BackgroundVon Willebrand factor (VWF) is an acute phase reactant synthesized in the megakaryocytes and endothelial cells. VWF forms ultra-large multimers (ULVWF) which are cleaved by the metalloprotease ADAMTS-13, preventing spontaneous VWF–platelet interaction. After trauma, ULVWF is released into circulation as part of the acute phase reaction. We hypothesized that trauma patients would have increased levels of VWF and decreased levels of ADAMTS-13 and that these patients would have accelerated thrombin generation.MethodsWe assessed plasma concentrations of VWF antigen and ADAMTS-13 antigen, the Rapid Enzyme Assays for Autoimmune Diseases (REAADS) activity of VWF, which measure exposure of the platelet-binding A1 domain, and thrombin generation kinetics in 50 samples from 30 trauma patients and an additional 21 samples from volunteers. Samples were analyzed at 0 to 2 hours and at 6 hours from the time of injury. Data are presented as median (IQR) and Kruskal-Wallis test was performed between trauma patients and volunteers at both time points.ResultsREAADS activity was greater in trauma patients than volunteers both at 0 to 2 hours (190.0 (132.0–264.0) vs. 92.0 (71.0–114.0), p<0.002) and at 6 hours (167.5 (108.0–312.5.0) vs. 92.0 (71.0–114.0), p<0.001). ADAMTS-13 antigen levels were also decreased in trauma patients both at 0 to 2 hours (0.84 (0.51–0.94) vs. 1.00 (0.89–1.09), p=0.010) and at 6 hours (0.653 (0.531–0.821) vs. 1.00 (0.89–1.09), p<0.001). Trauma patients had accelerated thrombin generation kinetics, with greater peak height and shorter time to peak than healthy volunteers at both time points.DiscussionTrauma patients have increased exposure of the VWF A1 domain and decreased levels of ADAMTS-13 compared with healthy volunteers. This suggests that the VWF burst after trauma may exceed the proteolytic capacity of ADAMTS-13, allowing circulating ULVWF multimers to bind platelets, potentially contributing to trauma-induced coagulopathy.Level of evidenceProspective case cohort study.

Von Willebrand disease (VWD) is the most common inherited human bleeding disorder. It is caused by deficiencies or defects in the plasma protein von Willebrand factor (vWF). The current classification of VWD consists of six distinct types. Type 1 and 3 result in a quantitative vWF deficiency in patients while the four type 2 variants (type 2A, 2B, 2M & 2N) are caused by qualitative defects in vWF. The von Willebrand factor is a multimeric multidomain glycoprotein that is secreted into blood from vascular endothelial cells. The protein initiates platelet adhesion at sites of cardiovascular injury. In vWF three essential domains could be identified which are responsible for the interaction with platelets and subendothelial tissue. While the A1 domain is responsible for the interaction with platelets, the A3-domain interacts with collagen from the subendothelial tissue. The A2-domain contains a cleavage site for the zinc protease AdamTS13 which regulates the size and the function of the vWF multimers by cleaving the A2-domain. We have recently studied the effect of several type 2B (= gain of function, stronger interaction with platelets) and type 2M (= loss of function, weak or no interaction with platelets) mutations in the vWF A1-domain and found clear evidence that these mutations cause a misfolding of this domain resulting in either gain- or loss of function (Tischer et al. (2014) Biophys. J. Accepted article). Hence type 2M and 2B VWD are clearly protein folding disorder diseases such like Alzheimer or various Amyloidoses. However since our group has obtained the A1-domain recombinantly from E.coli, it was unclear whether indeed misfolding of A1 is occurring or whether it is the result of the expression of the proteins in bacteria. To investigate this issue we have expressed triple domains in mammalian HEK293 cells consisting of A1, A2 and A3 and harboring the type 2B mutation V1314D and the 2B mutation F1369I in the A1 domain. The impact of the mutations on the biological function was determined in shear flow-dependent assays by observing the translocation of platelets on surface-immobilized A1- or triple domain. Using high speed video microscopy we were able to obtain statistical valid parameters for platelet translocation such as mean pause times and velocities. While F1369I did not support platelet translocation at all, V1314D was found to almost immobilize platelets in the flow chamber. The triple domain constructs harboring the mutations were found to have very similar functional features as the single domain mutants. F1369I triple domain did not support platelet translocation whereas V1314D triple domain immobilized platelets in the flow chamber at all applied shear rates. Structural characterization of the single A1 domains and of the triple domains resulted in evidence for massive misfolding in the A1 domain induced by the mutations. Therefore, all attempts to understand VWD and a potential drug development are required to account for non-native conformations of the A1 domain. Disclosures No relevant conflicts of interest to declare.