Rare variants of RNF213 and moyamoya/non-moyamoya intracranial artery stenosis/occlusion disease risk: a meta-analysis and systematic review
Liao et al. Environmental Health and Preventive Medicine
Rare variants of RNF213 and moyamoya/ non-moyamoya intracranial artery stenosis/ occlusion disease risk: a meta-analysis and systematic review
Xin Liao 0 1
Jing Deng 0 1
Wenjie Dai 1
Tong Zhang 2
Junxia Yan 1
0 Equal contributors
1 Department of Epidemiology and Health Statistics, XiangYa School of Public Health, Central South University , Shang Mayuanling, KaiFu District, Changsha 410078 , China
2 Department of Neurology, the Second Hospital of Hebei Medical University , Heping West Road, Xinhua District, Shijiazhuang 050000 , China
Background: The p.R4810K and other rare variants of ring finger protein 213 gene (RNF213) were illustrated as susceptibility variants for moyamoya (MMD) and non-moyamoya intracranial artery stenosis/occlusion disease (ICASO) recently. However, the effect sizes of p.R4810K were in great discrepancy even in studies of the same ethnic population and firm conclusions of other rare variants have been elusive given the small sample sizes and lack of replication. Thus, we performed this study to quantitatively evaluate whether or to what extent the rare variants of RNF213 contribute to MMD and ICASO in different populations. Methods: A systematic search of PubMed, EMBASE, ISI web of science, CNKI, and WANFANG DATA was conducted up to 5 September 2017. Pooled odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using random- or fixed-effect models based on the between-study heterogeneity. The subgroup analyses were performed by the ethnicity and family history. Sensitivity and publication bias analysis were performed to test the robustness of associations. All the statistical analyses were conduct using STATA 12.0. Results: Twenty studies including 2353 MMD cases and 5488 controls and 11 studies including 1778 ICASO cases and 3140 controls were included in this study. Pooled ORs indicated that RNF213 p.R4810K significantly increased MMD and ICASO risk in East Asians with great effect sizes of discrepancy (dominant model: odds ratios 184.04, 109.77, and 31.53 and 10.07, 28.52, and 5.59 for MMD and ICASO, respectively, in Japan, Korea, and China). It significantly increased familial MMD risk in Japan, Korea, and China with 5 ~ 36 times larger effect sizes than that for sporadic ones in each country (dominant model ORs 1802.44, 512.42, 1109.02 and 134.35, 99.82, and 30.52, respectively, for familial and sporadic cases). The effect sizes of RNF213 p.R4810K to sporadic MMD were 3 ~ 4 times larger in Japan and Korea than those in China. RNF213 p.R4810K also increased the ICASO risk in Japan and Korea with 2 ~ 4 times larger effect sizes than that in China (dominant model ORs 10.71, 28.52, and 5.59, respectively). Another two rare variants- p.E4950D and p.A5021V significantly increased MMD risk in Chinese population (dominant model ORs 9.06 and 5.01, respectively). Various other rare variants in RNF213 were identified in Japanese, Chinese, European, and Hispanic American populations without association evidence available yet. (Continued on next page)
(Continued from previous page)
Moyamoya disease (MMD) is an idiopathic
stenoocclusive disease of intracranial arteries characterized by
progressive bilateral and occasionally unilateral stenosis
and occlusion of the distal internal carotid artery, with
frequent involvement of the middle cerebral artery and
anterior cerebral artery, and by the abnormal
development of a hazy network of basal collateral vessels [
MMD occurs worldwide, but its prevalence is highest in
East Asian countries, including Japan, Korea, and China
]. There are two incidence peaks for MMD, one in
children around 10 years of age and another in adults in
their 30–40 years [
]. Affected individuals are at risk for
intracranial hemorrhagic or ischemic stroke, seizures,
cognitive impairment, and developmental delays [
Although much progress has been made in our
understanding of MMD, the etiology is still not well
understood, and no medication can inhibit or reverse its
progression. At present, direct or indirect neurosurgical
revascularization is the mainstay MMD treatment [
Pathological clues for early diagnosis and novel
therapeutic approaches are needed.
Based on the existence of familial cases and the
observation of a strong ethnicity effect of MMD, a
genetic contribution is strongly suspected [
2011, two research groups identified ring finger protein
213 gene (RNF213) on 17q25.3 as a novel susceptibility
gene for MMD in Japan and East Asian population,
]. The RNF213 rare variant
p.R4810K [rs112735431, corresponding to c.14429G>A
on the basis of the NCBI Reference sequence
NM_001256071.2, theminor allele frequency (MAF) in
the 1000 Genome is 0.0012] significantly increases
MMD risk in Japan, Korea, and China (odds ratios
(ORs) were 338.94, 135.63, and 14.70 in a dominant
model, respectively) [
]. Further replication studies
confirmed that RNF213 p.R4810K was a founder
mutation in East Asian and absent from European, Hispanic,
and African-descent MMD cases [
several studies further revealed that RNF213 p.R4810K
was associated with intracranial artery stenosis/occlusion
that did not meet the diagnostic criteria for MMD
(ICASO) in Japan, Korea, and China [
hypothesized that some cases of ICASO ascribed to
unknown etiology or atherosclerosis might be an early
onset MMD which was misdiagnosed by the traditional
imaging diagnostic methods [
]. Since the
therapeutic strategies are different for these diseases,
genetic testing or sequencing of RNF213 is proposed for
MMD and ICASO diagnosis [
]. However, the
carrier rates of RNF213 p.R4810K in MMD and ICASO
were greatly discrepant in different studies. It varied
from 66.7 to 90.1% in Japanese and Korean MMD
patients, and to a lesser degree in Chinese ones with a
range from 9.4 to 31.4%, the effect sizes were
significantly different even in studies of the same ethnic
12, 13, 18, 19, 26, 27
]. For ICASO, there were
more than 20% of patients who carried RNF213
p.R4810K in Japan and Korea, while the rates were much
lower in China [
]. The lack of consistency of these
studies is probably due to population stratification or
small sample sizes in individual studies with inadequate
statistical power. In addition, many non-p.R4810K rare
variants (MAF < 0.005 in 1000 Genome database) in
RNF213 have been identified in both Asian and
Caucasian MMD cases recently [
11–17, 19, 28
However, RNF213 is a large gene (encodes 5207 amino acids)
and harbors a number of missense variants in the
general population as well as the patients [
]. The false
assignment of pathogenicity may lead to incorrect
therapeutic or prognostic assessments of patients [
scientifically quantitative evaluation of the contributions
of RNF213 rare variants to MMD and ICASO is urgently
needed for the future applications and studies.
Previously, Sun et al. performed meta-analysis to
investigate the associations between RNF213 variants
(mainly p.R4810K) and MMD susceptibility with eight
studies included [
]. They concluded that RNF213
p.R4810K is closely associated with MMD risk. Recently,
some other studies were subsequently performed.
Considering the discrepant results and only MMD was
involved in the previous meta-analysis, we performed
this study to quantitatively evaluate whether or to what
extent the rare variants of RNF213 contribute to MMD
and ICASO in different populations.
This meta-analysis was conducted according to the
Human Genome Epidemiology Network guidelines and
followed the published recommendations to improve the
quality of meta-analyses of genetic association studies
]. We assessed the quality of reporting of genotyping
on the basis of the Strengthening the Reporting of
Genetic Association Studies statement [
Literature search strategy
Electronic databases PubMed, EMBASE, Web of
Science, WANFANG DATA, and China National
Knowledge Infrastructure (CNKI) were used to retrieve
potentially relevant articles on human genetic studies of
MMD and ICASO that had been published up to 5
September 2017. Search terms used were RNF213*[tw]
or RNF 213*[tw] or ring finger protein 213*[tw]. Articles
in all languages were searched and translated as
necessary. After relevant articles were retrieved, references
were also checked for other potentially relevant articles
not found in the initial search.
Selection criteria and data extraction
We included related studies evaluating associations of
RNF213 rare variants with proven MMD or ICASO
(using computed tomography angiography or magnetic
resonance angiography or digital subtraction
angiography) in all ethnicities. The detailed inclusion criteria
were (1) well-designed case control studies to investigate
the relationship between at least one genetic variant of
RNF213 and MMD or ICASO, or case-only studies
which investigated the carrier rate of RNF213 variants in
MMD or ICASO and the carrier rates of the target
variants were available in the general population; (2)
clear diagnostic criteria of MMD and ICASO; (3)
original papers contained independent and sufficient
genotype data to calculate ORs and 95% confidence intervals
(CIs); (4) all variants included in the meta-analysis
should be evaluated in at least two published studies.
Where duplicate or overlapped datasets existed, only the
largest study was included. The studies without essential
information or with overlapped data, review articles,
case reports, and animal models were excluded. For the
variants identified just in one study or the sample
number that was limited to perform association analysis, a
qualitative systematic review was performed.
Data were extracted by two of the authors (XL and
JD), and differences were resolved by consensus (JY).
For each included study, the following information was
extracted: first author, year of publication, study
population (country), mean age, familial history of MMD,
numbers of patients and controls, frequency of genotypes,
and Hardy–Weinberg equilibrium (HWE) status. Where
genotype frequencies for each variant were unavailable,
we estimated the number of cases per genotype category
by using published information on risk allele frequencies
and ORs for MMD or ICASO. The HWE of controls
was obtained either directly from the article or indirectly
by calculating from genotype distributions using a
(http://www.oege.org/software/hwe-mrcalc.shtml). Quality assessment of primary studies was
performed using Newcastle–Ottawa quality assessment
scale (NOS) [
]. Each study with NOS scores ≥ 6 was
regarded as a high-quality study.
Statistical analyses were conducted using STATA12.0
software (Stata Corporation, College Station, TX, USA).
Frequency of the genotypes and alleles between MMD/
ICASO group and control group were compared using
Chi-square or Fisher exact test. For each genetic variant
with more than one publication, meta-analysis was
performed to determine a pooled OR and 95% CI
according to dominant, recessive and allelic models by
using a fixed- or random-effect model. The significance
of the pooled OR was determined using Z test, and
p < 0.05 was considered statistically significant.
Heterogeneity among studies was assessed using
Cochran Q test and quantified by using Higgins I2
statistic. CIs for I2 were also calculated. For Q test, p < 0.05
was considered as having significant heterogeneity. For
variant association showing significant inter-study
heterogeneity (Q test, p values < 0.05, and I2 > 50%), the
random-effect model was used as the pooling method;
otherwise, the fixed-effect model was used. To evaluate
ethnic-specific effects, subgroup analysis was performed
according to the nationality of the study population.
Publication bias was assessed by using the Egger
regression asymmetry test and visualization of funnel plots if
more than seven studies were included, and the
significance was set at the p < 0.05 level. Sensitivity analysis
was performed by sequentially excluding individual
study to calculate the pooled OR of the remaining
studies and assess the stability of the results.
Main characteristics of all the available studies
Five hundred sixty-four articles were identified through
the database check, and no article was identified through
the related references check. After screening for
duplication and eligibility, data from 24 studies met the
inclusion criteria and was included. A detailed workflow
chart showing the study selection is presented in Fig. 1.
In total, twenty articles investigated the association
between seven RNF213 rare variants (p.R2092C,
p.D4013N, p.R4062Q, p.A4399T, p.R4810K, p.E4950D,
and p.A5021V) and MMD [
11–19, 21–24, 27, 35–40
eleven articles investigated the association between
RNF213 p.R4810K and ICASO [
21–25, 36, 38, 40–43
These studies encompassed mainly Japanese, Korean,
and Chinese populations. Detailed characteristics of all
eligible studies are shown in Table 1.
Quantitative synthesis and heterogeneity analysis
RNF213 rare variants and MMD
Association between RNF213 p.R4810K and MMD
The most robust variant associated with MMD was
RNF213 p.R4810K. Nineteen articles representing 23
studies evaluated their associations, of which 8 were
conducted in Japanese; 7, in Korean; and 8, in Chinese
with a total of 2331 MMD cases and 5476 controls.
The pooled results suggested a significant association
between p.R4810K and MMD in all genetic models
(dominant model: OR 85.91, 95% CI 56.36–130.95,
p < 0.0001) (Table 2). Country-based subgroup analysis
showed that p.R4810K robustly associated with MMD in
Japanese, Korean, and Chinese populations with
3.5 ~ 5.8 times effect sizes difference (dominant model
ORs 184.04, 109.77, and 31.53 in Japan, Korea, and
China, respectively) (Table 2, Fig. 2a).
Further stratified analysis by family history of MMD
(familial index cases or sporadic cases) in each ethnic
population revealed that RNF213 p.R4810K significantly
increased familial MMD risk in Japanese, Korean, and
Chinese population, with 5 ~ 36 times larger effect sizes
than that in sporadic cases (Table 2). For the sporadic
MMD, the effect sizes of RNF213 p.R4810K were in
great discrepancy in different countries. It was 3 ~ 4
times larger in Japanese and Korean than that in Chinese
(dominant model ORs 134.35, 99.82, and 30.52,
respectively) (Table 2, Fig. 2a, b).
Association between RNF213 non-p.R4810K variants
and MMD Except RNF213 p.R4810K, the associations
between the other six rare variants (p.R2092C,
p.D4013N, p.R4062Q, p.A4399T, p.E4950D, and
p.A5021V) and MMD were evaluated in at least two
published studies. The detailed information was
presented in Tables 1 and 2.
There were two rare variants—p.E4950D and
p.A5021V—significantly associated with MMD in
Chinese population in the pooled analysis (pooled ORs 9.06
and 5.01, 95% CIs 1.49–55.27 and 1.57–15.98,
respectively, in a dominant model) (Fig. 3a, b). No
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significant associations were observed between the other
four variants and the susceptibility of MMD in this
meta-analysis (Table 2).
Association between RNF213 p.R4810K and ICASO
The association between p.R4810K and ICASO was
investigated by 11 studies, including 1778 ICASO
patients and 3140 controls. Result showed that
p.R4810K was significantly associated with the risk of
ICASO (dominant model: OR 13.89, 95% CI 8.01–24.09,
p < 0.0001 (Table 2 and Fig. 4a).
Subgroup analysis showed that the strongest
association was observed in Korea (dominant model:
OR 28.52; 95% CI 11.04–73.67, p < 0.0001), followed
by that in Japan (dominant model: OR 10.71, 95% CI
3.97–28.91, p < 0.0001) and China (dominant model:
OR 5.59, 95% CI 2.12–14.75, p = 0.001) (Table 2,
Owning to the association between RNF213 p.R4810K and
MMD that was investigated by 23 studies, we used Begg’s
funnel plot and the Egger regression asymmetry test to assess
the publication bias of these studies. In the dominant model,
the results of Begg’s funnel plot (continuity corrected p value,
0.561) and the Egger regression asymmetry test (t = − 1.27,
p = 0.218) did not find significant asymmetry (Fig. 5a). For
the association between RNF213 p.R4810K and ICASO, no
significant publication bias was observed (Fig. 5b).
Sensitivity analysis was performed by sequentially
excluding individual study for each meta-analysis to assess
the stability of the results. For the association between
RNF213 p.R4810K and MMD or ICASO, corresponding
pooled ORs showed no significant change when
sequentially excluded one study from each meta-analysis, which
indicated that these results are stable and reliable
(Additional file 1: Figure S1).
Systematic review of other RNF213 rare variants and
Except variants mentioned above, various other rare
variants of RNF213 were identified in Japanese, Chinese,
European, and Hispanic American populations (Fig. 6
and Additional file 2: Table S1) [
11–14, 16, 17, 28
variants were not found in control subjects and were
detected in only one patient, suggesting that they had
potential causative effects in MMD development.
MMD is a rare idiopathic intracranial vascular disorder
with strong genetic components. Genetic study of
familial MMD clearly indicated autosomal dominant
inheritance pattern [
]. RNF213 was the first identified
susceptibility gene for MMD recently. We performed
this study to quantitatively evaluate whether or to what
extent the rare variants of RNF213 contribute to MMD
and ICASO in different populations. The main results
showed that RNF213 p.R4810K significantly increased
familial MMD risk in Japanese, Korean, and Chinese
population (dominant model ORs 1802.44, 512.42, and
1109.02), with 5 ~ 36 times larger effect sizes than that
for sporadic cases (dominant model ORs 134.35, 99.82,
and 30.52) (Table 2). The pooled results were similar to
the original report by Liu et al. [
] and illustrated that
genetic screening of RNF213 p.R4810K in Japanese,
Korean, and Chinese population especially in the people
with familial history of MMD would be an effective
approach to identify asymptomatic patients [
]. For the
sporadic cases, significant effect sizes difference was
observed in different countries. The effect sizes of
RNF213 p.R4810K were 3 ~ 4 times greater in Japanese
and Korean population than that in Chinese. This
illustrated that distinct genetic background may exist and
other environmental or genetic factor(s) may contribute
to sporadic MMD. In this study, we found another two
rare variants—p.E4950D and p.A5021V—in RNF213
significantly increased MMD risk in Chinese population
in the pooled analysis (pooled ORs 9.06 and 5.01, 95%
CIs 1.49–55.27 and 1.57–15.98, respectively, in the
dominant model). In addition, more than 40 other rare
missense variants of RNF213 were identified in Chinese
MMD cases but absent in controls (such as p.D4013N,
p.R4062Q, p.D4863N, p.D5160E, and p.E5176G) [
]. Of them, p.D4013N and p.R4062Q have been
independently reported by different studies, highly indicating
the causative effects [
]. Recently, Kobayashi et
al. found that RNF213 p.D4013N-transfected human
umbilical vein endothelial cells displayed significant lowered
migration activity which was similar with the experiment
result of p.R4810K transfection and strongly indicated the
disease-causing effect . However, due to the low allele
frequency and the limited sample size, it was difficult to
get association evidences for them. Furthermore, except
for the rare variants mentioned above, more than half of
Chinese MMD has not been identified the possible
disease-causing variants of RNF213 [
]. MMD appears to
have more complex determiners in China. In addition,
even in Japan and Korea, the majority of carriers with
RNF213 p.R4810K remain unaffected with MMD [
Unknown factors are considered to overlay the
genetic predisposition to develop MMD [
genetic and environmental triggers should be explored
in the future studies.
Except for the variants mentioned above in the Asian
population, various RNF213 rare variants were identified
in MMD cases worldwide [
]. Even RNF213
p.R4810K was not identified in European, Hispanic, or
Black descent MMD patients, other rare variants in
RNF213 were identified in these populations, such as
p.A529del, p.R3922Q, p.N3962Q, p.C3997Y, p.D4013N,
and p.R4019C (Fig. 6) [
12, 14, 20, 28
]. Due to the low
allele frequency and the limited sample size, no
associations were observed between these variants and MMD.
However, there is evidence suggesting that many of these
variants are disease causing. First, the variants are either
not present or present at extremely low frequencies
(MAF < 0.001) in the Exome Variant Server database.
Second, most of these variants located in the C terminus
of RNF213 protein, which is where the RNF213
p.R4810K founder variant located [
]. Even with limited
information about these variants, causative effect was
highly suspected. The genetic heterogeneity may partly
explain why manifestations of MMD vary by geographic
regions and ethnic groups.
In this study, we also found that RNF213 p.R4810K
was significantly associated with ICASO in Japan and
Korea (pooled OR 10.71 and 28.52, 95% CI 3.97–28.91
and 11.04–73.67, respectively) and to a less degree in
Chinese population (pooled OR 5.59; 95% CI 2.12–14.75).
About the association results, there are two possible
explanations: (1) MMD has been misclassified as ICASO
due to the atypical manifestation with the absence of one
or two diagnostic criteria and lead to the spurious
association between RNF213 p.R4810K and ICASO or (2)
RNF213 p.R4810K is indeed associated with ICASO.
Currently, MMD was diagnosis based on the findings of
magnetic resonance angiography or digital subtraction
angiography: (1) steno-occlusive lesions around the
terminal portions of the internal carotid arteries (including
proximal portions of the anterior and middle cerebral
arteries), (2) moyamoya vessels at the base of the brain
appearing as abnormal vascular networks, (3) findings 1
and 2 are present bilaterally [
]. Bang et al. analyzed 352
consecutive ischemic patients within the middle cerebral
artery distribution and found that the occurrence of
RNF213 p.R4810K increased with the number of observed
angiographic criteria. They demonstrated that the current
criteria is limited in distinguishing MMD and ICASO, and
a substantial proportion of patients with adult-onset
MMD may be misclassified as having ICASO [
However, they found that more than one fifth of ICASO
patients confirmed by high-resolution magnetic resonance
imaging and conventional angiography had RNF213
p.R4810K variant in a subsequent research, which
demonstrated that the RNF213 p.R4810K is also a high-risk
variant for ICASO [
]. We prefer to agree that there exist
a new entity of ICASO caused by the RNF213 p.R4810K
variant, which can be differentiated from ICASO caused
by atherosclerosis by using genetic analysis [
However, similar with MMD, geographic and ethic
discrepancies are also highly indicated for ICASO. In China,
RNF213 p.R4810K variant contributed less extent of
ICASO risk compared to that in Korea and Japan (pooled
ORs were 5.59, 28.52, and 10.71 in China, Korea, and
Japan, respectively). Similar with MMD, ethnicity-specific
genetic and environmental factors may contribute to this
discrepancy. Further well-designed genetic epidemiology
studies focusing on ethnicity-specific risk factors such as
choosing the relative genetically homogenous population
and comprehensively collecting the detailed
environmental factors of ICASO are needed.
To date, the mechanisms of how RNF213 p.R4810K
and other rare variants lead to intracranial vascular
lesions are still unknown [
]. An in vitro functional
study revealed that RNF213 p.R4810K affected neither
the transcription level nor the ubiquitin ligase activity of
the protein [
]. Knockdown of RNF213 in zebrafish
leads to abnormal sprouting and irregular diameter of
intracranial vessels, suggesting some role of RNF213 in
the vascular formation [
]. Hitomi et al. observed
reduced angiogenic activity and genomic instability in
endothelial cells derived from induced pluripotent stem
cells of p.R4810K-mutated patients [
ablation of Rnf213 in mice did not induce any apparent
abnormality of the vascular system [
factors are considered to overlay the genetic
predisposition in the RNF213 p.R4810K carrier to develop
vascular lesions [
]. Recently, Kobayashi et al. found that
RNF213 p.R4810K showed a reduced angiogenesis of
transgenic mouse response to hypoxia in vivo [
Scholz et al. found that Rnf213 was a co-regulated gene
for the WNT signaling enhancer R-spondin3 (RSPO3)
and identified that endothelial RSPO3-driven non-canonical
WNT/Ca(2+)/NFAT signaling as a critical maintenance
pathway of the remodeling vasculature [
]. Banh et al.
found that protein-tyrosine phosphatase-1B (PTP1B)
controlled non-mitochondrial oxygen consumption by
regulating RNF213 to promote tumor survival during hypoxia
and concluded that PTP1B/RNF213/α-KGDD pathway was
critical for survival of tumors in the hypoxic
] The investigation of WNT signaling and PTP1B/
RNF213/α-KGDD pathway in cells expressing RNF213
R4810K and other rare variants under different
environmental condition such as hypoxia and chronic inflammation is
expected to provide answers to the pending questions.
The limitations of this study should be considered. First,
due to the fact that we analyzed the association between rare
variants and diseases, the number of cases and controls
involved in the meta-analysis for moderate effect rare variants
may be less powered, studies with larger sample size and high
quality are needed to explore the associations in the future;
second, MMD and ICASO appears to have complex
determiners, with both genetic predisposition and environmental
triggers. Unknown modifier factor(s) may also be
contributory to MMD and ICASO. Multivariate analysis to adjust for
the confounding factors such as behavior or clinical or
biochemical factors in our meta-analysis was not available.
Further comprehensive studies focusing on multiple
ethnicity-specific factors are needed; third, ICASO may
represent a broad spectrum of diseases and there are various
phenotypes (i.e., bilateral M1 occlusion or unilateral M2
stenosis and so on), which may belong to different clinical
entities. Due to no more clinical information available in the
original papers, subgroup analysis could not be performed
according to these factors, which may lead to bias. Further
studies with detailed clinical features are needed; fourth, this
analysis was constrained to studies which were published and
deposited in English and Chinese databases, the other
databases were not available, and selection bias could not be
excluded (Additional file 3).
This comprehensive systematic review and meta-analysis
reveals that the critical roles of RNF213 p.R4810K in
MMD especially familial MMD and ICASO in Japan,
Korea, and China. It significantly increases MMD and
ICASO risk in Japanese and Korean population and to a
less degree in Chinese population. Except for RNF213
p.R4810K, another two rare variants—p.E4950D and
p.A5021V—increased MMD risk in Chinese population.
MMD seems to have more complex determiners in
China. Distinct genetic background exists, and other
environmental or genetic factor(s) may contribute to
MMD. Studies focused on delineating the
ethnicityspecific factors and pathological role of RNF213 variants
in MMD and ICASO are needed.
Additional file 1: Figure S1. Sensitivity analysis of the association of
RNF213 p.R4810K with MMD and ICASO under a dominant model (TIFF
Additional file 2: Table S1. Other rare variants of RNF213 identified in
different populations (XLSX 14 kb)
Additional file 3: Literature list (XLSX 67 kb)
ICASO: Non-moyamoya intracranial major artery stenosis/occlusion;
MMD: Moyamoya disease; RNF213: The ring finger protein 213
This work was supported by grants from the National Nature Science
Foundation of China, Nature Science Foundation of Hunan province and
China postdoctoral science foundation to J.Y (No. 81502881, 2017JJ3428, and
2015M582351). Dr. Yan is a postdoctoral fellow at Central South University
(No. 149946), supported by the Postdoctoral International Exchange Plan in
China. The funders had no role in the study design, data collection and
analysis, decision to publish, or preparation of the manuscript.
Availability of data and materials
The datasets analyzed during the current study are available from the
corresponding author on reasonable request.
XL, JD, and WD participated in the literature search, data extraction, and data
analysis. TZ and JY took charge of the study design and coordination. JY and
XL drafted the manuscript. All authors read and approved the final
Ethics approval and consent to participate
Consent for publication
The authors declare that they have no competing interests.
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
1. Research Committee on the Pathology and Treatment of Spontaneous Occlusion of the Circle of Willis; Health Labour Sciences Research Grant for Research on Measures for Infractable Diseases. Guidelines for diagnosis and treatment of moyamoya disease (spontaneous occlusion of the circle of Willis) . Neurol Med Chir (Tokyo). 2012 ; 52 : 245 - 66 .
2. Scott RM , Smith ER . Moyamoya disease and moyamoya syndrome . N Engl J Med . 2009 ; 360 : 1226 - 37 . doi: 10 .1056/NEJMra0804622.
3. Hayashi K , Horie N , Izumo T , Nagata I. A nationwide survey on unilateral moyamoya disease in Japan . Clin Neurol Neurosurg . 2014 ; 124 : 1 - 5 . doi: 10 . 1016/j.clineuro. 2014 . 06 .010.
4. Ahn IM , Park DH , Hann HJ , Kim KH , Kim HJ , Ahn HS . Incidence, prevalence, and survival of moyamoya disease in Korea: a nationwide, population-based study . Stroke . 2014 ; 45 : 1090 - 5 . doi: 10 .1161/strokeaha.113.004273.
5. Starke RM , Crowley RW , Maltenfort M , Jabbour PM , Gonzalez LF , Tjoumakaris SI , et al. Moyamoya disorder in the United States . Neurosurgery . 2012 ; 71 : 93 - 9 . doi: 10 .1227/NEU.0b013e318253ab8e.
6. Miao W , Zhao PL , Zhang YS , Liu HY , Chang Y , Ma J , et al. Epidemiological and clinical features of moyamoya disease in Nanjing , China. Clin Neurol Neurosurg . 2010 ; 112 : 199 - 203 . doi: 10 .1016/j.clineuro. 2009 . 11 .009.
7. Kim JS . Moyamoya disease: epidemiology, clinical features, and diagnosis . J Stroke . 2016 ; 18 : 2 - 11 . doi: 10 .5853/jos. 2015 . 01627 .
8. Miyamoto S , Yoshimoto T , Hashimoto N , Okada Y , Tsuji I , Tominaga T , et al. Effects of extracranial-intracranial bypass for patients with hemorrhagic moyamoya disease: results of the Japan Adult Moyamoya Trial . Stroke . 2014 ; 45 : 1415 - 21 . doi: 10 .1161/strokeaha.113.004386.
9. Yamauchi T , Tada M , Houkin K , Tanaka T , Nakamura Y , Kuroda S , et al. Linkage of familial moyamoya disease (spontaneous occlusion of the circle of Willis) to chromosome 17q25 . Stroke . 2000 ; 31 : 930 - 5 .
10. Kuroda S , Houkin K. Moyamoya disease: current concepts and future perspectives . Lancet Neurol . 2008 ; 7 : 1056 - 66 . doi: 10 .1016/s1474- 4422 ( 08 ) 70240 - 0 .
11. Kamada F , Aoki Y , Narisawa A , Abe Y , Komatsuzaki S , Kikuchi A , et al. A genome-wide association study identifies RNF213 as the first moyamoya disease gene . J Hum Genet . 2011 ; 56 : 34 - 40 . doi: 10 .1038/jhg. 2010 . 132 .
12. Liu W , Morito D , Takashima S , Mineharu Y , Kobayashi H , Hitomi T , et al. Identification of RNF213 as a susceptibility gene for moyamoya disease and its possible role in vascular development . PLoS One . 2011 ; 6:e22542 . doi: 10 . 1371/journal.pone. 0022542 .
13. Wu Z , Jiang H , Zhang L , Xu X , Zhang X , Kang Z , et al. Molecular analysis of RNF213 gene for moyamoya disease in the Chinese Han population . PLoS One . 2012 ; 7:e48179 . doi: 10 .1371/journal.pone. 0048179 .
14. Cecchi AC , Guo D , Ren Z , Flynn K , Santos-Cortez RL , Leal SM , et al. RNF213 rare variants in an ethnically diverse population with moyamoya disease . Stroke . 2014 ; 45 : 3200 - 7 . doi: 10 .1161/strokeaha.114.006244.
15. Lee MJ , Chen YF , Fan PC , Wang KC , Wang K , Wang J , et al. Mutation genotypes of RNF213 gene from moyamoya patients in Taiwan . J Neurol Sci . 2015 ; 353 : 161 - 5 . doi: 10 .1016/j.jns. 2015 . 04 .019.
16. Moteki Y , Onda H , Kasuya H , Yoneyama T , Okada Y , Hirota K , et al. Systematic validation of RNF213 coding variants in Japanese patients with moyamoya disease . J Am Heart Assoc . 2015 ;4 doi:10.1161/jaha.115. 001862 .
17. Shoemaker LD , Clark MJ , Patwardhan A , Chandratillake G , Garcia S , Chen R , et al. Disease variant landscape of a large multiethnic population of moyamoya patients by exome sequencing . G3 (Bethesda) . 2016 ; 6 : 41 - 9 . doi: 10 .1534/g3. 115 .020321.
18. Huang Y , Cheng D , Zhang J , Zhao W . Association between the rs112735431 polymorphism of the RNF213 gene and moyamoya disease: a case-control study and meta-analysis . J Clin Neurosci . 2016 ; 32 : 14 - 8 . doi: 10 .1016/j.jocn. 2015 . 11 .035.
19. Zhang Q , Liu Y , Zhang D , Wang R , Zhang Y , Wang S , et al. RNF213 as the major susceptibility gene for Chinese patients with moyamoya disease and its clinical relevance . J Neurosurg . 2016 : 1 - 8 . doi: 10 .3171/ 2016 .2.jns152173.
20. Liu W , Senevirathna ST , Hitomi T , Kobayashi H , Roder C , Herzig R , et al. Genomewide association study identifies no major founder variant in Caucasian moyamoya disease . J Genet . 2013 ; 92 : 605 - 9 .
21. Miyawaki S , Imai H , Takayanagi S , Mukasa A , Nakatomi H , Saito N . Identification of a genetic variant common to moyamoya disease and intracranial major artery stenosis/occlusion . Stroke. 2012 ; 43 : 3371 - 4 . doi: 10 . 1161/strokeaha.112.663864.
22. Miyawaki S , Imai H , Shimizu M , Yagi S , Ono H , Mukasa A , et al. Genetic variant RNF213 c.14576G>A in various phenotypes of intracranial major artery stenosis/occlusion . Stroke. 2013 ; 44 : 2894 - 7 . doi: 10 .1161/strokeaha.113. 002477.
23. Bang OY , Ryoo S , Kim SJ , Yoon CH , Cha J , Yeon JY , et al. Adult moyamoya disease: a burden of intracranial stenosis in East Asians? PLoS One . 2015 ; 10 : e0130663. doi: 10 .1371/journal.pone. 0130663 .
24. Bang OY , Chung JW , Cha J , Lee MJ , Yeon JY , Ki CS , et al. A polymorphism in RNF213 is a susceptibility gene for intracranial atherosclerosis . PLoS One . 2016 ; 11 :e0156607. doi: 10 .1371/journal.pone. 0156607 .
25. Kim YJ , Lee JK , Ahn SH , Kim BJ , Kang DW , Kim JS , et al. Nonatheroscleotic isolated middle cerebral artery disease may be early manifestation of moyamoya disease . Stroke . 2016 ; 47 : 2229 - 35 . doi: 10 . 1161/strokeaha.116.012751.
26. Liu W , Hitomi T , Kobayashi H , Harada KH , Koizumi A . Distribution of moyamoya disease susceptibility polymorphism p.R4810K in RNF213 in East and Southeast Asian populations . Neurol Med Chir (Tokyo). 2012 ; 52 : 299 - 303 .
27. Wang X , Zhang Z , Liu W , Xiong Y , Sun W , Huang X , et al. Impacts and interactions of PDGFRB, MMP-3, TIMP-2, and RNF213 polymorphisms on the risk of moyamoya disease in Han Chinese human subjects . Gene . 2013 ; 526 : 437 - 42 . doi: 10 .1016/j.gene. 2013 . 05 .083.
28. Kobayashi H , Brozman M , Kyselova K , Viszlayova D , Morimoto T , Roubec M , et al. RNF213 rare variants in Slovakian and Czech moyamoya disease patients . PLoS One . 2016 ; 11 :e0164759. doi: 10 .1371/journal.pone. 0164759 .
29. Koizumi A , Kobayashi H , Hitomi T , Harada KH , Habu T , Youssefian S. A new horizon of moyamoya disease and associated health risks explored through RNF213 . Environ Health Prev Med . 2016 ; 21 : 55 - 70 . doi: 10 .1007/s12199-015-0498-7.
30. MacArthur DG , Manolio TA , Dimmock DP , Rehm HL , Shendure J , Abecasis GR , et al. Guidelines for investigating causality of sequence variants in human disease . Nature . 2014 ; 508 : 469 - 76 . doi: 10 .1038/nature13127.
31. Sun XS , Wen J , Li JX , Lai R , Wang YF , Liu HJ , et al. The association between the ring finger protein 213 (RNF213) polymorphisms and moyamoya disease susceptibility: a meta-analysis based on case-control studies . Mol Gen Genomics . 2016 ; 291 : 1193 - 203 . doi: 10 .1007/s00438-016-1172-5.
32. Minelli C , Thompson JR , Abrams KR , Thakkinstian A , Attia J. The quality of meta-analyses of genetic association studies: a review with recommendations . Am J Epidemiol . 2009 ; 170 : 1333 - 43 . doi: 10 .1093/aje/ kwp350.
33. Little J , Higgins JP , Ioannidis JP , Moher D , Gagnon F , von Elm E , et al. Strengthening the reporting of genetic association studies (STREGA): an extension of the STROBE Statement . Hum Genet . 2009 ; 125 : 131 - 51 . doi: 10 . 1007/s00439-008-0592-7.
34. Stang A . Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses . Eur J Epidemiol . 2010 ; 25 : 603 - 5 . doi: 10 .1007/s10654-010-9491-z.
35. Miyatake S , Miyake N , Touho H , Nishimura-Tadaki A , Kondo Y , Okada I , et al. Homozygous c.14576G>A variant of RNF213 predicts early-onset and severe form of moyamoya disease . Neurology . 2012 ; 78 : 803 - 10 . doi: 10 .1212/WNL. 0b013e318249f71f.
36. Huang Y , Cheng D , Zhang J , Zhao W , Luo M. Association between RNF213 gene polymorphisms and the genetic susceptibility of adult moyamoya disease of Zhuang population in Guangxi . J Apoplexy Nerv Dis . 2015 ; 32 : 918 - 21 .
37. Kim EH , Yum MS , Ra YS , Park JB , Ahn JS , Kim GH , et al. Importance of RNF213 polymorphism on clinical features and long-term outcome in moyamoya disease . J Neurosurg . 2016 ; 124 : 1221 - 7 . doi: 10 .3171/ 2015 .4. jns142900.
38. Park MG , Shin JH , Lee SW , Park HR , Park KP . RNF213 rs112735431 polymorphism in intracranial artery steno-occlusive disease and moyamoya disease in Koreans . J Neurol Sci . 2017 ; 375 : 331 - 4 . doi: 10 . 1016/j.jns. 2017 . 02 .033.
39. Jang MA , Chung JW , Yeon JY , Kim JS , Hong SC , Bang OY , et al. Frequency and significance of rare RNF213 variants in patients with adult moyamoya disease . PLoS One . 2017 ; 12 :e0179689. doi: 10 .1371/ journal.pone. 0179689 .
40. Shinya Y , Miyawaki S , Imai H , Hongo H , Ono H , Takenobu A , et al. Genetic analysis of ring finger protein 213 (RNF213) c.14576G>A in intracranial atherosclerosis of the anterior and posterior circulations . J Stroke Cerebrovasc Dis . 2017 ; doi:10.1016/j.jstrokecerebrovasdis. 2017 . 06 .043.
41. Shang D , Shi C , Mao C , Qin J , Gao Y , Zhao L , et al. Association between ring finger protein 213 gene polymorphism and ischemic stroke in a Chinese Han population . J Apoplexy Nerv Dis . 2015 ; 32 : 594 - 7 .
42. Zhang T , Guo C , Liao X , Xia J , Wang X , Deng J , et al. Genetic analysis of RNF213 p.R4810K variant in non-moyamoya intracranial artery stenosis/ occlusion disease in a Chinese population . Environ Health And Prev Med . 2017 ; 22 doi:10.1186/s12199-017-0649-0.
43. Xue S , Cheng W , Wang W , Song H , Feng WW , Ovbiagele B . Genetic variant RNF213 in non-MMD intracranial major artery stenosis/occlusion in Chinese Han population and HR-MRI findings . Stroke . 2017 ; 48 ( Suppl 1 ): AWP151 .
44. Mineharu Y , Takenaka K , Yamakawa H , Inoue K , Ikeda H , Kikuta KI , et al. Inheritance pattern of familial moyamoya disease: autosomal dominant mode and genomic imprinting . J Neurol Neurosurg Psychiatry . 2006 ; 77 : 1025 - 9 . doi: 10 .1136/jnnp. 2006 . 096040 .
45. Sonobe S , Fujimura M , Niizuma K , Nishijima Y , Ito A , Shimizu H , et al. Temporal profile of the vascular anatomy evaluated by 9.4-T magnetic resonance angiography and histopathological analysis in mice lacking RNF213: a susceptibility gene for moyamoya disease . Brain Res . 2014 ; 1552 : 64 - 71 . doi: 10 .1016/j.brainres. 2014 . 01 .011.
46. Hitomi T , Habu T , Kobayashi H , Okuda H , Harada KH , Osafune K , et al. Downregulation of Securin by the variant RNF213 R4810K (rs112735431, G>A) reduces angiogenic activity of induced pluripotent stem cell-derived vascular endothelial cells from moyamoya patients . Biochem Biophys Res Commun . 2013 ; 438 : 13 - 9 . doi: 10 .1016/j.bbrc. 2013 . 07 .004.
47. Hitomi T , Habu T , Kobayashi H , Okuda H , Harada KH , Osafune K , et al. The moyamoya disease susceptibility variant RNF213 R4810K (rs112735431) induces genomic instability by mitotic abnormality . Biochem Biophys Res Commun . 2013 ; 439 : 419 - 26 . doi: 10 .1016/j.bbrc. 2013 . 08 .067.
48. Kobayashi H , Yamazaki S , Takashima S , Liu W , Okuda H , Yan J , et al. Ablation of Rnf213 retards progression of diabetes in the Akita mouse . Biochem Biophys Res Commun . 2013 ; 432 : 519 - 25 . doi: 10 .1016/j.bbrc. 2013 . 02 .015.
49. Kobayashi H , Matsuda Y , Hitomi T , Okuda H , Shioi H , Matsuda T , et al. Biochemical and functional characterization of RNF213 (Mysterin) R4810K, a susceptibility mutation of moyamoya disease, in angiogenesis in vitro and in vivo . J Am Heart Assoc . 2015 ;4 doi:10.1161/jaha.115.002146.
50. Scholz B , Korn C , Wojtarowicz J , Mogler C , Augustin I , Boutros M , et al. Endothelial RSPO3 controls vascular stability and pruning through non-canonical WNT/Ca(2+)/NFAT signaling . Dev Cell . 2016 ; 36 : 79 - 93 . doi: 10 .1016/j.devcel. 2015 . 12 .015.
51. Banh RS , Iorio C , Marcotte R , Xu Y , Cojocari D , Rahman AA , et al. PTP1B controls non-mitochondrial oxygen consumption by regulating RNF213 to promote tumour survival during hypoxia . Nat Cell Biol . 2016 ; 18 : 803 - 13 . doi: 10 .1038/ncb3376.