Deficiency Of vWF-cleaving Protease Research Articles

Von Willebrand factor cleaving protease and ADAMTS13mutations in childhood TTP

Thrombotic thrombocytopenic purpura (TTP) is caused by the persistence of the highly reactive high-molecular-weight multimers of von Willebrand factor (VWF) due to deficiency of the specific VWF-cleaving protease (VWF-CP) ADAMTS13, resulting in microangiopathic disease. The acquired form is caused by autoantibodies against VWF-CP, whereas homozygous or compound heterozygous mutations of ADAMTS13 are responsible for recessively inherited TTP. We investigated 83 children with hemolytic or thrombocytopenic episodes with or without additional neurologic symptoms or renal failure. The presumed diagnosis was chronic idiopathic thrombocytopenic purpura (ITP; n = 50), TTP (n = 8), hemolytic uremic syndrome (HUS; n = 24), and Evans syndrome (n = 1). A severe deficiency of VWF-CP (< or = 5%) was found in all investigated patients with TTP and in none of those with HUS. Additionally, 2 of 50 patients with a prior diagnosis of ITP were deficient for VWF-CP. Antibodies against VWF-CP were found in 4 children. Mutation analysis of the ADAMTS13 gene in the patients deficient in VWF-CP by direct sequencing of all 29 exons identified 8 different mutations, suggesting the hereditary form of TTP in 1 patient with ITP, in the patient with Evans syndrome, and in 5 of the 8 patients with TTP. The phenotype of TTP in childhood can be rather variable. Besides the classical clinical picture, oligosymptomatic forms may occur that can delay the identification of patients at risk.

Complete Defect in vWF-cleaving Protease Activity Associated with Increased Shear-induced Platelet Aggregation in Thrombotic Microangiopathy

Von Willebrand factor (vWF) cleaving metalloprotease activity represents an important factor in understanding the pathophysiology of thrombotic microangiopathies (TMA). Thrombotic events, leading to dramatic complications, occur preferentially in the microvasculature. Our aim was to determine the ability of TMA plasma with a complete deficiency of protease activity to promote shear-induced platelet aggregation (SIPA) at high shear rates using a coaxial cylinder shearing device. We have demonstrated the ability of four out of seven TMA plasma to aggregate normal washed platelets at 4,000 s(-1). In these four TMA plasma, significant SIPA was obtained, whereas control plasma did not induce more SIPA than buffer. The % of unusually large (UL) multimers in TMA plasma varied from 1 to 18%. Surprisingly, the extent of SIPA in TMA plasma appeared independent of the percentage of UL multimers. Interestingly, anti-GPIb antibody 6D1 could block completely this pathological aggregation, opening new therapeutic possibilities. In contrast, none of eight other TMA patients' plasma with a normal protease activity, exhibited any increase of SIPA compared with control plasma. These results strongly suggest that the deficiency of vWF-cleaving protease appears to be necessary, but not sufficient for elevated SIPA. In contrast, the % of UL is not associated with increased SIPA.

Von Willebrand Factor-cleaving Protease in Childhood Diarrhoea-associated Haemolytic Uraemic Syndrome

A deficiency of von Willebrand factor (vWF)-cleaving protease, either due to a congenital deficiency or to the presence of a protease inhibitor of vWF-cleaving protease has been associated with thrombotic thrombocytopenic purpura (TTP). We have studied vWF-cleaving protease in diarrhoea-associated haemolytic uraemic syndrome (D+ HUS), which shares clinical features with TTP. 29 children with acute D+ HUS and 13 control children were studied. vWF-cleaving protease activity was normal (range 50-150%) in 39 of 42 plasma samples. Levels of protease activity between 25 and 50% were noted in plasma from two D+ HUS patients. One D+HUS patient, who had clinical features of TTP, had a vWF-cleaving protease inhibitor producing a severe deficiency of vWF-cleaving protease. Thus a deficiency of vWF-cleaving protease appears to be atypical in D+HUS. The detection of a vWF-cleaving protease inhibitor in one patient suggests it may be associated with infection such as E. coli O157.