Journal of Thrombosis and Haemostasis, 14: 953963

DOI: 10.1111/jth.13294

ORIGINAL ARTICLE

Aging and ABO blood type influence von Willebrand factor

and factor VIII levels through interrelated mechanisms

E Z , * K . O G I W A R A , * A . M I C H E L S , * W . H O P M A N , J . G R A B E L L , P . J A M E S and
S . A L B AN
D. LILLICRAP*
*Department of Pathology and Molecular Medicine; Department of Public Health Sciences; and Department of Medicine, Queens
University, Kingston, ON, Canada

To cite this article: Alb
anez S, Ogiwara K, Michels A, Hopman W, Grabell J, James P, Lillicrap D. Aging and ABO blood type influence von
Willebrand factor and factor VIII levels through interrelated mechanisms. J Thromb Haemost 2016; 14: 95363.

Essentials

von Willebrand factor (VWF) and factor VIII (FVIII)
levels are modulated by age and ABO status.

The effect of aging and ABO blood type on VWF and
FVIII was assessed in 207 normal individuals.

Aging and ABO blood type showed combined and bidirectional influences on VWF and FVIII levels.

Aging and ABO blood type influence VWF levels
through both secretion and clearance mechanisms.
Summary. Background: The effect of aging and ABO
blood type on plasma levels of von Willebrand factor
(VWF) and factor VIII (FVIII) have been widely
reported; however, a comprehensive analysis of their combined effect has not been performed and the mechanisms
responsible for the age-related changes have not been
determined. Objectives: To assess the influence of aging
and ABO blood type on VWF and FVIII levels, and to
evaluate the contribution of VWF secretion and clearance
to the age-related changes. Methods: A cross-sectional
observational study was performed in a cohort of 207
normal individuals, whose levels of VWF, FVIII, VWF
propeptide (VWFpp), VWFpp/VWF:Ag ratio and blood
type A antigen content on VWF (A-VWF) were quantified. Results: Aging and ABO blood type exerted interrelated effects on VWF and FVIII plasma levels, because
the age-related increase in both proteins was significantly
higher in type non-O individuals (b = 0.011 vs. 0.005).
This increase with age in non-O subjects drove the differCorrespondence: David Lillicrap, Department of Pathology and
Molecular Medicine, Richardson Laboratory, Queens University,
Kingston, ON K7L 3N6, Canada.
Tel.: +1 613 533 6342; fax: +1 613 533 2907.
E-mail: dpl@queensu.ca
Received 7 August 2015
Manuscript handled by: F. R. Rosendaal
Final decision: F. R. Rosendaal, 7 February 2016
2016 International Society on Thrombosis and Haemostasis

ences between blood types in VWF levels, as the mean

difference increased from 0.13 U/mL in the young to
0.57 U/mL in the old. Moreover, A-VWF was associated
with both VWF antigen (b = 0.29; 95% confidence interval [CI], 0.09, 0.50) and VWF clearance (b = 0.15; 95%
CI, 0.25, 0.06). We also documented an effect of ABO
blood type on VWF secretion with aging, as old individuals with blood type non-O showed higher levels of
VWFpp (mean difference 0.29 U/mL). Conclusions: Aging
and ABO blood type have an interrelated effect on VWF
and FVIII levels, where the effect of one is significantly
influenced by the presence of the other.
Keywords: ABO blood group system; aging; metabolic
clearance rate; secretion; von Willebrand factor.

Introduction
von Willebrand factor (VWF) is a multimeric glycoprotein synthesized by endothelial cells and megakaryocytes
that carries coagulation factor VIII (FVIII) and promotes
platelet adhesion and aggregation [1]. Adequate levels of
VWF in plasma are needed for a balanced hemostasis,
because high levels of VWF are associated with an
increased risk of cardiovascular disease [24], while VWF
deficiency results in von Willebrand disease (VWD) [5].
Nevertheless, plasma levels of VWF have been shown to
be influenced by several genetic and environmental factors, including exercise, hormones, ABO blood type and
age [68].
The ABO locus alone accounts for ~30% of the genetic
determinants of VWF levels [9]. Indeed, blood type O
individuals have been shown to have ~25% lower levels
of VWF in plasma, as the presence of ABO antigens on
VWF might protect against clearance [10,11]. Moreover,
individuals with blood type O are over-represented in
type 1 VWD [12], whereas individuals with blood type
non-O are at increased risk of cardiovascular diseases
[1315].

954 S. Alb
anez et al

Many studies have also shown a positive correlation

between aging and VWF levels. In centenarians, VWF
levels were found to be significantly elevated, and even
more elevated than those in a control group of individuals aged 4586 years [8]. This phenomenon has also been
observed in individuals with type 1 VWD, where the
levels of VWF can normalize with advancing age [16,17].
Although the hemostatic system in general seems to shift
towards a more procoagulant state with aging [1820], little is known about the mechanisms that control the
increase in VWF levels with age.
FVIII levels have also been shown to be influenced by
both aging and ABO blood type, although reports on
the presence of ABO antigens on FVIII are controversial
[21,22]. The changes in FVIII levels are likely to be
dependent on the changes in VWF, as FVIII circulates
in a complex with VWF, which protects FVIII from
early degradation. In addition, deficiency of VWF is
accompanied by reduced levels of FVIII, whereas usually
an increase in VWF levels drives an increase in FVIII
levels [23,24]. The dependency of FVIII levels on VWF
was further demonstrated by the fact that the genetic
determinants found for FVIII plasma levels in a large
genome-wide association study (GWAS) meta-analysis
overlapped with those found for VWF [25].
Plasma levels of VWF are the combined result of protein secretion and clearance. Consequently, an increase in
VWF levels could be the result of enhanced secretion,
reduced clearance, or both. VWF propeptide (VWFpp), a
741 aa cleavage product of VWF, is stored together and
remains associated with VWF until both are secreted into
the circulation in equimolar concentrations. Once in the
plasma, the interaction between VWFpp and the mature
VWF is lost and both proteins follow different clearance
kinetics, where the estimated half-life for VWFpp is
approximately 2 h while that for the mature form is
around 812 h [26,27]. For this reason, many studies have
used VWFpp levels as a marker for endothelial cell activation and VWF release, as it is independent of VWF
clearance [2832]. Moreover, because for every molecule
of VWFpp released there is one molecule of VWF, the
ratio between these two proteins can serve as a surrogate
marker for VWF clearance, as has been shown in VWD
patients with accelerated VWF clearance [3336].
In this study, we investigated the effect of aging and
ABO blood type on VWF and FVIII plasma levels and
the contribution of VWF secretion and clearance mechanisms to the age-related changes, by evaluating surrogate
markers in a normal aging population.
Methods
Study design and human samples

A cross-sectional observational study was performed with

a total of 207 normal controls, who agreed to participate

in the study. Analysis was done using age both as a

continuous and discrete variable, in which samples were
categorized into three age groups: young (mean 7  5, 1
17 years, n = 52), middle age (mean 41  6, 3049 years,
n = 42) and old (mean 71  7, 5587 years, n = 113).
The age categories were chosen to represent children
(< 18 years old), individuals with a mean age half of the
life expectancy (middle age) and the elderly (> 55 years
old), with the aim of studying progressive vs. age-specific
changes. The three age groups were similar in gender and
ABO blood type composition (~50% female and ~50%
blood type O). Pediatric subjects were recruited from the
waiting room of the Childrens Outpatient Clinic at Hotel
Dieu Hospital in Kingston, Ontario. Adult subjects were
recruited from either community volunteers who
responded to a local advertisement or from the waiting
room of a presurgical clinic for knee and hip replacement
at Hotel Dieu Hospital. All individuals responded to a
bleeding questionnaire [37] and had negative bleeding
scores, and were presumed to be in good health. Blood
samples were collected by venipuncture and the blood
centrifuged at 4000 9g for 20 min to obtain the plasma,
after which it was stored at 80 C until protein measurements. Research Ethics Board approval was obtained
from Queens University and all subjects gave informed
consent to participate.
Protein measurements

VWF antigen levels (VWF:Ag) were determined by

enzyme-linked immunosorbent assay (ELISA) using VWF
polyclonal antibodies (DAKO, Glostrup, Denmark).
VWF ristocetin cofactor activity (VWF:RCo) was quantified using a standard platelet agglutination assay. Plasma
levels of VWF propeptide (VWFpp) were measured with
a VWFpp ELISA kit (Immucor GTI Diagnostics, Waukesha, WI, USA). Angiopoetin-2 (Ang-2) levels were quantified using the Angiopoetin-2 Duo Set ELISA kit (R&D
Systems, Minneapolis, MN, USA). Factor VIII antigen
levels (FVIII:Ag) were quantified using a matched-pair
antibody set for ELISA (Affinity Biologicals, Ancaster,
ON, Canada). FVIII activity (FVIII:C) was measured
through a standard one-stage clotting assay. Normal
human reference plasma (NRP) was used as a standard
(Precision Biologics, Dartmouth, NS, Canada).
Estimation of VWF half-life

VWF half-life was estimated as previously reported [38],

taking into consideration the VWFpp/VWF:Ag ratio and
the molar concentrations of both VWF and VWFpp. This
estimation assumes that VWFpp half-life is relatively
invariable, that the clearance pattern of both the mature
VWF and the propeptide follows first-order kinetics and
that both are at steady state. VWF half-life was defined
as:
2016 International Society on Thrombosis and Haemostasis

Aging and ABO co-regulate VWF and FVIII levels 955

VWFhalflife

2  5:05
VWFpp
VWF:Ag

where 2 (h) is the estimated half-life of VWFpp and 5.05

the ratio between the molar concentrations of VWF
(31 nM) and VWFpp (6.13 nM).
Blood type A antigen content on VWF

The amount of blood type A antigen present on VWF

(A-VWF) was measured by ELISA in all samples with
blood type A (n = 73). Briefly, plasma samples were incubated on a plate coated with a rabbit polyclonal antiVWF antibody (DAKO, Glostrup, Denmark) and
blocked with 5% milk-PBS. A mouse monoclonal antiblood group A antibody was then added (Sigma-Aldrich,
St Louis, MO, USA) and the amount of A-VWF present
determined with a goat anti-mouse IgG antibody conjugated with HRP (Santa Cruz Biotechnology, Dallas, TX,
USA). Pooled plasma from healthy blood type A individuals was used as a standard and the content calculated
relative to the mean levels of young individuals.
Statistical analysis

Protein levels and half-lives are presented as means and

standard deviations, unless otherwise stated. The difference in mean protein levels (meanD) between groups was
calculated. Although samples were fairly normally distributed, non-parametric tests were applied, including the
MannWhitney U-test, KruskalWallis tests and Spearmans correlations. Statistical analysis and graphs were
carried out with GraphPad Prism v.4 (San Diego, CA,
USA) and a P-value less than 0.05 was considered significant. Associations between the different variables was
tested through univariate and multivariate linear regression analysis using IBM SPSS Version 22 for Windows
(Armonk, New York, NY, USA, 2015). Slopes were compared using the method available in GraphPad Prism v.4,
which is equivalent to an analysis of covariance.
Results
Effect of aging and ABO blood type on VWF levels

Plasma levels of VWF showed significant increases with

age, with an overall change of 1.56-fold by later life
(Table 1). This increase was accompanied by an increase
in VWF:RCo, as the activity was strongly associated with
VWF:Ag levels (b = 0.67; 95% confidence interval [CI],
0.580.77; P < 0.0001). Aging was positively associated
with VWF:Ag levels (Fig. 1A) and increased similarly
between genders (P = 0.62). However, there was a clear
distinction between ABO blood types, where VWF levels
were more strongly associated with aging in individuals
with blood type non-O (b = 0.011, 95% CI 0.0070.014,
2016 International Society on Thrombosis and Haemostasis

P < 0.0001) than in type O subjects (b = 0.005; 95% CI;

0.0020.007; P = 0.0004) (P = 0.008) (Fig. 1B).
For those individuals with blood type non-O, VWF
levels increased progressively and significantly with age,
reaching a 1.71-fold change by old age (0.98  0.32 vs.
1.22  0.43 vs. 1.68  0.62 U/mL [meanD 0.24 and
0.70 U/mL]; P < 0.0001) (Fig. 2A). In contrast, VWF
levels in blood type O individuals did not increase significantly by middle age (0.85  0.25 vs. 0.95  0.34 U/mL
[meanD 0.10]; P = 0.42), and even when they were significantly elevated in the old population (0.85  0.25 vs.
1.11  0.38 U/mL [meanD 0.26]; P = 0.002), they only
increased by 1.25-fold.
The well-known differences in VWF levels between ABO
blood types was observed when samples from all agegroups were combined and classified by blood type, with
significantly higher levels in non-O individuals (1.01 
0.36 vs. 1.42  0.60 U/mL [meanD 0.41]; P < 0.0001).
Nevertheless, the influence of ABO blood type was more
evident with advancing age, as small but not significant
differences were observed in young individuals (type
O 0.85  0.25 vs. non-O 0.98  0.32 U/mL [meanD 0.13];
P = 0.25) (Fig. 2A). With aging, the differences
became evident in the middle-age population (0.95  0.34
vs. 1.22  0.43 U/mL [meanD 0.27]; P = 0.011) and were
even more pronounced in the old (1.11  0.38 vs.
1.68  0.62 U/mL [meanD 0.57]; P < 0.0001).
Effect of aging and ABO blood type on FVIII levels

The FVIII coagulant activity and antigen levels were measured in the three age categories and showed a gradual
increase with age, both reaching a 1.5-fold increase by
later life, similar to VWF:Ag levels (Table 1). As
expected, FVIII:Ag levels were found to be highly associated with VWF:Ag levels (b = 0.46; 95% CI, 0.410.50;
P < 0.0001) and increased proportionately with VWF, as
no differences were observed in the FVIII/VWF antigen
ratios (data not shown).
Consequently, FVIII levels were also associated with
aging and the distinct effect of ABO blood type was also
observed (Fig. 1C, D). FVIII:C increased significantly
with age in individuals with blood type non-O, achieving
a 1.75-fold increase by old age (0.97  0.40 vs.
1.35  0.31 vs. 1.70  0.53 U/mL [meanD 0.38 & 0.73];
P < 0.0001), in contrast to a 1.29-fold increase in individuals with blood type O (0.94  0.38 vs. 1.03  0.38 vs.
1.21  0.42 U/mL [meanD 0.09 & 0.27]; P = 0.04)
(Fig. 2B). Furthermore, no significant difference in FVIII
levels was observed in young subjects of different blood
types (0.94  0.38 vs. 0.97  0.40 U/mL [meanD 0.03];
P = 0.98), whereas with aging, significantly higher levels
of FVIII were observed in blood type non-O middle-age
(1.03  0.38 vs. 1.35  0.31 U/mL [meanD 0.32]; P = 0.005)
and old subjects (1.21  0.42 vs. 1.70  0.53 U/mL
[meanD 0.49]; P < 0.0001) (Fig. 2B).

956 S. Alb
anez et al
Table 1 Age-related changes in von Willebrand factor (VWF) and factor VIII (FVIII) levels, as well as markers of VWF secretion and clearance.
Variable

Median

VWF:Ag (U/mL)
Young
0.87
Middle age
1.03
Old
1.31
VWF:RCo (U/mL)
Young
0.66
Middle age
0.81
Old
1.27
FVIII:C (U/mL)
Young
0.92
Middle age
1.22
Old
1.23
FVIII:Ag (U/mL)
Young
0.60
Middle age
0.78
Old
0.96
VWFpp (U/mL)
Young
1.07
Middle age
1.03
Old
1.18
VWFpp/VWF:Ag ratio
Young
1.24
Middle age
0.99
Old
0.93
Estimated VWF half-life (h)
Young
8.2
Middle age
10.2
Old
10.9

Mean

95% CI

SD

MeanD

P-value

Fold change

0.91
1.08
1.42

0.830.99
0.961.21
1.311.53

0.29
0.41
0.59

0.17
0.51

0.028
< 0.0001

1.19
1.56

0.66
0.76
1.34

0.580.74
0.700.83
1.211.48

0.21
0.14
0.55

0.10
0.68

0.0320
< 0.0001

1.15
2.03

0.95
1.19
1.48

0.821.07
1.071.31
1.381.58

0.39
0.38
0.54

0.24
0.53

0.007
< 0.0001

1.25
1.56

0.65
0.80
0.99

0.590.70
0.730.88
0.941.05

0.19
0.24
0.32

0.15
0.34

0.0005
< 0.0001

1.23
1.52

1.08
1.09
1.26

1.021.14
0.971.20
1.191.34

0.22
0.36
0.39

0.01
0.18

0.315
0.009

1.01
1.17

1.24
1.04
0.95

1.161.32
0.951.13
0.910.99

0.28
0.28
0.23

0.20
0.29

0.0005
< 0.0001

0.84
0.77

2.0
2.4
2.7

1.7
2.6

0.0005
< 0.0001

1.20
1.30

8.6
10.3
11.2

8.09.1
9.511.0
10.711.8

Young, 7  5 years (117), n = 52; middle-age, 41  6 (3049), n = 42; old, 71  7 (5587), n = 113. All P-values and fold-change were
obtained using the young population as a reference. VWF:RCo results available only for 32, 20 and 65 samples in each of the age categories,
respectively. SD, standard deviation; CI, confidence interval; VWF:Ag, VWF antigen levels; VWF:RCo, VWF ristocetin cofactor; VWFpp,
VWF propeptide; FVIII:C, FVIII activity; FVIII:Ag, FVIII antigen levels.

Age-related changes in VWF secretion

When VWFpp levels were measured as a marker of VWF

secretion, increased levels were observed in the elderly,
whereas no differences were found between young and
middle-age individuals (Table 1).
Despite weak prior evidence suggesting that ABO
blood type has also an effect on VWFpp levels, we found
significantly higher levels of VWFpp in individuals with
blood type non-O (1.08  0.31 vs. 1.28  0.37 U/mL
[meanD 0.20]; P < 0.0001), when all samples were combined by blood type. Nevertheless, this effect was only
observed in the old population (Fig. 3), as levels of
VWFpp were 1.26-fold higher in older subjects with
blood type non-O when compared with old subjects with
blood type O (1.11  0.33 vs. 1.40  0.39 U/mL [meanD
0.29]; P < 0.0001). No significant differences were
observed in VWFpp levels between genders for any of the
three populations (data not shown).
To test whether the effect of ABO blood type on
VWFpp levels was due to changes in VWFpp clearance
in later life, another marker of WPB exocytosis was measured. In a subgroup of 46 subjects with either high or

low VWFpp levels, Ang-2 levels were found to be significantly correlated with both VWFpp (r = 0.43, P = 0.003)
and VWF:Ag levels (r = 0.52, P = 0.0002), supporting the
proposal that enhanced VWF secretion is responsible for
high levels of VWFpp in old age.
Age-related changes in VWF clearance and estimated halflife

Analysis of VWF clearance in each age-specific population showed marked differences in terms of the VWFpp/
VWF:Ag ratio and estimated half-life. The VWFpp/
VWF:Ag ratio showed a gradual decrease with age, with
a 0.77-fold change between the young and old populations (Table 1). Similarly, a gradual increase in the estimated VWF half-life was observed, with an overall 1.30fold change. These changes occurred independent of gender, but were influenced by blood type, as expected from
the previous results on VWF:Ag and VWFpp levels.
The change in VWF clearance for type non-O subjects
occurred gradually, with a significant reduction of the
VWFpp/VWF:Ag ratio by middle age (1.22  0.31 vs.
0.94  0.20 [meanD 0.28]; P = 0.0013) and even greater
2016 International Society on Thrombosis and Haemostasis

Aging and ABO co-regulate VWF and FVIII levels 957

3.5
P<0.0001

VWF:Ag (U mL1)

VWF:Ag (U mL1)

3.0
2.5
2.0
1.5
1.0

3.5
Blood type non-O
P<0.0001

3.0
2.5

Blood type O
P = 0.0004

2.0
1.5

Non-O vs. O:
P = 0.008

1.0
0.5

0.5

0.0

0.0
0

10

20

30

40

50

60

70

80

90

10

20 30

40

50 60

70

80 90

Age (years)

Age (years)
C

D
2.5

2.5
2.0

Blood type non-O

P<0.0001

1.5

Blood type O
P<0.0001

FVIII:Ag (U mL1)

FVIII:Ag (U mL1)

P<0.0001
2.0
1.5
1.0
0.5

1.0

Non-O vs. O:
P = 0.004

0.5
0.0

0.0
0

10

20

30 40 50 60
Age (years)

70

80

90

10

20 30

40 50 60
Age (years)

70

80

90

Fig. 1. Distinct associations of aging with plasma von Willebrand factor (VWF) and factor VIII (FVIII) levels. Aging was positively associated
with both VWF (b = 0.008; 95% confidence interval [CI], 0.0060.011; P < 0.0001) (A) and FVIII levels (b = 0.006; 95% CI, 0.0040.007;
P < 0.0001) (C). A distinct effect of aging on VWF and FVIII levels was observed between blood types. Aging was more strongly associated
with VWF antigen levels in individuals with blood type non-O (b = 0.011; 95% CI, 0.0070.014; P < 0.0001) than in those with type O
(b = 0.005; 95% CI, 0.0020.007; P = 0.004) (B). Likewise, aging was more strongly associated with FVIII antigen levels in individuals with
blood type non-O (b = 0.007; 95% CI, 0.0050.009; P < 0.0001) vs. those with type O (b = 0.004; 95% CI, 0.0020.005; P < 0.0001) (D). Linear regression with 95% CI lines (dotted lines) are shown.

reduction by old age (1.22  0.31 vs. 0.88  0.20 [meanD

0.34]; P < 0.0001) (Fig. 4A). This was also seen with the
estimated VWF half-life, which gradually increased with
advancing age (8.7  2.1 vs. 11.2  2.2 vs. 12.2  2.8 h
[meanD 2.5 & 3.5]; P < 0.0001) (Fig. 4B). Although individuals with blood type O also had a decreased clearance
with advancing age, the effect was less marked and was
only significant in the old population for both VWFpp/
VWF:Ag ratio (1.26  0.25 vs. 1.04  0.23 [meanD 0.22];
P = 0.001) and estimated VWF half-life (8.4  2.0 vs.
10.2  2.2 h [meanD 1.8]; P = 0.0011) (Fig. 4C).
The influence of ABO blood type on VWF clearance
and half-life was again most evident with aging. Hence,
no significant differences were observed in the young population between blood types for either the VWFpp/VWF:
Ag ratio (1.26  0.25 vs. 1.22  0.31 [meanD 0.04];
P = 0.49) or estimated VWF half-life (8.4  2.0 vs.
8.7  2.1 h [meanD 0.3]; P = 0.49) (Fig. 5A, B). By middle age, the difference in VWF clearance between the
different blood types became evident, and in later life
the difference reached 1.2-fold, as individuals with blood
type non-O had the smallest VWFpp/VWF:Ag ratio
(1.04  0.23 vs. 0.88  0.20 [meanD 0.16]; P = 0.0002)
2016 International Society on Thrombosis and Haemostasis

and the longest estimated VWF half-life (10.2  2.2 vs.

12.2  2.8 h [meanD 2.0]; P = 0.0002).
Blood type A antigen content on VWF throughout aging

In an attempt to explain the differential changes in VWF

levels with age and ABO blood type, the amount of AVWF was measured in all subjects with blood type A. A
significant association between A-VWF levels and
advancing age was obtained (Fig. 6A). When compared
by age groups, a significant increase in A-VWF levels was
found in the middle-age (1.52-fold, P = 0.01, n = 13) and
old populations (1.35-fold, P = 0.03, n = 40) when compared with young individuals (n = 20). Furthermore, the
amount of A-VWF was associated with VWF:Ag levels
(b = 0.29; 95% CI, 0.090.50; P = 0.006) and VWFpp/
VWF:Ag ratio (b = 0.15; 95% CI, 0.25 to 0.06;
P = 0.001), but not with VWFpp (b = 0.10; 95% CI,
0.020.23; P = 0.11) (Fig. 6BD). These findings support our observations of the role of ABO antigens in
VWF clearance with age, but does not explain the differential increase in VWF secretion documented with non-O
blood type.

958 S. Alb
anez et al

VWF:Ag (U mL1)

2.5

**

2.0

***
***

*
1.5

Blood type O
Blood type non-O

1.0
0.5
0.0
Young

FVIII:C (U mL1)

2.5
2.0
1.5

Middle-age

Old

***
*
**
**

***

Blood type O
Blood type non-O

Discussion

1.0
0.5
0.0
Young

Middle-age

Old

Fig. 2. Combined effect of ABO blood type and aging on von Willebrand factor (VWF) and factor VIII (FVIII) levels. In the young
population, levels of VWF and FVIII were not significantly different.
With aging, as the levels of VWF and FVIII increased in individuals
with blood type non-O, the difference between blood type O and
non-O became evident and more marked with advanced age (A,B).
Mean values are depicted and error bars represent standard error
of the mean (SEM). *P < 0.05, **P < 0.01, ***P < 0.001. Exact
P-values are described in the text.

2.0
VWFpp (U mL1)

with age and VWF secretion being enhanced only in later

life. Moreover, the effect of ABO blood type and age on
VWF:Ag levels was lost when both secretion and clearance variables were included in the multivariate model,
but was highly significant when they were not included
(P < 0.001), as also indicated with the univariate analysis
results. These findings support the proposal that aging
and ABO blood type act through both secretion and
clearance mechanisms. FVIII antigen levels were associated with all variables previously associated with VWF
antigen levels, highlighting the dependency of FVIII on
VWF.

**
***

1.5

Blood type O
Blood type non-O

1.0
0.5
0.0
Young

Middle-age

Old

Fig. 3. Increases in von Willebrand factor propeptide (VWFpp)

levels with aging and different blood types. No significant differences
in VWFpp levels throughout aging were observed in individuals with
blood type O, whereas VWFpp levels were significantly elevated in
old individuals with blood type non-O. Mean values are depicted
and error bars represent standard error of the mean (SEM).
**P < 0.01, ***P < 0.001. Exact P-values are described in the text.

Contribution of VWF secretion and clearance to the agerelated changes

As plasma levels of VWF are the net result of protein

secretion and clearance, we established the contribution
of each of these mechanisms to the increase in VWF and
FVIII levels with age, using univariate and multivariate
regression analysis (Table 2). We found that VWF:Ag
levels were equally associated with both secretion and
clearance, despite clearance being reduced progressively

In this study we found that ABO blood type and aging

have combined and bidirectional influences on VWF
and, therefore, FVIII levels. This is the first time that
this combinatorial mechanistic influence has been documented. The presence of both aging and A/B antigens
had a major effect on VWF plasma levels, in contrast to
when only one factor was present. In the young, the
effect of ABO blood type on VWF levels was limited
(1.15-fold); likewise, VWF levels in elderly individuals
with blood type O only increased by 1.25-fold. In contrast, when both aging and A/B antigen influences were
present, VWF levels increased 1.71-fold. Therefore, the
presence of A/B antigens was found to be a main driver
for the increase in VWF and FVIII levels with age, while
aging explained most of the differences between blood
types. Furthermore, our study suggests that the increase
in VWF levels with age is independent of platelet contribution, as it has been shown that platelet VWF does not
possess A/B antigens [39,40].
Our findings are supported by other studies in which
VWF levels were measured in pediatric and adult populations, although none of these studies evaluated the proposal that aging and ABO blood type could influence
VWF levels by interrelated mechanisms. Akin et al. found
similar results to ours when analyzing 200 children with a
mean age of 8 years (217), as only a 15% difference in
VWF levels was found between blood type O and non-O
children [41]. In addition, in a study of over 500 healthy
children, Klarmann et al. found no ABO blood typerelated differences in VWF levels during early childhood,
but did observe these differences during adolescence, and
suggested that this was associated with the physiologic
development of the ABO blood system [42]. Here, we suggest that the ABO blood system continues to change
throughout aging and is a major contributor to the
increase in VWF levels with age.
In more than 400 healthy adults, Favoloro et al. found
a positive correlation between VWF levels and age, as
well as higher levels of VWF in type non-O individuals
[43]. However, they noted that the major differences in
ABO-related VWF levels were at the high end of VWF
2016 International Society on Thrombosis and Haemostasis

Aging and ABO co-regulate VWF and FVIII levels 959

Blood type non-O

***

1.5

**

15
Estimated VWF half-life (h)

VWFpp/VWF:Ag ratio

Blood type O
B

1.0

0.5

Young

Middle-age

**

1.5

Young

Old

Estimated VWF half-life (h)

VWFpp/VWF:Ag ratio

10

0.0

***
**

1.0

0.5

Middle-age

Old

15
**
10

0.0
Young

Middle-age

Old

Young

Middle-age

Old

Fig. 4. Distinct changes in von Willebrand factor (VWF) clearance with age and the effect of ABO blood type. A significant reduction in VWF
clearance in individuals with blood type non-O was observed, as shown by a decrease in the VWF propeptide (VWFpp)/VWF:Antigen (VWF:
Ag) ratio (A) and by an increase in the estimated VWF half-life (B). A small reduction in VWF clearance in later life was observed in individuals with blood type O, based on the VWFpp/VWF:Ag ratio (C) or the estimated VWF half-life (D). Mean values are depicted and error bars
represent standard error of the mean (SEM). **P < 0.01, ***P < 0.001. Exact P-values are described in the text.

levels, rather than at the low end. Gill et al. found a similar trend in VWF levels with age between blood types in
more than 1000 healthy adults in more than 1000 healthy
adults [10]. Furthermore, a study by Vischer et al. with
219 adults found a significant association between aging
and VWF levels only in individuals with blood type nonO [44]. Interestingly, Coppola et al. did not find significant differences in VWF levels between ABO blood types
in centenarians, although they observed it in younger controls (1.54-fold in individuals > 45 years old) [8]. It is
possible that type O individuals take longer to achieve
the high VWF levels that blood type non-O individuals
achieved much earlier in life, and thus the lack of
significance in centenarians, or that additional factors
participate in the increase in VWF levels in advanced old
age.
ABO blood type has been associated with differences
in VWF clearance, but not with VWF secretion. In a
study performed on healthy volunteers infused with 1,8deamino-D-arginine vasopressin (DDAVP), Gallinaro
et al. found that individuals with blood type non-O had
a significantly longer VWF half-life [11]. The participants had a mean age of 40 years (2470), similar to
2016 International Society on Thrombosis and Haemostasis

our middle-age group, in which the differences in VWF

levels between ABO blood types are evident, and in
which a reduction in VWF clearance and increase in
VWF half-life for type non-O individuals was found. We
observed very significant differences in VWF clearance
between ABO blood types with advancing age. Studies
have linked the ABO genotype to the amount of ABO
antigens present on VWF, and their quantity explains
approximately 18% of the variation in VWF plasma
levels [45,46]. Nevertheless, in a very recent study, the
ABO blood type status of the individual rather than the
presence of ABO antigens on VWF was shown to be
responsible for the differences in VWF clearance [47].
In our study, the amount of blood type A antigen present on VWF was significantly elevated in middle-aged
and old individuals, which could explain the significant
increase in VWF levels with age in type non-O subjects.
However, the ABO genotype of our study group was not
available, so the distribution of the different A subtypes
within each age group is unknown and thus it is possible
that a skewed distribution of the genotypes caused the
differences in blood type A antigen content between the
age groups. In addition, the small number of samples

960 S. Alb
anez et al

VWFpp/VWF:Ag ratio

A 1.5
*

***

Blood type O
Blood type non-O

1.0

0.5

0.0
Young

Middle-age

Old

Estimated VWF half-life (h)

B
15
*

***

Blood type O
Blood type non-O

10

0
Young

Middle-age

Old

Fig. 5. Distinct changes in von Willebrand factor (VWF) clearance

with age and blood types. The differences in the VWF propeptide
(VWFpp)/VWF:Antigen (VWF:Ag) ratio with blood type were
apparent only with advancing age, as no differences were observed
in the young population (A). Similarly, no differences in the estimated VWF half-life were observed between blood types in young
individuals, but were found with increasing age (B). Mean values are
depicted and error bars represent standard error of the mean (SEM).
*P < 0.05, ***P < 0.001. Exact P-values are described in the text.

with blood type A in each population could have also

skewed the results.
Nonetheless, the amount of blood type A antigen on
VWF was significantly associated with aging, VWF:Ag
levels and VWF clearance, supporting the hypothesis that
an increase in the amount of these antigens per VWF
molecule could cause the increase in VWF levels with
age, by decreasing its clearance and, therefore, creating
the well-known differences in VWF levels between ABO
blood types. Furthermore, altered expression of blood
type A antigens on VWF has been reported in response
to inflammation [48], which could also explain the
changes we observed with aging, as these modified antigens might help stabilize VWF under conditions of
inflammation. Moreover, additional age-related but ABO
blood type-independent changes in VWF glycosylation
could also contribute to the reduction in VWF clearance,
as observed in elderly type O subjects.
Of note, our study also found an effect of ABO blood
type on the secretion of VWF, an influence not previously documented. However, this effect was only
observed in later life. Therefore, to establish if this effect
could be the result of changes in VWFpp clearance with
age, we measured the levels of another marker of WPB
exocytosis, and found that the levels of Ang-2 were significantly associated with those of VWFpp, supporting
the observation of increased endothelial cell secretion.

The mechanism responsible for this effect will prove

challenging to investigate, as expression of ABO antigens
by endothelial cells is highly heterogeneous and most
cells used for analysis of VWF in vitro do not express
ABO antigens [40,49]. Moreover, the evidence of an
effect of ABO on VWFpp levels is limited, as only one
meta-analysis GWAS showed a signal at the ABO locus
[50], and the presence of ABO antigens on VWFpp has
not been proved [38]. Finally, the elevated levels of
VWFpp in non-O individuals in later life could be the
result of an indirect effect, such as the presence of coexisting aging cardiovascular pathologies, for which, in
many cases, an association with ABO blood type has
already been established [51,52], and in which endothelial
cell activation or dysfunction occurs. For example, VWF
has been independently associated with atherosclerosis
in asymptomatic individuals [53], whereas blood type A
was recently associated with the severity of coronary
atherosclerosis [54], suggesting a possible link between
these three factors.
Our findings indicate that the effect of aging on VWF
plasma levels was equally dependent on VWF secretion
and clearance mechanisms. A progressive reduction in
VWF clearance with age, enhanced by increased secretion
in later life, results in significantly elevated levels of
VWF, as observed in older individuals with blood type
non-O.
Lastly, our results could have implications for the treatment of von Willebrand disease and hemophilia A
patients, particularly of those with blood type non-O.
Elderly patients treated with DDAVP could experience a
greater than expected VWF release into the circulation if
biosynthesis is enhanced. Alternatively, a reduction in
VWF clearance with age will result in an extended presence of the newly secreted protein. For hemophilia A
patients, a parallel increase in the half-life of infused and
native FVIII protein should also be expected as VWF
half-life increases with advancing age.
In conclusion, our study suggests that aging and ABO
blood type regulate VWF levels through interrelated
mechanisms, where the amount of A/B antigens seems to
be a key factor in the changes in VWF levels with age.
Finally, our study suggests that VWF secretion is also
influenced by ABO blood type in later life. The mechanism responsible for this finding remains to be elucidated.
Addendum
S. Alb

anez designed the study, performed and interpreted
the research, and wrote the manuscript. K. Ogiwara
designed the study and interpreted data. A. Michels performed research. W. Hopman performed statistical analysis. J. Grabell contributed to sample and data collection.
P. James helped with data interpretation and edited the
paper. D. Lillicrap designed and overviewed research,
interpreted data and edited the paper.
2016 International Society on Thrombosis and Haemostasis

Aging and ABO co-regulate VWF and FVIII levels 961

2.5

3.0
P = 0.006
2.5

VWF:Ag (U mL1)

Relative A-VWF content

P = 0.026
2.0

1.5

2.0
1.5
1.0

1.0
0.5
0.0

0.5
0

10

20

30

40

50

60

70

80

0.0

90

0.5

2.5

1.5

2.0

2.5

2.0

2.5

2.0

P = 0.11

P = 0.001

2.0

VWFpp/VWF:Ag Ratio

VWFpp (U mL1)

1.0

Relative A-VWF content

Age

1.5
1.0
0.5
0.0

1.5

1.0

0.5

0.0
0.0

0.5

1.0

1.5

2.0

2.5

0.0

Relative A-VWF content

0.5

1.0

1.5

Relative A-VWF content

Fig. 6. Relative blood type A antigen content on von Willebrand factor (VWF) with aging and its association with VWF levels. Relative
A-VWF levels were associated with advancing age (b = 0.004; 95% confidence interval [CI], 0.00040.007; P = 0.026) (A), VWF antigen
(VWF:Ag) levels (b = 0.29; 95% CI, 0.090.50; P = 0.006) (B) and VWF clearance (b = 0.15; 95% CI, 0.25 to 0.06; P = 0.001)
(D), but not with VWF secretion (b = 0.10; 95% CI, 0.02 to 0.23; P = 0.11) (C). Linear regression with 95% CI lines (dotted lines)
are shown.

Table 2 Univariate and multivariate regression analysis of von Willebrand factor and factor VIII antigen levels.
Univariate
Variable
VWF:Ag
Age
Gender
Blood type
VWFpp
VWFpp/VWF:Ag
FVIII:Ag
Age
Gender
Blood type
VWF:Ag
VWFpp
VWFpp/VWF:Ag

Multivariate

Coefficient (b)

95% CI

0.008
0.037
0.409
1.163
1.111

0.006,
0.112,
0.547,
1.027,
1.304,

0.006
0.012
0.244
0.452
0.581
0.519

0.004,
0.075,
0.324,
0.402,
0.490,
0.643,

P-value

Coefficient (b)

95% CI

0.011
0.185
0.271
1.299
0.918

< 0.001
0.628
< 0.001
< 0.001
< 0.001

0.000
0.015
0.040
1.087
1.001

0.001,
0.063,
0.091,
1.015,
1.092,

0.001
0.033
0.012
1.160
0.910

0.626
0.536
0.133
< 0.001
< 0.001

0.007
0.099
0.163
0.501
0.672
0.395

< 0.001
0.787
< 0.001
< 0.001
< 0.001
< 0.001

0.002
0.023
0.084
0.148
0.317
0.194

0.001,
0.073,
0.138,
0.002,
0.141,
0.368,

0.003
0.027
0.030
0.294
0.493
0.020

< 0.001
0.359
0.003
0.047
< 0.001
0.029

P-value

CI, confidence interval; VWF:Ag, VWF antigen levels; VWFpp, VWF propeptide; FVIII:Ag, FVIII antigen levels.

Disclosure of Conflict of Interests

P. James receives research funding from Bayer, CSL Behring and Octapharma, honoraria from Baxalta, Biogen,
Octapharma and CSL Behring and participates on
advisory boards for CSL Behring, Baxalta and Biogen. D.
Lillicrap receives research funding from Biogen, Bayer,
CSL-Behring and Octapharma and participates on
2016 International Society on Thrombosis and Haemostasis

advisory boards for Baxalta, CSL-Behring and Biogen.

The remaining authors declare no competing financial
interests.
Acknowledgements
This work was supported by operating grants from the
Canadian Institutes of Health Research (MPO 97849),

962 S. Alb
anez et al

NIH NHLBI (grant # PO1HL081588) and the Heart and

Stroke Foundation of Ontario (#000293). D. Lillicrap is
the recipient of a Canada Research Chair in Molecular
Hemostasis.
References
1 Lenting PJ, Christophe OD, Denis C. von Willebrand factor
biosynthesis, secretion, and clearance: connecting the far ends.
Blood 2015; 125: 201928.
2 Vischer UM. von Willebrand factor, endothelial dysfunction, and
cardiovascular disease. J Thromb Haemost 2006; 4: 118693.
3 Spiel AO, Gilbert JC, Jilma B. Von Willebrand factor in cardiovascular disease: focus on acute coronary syndromes. Circulation
2008; 117: 144959.
4 Frankel DS, Meigs JB, Massaro JM, Wilson PWF, ODonnell
CJ, DAgostino RB, Tofler GH. Von Willebrand factor, type 2
diabetes mellitus, and risk of cardiovascular disease: the Framingham Offspring Study. Circulation 2008; 118: 25339.
5 Robertson J, Lillicrap D, James PD. Von Willebrand disease.
Pediatr Clin North Am 2008; 55: 37792.
6 Jenkins PV, ODonnell JS. ABO blood group determines plasma
von Willebrand factor levels: a biologic function after all? Transfusion 2006; 46: 183644.
7 Stakiw J, Bowman M, Hegadorn C, Pruss C, Notley C, Groot
E, Lenting PJ, Rapson D, Lillicrap D, James P. The effect of
exercise on von Willebrand factor and ADAMTS-13 in individuals with type 1 and type 2B von Willebrand disease. J Thromb
Haemost 2008; 6: 906.
8 Coppola R, Mari D, Lattuada A, Franceschi C. Von Willebrand
factor in Italian centenarians. Haematologica 2003; 88: 3943.
9 Matsui T, Titani K, Mizuochi T. Structures of the asparaginelinked oligosaccharide chains of human von Willebrand factor.
Occurrence of blood group A, B, and H(O) structures. J Biol
Chem 1992; 267: 872331.
10 Gill JC, Endres-Brooks J, Bauer PJ, Marks WJ, Montgomery
RR. The effect of ABO blood group on the diagnosis of von
Willebrand disease. Blood 1987; 69: 16915.
11 Gallinaro L, Cattini MG, Sztukowska M, Padrini R, Sartorello
F, Pontara E, Bertomoro A, Daidone V, Pagnan A, Casonato
A. A shorter von Willebrand factor survival in O blood group
subjects explains how ABO determinants influence plasma von
Willebrand factor. Blood 2008; 111: 35405.
12 De Meyer SF, Deckmyn H, Vanhoorelbeke K. von Willebrand
factor to the rescue. Blood 2009; 113: 504957.
13 Zhang H, Mooney CJ, Reilly MP. ABO blood groups and cardiovascular diseases. Int J Vasc Med 2012; 2012: 111.
14 Schleef M, Strobel E, Dick A, Frank J, Schramm W, Spannagl
M. Relationship between ABO and secretor genotype with
plasma levels of factor VIII and von Willebrand factor in thrombosis patients and control individuals. Br J Haematol 2005; 128:
1007.
15 Wu O, Bayoumi N, Vickers MA, Clark P. ABO(H) blood
groups and vascular disease: a systematic review and meta-analysis. J Thromb Haemost 2008; 6: 629.
16 Sanders Y, Giezenaar MA, van Laros-Gorkom B, Meijer K, van
der Bom J, Cnossen M, Nijziel M, Ypma P, Fijnvandraat K,
Eikenboom J, Mauser-Bunschoten E, Leebeek F. von Willebrand
disease and aging: an evolving phenotype. J Thromb Haemost
2014; 12: 10661075.
17 Rydz N, Grabell J, Lillicrap D, James PD. Changes in von
Willebrand factor level and von Willebrand activity with age in
type 1 von Willebrand disease. Haemophilia 2015; 21: 63641.
18 Franchini M. Hemostasis and aging. Crit Rev Oncol Hematol
2006; 60: 14451.

19 Mari D, Coppola R, Provenzano R. Hemostasis factors and

aging. Exp Gerontol 2008; 43: 6673.
20 Tofler GH, Massaro J, Levy D, Mittleman M, Sutherland P,
Lipinska I, Muller JE, DAgostino RB. Relation of the prothrombotic state to increasing age (from the Framingham Offspring Study). Am J Cardiol 2005; 96: 12803.
21 Matsui T, Fujimura Y, Nishida S, Titani K. Human plasma
alpha 2-macroglobulin and von Willebrand factor possess covalently linked ABO(H) blood group antigens in subjects with corresponding ABO phenotype. Blood 1993; 82: 6638.
22 Hironaka T, Furukawa K, Esmon PC, Fournel MA, Sawada S,
Kato M, Minaga T, Kobata A. Comparative study of the sugar
chains of factor VIII purified from human plasma and from the
culture media of recombinant baby hamster kidney cells. J Biol
Chem 1992; 267: 801220.
23 Samai A, Monlezun D, Shaban A, George A, Dowell L, KruseJarres R, Schluter L, El Khoury R, Martin-Schild S. Von Willebrand factor drives the association between elevated factor VIII
and poor outcomes in patients with ischemic stroke. Stroke 2014;
45: 278991.
24 Lippi G, Franchini M, Salvagno GL, Montagnana M, Poli G,
Guidi GC. Correlation between von Willebrand factor antigen,
von Willebrand factor ristocetin cofactor activity and factor VIII
activity in plasma. J Thromb Thrombolysis 2008; 26: 1503.
25 Smith NL, Chen M-H, Dehghan A, Strachan DP, Basu S, Soranzo N, Hayward C, Rudan I, Sabater-Lleal M, Bis JC, de Maat
MPM, Rumley A, Kong X, Yang Q, Williams FMK, Vitart V,
Campbell H, Malarstig A, Wiggins KL, Van Duijn CM, et al.
Novel associations of multiple genetic loci with plasma levels of
factor VII, factor VIII, and von Willebrand factor: the
CHARGE (Cohorts for Heart and Aging Research in Genome
Epidemiology) Consortium. Circulation 2010; 121: 138292.
26 van Mourik J, Boertjes R, Huisveld I, Fijnvandraat K, Pajkrt D,
van Genderen PJ, Fijnheer R. von Willebrand factor propeptide
in vascular disorders: a tool to distinguish between acute and
chronic endothelial cell perturbation. Blood 1999; 94: 17985.
27 Borchiellini A, Fijnvandraat K, ten Cate J, Pajkrt D, van Deventer S, Pasterkamp G, Meijer-Huizinga F, Zwart-Huinink L,
Voorberg J, van Mourik J. Quantitative analysis of von Willebrand factor propeptide release in vivo: effect of experimental
endotoxemia and administration of 1-deamino-8-D-arginine
vasopressin in humans. Blood 1996; 88: 29518.
28 Conroy AL, Phiri H, Hawkes M, Glover S, Mallewa M, Seydel
KB, Taylor TE, Molyneux ME, Kain KC. Endothelium-based
biomarkers are associated with cerebral malaria in Malawian
children: a retrospective case-control study. PLoS ONE 2010; 5:
e15291.
29 van Mourik J, de Romani Wit T. Von Willebrand factor propeptide in vascular disorders. Thromb Haemost 2001; 86: 164171.
30 Verrotti A, Greco R, Basciani F, Morgese G, Chiarelli F. von
Willebrand Factor and its Propeptide in children with diabetes.
Relation between endothelial dysfunction and microalbuminuria.
Pediatr Res 2003; 53: 3826.
31 Habe K, Wada H, Ito-Habe N, Hatada T, Matsumoto T, Ohishi
K, Maruyama K, Imai H, Mizutani H, Nobori T. Plasma
ADAMTS13, von Willebrand factor (VWF) and VWF propeptide
profiles in patients with DIC and related diseases. Thromb Res
2012; 129: 598602.
32 Ito-Habe N, Wada H, Matsumoto T, Ohishi K, Toyoda H, Ishikawa E, Nomura S, Komada Y, Ito M, Nobori T, Katayama N.
Elevated Von Willebrand factor propeptide for the diagnosis of
thrombotic microangiopathy and for predicting a poor outcome.
Int J Hematol 2011; 93: 4752.
33 Haberichter SL, Balistreri M, Christopherson P, Morateck P,
Gavazova S, Bellissimo DB, Manco-Johnson MJ, Gill JC, Montgomery RR. Assay of the von Willebrand factor (VWF) propep-

2016 International Society on Thrombosis and Haemostasis

Aging and ABO co-regulate VWF and FVIII levels 963

34

35

36

37

38

39

40

41

42

43

tide to identify patients with type 1 von Willebrand disease with

decreased VWF survival. Blood 2006; 108: 334451.
Haberichter SL, Castaman G, Budde U, Peake I, Goodeve A,
Rodeghiero F, Federici AB, Batlle J, Meyer D, Mazurier C,
Goudemand J, Eikenboom J, Schneppenheim R, Ingerslev J,
Vorlova Z, Habart D, Holmberg L, Lethagen S, Pasi J, Hill FG,
et al. Identification of type 1 von Willebrand disease patients
with reduced von Willebrand factor survival by assay of the
VWF propeptide in the European study: molecular and clinical
markers for the diagnosis and management of type 1 VWD
(MCMDM-1VWD). Blood 2008; 111: 497985.
Eikenboom J, Federici AB, Dirven RJ, Castaman G, Rodeghiero
F, Budde U, Schneppenheim R, Batlle J, Canciani MT, Goudemand J, Peake I, Goodeve A. VWF propeptide and ratios
between VWF, VWF propeptide, and FVIII in the characterization of type 1 von Willebrand disease. Blood 2013; 121: 23369.
Casonato A, Gallinaro L, Cattini MG, Sartorello F, Pontara E,
Padrini R, Bertomoro A, Daidone V, Pagnan A. Type 1 von
Willebrand disease due to reduced von Willebrand factor synthesis and/or survival: observations from a case series. Transl Res
2010; 155: 2008.
Bowman M, Mundell G, Grabell J, Hopman WM, Rapson D,
Lillicrap D, James P. Generation and validation of the Condensed MCMDM-1VWD Bleeding Questionnaire for von Willebrand disease. J Thromb Haemost 2008; 6: 20626.
Nossent A, van Marion V, van Tilburg N, Rosendaal F, Bertina
R, van Mourik J, Eikenboom H. von Willebrand factor and its
propeptide: the influence of secretion and clearance on protein
levels and the risk of venous thrombosis. J Thromb Haemost
2006; 4: 255662.
McGrath R, van den Biggelaar M, Byrne B, OSullivan J, Rawley
O, OKennedy R, Voorberg J, Preston R, ODonnell J. Altered
glycosylation of platelet-derived von Willebrand factor confers
resistance to ADAMTS13 proteolysis. Blood 2013; 122: 410710.
Brown S, Collins PW, Bowen DJ. Heterogeneous detection of Aantigen on von Willebrand factor derived from platelets,
endothelial cells and plasma. Thromb Haemost 2002; 87: 9906.
Akin M, Balkan C, Karapinar DY, Kavakli K. The influence of
the ABO blood type on the distribution of von Willebrand factor
in healthy children with no bleeding symptoms. Clin Appl
Thromb Hemost 2012; 18: 3169.
Klarmann D, Eggert C, Geisen C, Becker S, Seifried E, Klingebiel T, Kreuz W. Association of ABO(H) and I blood group
system development with von Willebrand factor and Factor VIII
plasma levels in children and adolescents. Transfusion 2010; 50:
157180.
Favaloro EJ, Soltani S, McDonald J, Grezchnik E, Easton L,
Favaloro JWC. Reassessment of ABO blood group, sex, and age

2016 International Society on Thrombosis and Haemostasis

44

45

46

47

48

49

50

51

52
53

54

on laboratory parameters used to diagnose von Willebrand

Disorder. Am J Clin Pathol 2005; 124: 9107.
Vischer UM, Herrmann FR, Peyrard T, Nzietchueng R, Benetos
A. Plasma von Willebrand factor and arterial aging. J Thromb
Haemost 2005; 3: 7945.
ODonnell J, Boulton F, Manning R, Laffan M. Amount of H
antigen expressed on circulating von Willebrand Factor is modified by ABO Blood Group Genotype and is a major determinant
of plasma von Willebrand Factor antigen levels. Arterioscler
Thromb Vasc Biol 2002; 22: 33541.
Morelli VM, de Visser MCH, van Tilburg NH, Vos HL, Eikenboom JCJ, Rosendaal FR, Bertina RM. ABO blood group genotypes, plasma von Willebrand factor levels and loading of von
Willebrand factor with A and B antigens. Thromb Haemost 2007;
97: 53441.
Groeneveld DJ, van Bekkum T, Cheung KL, Dirven RJ, Castaman G, Reitsma PH, van Vlijmen B, Eikenboom J. No evidence
for a direct effect of von Willebrand factors ABH blood group
antigens on von Willebrand factor clearance. J Thromb Haemost
2015; 13: 592600.
Nosaka M, Ishida Y, Tanaka A, Hayashi T, Miyashita T, Kaminaka C, Eisenmenger W, Furukawa F, Kimura A. Aberrant
expression of histo-blood group A type 3 antigens in vascular
endothelial cells in inflammatory sites. J Histochem Cytochem
2008; 56: 22331.
ODonnell J, Mille-Baker B, Laffan M. Human umbilical
vein endothelial cells differ from other endothelial cells in failing
to express ABO blood group antigens. J Vasc Res 2010; 37: 540
7.
Desch KC, Ozel AB, Siemieniak D, Li JZ, Ginsburg D. Linkage
and association analysis of von Willebrand factor propeptide
levels provides mechanistic insight into the genetic control of
plasma von Willebrand factor levels. Abstract presented at the
63rd Annual Meeting of the American Society of Human Genetics (2013) in Boston, MA, USA.
Rizzo C, Caruso C, Vasto S. Possible role of ABO system in
age-related diseases and longevity: a narrative review. Immun
Ageing 2014; 11: 1623.
Franchini M, Bonfanti C. Evolutionary aspects of ABO blood
group in humans. Clin Chim Acta 2015; 444: 6671.
P
aramo J, Beloqui O, Colina I, Diez J, Orbe J. Independent
association of von Willebrand factor with surrogate markers of
atherosclerosis in middle-aged asymptomatic subjects. J Thromb
Haemost 2005; 3: 6624.
Gong P, Luo S-H, Li X-L, Guo Y-L, Zhu C-G, Xu R-X, Li S,
Dong Q, Liu G, Chen J, Zeng R-X, Li J-J. Relation of ABO
blood groups to the severity of coronary atherosclerosis: an Gensini score assessment. Atherosclerosis 2014; 237: 74853.