Two-Stage Whole-Exome Sequencing Improves to Predict a Risk of Adult Moyamoya Disease in 369,570 Individuals

Whole-exome sequencings (WES) have an informative in the limelight to identify causative mutations for adult moyamoya disease (MMD), understanding genomic structures of etiology. Here, we conducted inaugural two-stage WES aimed at uncovering coding modifiers implicated in MMD. Our study comprised an initial discovery phase with 105 MMDs and 115 controls, followed by validation phases involving 55 MMDs and 74 controls, alongside 100 disease-free subjects. We extended comparisons of the allele frequencies of 369,121 individuals derived from UK Biobank (UKB) WES data. Mutant allele risk scores (MARS) were created on the basis of WES-driven mutations. Gene-based association and East-Asian pooled analyses were further performed. During the discovery phase, p.G576S (rs1800307- GAA ) and p.R4810K (rs112735431- RNF213 ) reached at a genome-wide significance threshold ( P = 2.63×10 ^-8 and 2.24×10 ^-16 , respectively), with p.R4810K being confirmed in the validation phase ( P = 3.08×10 ^-8 ). One insertion (p.S2026ins:rs112774151- MUC4 ) demonstrated the most significance in 160 MMDs and 100 disease-free controls ( P = 5.65×10 ^-16 ). Fourteen mutations exhibited significant differences in allele frequencies between patients and UKB controlled data ( P < 1×10 ^-8 ). MARS9 incorporating nine missense mutations resulted in an enhanced predictability for MMD (AUROC = 0.8323). Gene-based associations replicated across all phases for GAA , RNF213 , CHMP6 , and CARD14 ( P < 5×10 ^-7 ). For mutations in RNF213 , p.V1195M, p.D1331G, p.S2334N, and p.R4810K were validated in East-Asian populations ( P < 3×10 ^-8 ). Our pioneering study corroborate the significance of p.R4810K and uncover several novel mutations predisposing patients, thereby understanding polygenetic aspect to the etiology of MMD.