Correction: Rewriting the script: gene therapy and genome editing for von Willebrand Disease
Frontiers in Genome Editing, vol. 7, pp. 1719330
Abstract
The heterogeneous landscape of VWD Von Willebrand Disease (VWD) is the most commonly inherited bleeding disorder, estimated to have a worldwide prevalence of 25.6 per million people in the general population (Leebeek and Eikenboom 2016;Stonebraker et al. 2023). Patients with VWD have qualitative and/or quantitative abnormalities with von Willebrand Factor (VWF), a large multimeric protein that is pivotal during primary hemostasis. There are different types of VWD, with ranging severities.Type 1 VWD is the most common, where patients have reduced VWF in circulation and a mild bleeding phenotype (Atiq et al. 2023). If the reduced amount of VWF is due to enhanced clearance, it is described as type 1C VWD. Type 2 VWD is characterized by a qualitative deficiency of VWF and can be further classified into various subtypes: A, B, M, and N (Figure 1A Table 1). The qualitative impairment spans from insufficient multimerization of VWF dimers into its hemostatically active mature VWF multimer, to impaired binding and susceptibility to other proteins involved in maintaining hemostasis (Daniel et al. 2024;Jacobi et al. 2012;Maas et al. 2021;Othman and Favaloro 2021). Type 3 is the rarest but most severe form, where patients have close to undetectable VWF levels in circulation and experience a severe bleeding phenotype (Eikenboom 2001;van Kwawegen and Leebeek 2024).The different types of VWD often arise from mutations impacting different domains of VWF (Figure 1A). Currently, more than 750 unique pathogenic VWF mutations are known, leading to a range of bleeding complications including mucocutaneous bleeding, heavy menstrual bleeding, joint bleeds, gastrointestinal bleeding and bleeding during surgery (de Jong and Eikenboom 2017;Weyand and Flood 2021). The Leiden Open Variation Database (LOVD) alone reported a list of 505 VWF variants that were found in VWD patients in the clinic, of which ~450 were missense and nonsense variants (Seidizadeh et al. 2023a). Utilizing those variants from the LOVD database as an example, Figure 1B illustrates the distribution of VWF variants.Variants resulting in type 1 and 3 VWD can be found throughout VWF. In contrast, type 2 VWD variants are often located around the A1 domain, affecting the binding to platelets and/or collagen, or around the D'D3 or CK domains, impacting multimerization. More VWF variants have been reported by various studies and can be found in additional databases such as ClinVar, GnomAD, genome browser, human gene mutation database (HGMD) and more (UCSC Genome Browser; gnomAD; ClinVar; HGMD®). Although the prevalence of VWD subtypes varies per database and cohort, multiple studies have shown that type 1 VWD is by far the most common form, accounting for around 60-85% of VWD cases. Type 2 VWD follows as the second most common with a prevalence of 15-45% (Michael Soucie et al. 2021;Seidizadeh et al. 2023b). Orphanet estimates the prevalence of type 1 VWD worldwide to be 1-5 / 10 000, and the prevalence of type 2 VWD worldwide to be 1-9/1 000 000 (Orphanet: Von Willebrand disease type 1 n.d.; Orphanet: Von Willebrand disease type 2 n.d.). Type 3 VWD remains the rarest form of the disease.Even though in around 30% of patients no pathogenic mutation in VWF could be identified, VWD is generally considered a monogenic disease. Detecting the location of a diseasecausing variant within VWF may indicate the impaired domain and binding site of the protein, thus implying the underlying molecular mechanism impairing VWF. However, the majority of variants that are found within VWF are not sufficiently characterized and are thus classified as variants of uncertain significance (VUS). To shed light on this, studies have sequenced large patient populations and performed ex vivo characterization experiments to explore which VWD variants are truly pathogenic (Atiq et al. 2022;Bär et al. 2025;Christopherson et al. 2022Christopherson et al. , 2024;;James et al. 2006;Laan et al. 2024;Tosetto et al. 2020;Vangenechten et al. 2022).VWD is predominantly inherited as an autosomal dominant disease, with the majority of VWF variants being heterozygous missense mutations. This results mostly in VWD type 1 and 2 subtypes, while type 3 and type 2N often derive out of homozygous null mutations or compound heterozygous and are therefore rarer forms of VWD with a typically recessive inheritance pattern. The prevalence for type 3 lays around 1:250,000 to 1:1,000,000 but is challenging to determine because of the increased prevalence in regions where consanguinity is more common (Nichols et al. 2008).In VWD there can be quantitative or functional deficiency of VWF: a large multimeric protein that is produced by endothelial cells (EC) and megakaryocytes. Long VWF strings are primarily stored in Weibel-Palade bodies (WPB) of ECs and α-granules of platelets, respectively (Lenting, Christophe, and Denis 2015). In ECs after synthesis (Figure 2A), VWF is translocated to the endoplasmic reticulum (ER) where the VWF signal peptide is removed, and C-terminal dimerization occurs between VWF monomers via the CK domains (Hordijk, Carter, and Bierings 2024). The dimers are subsequently shuttled to the Golgi, where Furin cleaves the VWF propeptide domain (VWFpp) off the dimers, allowing for their multimerization via the Nterminal D' D3 domains. Importantly, the VWFpp remains non-covalently bound to the VWF multimers which is essential for trafficking and packaging of VWF multimers into WPBs (Haberichter 2015). These organelles store ultra large (UL) and high molecular weight (HMW) VWF multimers which are secreted into the bloodstream upon endothelial activation. At the same time, low molecular weight (LMW) VWF is constantly secreted by the ECs in a process called constitutive secretion. The third secretion pathway of VWF is the unstimulated fusion of WPBs and the release of its content during basal secretion (Da Silva and Cutler 2016). The basally secreted VWF is considered the main contributor to stable VWF levels in plasma. When secreted, the UL and HMW VWF strings undergo cleavage by ADAMTS13, resulting in a distinct multimeric pattern of different sizes (Giblin, Hewlett, and Hannah 2008;Zhang et al. 2009).Biosynthesis of VWF in megakaryocytes also results in the formation of HMW VWF multimers that are eventually stored in tubular sub-compartments of platelet α-granules (Karampini, Bierings, and Voorberg 2020).In plasma, VWF acts as a chaperone for FVIII, protecting it from clearance and proteolytic cleavage (Pipe et al. 2016). At sites of vascular injury, VWF binds to the exposed sub-endothelial collagen layer through its A3 domain, anchoring itself and unfolding to expose its platelet binding sites (Romijn et al. 2001). The unfolded VWF strings provide a platform for platelets to bind to the A1 domain through their glycoprotein Ibα (GPIbα) receptor, initiating the formation of a platelet plug (Lenting, Denis, and Christophe 2024) (Figure 2B). This completes the process called primary hemostasis (Karampini et al. 2020). Due to the versatile role of VWF and its complex structure including several binding sites, the variety in VWD phenotypes is not surprising. Deficiency of VWF impacts other proteins involved in coagulation and the treatment and prevention of bleeds caused by faulty or missing VWF is challenging.The plethora of pathogenic variants and disease mechanisms complicates treatment of VWD tremendously. In addition, the lack of knowledge about the disease-underlying causes currently prevents personalized treatment in the clinic. Current treatment aims to increase VWF and FVIII plasma concentrations on demand in case of a bleeding event or before and after interventions. A common treatment approach for VWD patients, especially type 1, is to increase circulating VWF and FVIII levels by stimulating release of stored VWF and FVIII from ECs. 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Authors 7
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Sanquin · Amsterdam University Medical Centers
Affiliation as printed
Molecular Hematology, Sanquin Research and Landsteiner Laboratory, Amsterdam University Medical Centre, Amsterdam, Netherlands
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Emma Kinderziekenhuis · Amsterdam University Medical Centers · University of Amsterdam
Affiliation as printed
Department of Pediatric Hematology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
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Leiden University · Leiden University Medical Center
Affiliation as printed
Division of Thrombosis and Hemostasis, Department of Internal Medicine, Leiden University Medical Centre, Leiden, Netherlands
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Affiliation as printed
Department of Hematology, Erasmus University Medical Centre, Rotterdam, Netherlands
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Affiliation as printed
Department of Hematology, Erasmus University Medical Centre, Rotterdam, Netherlands
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Jan Voorberg corresponding
Sanquin · Amsterdam University Medical Centers
Affiliation as printed
Molecular Hematology, Sanquin Research and Landsteiner Laboratory, Amsterdam University Medical Centre, Amsterdam, Netherlands
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Sanquin · Amsterdam University Medical Centers
Affiliation as printed
Molecular Hematology, Sanquin Research and Landsteiner Laboratory, Amsterdam University Medical Centre, Amsterdam, Netherlands
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