Type 1 von Willebrand disease (VWD) is the most common inherited human bleeding disorder. However, diagnosis is complicated by incomplete penetrance and variable expressivity, as well as wide variation in von Willebrand factor (VWF) levels among the normal population. Previous work has exploited the highly variable plasma VWF levels among inbred strains of mice to identify 2 major regulators, Mvwf1 and Mvwf2 (modifier of VWF).Mvwf1 is a glycosyltransferase and Mvwf2 is a natural variant in Vwf that alters biosynthesis. We report the identification of an additional alteration at the Vwf locus (Mvwf5), as well as 2 loci unlinked to Vwf (Mvwf6-7) using a backcross approach with the inbred mouse strains WSB/EiJ and C57BL/6J. Through positional cloning, we show that Mvwf5 is a cis-regulatory variant that alters Vwf mRNA expression. A similar mechanism could potentially explain a significant percentage of human VWD cases, especially those with no detectable mutation in the VWF coding sequence. Mvwf6 displays conservation of synteny with potential VWF modifier loci identified in human pedigrees, suggesting that its ortholog may modify VWF in human populations.
Introductionvon Willebrand factor (VWF) is a central component of hemostasis, serving as the adhesive link between platelets and the injured blood vessel wall, as well as the carrier for factor VIII. Deficiencies in VWF result in von Willebrand disease (VWD), the most common inherited bleeding disorder in humans. Elevated VWF levels may also be an important risk factor for thrombosis, both through a direct role in platelet adhesion, 1 as well as indirectly by causing elevated levels of factor VIII. [2][3][4] Diagnosis of VWD is elusive in many cases because of its variable expressivity and incomplete penetrance 5 and the nonspecific nature of bleeding symptoms. 6 VWF plasma protein levels also display a broad distribution in the normal human population. Thus, it is often difficult to determine whether a person has VWD and is at risk for pathologic hemorrhage or simply has VWF levels in the low range of normal.Levels of plasma VWF have been shown to be largely determined by genetic factors, with estimates of heritability in humans ranging from 25% to 32% by pedigree analysis, 7,8 to 66% to 75% in twin studies. 9,10 ABO blood group is responsible for one-third of the genetic variability in VWF plasma levels. 11 However, the loci responsible for the remaining two-thirds of this genetic component are unknown. Recent evidence from European and Canadian cooperative studies on type 1 VWD have found that disease diagnosis does not segregate with VWF genotype in approximately 50% of families, supporting the existence of additional genetic factors. [12][13][14][15][16] Laboratory mice display wide variation in VWF levels with 65% heritability in a cross between the strains A/J and CASA/RkJ, 17 strikingly similar to the estimates for humans derived from twin studies. 9,10 This variability among inbred mouse strains has been used to identify genetic loci modifying VWF level...