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  • Review Article
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Haemophilia A: from mutation analysis to new therapies

Nature Reviews Genetics volume 6, pages 488–501 (2005)Cite this article

Key Points

  • Mutations in the X-linked coagulation factor VIII (F8) gene lead to haemophilia A of different grades of severity in humans.

  • Approximately half the severe cases are due to intron-22 inversions. For smaller deletions, insertions or point mutations, the degree of severity depends on the function of the affected domains. Surprisingly, in about 4% of the haemophiliacs no mutation can be found in the coding exons and their flanking sequences.

  • Several hundred missense mutations in the F8 gene have been identified; these are used to understand the function of the various domains of the F8 protein.

  • Many proteins interact with F8 during its transport through cellular compartments, and regulate its activation and inactivation. Mutations in genes that code for these proteins lead to haemophilia-like symptoms (in particular mutations in the VWD, LMAN1 and MCFD2 genes).

  • Because ∼2% of haemophiliacs do not carry mutations in the coding regions of the F8 gene, further efforts are needed to analyse the F8 mRNA (and the corresponding cDNA) from its ectopic expression in lymphocytes.

  • Haemophilia A has been a leading model in the field of gene therapy; however, the disappointingly low levels and short time range of F8 expression need to be increased.

  • Current research focuses on increasing the yield of recombinant F8, improving its transport, extending its half-life and reducing its antigenicity.

Abstract

Haemophilia is caused by hundreds of different mutations and manifests itself in clinical conditions of varying severity. Despite being inherited in monogenic form, the clinical features of haemophilia can be influenced by other genetic factors, thereby confounding the boundary between monogenic and multifactorial disease. Unlike sufferers of other genetic diseases, haemophiliacs can be treated successfully by intravenous substitution of coagulation factors. Haemophilia is also the most attractive model for developing gene-therapy protocols, as the normal life expectancy of haemophiliacs allows the side effects of gene therapy, as well as its efficiency, to be monitored over long periods.

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Figure 1: Principal features of the coagulation factor VIII gene and protein.
Figure 2: Properties and interaction sites of the coagulation factor VIII protein.
Figure 3: Pathological inversions of the coagulation factor VIII gene.

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Acknowledgements

This work of H.H.B., J.G., J.O., R.S. and W.S. was supported in part by a grant from the German Human Genome Project (DHGP) to the 'Genotype–Phenotype Correlation in Haemophilia A' consortium.

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Authors and Affiliations

  1. GSF-National Research Centre for Environment and Health, Institute of Developmental Genetics, Neuherberg, D-85764, Germany

    Jochen Graw

  2. Institute for Experimental Haematology and Transfusion Medicine, University of Bonn, Bonn, D-53105, Germany

    Hans-Hermann Brackmann & Rainer Schwaab

  3. Institute of Transfusion Medicine and Immune-Haematology, DRK Blood Donor Service Baden-Württemberg/Hessen, Frankfurt, D-60528, Germany

    Johannes Oldenburg

  4. Department of Paediatric Haematology/Oncology, University Medical Centre Hamburg-Eppendorf, Hamburg, D-20246, Germany

    Reinhard Schneppenheim

  5. Department of Haemostasis and Transfusion Medicine, University Hospital Munich, München, D-80336, Germany

    Michael Spannagl

Authors
  1. Jochen Graw
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  2. Hans-Hermann Brackmann
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  3. Johannes Oldenburg
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  4. Reinhard Schneppenheim
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  5. Michael Spannagl
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Correspondence to Jochen Graw.

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Related links

DATABASES

Entrez

APC

CEBPA

CEBPB

F5

F8

F8A

F9

F10

HNF1

HNF4

LMAN1

MCFD2

MTHFR

VWF

OMIM

Haemophilia A

Haemophilia B

Huntington disease

von Willebrand disease

FURTHER INFORMATION

HAMSTeRS

International Society on Thrombosis and Haemostasis web site

Nature Genetics

Glossary

ANTI-IDIOTYPIC ANTIBODIES

Antibodies that bind to the specific antigen-binding sites of other antibodies.

CD4+ CELLS

A subset of white blood cells that identify, attack and destroy infection and cancerous cells.

CHRONIC SYNOVITIS

The concurrent non-use of muscles around a joint that is subject to repeated bleeding leads to a periarticular muscular atrophy with loss of dynamic support, which predisposes the joint to further bleeding.

THROMBOPHILIA

Abnormal haemostasis parameters, as assessed in the laboratory, that are associated with an increased risk of blood clotting in veins or arteries.

CERULOPLASMIN

A plasma metalloprotein that binds most copper ions in the plasma. It is involved in the peroxidation of Fe2+ transferrin to form Fe3+ transferrin. Ceruloplasmin, F5 and F8 have a common evolutionary origin. Loss of ceruloplasmin activity leads to diabetes mellitus, retinal degeneration and dementia.

ONE-STAGE CLOTTING ASSAY

Plasma from a patient is mixed with plasma that is known to be deficient in F8, and the time of formation of a fibrin clot is measured. The assay therefore compares the activity of the blood coagulation cascade in the patient's plasma with the normal activity.

CHROMOGENIC ASSAY

Diluted patient plasma is mixed with thrombin, F10 and activated F9 reagents. Activated F9 hydrolyses the chromogenic substrate S–2,765 and releases a chromophore. The colour intensity released by the chromophore is proportional to F8 activity in the sample.

ALLOANTIBODY

Usually refers to an antibody that is raised naturally against foreign tissues from a member of the same species; in the case of haemophilia it describes the formation of antibodies against the therapeutic F8 protein. As the recombinant protein is of human origin it should be recognized as 'self', but it is not.

TRANSAMINASE

A class of enzymes that causes transamination; that is, the transfer of an amino group. Elevated levels of transminase indicate various hepatic disorders.

OMENTUM

A sheet of fat that is covered by peritoneum. The greater omentum is attached to the bottom edge of the stomach and hangs down in front of the intestine. Its other edge is attached to the transverse colon. The lesser omentum is attached to the top edge of the stomach and extends to the lower surface of the liver.

RANDOMIZED THREE-WAY CROSS-OVER STUDY

Three groups of patients are formed by the random distribution of probands. Participants in one group receive one intervention for a period of time, then switch over to a second intervention and then to a third intervention (participants in the second group start with the second intervention and switch to the third, then the first, and so on). The result is that all groups will be treated with all three protocols (so, the term 'cross-over' is used).

HAEMOSTASIS

A balanced interaction of blood cells, vasculature, plasma proteins and low molecular weight substances. Perfect homeostasis means absence of bleeding and of thrombosis.

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Graw, J., Brackmann, HH., Oldenburg, J. et al. Haemophilia A: from mutation analysis to new therapies. Nat Rev Genet 6, 488–501 (2005). https://doi.org/10.1038/nrg1617

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