Hum Genet (2001) 108 : 290–298 DOI 10.1007/s004390100490 O R I G I N A L I N V E S T I G AT I O N C. Le Maréchal · M. P. Audrézet · I. Quéré · O. Raguénès · S. Langonné · C. Férec Complete and rapid scanning of the cystic fibrosis transmembrane conductance regulator (CFTR) gene by denaturing high-performance liquid chromatography (D-HPLC): major implications for genetic counselling Received: 8 January 2001 / Accepted: 12 February 2001 / Published online: 4 April 2001 © Springer-Verlag 2001 Abstract More than 900 mutations and more than 200 different polymorphisms have now been reported in the cystic fibrosis transmembrane conductance regulator (CFTR) gene. Ten years after the cloning of the CFTR gene, the complete scanning of the 27 exons to identify known and novel mutations remains challenging. Rapid accurate identification of mutated alleles is important for prenatal diagnosis, for cascade screening in families at risk of cystic fibrosis (CF) and for understanding the correlation between genotype and phenotype. In this study, we report the successful use of denaturing ion-pair reverse-phase high performance liquid chromatography (D-HPLC) to analyse rapidly the complete coding sequence of the CFTR gene. With 27 pairs of polymerase chain reaction primers, we optimised the temperature conditions required for the analysis of each amplicon and validated thetest conditions on samples from a panel of 1552 CF patients who came from France and other European countries and who had mutations and polymorphisms located in the various melting domains of the gene. D-HPLC identified 415 mutated alleles previously characterised by denaturing gradient gel electrophoresis and DNA sequencing, plus 74 novel mutations reported here.This new technique for screening DNA for sequence variation was extremely accurate (it identified 100% of the CFTR alleles tested so far) and rapid (the complete CFTR gene could be analysed in less than a week). Our approach should reduce the number of untyped CF alleles in populations and thus decrease the residual risk in couples at risk of CF. This technique may be important not only for CF,but also for many other genes with a high frequency of point mutations at a variety of sites. C. Le Maréchal · C. Férec (✉) EFS-Bretagne, EPI 01-15, Site de Brest, CHU, Brest; France e-mail: [email protected], Tel.: +33-2-98445064, Fax: +33-2-98430555 M. P. Audrézet · I. Quéré · O. Raguénès · S. Langonné · C. Férec Laboratoire de Génétique Moléculaire, EPI 01-15, CHU, 29200 Brest, France Introduction With an incidence of about 1 in 3000 live births in Caucasians of European extraction (Welsh et al. 1995), cystic fibrosis (CF) is one of the most common lethal diseases in childhood. CF can result from many different mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene (ABCC7, MIM 602421). In addition to the ∆F508 deletion, which accounts for about 66% of all CF alleles world-wide, more than 900 different mutations have been reported throughout the 27 exons of the CFTR gene by the Cystic Fibrosis Genetic Analysis Consortium (http://www.genet.sickkids.on.ca). CF mutations have also been found in other clinical diseases such as congenital bilateral absence of the vas deferens (CBAVD; Chillon et al. 1995; de Braekeleer and Ferec 1996; Dumur et al. 1990; Mercier et al. 1995), disseminated bronchiectasis (Girodon et al. 1997; Pignatti et al. 1995) and chronic pancreatitis (Cohn et al. 1998; Sharer et al. 1998). The particularly large number of different alleles, combined with marked variation in their distribution and frequency according to geographic and ethnic origin (Estivill et al. 1997; Tsui 1992) makes clinical testing for mutated alleles particularly difficult. It is only in a few populations, such as those in Brittany (France) and in Quebec (Saguenay Lac St Jean) that 98%–100% of the mutated alleles have been identified so far (de Braekeleer et al. 1998; Férec et al. 1992). During the last ten years, the development of technology for mutation screening has been extremely productive with the appearance of powerful techniques such as polymerase chain reaction (PCR), single strand conformational polymorphism (SSCP) (Orita et al. 1989), chemical and enzymatic cleavages (Cotton et al. 1988; Babon et al. 1999), denaturing gradient gel electrophoresis (DGGE) (Lerman and Silverstein 1987) and, more recently, denaturing ion-pair reverse-phase high-performance liquid chromatography (D-HPLC) (Oefner and Underhill 1998). D-HPLC is an automated technology for mutation screening based on the separation of heteroduplexes from ho- 291 moduplexes on a stationary phase under partially denaturing conditions. This technique was originally used to identify single nucleotide polymorphisms (SNPs) on the Y chromosome (Underhill et al. 1996). The ideal technique for mutation detection has to be sensitive, specific and robust (Cotton 1997). Although it is unfortunately time-consuming and technically difficult to implement, DGGEis probably one of the most powerful techniques available for the detection of point mutations. This is particularly true for large genes with many different mutations, such as CFTR. These limitations have led us to search for a new technique and to focus on D-HPLC. We now report the complete scanning of the CFTR gene by D-HPLC. All the previously characterised mutated alleles tested 415 different nucleotide changes including mutations (334), polymorphisms (50) and 31 complex haplotypes, have been correctly identified, and we report the identification of 74 novel mutations. We propose that this technique should become standard for quick and efficient scanning of the CFTR gene as it allows rapid genotyping and has greatly improved our Bayesian calculations for couples at risk of CF. Materials and methods Sample collection This study is the result of 10 years of CFTR analysis carried out within our genetic laboratory. We analysed by DGGE the 27 exons of the CFTR gene(ABCC7) in clinical situations involving CFTR abnormalities (CF, CBAVD, bronchiectasis, chronic pancreatitis) and also in a control population. This analysis revealed 359 mutated samples and SNPs distributed all over the coding sequence from our cohort of1552 French CF patients and 253 CBAVD patients. Collaborations with several centres from various countries and with members of the Cystic Fibrosis Genetic Analysis Consortium increased the diversity of our collection of mutated samples (56 different mutated samples). A list of the mutations and SNPs tested is available upon request. DNA amplification DNA was isolated from blood cells by the salt precipitation method. Primers were designed by using Primer Express software (Applied Biosystems). PCR was performed in 50 µl containing 0,5 µM of each primer, 1–2.5 mM MgCl2, 1×PCR buffer II (Applied Biosystems), 200 µM each dNTP (Amersham-Pharmacia Biotech), 0.2 U AmpliTaq DNA polymerase (Applied Biosystems), and 50 ng DNA. We chose a touchdown PCR protocol as previously described (Don et al. 1991). This enabled us to minimise experimentation and reducethe number of thermocycler programs: indeed, two protocols were enough to amplify all 27 exons of the CFTR gene. Cycling conditions were as follows: a denaturation step at 94°C for 3 min, 14 touchdown cycles with annealing temperature decreasing 0.5°C per cycle (denaturation 94°C for 20 s, annealing for 40 s, primer extension 72°C for 45 s), 25 cycles at the final touchdown annealing temperature and a final elongation step at 72°C for 7 min. Heteroduplexes were formed by denaturing at 95°C and cooling by 1°C per minute to 65°C. Amplicons were stored at 4°C until D-HPLC analysis. All reactions were carried out using the GeneAmp PCR system 9700 (Applied Biosystems). Specific sizes and quantities of amplicons were checked by agarose gel electrophoresis. D-HPLC analysis of a wild-type sample amplified with 1, 1.5, 2 and 2.5 mM MgCl2 was performed to find the magnesium concentration that gave no spurious products. Table 1 summarises PCR conditions for the 27 exons of CFTR gene. D-HPLC analysis Denaturing high performance liquid chromatography (D-HPLC) analysis is a reverse-phase ion-pair high-performance liquid chromatography that allows the identification of heteroduplex molecules (Oefner and Underhill 1998). It was performed using the Transgenomic WAVE system as described by Kuklin et al. (1998). Aliquots of 3–5 µl crude PCR samples were loaded onto a preheated C18 reverse-phase column based on non-porous poly (styrene-divinyl benzene) particles (DNASep column Transgenomic). DNA (homoduplexes with or without heteroduplexes) was eluted from the column by a linear acetonitrile gradient in 0.1 mM triethylamine acetate buffer (TEAA; Transgenomic), pH 7, at a constant flow rate of 0.9 ml/min. The gradient was formed by mixing buffer A (0.1 mM TEAA) and buffer B (0.1 mM TEAA, 25% v/v acetonitrile). The temperature of the oven for optimal heteroduplex separationwith partial DNA denaturation was deduced from the melting profile of the DNA sequence. Wavemaker 3.4.4 software (Transgenomic) was first used to compute melting curves and to estimate the temperature for analysis. This was tested experimentally by injecting a wild-type sample onto the column at approximately the calculatedtemperature (±2°C) by 1°C steps; we chose the temperature just below that at which denaturation occurred (1 min retention time shift compared with non-denaturing conditions of 50°C in most cases). If the sequence possessed several melting domains with more than 4°C difference, the melting curve indicated the various temperatures that had to be investigated. The analytic gradient was 3.5 min long and buffer B increased at 2% per minute. For each fragment, the initial and final concentrations of buffer B were adjusted to obtain a retention time between 3 and 5 min; the conditions are listed in Table 1. The column was then cleaned with 100% buffer B for 30 s and equilibrated at the start conditions for 2 min before the next injection. Elution of DNA was detected by 260 nm UV absorbance. HSM software regulated every parameter of the Wave system during analysis and stored the data. Data analysis Two researchers interpreted the results independently. Four wildtypesamples were always used as negative controls to ensure that a normal homoduplex profile was reproducibly obtained (retention time and peak profile). Chromatograms were overlaid with one from a wild-type. Samples with extra peaks (one, two or three more)or with a difference in peak appearance were scored as positive. Direct sequencing Samples showing abnormal D-HPLC profiles were re-amplified from genomic DNA. PCR products were purified on microcon 100 columns (Millipore). Direct sequencing was performed with the BigDye Terminator cycle sequencing kit from Applied Biosystems, with 25 ng template, 3 pmol selected primer and RRmix as supplied by the manufacturer. Cycle sequencing (25 cycles at 95°C for 5 s, 60°C for 10 s and 72°C for 4 min) was performed with a GeneAmp PCR system 9700 (Applied Biosystems). Centrifugation through a Centrisep spin column removed excess dye terminator. An aliquot of 10 µl Template Suppression Reagent (TSR) was added to 10 µl purified reaction product, after which the products were denatured at 94°C for 2 min and kept on ice before being analysed by capillary electrophoresis on an ABIprism 310 (Applied Biosystems). 292 Table 1 PCR (primers sequences, final touchdown annealing temperature) and DHPLC (oven temperature, Acetonitril gradient) analysis conditions for 27 exons of the CFTR gene (ABCC7) Exon 1 2 3 4 5 6a 6b 7 8 9 10 11 12 13 14A 14b 15 16 17a 17b 18 19 20 21 22 23 24 Primer Sequences 5’→3’ Amplicon length (bp) MgCl2 (mM) final annealing temp (°C) Oven temp % B buffer start/end h1i5 h1i3 2i5b 2i3” 3i5 3i3 h4i5 4i3 5i5 5i3 h6ai5 h6ai3 6bi5B 6bi3 h7i5 7i3b 8i5b 8i3b 9i5C 9i3D h10i5 C16D* h11i5 11i3ter H12i5 h12i3 13i5 TTgAgCggCAggCACC gCACgTgTCTTTCCgAAgCT CAAATCTgTATggAgACC CAACTAAACAATgTACATgAAC GAAATAggACAACTAAAATA ATTCACCAgATTTCgTAGTC CACATATggTATgACCCTCT ATCCATCACTCgACCATgTT GTTgAAATTATCTAACTTTC AACTCCgCCTTTCCAgTTgT TCCTTTTACTTgCTTTCTTTCA TATgCATAgAgCAgTCCTggTT GATTTACAgAgATCAgAg gAggTggAAgTCTACCATgA TgCTCAgATCTTCCATTCCAAg AACTgATCTATTgACTgAT AATgCATTAATgCTATTCTgATTC AgTTAggTgTTTAgAgCAAACAA TggggAATTATTTgAgAAAg CTTCCAgCACTACAAACTAgAAA TgATAATgACCTAATAATgAT CATTCACAgTAgCTTACCCA TgCCTTTCAAATTCAgATTgAgC ACAgCAAATgCTTgCTAgACC gAA TCg ATg Tgg TgA CCA TAT TgT CCA gTA ggg CAg ATC AgA TTT gA TgCTAAAATACgAgACATATTgC 181 1.5 56 63°C 52/59 194 1 50 58°C 51/58 259 2 50 437 2 56 56°C 58°C 59°C 52/59 51/58 54/61 192 2.5 50 55°C 51/58 344 2 50 221 2 56 56°C 61°C 56°C 58/65 53/60 52/59 390 1.5 56 190 2.5 56 55°C 61°C 54°C 57/64 51/58 55/62 258 1 56 56/63 386 1.5 56 197 1.5 56 55°C 58°C 50°C 56°C 57°C 58/65 56/63 54/61 366 2 50 55°C 57/64 906 1.5 50 13i3 TACACCTTATCCTAATCCTAT h14ai5 14i3 H14bi5 14bi3b H15i5 h15i3 h16i5 h16i3 h17ai5 h17ai3 h17Bi5 17Bi3B 18I5 H18I3 19i5 19i3B h20i5 h20i3 21i5A 21i3 h22i5 h22i3 H23i5mod h23i3 24i5C 24i3C CACAATggTggCATgAAACT gTATACATCCCCAAACTATCT ggg Agg AAT TAg gTg AAg AT TAC ATA CAA ACA TAg Tgg ATT TgTATTggAAATTCAgTAAgTAACTTTgg AgCCAgCACTgCCATTAgAAA CTgAATgCgTCTACTgTgATCCA TgTgggATTgCCTCAggTTT AATCACTgACACACTTTgTCCACTT TCAAATAgCTCTTATAgCTTTTTTACAAgATg AAT gAC ATT TgT gAT ATg AT CTTAAATgCTTAgCTAAAgT AgTCgTTCACAgAAgAgAgA AAT gAC AgA TAC ACA gTg ACC CTC A GTgAAATTgTCTgCCATTCT ACTCCATATAATAAAACATgTgTg ATCTTCCACTggTgACAggA AAAgACAgCAATgCATAACAA AATgTTCACAAgggACTCCA CAAAAgTACCTgTTgCTCCA ATCAATTCAAATggTggCAggT AATgATTCTgTTCCCACTgTgCT CggCAAggTAAATACAgATCAT GCA ggA ACT ATC ACA TgT gA TCCCTgCTCTggTCTgACCTgC CATgAggTgACTgTCCCACgAg 256 1.5 56 54°C 57°C 59°C 62°C 56°C 62/69 60/67 57/64 52/59 55/62 174 2 50 57°C 52/59 401 1.5 56 59°C 56/63 401 2 56 55°C 56/63 281 1.5 56 58°C 55/62 380 1.5 50 311 1.5 50 56°C 59°C 56°C 56/63 53/60 55/62 449 2.5 50 59°C 55/62 401 2 50 477 1.5 56 370 1 56 54°C 58°C 59°C 58°C 60 59/66 54/61 52/59 48/55 53/60 250 1.5 56 57°C 53/60 329 1 56 62°C 55/62 293 Results D-HPLC allows the separation of homoduplexes and heteroduplexes in double-stranded DNA molecules up to 1 kb in length. Taking advantage of our knowledge of the CFTR gene and its mutations, which we have studied for more than 10 years, we defined the primer and temperature conditions for each of the 27 exons of the CFTR gene. The melting profiles were studied by using Wavemaker software. As an example, Fig. 1A illustrates the melting profile obtained for exon 3 of the CFTR gene. The coding sequence, localised between the two dotted lines, has two melting domains. The 5’ domain has a melting temperature at 58°C, whereas the 3’ domain melts at 55°C. Two positive samples, with mutations localised in the two different domains, were selected (E60X and G85E). Analysis of the fragment was performed at 57°C and 58°C and the experiment revealed that a 1°C shift radically changed the studied domain. At 57°C, only the low melting domain represented by the mutation G85E in this example is analysed. At 58°C, only the 5’ part of the sequence (highlighted; mutation E60X) is correctly analysed (Fig. 1B). Fig. 1 A Melting profile of exon 3 of the CFTR gene: the coding sequence is located between the two dotted lines and the two mutations chosen are positioned on the sequence. B Chromatograms show the shift of the studied domains with only a 1°C change. At 57°C, the 3’ part is studied (low melting) represented by mutation G85E (green), whereas at 58°C, the 5’ part with mutation E60X (pink) is analysed For each of the 27 exons, all the melting domains were validated with positive samples. This allowed us to be sure that the domain was well studied at the exact temperature. For the majority ofthe fragments (22 exons), one temperature was enough. Two temperatures were necessary for exons 3, 7, 17b and 21. Exon 13, which encodes the R domain of the protein (725 bp), required four different analysis conditions (54°C, 57°C, 59°C and 62°C) from the same amplicon. We chose one additional condition for exons 6a and 20. This permitted us to explore the intronic sequence amplified with the primers, containing respectively the 875+40 A→G and 4005+33 A→G polymorphisms. Exon 10 of the CFTR gene contains the most frequent mutation, ∆F508, which corresponds to a 3-bp deletion and accounts for about 66% of CF chromosomes worldwide. Analysis of this fragment under non-denaturing condition (at 50°C) permits us to search specifically for this mutation and to distinguish it from the frequent variant M470 V that appears identical under the classical analysis condition (56°C) for exon 10 (Fig. 2). Our series of 415 mutated alleles included 198 transitions, 124 transversions and 63 insertion/deletions as representatives of the abnormalities observed in the CFTR 294 Fig. 2 Exon 10: analysis under non-denaturing conditions (50°C) allows the identification of ∆F508. At 56°C, the profiles of ∆F508 and M470V are identical gene. This collection of samples corresponds to the 415 previously known variants plus 74 novel nucleotide changes, three of which were identified for the first time by D-HPLC (Table 2). All 415 of the 415 positive sequences tested were identified under the conditions specified for each exon. Thus, the sensitivity of D-HPLC for the CFTR gene is 100% in this collection of mutated samples. As soon as the conditions of analysis were established for each exon, we studied the unidentified chromosomes from our cohort of 1552 French CF patients. At the end of this study, only 61 chromosomes remained unidentified, corresponding to a detection rate of more than 98% of the mutated alleles. Discussion Since the CFTR gene was cloned in 1989, more than 900 mutations have been reported spread throughout the gene. Mutations have also been reported in many related diseases in adults, such CBAVD (Chillon et al. 1995; Dumur et al. 1990; Mercier et al. 1995), disseminated bronchiectasis (Pignatti et al. 1995) and pancreatitis (Sharer et al. 1998). Apart from ∆F508 and a few mutations that are found all over the world, most of these mutated alleles are private mutations (http://www.genet.sickkids.on.ca). The ideal screening technique should identify known mutations and novel private ones that could lie anywhere in the gene. Since the arrival of the PCR technique, many methods have been used to screen for specific mutations. Heteroduplex analysis and restriction enzyme analysis are the most common methods (Dequeker and Cassiman 1998). Other techniques, such as dot-blot or reverse dot-blot (Cuppens et al. 1992), or allele specific mutation detection systems (Ferrie et al. 1992) are also commonly used. More recently, Applied Biosystems has developed commercial kits based on the oligonucleotide ligation assay and allowing the detection of 31 mutations (Brinson et al. 1997). This test is robust but persistently fails to identify certain mutations that are common in particular ethnic groups. Scanning methods are thus essential, as they can identify known mutations and novel ones. The most frequently used are SSCP (Orita et al. 1989) and the DGGE method initially proposed by Lerman and Silverstein (1987). To date, DGGE is the most popular and sensitive technique for CFTR gene analysis. Nevertheless, these methods still have limitations, basically with regard to the time that they require and to their sensitivity. In order to develop a powerful, rapid and robust method to identify mutant CF alleles, we have used the DHPLC method initially described by Oefner and Underhill (1995). D-HPLC allows the separationof homoduplexes and heteroduplexes in double-stranded DNA molecules up to 1 kb, based on a difference in denaturation characteristics. We have designed pairs of PCR primers for each of the 27 exons and exon/intron boundaries and have determined the temperature conditions required to obtain the best resolution. During the last 10 years, we have collected a large number of CF alleles from various European countries (e.g. France, Belgium, Italy, Ireland, Slovenia, Russia, Bulgaria; Mercier et al. 1993; Audrézet et al. 1993, 1994; Verlingue et al. 1995) and from native American people (Mercier et al. 1994). Being comprised of 415 characterised alleles and 74 undescribed mutations previously identified by DGGE, this collection has provided a good test of the ability of D-HPLC to identify mutations. By using the molecular tools presented here, we have shown that the sensitivity of the technique is 100%; furthermore, we report the identification of 74 novel mutations. The technique is both inexpensive and quick: for the scanning of the whole coding sequence, we assess the cost at US $50 (excluding labour costs) and the complete coding sequence of the gene can now be studied in less than a week. The sensitivity and specificity of D-HPLC have also been analysed by Ellis and co-workers (2000), 295 Table 2 Novel nucleotide changes identified in the CFTR gene and detected by D-HPLC Exon/ intron Mutant name Nucleic acid change Amino acid change 1 2 2 2 2 3 3 3 3 4 4 4 5 5 6a 6a 6a 6a 6a 6b 7 7 7 7 7 8 8 8 9 10 10 10 10 185+1 G to T 186 – 13 C to G 211 Del G 237 Ins A 296+2 T to C W 57 X2 306 InsA 306 Ins C W 79 X A 96 E L 127 X 541 Del CTCC L 165 S R 170 C L 206 F A 209 S A 209 A C 225 X G 241 R 905 Del G A 309 A V 322 M R 334 Q Q 353 H 1248+1 G to C L 383 L W 401 X E 403 D 1367 Del C 1525 – 2 A to G G 480 G 1576 Ins T H 484 R G to T at 185+1 C to G at 186–13 Deletion of G at 211 Insertion A at 237 296+2 T to C G to A at 303 Insertion of A at 306 Insertion of C at 306 G to A at 368 C to A at 419 T to G at 512 Deletion of CTCC at 541 T to C at 626 C to T at 640 G to T at 750 G to T at 757 A to G at 759 T to A at 807 G to A at 852 Deletion of Gat 905 C to G at 1059 G to A at 1096 G to A at 1133 A to C at 1191 G to C at 1248+1 G to A at 1281 G to A at 1334 G to C at 1341 Deletion of C at 1367 T to C at 1572 Insertion of T at 1576 A to G at 1583 Gly to Gly at 480 (GGT to GGC) 10 11 I506 V 1717 – 19 T to C A to G at 1648 T to C at 1717–19 Ileto Val at 506 (ATC to GTC) Silent Splicing ? 11 11 12 12 13 14a 14a 14a 14b 14b 14b 15 15 15 G 544 G 1802 Del C Y 569 X 1898+5 G to A 2335 Del A E 831 X C 866 Y V 868 V 2752 – 1 G to T 2752 – 97 C to T W 882 X S 895 T F 932 S 3040+23 T to C T to G at 1764 Deletion of C at 1802 T to A at 1839 G to A at 1898+5 Deletion of A at 2335 G to T at 2623 G to A at 2729 G to A at 2736 G to T at 2752–1 C to T at 2752–97 G to A at 2777 G to C at 2816 T to C at 2927 T to C at 3040 +23 Gly to Gly at 544 (GGT to GGG) Silent Frameshift Nonsense Splicing Frameshift Nonsense Missense Silent Splicing Silent Nonsense Missense Missense Silent Trp to Stop at 57 (TGG to TGA) Trp to Stop at 79 (TGG to TAG) Ala to Glu at 96 (GCA to GAA) Leu to Stop at 127 (TTA to TGA) Leu to Ser at 165 (TTA to TCA) Arg to Cys at 170 (CGT to TGT) Leu to Phe at 206 (TTG to TTT) Ala to Ser at 209 (GCA toTCA) Ala to Ala at 209 (GCA to GCG) Cys to Stop at 225 (TGT to TGA) Gly to Arg at 241 (GGG to AGG) Ala to Ala at 309 (GCC to GCG) Val to Met at 322 (GTG to ATG) Arg to Gln at 334 (CGG toCAG) Gln to His at 353 (CAA to CAC) Leu to Leu at 383 (TTG to TTA) Trp to Stop at 401 (TGG to TAG) Glu to Asp at 403 (GAG to CAG) His to Arg at 484 (CAC to CGC) Tyr to Stop at 569 (TAT to TAA) Glu to Stop at 831 (GAG to TAG) Cys to Tyr at 866 (TGC to TAC) Val to Val at 868 (GTA to GTG) Trp to Stop at 882 (TGG to TAG) Ser to Thr at 895 (AGT to ACT) Phe to Ser at 932 (TTC to TCC) Effect on amino acid sequence Patient Splicing Silent Frameshift Frameshift Splicing Nonsense Frameshift Frameshift Nonsense Missense Nonsense Frameshift Missense Missense Missense Missense Silent Nonsense Missense Frameshift Silent Silent Missense Missense Splicing Silent Nonsense Missense Frameshift Splicing Silent Frameshift Missense CF patient CF patient CF patient CF patient CF patient CF patient CF patient CF patient CF patient CF patient CF patient CF patient CF patient Control CF patient CF patient CF patient CF patient CF patient CF patient Control CF patient Control CF patient CF patient Control CF patient CF patient CF patient CF patient CF patient CF patient Neonatal hypertrypsinaemia Control Neonatal hypertrypsinaemia Control CF patient CF patient CF patient CF patient CF patient CF patient CF patient CF patient Control CF patient Control Control Control 296 Table 2 (continued) Exon/ intron Mutant name Nucleic acid change Amino acid change Effect on amino acid sequence Patient 16 17a 17a 17b 17b 17b 17b 17b 18 18 S 977 F G 1003 X Q 1042 X L 1059 L R 1066 S T 1115 T 3499+6 A to G 3499+7 T to G Delta M 1140 M 1140 K C to Tat 3062 G to T at 3139 C to T at 3256 A to G at 3309 C to A at 3328 C to A at 3477 A to G at 3499 T to G at 3499+7 Deletion of 3 pb T to A at 3551 Ser to Phe at 977 (TCC to TTC) Gly to Stop at 1003 (GGA to TGA) Gln to Stop at 1042 (CAA to TAA) Leu to Leu at 1059 (TTA to TTG) Arg to Ser at 1066 (CGT to AGT) Thr to Thr at 1115 (ACC to ACA) Missense Nonsense Nonsense Silent Missense Silent Splicing Splicing Frameshift Missense 19 19 19 20 20 S 1159 F S 1161 R S 1206 X F 1257 L 4005+33 A to G C to T at 3608 C to G at 3615 C to G at 3749 T to G at 3903 A to G at 4005 +33 Ser to Phe at 1159 (TCT to TTT) Ser to Arg at 1161 (AGC to AGG) Ser to Stop at 1206 (TCA to TGA) Phe to Leu at 1257 (TTT to TTG) Missense Missense Nonsense Missense Splicing 21 21 21 21 21 22 22 22 23 24 V1293I 4015 Del A N 1303 I P 1306 P E 1308 X 4172 Del GC R 1358 S I 1366 T 4374+10 T to C D 1477 D G to A at 4009 Deletion of A at 4015 A to T at 4040 C to T at 4050 G to T at 4064 Deletion of GC at 4172 A to T at 4206 T to C at 4229 T to C at 4374+ 10 T to C at 4563 Val to Ile at 1293 Missense Frameshift Missense Silent Nonsense Frameshift Missense Missense Splicing Silent CF patient CF patient CF patient Control CF patient Control CF patient Control CF patient Bronchiectasis CF patient CF patient CF patient CF patient Bronchiectasis Control CF patient CF patient CF patient CF patient CF patient Control Control CF patient Control Met to Lys at 1140 (ATG to AAG) Asn to Ile at 1303 (AAC to ATC) Pro to Pro at 1306 (CCC to CCT) Glu to Stop at 1308 (GAA to TAA) Arg to Ser at 1358 (AGA to AGT) Ile to Thr at 1366 (ATC to ACC) Asp to Asp at 1477 (GAT to GAC) who have compared the sensitivity of fluorescent-SSCP (F/SSCP) and D-HPLC from a collection of 67 different mutations from different genes (ABCC7, MIM 602421, VHL, MIM 193300; Gross et al. 1999). They report a specificity of 100% and a sensitivity of 95% for the ABCC7 gene, a result comparable to others reported in the literature (Liu et al. 1998; O’Donovan et al. 1998). The 100% sensitivity that we have obtained is probably attributable to our prior experience with DGGE. The positions of primers and the choice of the appropriate temperature for each fragment was partly based on our previously defined DGGE conditions. Our significant collection of various point mutations distributed in all the different melting domains of the coding sequence of the gene has been particularly helpful in optimising the experimental analysis conditions. However, homozygous mutations do not generally alter the stability of DNA fragments. Analysis of DNA from an obligate carrier (mother or father) or of a mixture of PCR products from the patient and a normal control in order to create heteroduplexes, overcomes this problem. All PCR-based mutation screening approaches involving diploid DNA miss large deletions. For example, the 50-kb deletion described in a Spanish chromosome (Morral et al. 1993) or the 21-kb deletion (CFTRdelE2,3) re- cently found in CF patients of Eastern and Western Slavic descent (Dörk et al. 2000). They also miss mutations located deep inside introns, for example 3849+10 kb C→T (Highsmith et al. 1994) or the 1811+1.6 kb A→G that is common in Spain (Casals et al. 1997). Specific amplicons can be proposed to search for these mutations. Other scanning methods, such as chemical cleavage, enzymatic cleavage and the protein truncation test, have been used for CFTR gene mutation analysis (Girodon-Boulandet et al. 2000). All these are less sensitive and more time-consuming. Obviously, these scanning methods require direct DNA sequencing to be performed to characterise the mutation. Using D-HPLC and the technical protocols that we report in this paper, we have shown that, so far, all the previously known and new mutations can be identified. Despite the high level of heterogeneity of the CFTR mutation in Europe and United States, we think that a mutationdetection rate of 95% is achievable and that a detection rate of 98% can be reached in most of the countries of European extraction. In our cohort of 1552 French CF patients, only 61 chromosomes remained unidentified, increasing the detection rate to more than 98%. Considering that the tested population is highly heterogeneous, this is a high level of point mutation detection. 297 This new tool thus greatly improves genetic counselling. For example, the residual risk of CF for a couple (a partner of a heterozygote with 98% of mutations being discarded) is now 1/5000 in our population with a carrier rate of 1/25. Moreover, for the rare CF chromosomes, in which the mutation remains unidentified, the characterisation of intragenic polymorphisms can provide us with information for prenatal diagnosis. Ultrasound screening has become routine in pregnancy and the discovery of a fetus with a hyperechogenic bowel or ascities is suggestive of CF. In this emergency situation, we first screen for common known mutations. If one parent is a carrier and the mutation is also present in the fetus, we urgently have to scan the entire CFTR gene for a second mutation. The residual risk for this fetus depends upon the detection rate of the test used. For example, if only the ∆F508 and the other most common mutations (G551D, G542X, W1282X, 1717–1 G→A) are sought, the detection rate is 70% and the residual risk is around 1/3. If D-HPLC is used, we can analyse, within a few days, the whole gene and scan all the known and new private mutations with a detection rate of 98%. The residual risk becomes 1/60 (V. Scottet et al. in preparation). A thorough analysis of the CFTR gene is also much needed in partners of CF patients. For these couples, the a priori risk is 1/25 and a complete scanning of the gene allows one to reach a residual risk of 1/2500. Although neonatal screening for CF is still a matter of debate in the medical community, it has become a reality in some countries. The main protocol includes a combined analysisofimmunoreactive trypsin (IRT) and mutation analysis. It is evident that the specific choice of the exons analysed with respect to the distribution of mutations in the country will greatly improve the specificity of the scanning protocol (Scottet et al.2000). D-HPLC dramatically enhances our capacity to identify mutated alleles. However, we know from genotype/ phenotype correlation studies that the detection of a mutation alone is no longer sufficient to make a clinical diagnosis and assessment of CF. We have to determine the precise sequence abnormality for at least two reasons. First, genotypes can be assigned to one of five classes based on the molecular outcome. Class I mutations cause defective protein production; class II mutations are associated with defective protein processing; class III mutations cause defective regulation; class IV mutations correspond to mutations localised in the transmembrane domain of the protein and cause defective conductance; finally, class V mutations include those affecting the level of normal mRNA transcript and, thus, of protein required for normal function (Estivill 1996; Welsh and Smith 1993). The identification of class IV mutations, which affect channel conductance or channel gating, and class V mutations, which reduce the level of normal CFTR protein by altering the promotor or splicing, is highly significant for genetic counselling. 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