A novel ELISA-based diagnosis of acquired von Willebrand disease with increased VWF proteolysis

Summary

Von Willebrand disease-type 2A (VWD-2A) and acquired von Willebrand syndrome (AVWS) due to aortic stenosis (AS) or left ventricular assist device (LVAD) are associated with an increased proteolysis of von Willebrand factor (VWF). Analysis of VWF multimeric profile is the most sensitive way to assess such increased VWF-proteolysis. However, several technical aspects hamper a large diffusion among routine diagnosis laboratories. This makes early diagnosis and early appropriate care of increased proteolysis challenging. In this context of unmet medical need, we developed a new ELISA aiming a quick, easy and reliable assessment of VWF-proteolysis. This ELISA was assessed successively in a LVAD-model, healthy subjects (n=39), acquired TTP-patients (n=4), VWD-patients (including VWD-2A(IIA), n=22; VWD-2B, n=26; VWD-2A(IIE), n=21; and VWD-1C, n=8) and in AVWS-patients (AS, n=9; LVAD, n=9; and MGUS, n=8). A standard of VWF-proteolysis was specifically developed. Extent of VWF-proteolysis was expressed as relative percentage and as VWF proteolysis/VWF:Ag ratio. A speeddependent increase in VWF-proteolysis was assessed in the LVAD model whereas no proteolysis was observed in TTP-patients. In VWDpatients, VWF-proteolysis was significantly increased in VWD-2A(IIA) and VWD-2B and significantly decreased in VWD-2A(IIE) versus controls (p< 0.0001). In AVWS-patients, VWF-proteolysis was significantly increased in AS- and LVAD-patients compared to controls (p< 0.0001) and not detectable in MGUS-patients. A significant increase in VWFproteolysis was detected as soon as three hours after LVAD implantation (p< 0.01). In conclusion, we describe a new ELISA allowing a rapid and accurate diagnosis of VWF-proteolysis validated in three different clinical situations. This assay represents a helpful alternative to electrophoresis-based assay in the diagnosis and management of AVWS with increased VWF-proteolysis.

Supplementary Material to this article is available online at www.thrombosis-online.com.

Keywords

von Willebrand disease - acquired von Willebrand syndrome - proteolysis - aortic stenosis - circulatory support device

• References

• 1 Zimmerman TS, Dent JA, Ruggeri ZM. et al. Subunit composition of plasma von Willebrand factor. Cleavage is present in normal individuals, increased in IIA and IIB von Willebrand disease, but minimal in variants with aberrant structure of individual oligomers (types IIC, IID, and IIE). J Clin Invest 1986; 77: 947-951.
• 2 Hassenpflug WA, Budde U, Obser T. et al. Impact of mutations in the von Willebrand factor A2 domain on ADAMTS13-dependent proteolysis. Blood 2006; 107: 2339-2345.
• 3 Vincentelli A, Susen S, Le Tourneau T. et al. Acquired von Willebrand syndrome in aortic stenosis. N Engl J Med 2003; 349: 343-349.
• 4 Van Belle E, Rauch A, Vincentelli A. et al. Von Willebrand factor as a biological sensor of blood flow to monitor percutaneous aortic valve interventions. Circ Res 2015; 116: 1193-1201.
• 5 Crow S, John R, Boyle A. et al. Gastrointestinal bleeding rates in recipients of nonpulsatile and pulsatile left ventricular assist devices. J Thorac Cardiovasc Surg 2009; 137: 208-215.
• 6 Meyer AL, Malehsa D, Budde U. et al. Acquired von Willebrand syndrome in patients with a centrifugal or axial continuous flow left ventricular assist device. JACC Heart Fail 2014; 2: 141-145.
• 7 Goldstein DJ, Aaronson KD, Tatooles AJ. et al. Gastrointestinal bleeding in recipients of the HeartWare Ventricular Assist System. JACC Heart Fail 2015; 3: 303-313.
• 8 Boisseau P, Ternisien C, Caron C. et al. Incidence of large VWF gene deletions and duplications in the french cohort of 1182 patients with von WIllebrand disease (VWD). Journal of thrombosis and haemostasis:. J Thromb Haemost 2013; 11 (Suppl. 02) 116.
• 9 Federici AB, Mannucci PM, Castaman G. et al. Clinical and molecular predictors of thrombocytopenia and risk of bleeding in patients with von Willebrand disease type 2B: a cohort study of 67 patients. Blood 2009; 113: 526-534.
• 10 Rauch A, Legendre P, Christophe OD. et al. Antibody-based prevention of von Willebrand factor degradation mediated by circulatory assist devices. Thromb Haemost 2014; 112: 1014-1023.
• 11 Favaloro EJ, Henniker A, Facey D. et al. Discrimination of von Willebrands disease (VWD) subtypes: direct comparison of von Willebrand factor: collagen binding assay (VWF: CBA) with monoclonal antibody (MAB) based VWF-capture systems. Thromb Haemost 2000; 84: 541-547.
• 12 Hulstein JJ, De Groot PJ, Silence K. et al. A novel nanobody that detects the gainof- function phenotype of von Willebrand factor in ADAMTS13 deficiency and von Willebrand disease type 2B. Blood 2005; 106: 3035-3042.
• 13 Kato S, Matsumoto M, Matsuyama T. et al. Novel monoclonal antibody-based enzyme immunoassay for determining plasma levels of ADAMTS13 activity. Transfusion 2006; 46: 1444-1452.
• 14 Moatti-Cohen M, Garrec C, Wolf M. et al. Unexpected frequency of Upshaw- Schulman syndrome in pregnancy-onset thrombotic thrombocytopenic purpura. Blood 2012; 119: 5888-5897.
• 15 Jacobi PM, Gill JC, Flood VH. et al. Intersection of mechanisms of type 2A VWD through defects in VWF multimerization, secretion, ADAMTS-13 susceptibility, and regulated storage. Blood 2012; 119: 4543-4553.
• 16 Rayes J, Hollestelle MJ, Legendre P. et al. Mutation and ADAMTS13-dependent modulation of disease severity in a mouse model for von Willebrand disease type 2B. Blood 2010; 115: 4870-4877.
• 17 Shim K, Anderson PJ, Tuley EA. et al. Platelet-VWF complexes are preferred substrates of ADAMTS13 under fluid shear stress. Blood 2008; 111: 651-657.
• 18 Springer TA. von Willebrand factor, Jedi knight of the bloodstream. Blood 2014; 124: 1412-1425.
• 19 Casonato A, Pontara E, Morpurgo M. et al. Higher and lower active circulating VWF levels: different facets of von Willebrand disease. Br J Haematol. 2015 Epub ahead of print
• 20 Schneppenheim R, Michiels JJ, Obser T. et al. A cluster of mutations in the D3 domain of von Willebrand factor correlates with a distinct subgroup of von Willebrand disease: type 2A/IIE. Blood 2010; 115: 4894-4901.
• 21 Federici AB, Bucciarelli P, Castaman G. et al. The bleeding score predicts clinical outcomes and replacement therapy in adults with von Willebrand disease. Blood 2014; 123: 4037-4044.
• 22 Blackshear JL, Wysokinska EM, Safford RE. et al. Shear stress-associated acquired von Willebrand syndrome in patients with mitral regurgitation. J Thromb Haemost 2014; 12: 1966-1974.
• 23 Le Tourneau T, Susen S, Caron C. et al. Functional impairment of von Willebrand factor in hypertrophic cardiomyopathy: relation to rest and exercise obstruction. Circulation 2008; 118: 1550-1557.
• 24 Loscalzo J. From clinical observation to mechanism--Heyde’s syndrome. N Engl J Med 2012; 367: 1954-1956.
• 25 Jackson CS, Gerson LB. Management of gastrointestinal angiodysplastic lesions (GIADs): a systematic review and meta-analysis. Am J Gastroenterol 2014; 109: 474-483.
• 26 Blackshear JL, Stark ME, Agnew RC. et al. Remission of recurrent gastrointestinal bleeding after septal reduction therapy in patients with hypertrophic obstructive cardiomyopathy-associated acquired von Willebrand syndrome. J Thromb Haemost 2015; 13: 191-196.
• 27 Heilmann C, Geisen U, Beyersdorf F. et al. Acquired von Willebrand syndrome in patients with ventricular assist device or total artificial heart. Thromb Haemost 2010; 103: 962-967.
• 28 Feldman D, Pamboukian SV, Teuteberg JJ. et al. The 2013 International Society for Heart and Lung Transplantation Guidelines for mechanical circulatory support: executive summary. J Heart Lung Transplant 2013; 32: 157-187.
• 29 Bunte MC, Blackstone EH, Thuita L. et al. Major bleeding during HeartMate II support. J Am Coll Cardiol 2013; 62: 2188-2196.
• 30 Fischer Q, Huisse MG, Voiriot G. et al. Von Willebrand factor, a versatile player in gastrointestinal bleeding in left ventricular assist device recipients?. Transfusion 2014; 55: 51-54.
• 31 Starling RC, Moazami N, Silvestry SC. et al. Unexpected abrupt increase in left ventricular assist device thrombosis. N Engl J Med 2014; 370: 33-40.