monensin in human endothelial cell culture produced experimental conditions that mimic Type IIA von Willebrand disease, in that the cells synthesized and secreted only low molecular weight von Willebrand protein multimers, which were functionally defective.

Glycogen storage disease type Ib: familial bleeding tendency

A mild bleeding tendency with characteristics of the von Willebrand disease was documented in family members of a girl with glycogen storage disease type Ib (GSD) Ib). It was assumed that a defective glucose-6-phosphate dependent microsomal glycoprotein synthesis was involved in the bleeding disorder of the patient and the GSD Ib heterozygotes.

Properties of human asialo-factor VIII. A ristocetin-independent platelet-aggregating agent

Human Factor VIII desialylated by treatment with Vibrio cholerae neuraminidase (ASVIII) aggregated human platelets in the absence of ristocetin in platelet-rich plasma and, to a lesser extent, in washed platelet suspensions. Aggregation is accompanied by thromboxane formation and is completely inhibited by EDTA. Aspirin blocks the second phase of aggregation and abolishes thromboxane production. Subaggregating doses of ASVIII and of either ADP, epinephrine, or collagen produce prompt and complete platelet aggregation. Bernard-Soulier syndrome platelets either did not aggregate with ASVIII (Two cases) or showed markedly decreased aggregation (one cases). Factor VIII complex was prepared from the plasma of two patients with variant von Willebrand's disease (sialic acid content 142 and 75 nmol/mg, respectively); neither protein generated platelet-aggregating activity upon desialylation. [3H]ASVIII binds rapidly to platelets and 37 degrees C, while tritiated, fully sialylated factor VIII binds to a negligible extent. As little as 1--2 micrograms ASVIII bound/10(9) platelets is capable of inducing platelet aggregation. ASVIII may be a useful tool for investigating platelet-Factor VIII interactions in the absence of ristocetin. Furthermore, desialylated Factor VIII might play a physiologic role in Factor VIII-mediated platelet reactions in vivo.

Quantitation of binding of factor VIII antigen to concanavalin A

This study establishes a convenient method for screening plasma samples for abnormalities of the carbohydrate content of the factor VIII (FVIII) molecule. A radioimmuno-electrophoretic technique has been developed to quantitate the percentage binding of FVIII-related antigen (VIII-Ag) to the lectin concanavalin A (Con A). Plasma samples were electrophoresed through a strip of agarose containing Con A into agarose containing a mixture of unlabelled anti-FVIII and 125I-anti-FVIII where precipitant lines formed, the height of which was dependent upon the degree of VIII-Ag binding to Con A in the first gel. Using this system reduced binding of VIII-Ag to Con A was found in the plasma of 12 patients with moderate classical von Willebrand's disease (vWd), while the Con A binding of six haemophilia A patients fell within the normal range. The VIII-Ag in normal cryoprecipitate showed increased % binding to Con A while the VIII-Ag remaining in the cryo-supernate demonstrated reduced Con A % binding.

New methods in coagulation

Recent advances in the elucidation of the molecular biochemistry of the coagulation proteins have provided the foundation for the development of synthetic substrates. These substrates are oligopeptide with either a chromophore or fluorophore group attached to the C-terminal end. They may be used in the laboratory to assay for a number of the serine proteases involved in either coagulation or fibrinolysis. Also, by suitably modifying the assay system, the various inhibitors can be quantitated. These substrates promise to revolutionize the coagulation laboratory allowing for more precise quantitation of trace enzymes and also improved standardization and precision of coagulation assays. In addition to these substrates, the introduction of a number of immunologic procedures into the diagnostic laboratory have been of major importance in elucidating the heterogeneity of hereditary coagulation defects. By correlating the immunologic assays, coagulation assays and clinical picture, a number of subgroups of hereditary deficiencies have been identified. Also, the immunologic assays have provided a means for identifying the carrier state of hemophilia A and have significantly contributed to the improved diagnosis of von Willebrand's disease. The use of ristocetin cofactor assays, when used in conjunction with the Factor VIII antigens, have enable the laboratory to more accurately diagnose the majority of patients with von Willebrand's disease. Ristocetin cofactor may be assayed utilizing either formalin fixed or washed platelets and recently a snake venom has been introduced to assay for this particular aspect of the Factor VIII complex. Platelet specific proteins (i.e., platelet factor 4 and beta-thromboglobulin) may be assayed utilizing either radioimmunoassays or in the case of platelet factor 4 modified coagulation assays. These proteins provide evidence of in vivo platelet activation and hopefully may, in the future, be correlated with platelet kinetics.

Studies on factor VIII-related protein. IV. Interaction of galactose-specific lectins with human factor VIII/Von Willebrand factor

Factor VIII of human cryoprecipitate was purified and fractionated on Sepharose CL-2B into three fractions of progressively decreasing multimer size and ristocetin cofactor activity. Following complete disulfide reduction, the resulting subunits were electrophoresed on 3% polyacrylamide gels and subsequently stained with two galactose-specific, fluorescein-labelled lectins from Ricinus communis (RCAI and RCAII). Measurements of fluorescence indicated that the reduced chains, derived from the largest factor VIII multimers, have stronger binding affinity for both lectins than those obtained after reduction of smaller factor VIII species. Ristocetin cofactor activity of purified factor VIII was competitively inhibited by both Ricinus lectins and by concanavalin A. RCAI-lectin was found to be a considerably more efficient inhibitor than RCAII or concanavalin A. Following removal of sialic acid from factor VIII, the inhibiting effect of RCAII-lectin was markedly potentiated, probably by exposing additional galactose residues, some of which must be located close to the ristocetin cofactor 'active site' of factor VIII. Ristocetin cofactor activity was also strongly inhibited with RCAII-lectin for binding sites which are located on the surface factor VIII multimers. Our results suggest that RCAI-lectin, which contains galactose-specific binding sites per molecule, and anti-factor VIII antibodies inhibit ristocetin cofactor activity by crosslinking and aggregation of factor VIII multimers.

Von Willebrand disease with an increased ristocetin-induced platelet aggregation and a qualitative abnormality of the factor VIII protein

Two cases of von Willebrand disease (VWD) that revelaed an increased ristocetin-induced platelet aggregation (RIPA) and a qualitative abnormality of the factor VIII protein are reported. The threshold concentration of ristocetin giving a 30% increase in light transmission was 0.5 mg/ml in the proband and 0.4 mg/ml in her father (normal: 1.16 +/- SD 0.18 mg/ml) although both patients showed reduced plasma von Willebrand factor activity (VIIIR:WF). In both patients, the amount of factor VIII related antigen (VIIIR:AG) in their platelets were normal, but an increased binding affinity of platelets to plasma factor VIII was demonstrated. The qualitative abnormality of the factor VIII protein was characterized by an increasead anodal migration of VIIIR:AG in crossed immunoelectrophoresis (CIE), a delayed elution pattern as demonstrated by gel filtration on Sepharose 2B, and a decreased precipitation with concanavalin A (Con A). The response to DDAVP was also investigated.

Studies on factor VIII-related protein. III. Size distribution and carbohydrate content of human and bovine factor VIII

Human and bovine factor VIII were isolated from cryoprecipitate of fresh frozen plasma by gel filtration on Sepharose CL-2B. The elution diagrams and SDS-agarose electrophoretic analysis of eluted fractions show no significant differences in the size-distribution of factor VIII aggregates between the two species. Agarose gels were stained for carbohydrate by two methods: (1) the dansyl hydrazine reaction following oxidation with periodic acid and (2) staining with fluorescein-labeled concanavalin A. Results of both procedures indicate that in human factor VIII neither the size distribution nor its ristocetin cofactor activity are related to carbohydrate content. Bovine factor VIII contains slightly less sugar than the human preparation as judged from the relative dansyl hydrazine staining intensities. In contrast to human factor VIII, the binding affinity for concanavalin A of bovine factor VIII was gradually decreased with increasing aggregate size. This finding suggests an impaired accessibility of reactive sugar residues in large aggregates of bovine factor VIII.

[A variant of the von Willebrand-Jürgens-syndrome with abnormalities of the factor VIII/von Willebrand factor protein (author's transl)]

A family is reported with a variant of von Willebrand's disease. The members of this family showed a qualitative defect of the factor VII/von Willebrand factor protein. The qualitative defect was characterized by an abnormal electrophoretical mobility of factor VIII-related antigen and an abnormal elution pattern as demonstrated by gelfiltration on Sepharose 4 B. Factor VIII-subunits in these patients were found to be normal by polyacrylamidgelelektrophoresis.

Severe factor VIII and factor IX deficiency in females

A survey of 11 hemophilia centers produced data concerning 28 females with extremely low levels of factor VIII or IX coagulant activity. Ten of the 28 have hemophilia A, six have hemophilia B, and 12 have severe von Willebrand's disease. The 16 females who have severe factor VIII or factor IX deficiency as an isolated defect exemplify several of the possible genetic explanations for the occurrence of hemophilia in females. All 16 bruise excessively, and several have had recurrent hemarthroses. Three of these girls, ages five, 10 and 23 years, have evidence of chronic hemophilic arthropathy. The 12 females with severe von Willebrand's disease are either homozygous for von Willebrand's disease or severely affected heterozygotes. All 12 have mucous membrane bleeding. In addition, five of the 12 have recurrent hemarthroses and three have evidence of chronic joint disease. However, the major problem in the adult females with von Willebrand's disease has been extreme menorrhagia. One of the seven adults underwent irradiation sterilization and another had a hysterectomy because of menorrhagia. The others have been managed with anovulatory drugs or plasma infusions and EACA. Despite menorrhagia, five pregnancies and deliveries have been uneventful in three of these women.

Effect of phospholipases on factor-VIII activity

The effect of the enzymes phospholipases C and D on Factor VIII were investigated. Phospholipase D was found to activate the partially purified intact Factor-VIII molecule maximally at a final concentration of 0.6 U/ml. Neither the dissociated small molecular weight component nor the high molecular weight component were activated. Phospholipase C, on the other hand, inactivated both the intact and the dissociated Factor-VIII molecule. Phospholipase D, however, had no effect on the haemophilic cryoprecipitate or the partially purified haemophilic Factor VIII. The implications of these results for the genetic control of the Factor-VIII molecule are discussed. In this connection, haemophilia A is hypothesized to be caused by an X-linked enzyme effect that impairs phospholipid assembly of the Factor-VIII protein, whereas von Willebrand's disease might be due to a structural defect of the Factor-VIII protein.

Von Willebrand's disease: combined qualitative and quantitative abnormalities

Studies of von Willebrand's disease typically show either a quantitative or a qualitative abnormality of the factor VIII/von Willebrand factor protein. In studies of five patients we found a combination of quantitative and qualitative defects. Quantitative abnormalities included decreased levels of procoagulant, antigen and von Willebrand factor activities in the plasma and in the column fractions of cryopercipitate from gel chromatography. Qualitative abnormalities included annormal migration or shape of the crossed antigen-antibody arcs, disproportionate reduction of von Willebrand factor in relation to antigen, altered gel elution patterns of procoagulant, and von Willebrand factor activities the negative carbohydrate stain of the VIII protein on polyacryl-amide-gel electrophoresis and, in two patients, a decreased sialic acid content of factor VIII protein. Our studies indicate that von Willebrand's disease comprises both quantitative and qualitative defects.

[Biology of lectins and their application in clinical biochemistry (author's transl)]

Lectins are proteins or glycoproteins, originally isolated from plant seeds. Characteristics are their ability to bind glycoproteins or glycolipids depending on the carbohydrate residues. The present review describes the structure of the lectins, their binding specificity and their functions with respect to precipitation of glycoproteins, agglutination of cells, transformation of lymphocytes and toxic action. Recently, lectin-analogs have been described in rabbit liver, which are responsible for hepatic uptake of circulating glycoproteins. The regulation of this process is intimately linked to the terminal N-Acetylneuraminic acid (NA-NA). Moreover, its significance is shown during fetal development, oncogenic transformation, immunologic recognition as well as homostasis. Due to the different terminal carbohydrate residues, glycoproteins of adult, fetal or transformed cells can be separated using affinity chromatography. Besides the purification of glycoproteins, lectins are also used for the separation of intact cells. Therefore the use of lectins is recommended for preparative and analytical methods, for the measurements of glycoprotein-turnover and for clinical diagnostics.

Borate and glycerol inhibition of the aggregation of guinea pig platelets by bovine factor VIII and ristocetin

To demonstrate the importance of the carbohydrate portions of bovine factor VIII and ristocetin for the induction of platelet aggregation, guinea pig platelets were treated with either borate or glycerol before and after addition of ristocetin or bovine factor VIII. Both borate and glycerol were capable of inhibiting the aggregation of blood platelets induced by adding bovine factor VIII or ristocetin to platelet-rich plasma. Furthermore, aggregates formed after treatment with either agent could be dispersed by high concentrations of either borate or glycerol. These effects did not appear to be solely the result of high ionic strength or of irreversible damage to the platelets. The results obtained support the hypothesis that the binding of the carbohydrate groups of factor VIII plays an important role in the induction of platelet aggregation and in the maintenance of aggregates formed in response to the treatment of platelet-rich plasma with bovine factor VIII or ristocetin.