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      Update on von Willebrand factor multimers: focus on high-molecular-weight multimers and their role in hemostasis


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          Normal hemostasis requires von Willebrand factor (VWF) to support platelet adhesion and aggregation at sites of vascular injury. VWF is a multimeric glycoprotein built from identical subunits that contain binding sites for both platelet glycoprotein receptors and collagen. The adhesive activity of VWF depends on the size of its multimers, which range from 500 to over 10 000 kDa. There is good evidence that the high-molecular-weight multimers (HMWM), which are 5000–10 000 kDa, are the most effective in supporting interaction with collagen and platelet receptors and in facilitating wound healing under conditions of shear stress. Thus, these HMWM of VWF are of particular clinical interest. The unusually large multimers of VWF are, under normal conditions, cleaved by the plasma metalloproteinase ADAMTS13 to smaller, less adhesive multimers. A reduction or lack of HMWM, owing to a multimerization defect of VWF or to an increased susceptibility of VWF for ADAMTS13, leads to a functionally impaired VWF and the particular type 2A of von Willebrand disease. This review considers the biology and function of VWF multimers with a particular focus on the characterization of HMWM – their production, storage, release, degradation, and role in normal physiology. Evidence from basic research and the study of clinical diseases and their management highlight a pivotal role for the HMWM of VWF in hemostasis.

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          Most cited references103

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          Biochemistry and genetics of von Willebrand factor.

          J Sadler (1998)
          Von Willebrand factor (VWF) is a blood glycoprotein that is required for normal hemostasis, and deficiency of VWF, or von Willebrand disease (VWD), is the most common inherited bleeding disorder. VWF mediates the adhesion of platelets to sites of vascular damage by binding to specific platelet membrane glycoproteins and to constituents of exposed connective tissue. These activities appear to be regulated by allosteric mechanisms and possibly by hydrodynamic shear forces. VWF also is a carrier protein for blood clotting factor VIII, and this interaction is required for normal factor VIII survival in the circulation. VWF is assembled from identical approximately 250 kDa subunits into disulfide-linked multimers that may be > 20,000 kDa. Mutations in VWD can disrupt this complex biosynthetic process at several steps to impair the assembly, intracellular targeting, or secretion of VWF multimers. Other VWD mutations impair the survival of VWF in plasma or the function of specific ligand binding sites. This growing body of information about VWF synthesis, structure, and function has allowed the reclassification of VWD based upon distinct pathophysiologic mechanisms that appear to correlate with clinical symptoms and the response to therapy.
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            Update on the pathophysiology and classification of von Willebrand disease: a report of the Subcommittee on von Willebrand Factor.

            von Willebrand disease (VWD) is a bleeding disorder caused by inherited defects in the concentration, structure, or function of von Willebrand factor (VWF). VWD is classified into three primary categories. Type 1 includes partial quantitative deficiency, type 2 includes qualitative defects, and type 3 includes virtually complete deficiency of VWF. VWD type 2 is divided into four secondary categories. Type 2A includes variants with decreased platelet adhesion caused by selective deficiency of high-molecular-weight VWF multimers. Type 2B includes variants with increased affinity for platelet glycoprotein Ib. Type 2M includes variants with markedly defective platelet adhesion despite a relatively normal size distribution of VWF multimers. Type 2N includes variants with markedly decreased affinity for factor VIII. These six categories of VWD correlate with important clinical features and therapeutic requirements. Some VWF gene mutations, alone or in combination, have complex effects and give rise to mixed VWD phenotypes. Certain VWD types, especially type 1 and type 2A, encompass several pathophysiologic mechanisms that sometimes can be distinguished by appropriate laboratory studies. The clinical significance of this heterogeneity is under investigation, which may support further subdivision of VWD type 1 or type 2A in the future.
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              Physiologic cleavage of von Willebrand factor by a plasma protease is dependent on its conformation and requires calcium ion.

              von Willebrand factor (vWF) in the circulation is subjected to proteolysis. In a recent study, we reported that normal plasma contains a protease activity that cleaves vWF in a shear-dependent manner, causing a decrease in its multimer size while generating dimers of the 140-kD and the 176-kD fragments indistinguishable from those found in normal plasma. In this study, the plasma protease has been partially purified and characterized and the role of vWF conformation in its cleavage by the protease has been further investigated. Guanidine HCl caused unfolding of vWF in a concentration-dependent manner, resulting in a shift in its fluorescence emission maxima to longer wavelengths. A dramatic increase in its proteolytic susceptibility was seen at 1.1 to 1.2 mol/L guanidine HCl, a concentration causing only a 3- to 4-nm shift in vWF emission maxima. Although vWF molecules refolded as guanidine HCl was removed by dialysis, the refolding was accompanied only by a partial recovery of the proteolytic resistance. The plasma protease, partially purified by approximately 900 folds by Sephacryl S-300 HR gel filtration, Matrex gel orange A dye affinity chromatography, and Q Sepharose anion exchange, had a molecular mass of approximately 200 kD and was inhibited by EDTA, EGTA, or 1,10-phenanthroline. The inhibition by EGTA or EDTA could be reversed by Ca2+ but not by mg2+. It was not inhibited by a panel of synthetic and natural protease inhibitors or adsorbed by gelatin-agarose, and it was present in plasmas deficient in proteins involved in coagulation and anticoagulation. The vWF fragments generated by the protease, as mapped by peptide-specific antibodies VP-1 and LJ-7745, were in distinguishable from the natural fragments but distinct from those produced by plasmin. High molecular weight endothelial vWF, after exposure to guanidine HCLI or high shear stress, was cleaved by the protease to smaller forms. These results support the model that endothelial secreted vWF is converted to multimers by a novel plasma metalloproteinase. Although native vWF exists in a conformation relatively resistant to cleavage, an alteration in the conformation by shear stress can lead to enhanced proteolytic susceptibility. This model may explain the decrease in vWF multimer sizes in various clinical conditions.

                Author and article information

                Blood Coagul Fibrinolysis
                Blood Coagul. Fibrinolysis
                Blood Coagulation & Fibrinolysis
                Lippincott Williams And Wilkins
                April 2014
                28 March 2014
                : 25
                : 3
                : 206-216
                [a ]CSL Behring GmbH, Marburg
                [b ]Department of Pediatric Hematology and Oncology, University Medical Center Hamburg-Eppendorf
                [c ]Department of Hemostaseology, Medilys Laborgesellschaft, Hamburg, Germany
                Author notes
                Correspondence to Marcus Stockschlaeder, MD, Global Medical Affairs, CSL Behring GmbH, Emil-von-Behring Strasse 76, 35041 Marburg, Germany Tel: +49 6421 39 4661; fax: +49 6421 39 4146; e-mail: marcus.stockschlaeder@ 123456cslbehring.com
                © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

                This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivitives 3.0 License, where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially.

                : 23 August 2013
                : 27 November 2013
                : 4 December 2013
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                adamts13,factor viii,hemostasis,high-molecular-weight multimers,platelets,von willebrand disease,von willebrand factor


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