The p.P1127S pathogenic variant lowers von Willebrand factor levels through higher affinity for the macrophagic scavenger receptor LRP1: Clinical phenotype and pathogenic mechanisms

BACKGROUND: The index case is a 21‐year‐old Italian woman with a mild hemorrhagic syndrome and von Willebrand factor antigen (VWF:Ag) = 34.3 U/dl, VWF recombinant glycoprotein Ib (VWF:GpIbR) = 32.8 U/dl, and factor VIII (FVIII) = 55.3 IU/dl. AIMS: The aim of this study is to characterize from a genetic and biochemical standpoint this low VWF phenotype. METHODS: Coagulation and biochemical methods were used to study the structural and functional pattern of VWF multimers in the index case’s plasma. Recombinant wild‐type and p.P1127S VWF variants were produced using human embryonic kidney (HEK)‐293 cells. In addition, genetic screening was carried out to detect single nucleotide variants of some scavenger VWF/FVIII receptor genes such as CLEC4M, STAB2, and ASGR2. RESULTS: Genetic investigation revealed that the index case inherited from her mother the heterozygous missense mutation c.3379C > T (VWF exon 25), causing the p.P1127S substitution in the VWF D′D3 domain. The index case was also homozygous for the scavenger receptor ASGR2 c.‐95 CC‐genotype. Desmopressin normalized the VWF level of the patient, although its clearance was faster (t (1/2) = 6.7 h) than in normal subjects (t (1/2) = 12 ± 0.7 h). FVIII‐VWF interaction, A Disintegrin And Metalloprotease with ThromboSpondin type 1 motif‐13 levels, ristocetin‐induced‐platelet‐aggregation, and VWF multimeric pattern were normal. The p.P1127S variant was normally synthesized and secreted by HEK‐293 cells, and molecular modeling predicts a conformational change showing higher affinity for the macrophagic scavenger receptor lipoprotein receptor‐related protein 1 (LRP1), as also experimentally verified. CONCLUSIONS: The p.P1127S variant may cause a low VWF phenotype, stemming from an increased VWF affinity for the scavenger receptor LRP1 and, consequently, an accelerated clearance of VWF.