Variant mapping using mass spectrometry-based proteotyping as a diagnostic tool in Von Willebrand Disease

Background Von Willebrand disease (VWD) is the most common inherited bleeding disorder, characterized by either partial or complete von Willebrand factor (VWF) deficiency or by the occurrence of VWF proteoforms of altered functionality. The gene encoding VWF is highly polymorphic, giving rise to a variety of proteoforms with varying plasma concentrations and clinical significance. Objectives To address this complexity, we translated genomic variation in VWF to corresponding VWF proteoforms circulating in blood. Patients/Methods VWF was characterized in VWD patients (n=64) participating in the Willebrand in the Netherlands (WiN) by conventional laboratory testing, DNA sequencing and complementary discovery and targeted mass spectrometry-based plasma proteomic strategies. Results Unbiased plasma profiling combined with immune-enrichment of VWF, verified VWF and its binding partner Factor VIII as key determinants of VWD and revealed a remarkable heterogeneity in VWF amino acid sequence coverage among patients. Subsequent VWF proteotyping enabled identification of both polymorphisms (e.g. p.Thr789Ala, p.Gln852Arg, p.Thr1381Ala), as well as pathogenic variants (n=16) along with their corresponding canonical sequences. Targeted proteomics using stable isotope labeled peptides confirmed unbiased proteotyping for five selected variants and suggested differential proteoform quantities in plasma. The variant-to-wildtype peptide ratio was determined in six type 2B patients heterozygous for p.Arg1306Trp, confirming the relatively low proteoform concentration of the pathogenic variant. The elevated VWFpp/VWF ratio indicated increased clearance of specific VWF proteoforms. Conclusions This study highlights how VWF proteotyping from plasma could be the first step to bridge the gap between genotyping and functional testing in VWD.