title: Limitations of the ristocetin cofactor assay in measurement of von Willebrand factor function.
abstract: BACKGROUND
  Type 2M von Willebrand disease (VWD) is characterized by a qualitative defect in von Willebrand factor (VWF) and diagnosed by a disproportionate decrease in VWF ristocetin cofactor activity (VWF:RCo) as compared with VWF antigen (VWF:Ag).
  
  
  OBJECTIVE
  We report here on the spurious diagnosis of VWD in a patient with a sequence variation in the ristocetin-binding domain of VWF.
  
  
  METHODS
  The index case had a VWF:RCo of 11 IU dL(-1), with VWF:RCo/VWF:Ag ratio of 0.09. DNA sequencing revealed a novel P1467S mutation in a known ristocetin-binding region of the A1 domain. Because of the discrepancy between the laboratory findings, consistent with type 2M VWD, and the patient's lack of bleeding symptoms, further studies were performed to determine whether this mutation affected VWF function or merely reduced its ability to interact with ristocetin.
  
  
  RESULTS
  Studies with recombinant VWF showed normal platelet binding with botrocetin, but a significant decrease in binding in response to ristocetin. Ristocetin-induced binding to recombinant GPIb was also absent, but normal binding was seen when a gain-of-function GPIb construct was used in the absence of ristocetin. VWF function under shear stress was normal when analyzed with a cone and plate(let) analyzer.
  
  
  CONCLUSIONS
  The decreased VWF:RCo seen with the P1467S sequence variation likely represents an artifact as a result of the use of ristocetin to measure VWF activity. The normal VWF function in other assays correlates with the lack of hemorrhagic symptoms, and suggests the need for more physiologically relevant assays of VWF function.
authors.affiliation: Division of Hematology/Oncology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA. vflood@mcw.edu
authors.forename: V H
authors.initials: VH
authors.lastname: Flood
authors.forename: K D
authors.initials: KD
authors.lastname: Friedman
authors.forename: J C
authors.initials: JC
authors.lastname: Gill
authors.forename: P A
authors.initials: PA
authors.lastname: Morateck
authors.forename: J S
authors.initials: JS
authors.lastname: Wren
authors.forename: J P
authors.initials: JP
authors.lastname: Scott
authors.forename: R R
authors.initials: RR
authors.lastname: Montgomery
mesh_terms: D001665:Binding Sites / Q000235:genetics; D002648:Child; D005260:Female; D006801:Humans; D020125:Mutation, Missense; D010979:Platelet Function Tests; D011485:Protein Binding / Q000235:genetics; D012310:Ristocetin; D014842:von Willebrand Diseases / Q000175:diagnosis*; D014841:von Willebrand Factor / Q000235:genetics / Q000502:physiology*
chemical_list: D014841:von Willebrand Factor; D012310:Ristocetin
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