Bi-allelic alterations in AEBP1 lead to defective collagen assembly and connective tissue structure resulting in a variant of Ehlers-Danlos syndrome
Open accessAbstract
AEBP1 encodes the aortic carboxypeptidase-like protein (ACLP) that associates with collagens in the extracellular matrix (ECM) and has several roles in development, tissue repair, and fibrosis. ACLP is expressed in bone, the vasculature, and dermal tissues and is involved in fibroblast proliferation and mesenchymal stem cell differentiation into collagen-producing cells. Aebp1-/- mice have abnormal, delayed wound repair correlating with defects in fibroblast proliferation. In this study, we describe four individuals from three unrelated families that presented with a unique constellation of clinical findings including joint laxity, redundant and hyperextensible skin, poor wound healing with abnormal scarring, osteoporosis, and other features reminiscent of Ehlers-Danlos syndrome (EDS). Analysis of skin biopsies revealed decreased dermal collagen with abnormal collagen fibrils that were ragged in appearance. Exome sequencing revealed compound heterozygous variants in AEBP1 (c.1470delC [p.Asn490_Met495delins(40)] and c.1743C>A [p.Cys581∗]) in the first individual, a homozygous variant (c.1320_1326del [p.Arg440Serfs∗3]) in the second individual, and a homozygous splice site variant (c.1630+1G>A) in two siblings from the third family. We show that ACLP enhances collagen polymerization and binds to several fibrillar collagens via its discoidin domain. These studies support the conclusion that bi-allelic pathogenic variants in AEBP1 are the cause of this autosomal-recessive EDS subtype.
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“DNA was extracted from blood withdraw of the proband and sequenced with a library containing the coding regions of the 20 genes causing the different variants of EDS (ADAMTS2, AEBP1, B3GALT6, B4GALT7, CHST14, COL1A1, COL1A2, COL3A1, COL5A1, COL5A2, COL12A1, C1R, C1S, DSE, FKBP14, PLOD1, PRDM5, SLC39A13, TNXB, ZNF489)…”
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“The Ehlers–Danlos syndromes (EDS) are a group of 14 heritable connective tissue disorders (CTDs) characterized by varying phenotypic presentation, often sharing common-alities of joint hypermobility, skin hyperextensibility, and ligament and tissue fragility [1,2].”
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“Accordingly, all EDS subclasses exhibit some level of changes in collagen microarchitecture (Royce et al., 1990; Hausser and Anton-Lamprecht, 1994; Burch et al., 1997; Colige et al., 2004;Malfait et al., 2007; Fukada et al., 2008; Rohrbach et al., 2011; Hermanns-Lê et al., 2012; Kapferer-Seebacher et al., 2016; Blackb…”
BackgroundInfluentialA biallelic truncating <i>AEBP1</i> variant causes connective tissue disorder in two siblings
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“The observed phenotypic variability is likely not attributable to the variant localization, as most disease associated variants reported to date are likely gene disrupting and subject to mRNA decay (Blackburn et al., 2018).”
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Self-citationA Cellular Atlas of the Developing Meninges Reveals Meningeal Fibroblast Diversity and FunctionPreprint
DeSisto, J. A., O’Rourke, R., Bonney, S. K., Jones, H. E., Guimiot, F., Jones, K. L., & Siegenthaler, J. A. (2019) · SSRN Electronic Journal · doi:10.1101/648642 · Cited by 14 · see citing works
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Pearce, G., Bell, L., Pezaro, S., & Reinhold, E. J. (2023) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph20206957 · Cited by 17 · see citing works
“The Ehlers–Danlos syndromes (EDS) are a heterogenous group of genetic disorders affecting the structure, processing and functioning of collagen [1,2] with features that may have an impact on childbearing [3].”
BackgroundPathogenic mechanisms in genetically defined Ehlers–Danlos syndromes
Syx, D., & Malfait, F. (2024) · Trends in Molecular Medicine · doi:10.1016/j.molmed.2024.06.001 · Cited by 14 · see citing works
Zhang, W., Li, Y. J., Zhang, N., Chen, S. Y., Tong, X. F., Wang, B. Q., Huang, T., You, H., & Chen, W. (2023) · Journal of Digestive Diseases · doi:10.1111/1751-2980.13230 · Cited by 12 · see citing works
“14 Collectively, it is likely conclusive that AEBP1 is involved in fibroblast cell development, tissue repair, and organ fibrosis.”
BackgroundLiu, N., Liu, D., Cao, S., & Lei, J. (2023) · Human Cell · doi:10.1007/s13577-023-00859-w · Cited by 16 · see citing works
“Furthermore, AEBP1 as a collagen-binding ECM protein that promotes collagen expression and polymerization [10, 11].”
BackgroundEhlers-Danlos Syndromes, Joint Hypermobility and Hypermobility Spectrum Disorders
Micale, L., Fusco, C., & Castori, M. (2021) · Advances in experimental medicine and biology · doi:10.1007/978-3-030-80614-9_9 · Cited by 16 · see citing works
Angwin, C., Ghali, N., & van Dijk, F. S. (2023) · Frontiers in Genetics · doi:10.3389/fgene.2023.1148224 · Cited by 12 · see citing works
“There are currently nine reported cases of clEDS as a result of variants in AEBP1 (Alazami et al., 2016; Blackburn et al., 2018; Hebebrand et al., 2019; Ritelli et al., 2019; Syx et al., 2019).”
BackgroundInfluentialYamaguchi, T., Hayashi, S., Nagai, S., et al. (2023) · Frontiers in Genetics · doi:10.3389/fgene.2023.1102101 · Cited by 12 · see citing works
“In Patient 3, a 1-bp deletion (c.1470del) in exon 12 in one allele led to the retention of intron 12 (p.Asn490_ Met495delinsLysAlaMetArgLysTrpTrpAlaProCysProGlySerTrp LeuCysSerHisCysLeuGlyGluGlyTrpAlaLeuArgGlyAlaGlySer ThrAlaLeuArgProAlaSerProGln) (Blackburn et al., 2018).”
BackgroundThe Ehlers–Danlos Syndromes against the Backdrop of Inborn Errors of Metabolism
Damme, T. V., Colman, M., Syx, D., & Malfait, F. (2022) · Genes · doi:10.3390/genes13020265 · Cited by 13 · see citing works
“AEBP1 codes for adipocyte enhancer-binding protein 1 (AEBP1; also known as aortic carboxypeptidase-like protein, ACLP) [64].”
BackgroundPezaro, S., Brock, I., Buckley, M., Callaway, S., Demirdas, S., Hakim, A. J., Harris, C. L., Gross, C. H., Karanfil, M., Ray, I. L., et al. (2024) · PLoS ONE · doi:10.1371/journal.pone.0302401 · Cited by 12 · see citing works
Doolan, B. J., Lavallee, M. E., Haußer, I., Pope, F. M., Seneviratne, S. L., Winship, I., & Burrows, N. (2023) · Journal of the American Academy of Dermatology · doi:10.1016/j.jaad.2023.01.034 · Cited by 12 · see citing works
Ehlers-Danlos syndromes: importance of defining the type
van Dijk, F. S., Ghali, N., & Chandratheva, A. (2023) · Practical Neurology · doi:10.1136/pn-2023-003703 · Cited by 11 · see citing works
“8 The genetic cause of the fourteenth type of EDS was reported later 9 10 (see table 1).”
BackgroundStock, F., Hanisch, M. R., Lechner, S., Biskup, S., Bohring, A., Zschocke, J., & Kapferer‐Seebacher, I. (2021) · Biomolecules · doi:10.3390/biom11020149 · Cited by 11 · see citing works
Black, W. R., Black, L. L., & Jones, J. T. (2023) · Global Pediatric Health · doi:10.1177/2333794x231212081 · Cited by 10 · see citing works
Arterial complications in classical Ehlers-Danlos syndrome: a case series
Angwin, C., Brady, A. F., Pope, F. M., Vandersteen, A., Baker, D., Cheema, H., Sobey, G. J., Johnson, D. S., von Klemperer, K., Kazkaz, H., et al. (2020) · Journal of Medical Genetics · doi:10.1136/jmedgenet-2019-106689 · Cited by 10 · see citing works
Joint hypermobility in children: a neglected sign needing more attention
Castori, M. (2020) · Minerva Pediatrics · doi:10.23736/s0026-4946.20.05766-7 · Cited by 10 · see citing works
Hertel, A., Black, W. R., Malloy-Walton, L. E., Martin, J. R., & Jones, J. T. (2024) · Current Cardiology Reviews · doi:10.2174/011573403x271096231203164216 · Cited by 11 · see citing works
Independent COL5A1 Variants in Cats with Ehlers-Danlos Syndrome
Kiener, S., Apostolopoulos, N., Schissler, J. R., et al. (2022) · Genes · doi:10.3390/genes13050797 · Cited by 10 · see citing works
Giosaffatte, N. D., Ferraris, A., Gaudioso, F., Lodato, V., Savino, E., Celletti, C., Camerota, F., Bargiacchi, S., Laino, L., Majore, S., et al. (2022) · Genes · doi:10.3390/genes13122358 · Cited by 9 · see citing works
“At a functional level, ACLP has been demonstrated to bind collagen type I, type III, and type V [4] and to enhance the stiffness, toughness, and tensile strength of COL1 fibers in vitro [9].”
BackgroundResultInfluentialTWIST1 drives endothelial-to-mesenchymal-transition to stabilize atherosclerotic plaques
Ayllón, B. T., Diagbouga, M. R., Das, A., Tian, S., Edsfeldt, A., Kalucka, J. M., Serbanovic‐Canic, J., Chambers, E. V., Sun, J., Gialeli, C., et al. (2026) · Nature Communications · doi:10.1038/s41467-026-69808-z · Cited by 10 · see citing works
“AEBP1 acts as a central regulator of collagen, with mutations in the AEBP1 gene linked to defective collagen assembly in Ehlers-Danlos syndrome 22 .”
Baeza-Velasco, C., Vergne, J., Poli, M., Kalisch, L., & Calati, R. (2025) · Autism · doi:10.1177/13623613251328059 · Cited by 10 · see citing works
“There are 14 subtypes of EDS currently described (Blackburn et al., 2018; Malfait et al., 2017).”
Longitudinal analysis of symptoms in the Ehlers‐Danlos syndromes
Schubart, J. R., Mills, S. E., Schaefer, É., Bascom, R., & Francomano, C. A. (2022) · American Journal of Medical Genetics Part A · doi:10.1002/ajmg.a.62640 · Cited by 9 · see citing works
“The Ehlers-Danlos syndromes (EDS) are a group of 14 heritable disorders of connective tissue (HDCT) characterized by joint laxity and skin involvement (Blackburn et al., 2018; Malfait et al., 2017; Rodgers et al., 2017).”
BackgroundSelf-citationKing, M. W., Jacob, S. M., Sharma, A., Lawrence, J. H., & Musiek, E. S. (2025) · Alzheimer s & Dementia · doi:10.1002/alz.70885 · Cited by 13 · see citing works
“48,49”
AEBP1 or ACLP, which is the key factor in inflammation and fibrosis?
Runtian, Z., Wenqiang, H., Zimeng, S., Tianyu, W., & Jingquan, Z. (2025) · International Journal of Biological Macromolecules · doi:10.1016/j.ijbiomac.2025.143554 · Cited by 9 · see citing works
Dube, C. T., Gilbert, H. T. J., Rabbitte, N., et al. (2025) · Arthritis Research & Therapy · doi:10.1186/s13075-025-03489-9 · Cited by 9 · see citing works
Fetal akinesia: The application of clinical exome sequencing in cases with decreased fetal movement
Cao, Q., Yang, Y., Pan, M., et al. (2021) · European Journal of Obstetrics & Gynecology and Reproductive Biology · doi:10.1016/j.ejogrb.2021.03.019 · Cited by 9 · see citing works
Spontaneous uterine rupture revealing vascular Ehlers-Danlos syndrome
Slaoui, A., Mahtate, M., Lazhar, H., Lakhdar, A., Baydada, A., & Kharbach, A. (2022) · International Journal of Surgery Case Reports · doi:10.1016/j.ijscr.2022.106840 · Cited by 8 · see citing works
Francisquini, R., Berton, R., Soares, S. G., Gonçalves, D. S. P. O., Camacho, M. F., Andrade-Silva, D., Barcick, U., Serrano, S. M. T., Chammas, R. J., Nascimento, M. C. V., et al. (2020) · Journal of Proteomics · doi:10.1016/j.jprot.2020.104063 · Cited by 8 · see citing works
Cao, L., Gao, W., Yang, H., Zeng, R., & Yin, Z. (2024) · Journal of Cell Communication and Signaling · doi:10.1002/ccs3.12022 · Cited by 8 · see citing works
“17 All these previous studies indicated that AEBP1 was closely related to cellular inflammation and the formation of the extracellular matrix.”
BackgroundFoy, M., de Mazancourt, P., Métay, C., Carlier, R., Allamand, V., Gartioux, C., Gillas, F., Miri, N., Jobic, V., Mekki, A., et al. (2021) · Clinical Case Reports · doi:10.1002/ccr3.4128 · Cited by 8 · see citing works
Okazaki, F., Yorozu, A., Sekiguchi, S., et al. (2024) · Scientific Reports · doi:10.1038/s41598-024-79061-3 · Cited by 7 · see citing works
“Bi-allelic Bi-allelic loss-of-function mutations in AEBP1 cause defective collagen assembly, leading to connective tissue abnormalities characteristic of EDS 18,20 .”
Ye, H., Sun, M., Su, M., Chen, D., Liu, H., Ma, Y., Luo, W., Li, H., & Xu, F. (2023) · Frontiers in Genetics · doi:10.3389/fgene.2023.1070605 · Cited by 8 · see citing works
“In our analysis, M25 indeed is associated with fibrosis, and Aebp1 is highly correlated with ECM genes Col1a1, Col1a2, Col3a1, Col4a1, Col4a2, Col5a1, Col6a3, And Col14a1 (Figure 8A).”
BackgroundBendre, A., Ottosson, L., Baroncelli, M., et al. (2025) · Bone · doi:10.1016/j.bone.2025.117594 · Cited by 7 · see citing works
Gastrointestinal medication burden among persons with the Ehlers‐Danlos syndromes
Dhingra, R., Bascom, R., Thompson, E., Francomano, C. A., & Schubart, J. R. (2021) · Neurogastroenterology & Motility · doi:10.1111/nmo.14077 · Cited by 7 · see citing works
Self-citationHa, Z. Y., Chijiwa, C., & Lewis, M. E. S. (2024) · Genes · doi:10.3390/genes15040461 · Cited by 6 · see citing works
“In Patient 3, a 1-bp deletion, c.1470del, in exon 12 led to the retention of intron 12 [6], which resulted in the peptide product being retained intracellularly and not secreted [7].”
InfluentialGonosomal Mosaicism for a Novel COL5A1 Pathogenic Variant in Classic Ehlers-Danlos Syndrome
Micale, L., Foiadelli, T., Russo, F., Cinque, L., Bassanese, F., Granatiero, M., Fusco, C., Savasta, S., & Castori, M. (2021) · Genes · doi:10.3390/genes12121928 · Cited by 6 · see citing works
“Recent studies have described another genetically distinct classic-like EDS type caused by biallelic deleterious variants in the AEPB1 gene [2], while additional cases have allowed to reclassify the so-called osteogenesis imperfecta/EDS overlap in COL1-related overlap disorder [1].”
BackgroundKim, H., Kim, M. J., Moon, S. A., Cho, H. J., Lee, Y., Park, S. J., Kim, Y., Baek, I., Kim, B., Lee, S. H., et al. (2023) · The FASEB Journal · doi:10.1096/fj.202300140r · Cited by 6 · see citing works
Ventral body wall closure: Mechanistic insights from mouse models and translation to human pathology
Formstone, C. J., Aldeiri, B., Davenport, M., & Francis‐West, P. H. (2024) · Developmental Dynamics · doi:10.1002/dvdy.735 · Cited by 7 · see citing works
“318,319”
Sanai, H., Nakamura, Y., Koike, Y., et al. (2023) · Journal of obstetrics and gynaecology research · doi:10.1111/jog.15541 · Cited by 6 · see citing works
“The AEBP1 gene is ubiquitously expressed and encodes the secreted aortic carboxypeptidase-like protein (ACLP) that can bind fibrillar collagens and assist in collagen polymerization.(7) The ACLP stimulates myofibroblast differentiation and is mainly expressed in collagen-rich tissues, including the dermis, vasculature…”
BackgroundUnraveling the matrisome signatures of quiescent and activated muscle stem cells
Guillon, E., Bacar, H., Gilquin, L., Sasaki, T., Mourikis, P., & Ruggiero, F. (2025) · Stem Cell Reports · doi:10.1016/j.stemcr.2025.102635 · Cited by 6 · see citing works
Boyarchuk, O. R. (2020) · Reumatologia/Rheumatology · doi:10.5114/reum.2020.93509 · Cited by 5 · see citing works
“Special attention was paid to clinical signs of HDCT [3, 5].”
BackgroundHuang, M., Hua, N., Zhuang, S., Fang, Q., Shang, J., Wang, Z., Tao, X., Niu, J., Li, X., Yu, P., et al. (2023) · Journal of Pharmaceutical Analysis · doi:10.1016/j.jpha.2023.04.004 · Cited by 5 · see citing works
More Genes for Thoracic Aortic Aneurysms and Dissections
Caspar, S. M., Dubacher, N., & Mátyás, G. (2019) · Journal of the American College of Cardiology · doi:10.1016/j.jacc.2018.09.094 · Cited by 5 · see citing works
ECM-Focused Proteomic Analysis of Ear Punch Regeneration in Acomys CahirinusPreprint
McCabe, M. C., Okamura, D. M., Erickson, C. B., et al. (2023) · bioRxiv (Cold Spring Harbor Laboratory) · doi:10.1101/2023.10.11.561940 · Cited by 5 · see citing works
A single cell transcriptional atlas of early synovial joint developmentPreprint
Bian, Q., Cheng, Y., Wilson, J. P., et al. (2019) · bioRxiv (Cold Spring Harbor Laboratory) · doi:10.1101/2019.12.23.887208 · Cited by 5 · see citing works
“The predicted regulators of the final stage included TFs associated with inflammatory response: Cebpd, Egr1; osteogenesis: Sp7, Cbfb (Lien et al. 2007), and tendon development: Klf10 (McConnell and Yang 2010), Klf2, Klf4, Aebp1 (Blackburn et al. 2018), Ddit3 (Caterson and Melrose 2018), and Bhlhe40 (Peffers et al. 201…”
Fett, J., Dimori, M., Carroll, J. L., & Morello, R. (2022) · Physiological Reports · doi:10.14814/phy2.15275 · Cited by 5 · see citing works
“The 2017 international Ehlers- Danlos syndrome classification describes 13 different types of EDS and a fourteenth rare subtype has recently been identified (Blackburn et al., 2018; Malfait et al., 2017).”
BackgroundA clinical update on hypermobile Ehlers-Danlos syndrome during pregnancy, birth and beyond
Pezaro, S., Pearce, G., & Reinhold, E. J. (2021) · British Journal of Midwifery · doi:10.12968/bjom.2021.29.9.492 · Cited by 5 · see citing works
Ocular manifestations in Ehlers-Danlos syndrome
Kim, S., Shaia, J. K., Kaelber, D. C., Singh, R. P., & Talcott, K. E. (2025) · Eye · doi:10.1038/s41433-025-03787-1 · Cited by 6 · see citing works
Left ventricular myocardial molecular profile of human diabetic ischaemic cardiomyopathy
Hunter, B., Zhang, Y., Harney, D., McEwen, H. P., Koay, Y. C., Pan, M., Malecki, C., Khor, J. X. Y., Hume, R. D., Guglielmi, G., et al. (2025) · EMBO Molecular Medicine · doi:10.1038/s44321-025-00281-9 · Cited by 5 · see citing works
Inactive metallopeptidase homologs: the secret lives of pseudopeptidases
Lyons, P. J. (2024) · Frontiers in Molecular Biosciences · doi:10.3389/fmolb.2024.1436917 · Cited by 5 · see citing works
Rahman, Q., Naidu, S., Chong, B. W., & Stone, W. M. (2019) · Vascular and Endovascular Surgery · doi:10.1177/1538574418824185 · Cited by 5 · see citing works
- Authors
- Blackburn, P. R., Xu, Z., Tumelty, K. E., Zhao, R. W., Monis, W. J., Harris, K. G., Gass, J. M., Cousin, M. A., Boczek, N. J., Mitkov, M. V., Cappel, M. A., Francomano, C. A., Parisi, J. E., Klee, E. W., Faqeih, E., Alkuraya, F. S., Layne, M. D., McDonnell, N. B., & Atwal, P. S.
- Affiliations
- Mayo Clinic (US)
- Boston University (US)
- Greater Baltimore Medical Center (US)
- King Fahd Medical City (SA)
- King Abdulaziz City for Science and Technology (SA)
- National Institutes of Health (US)
- Corresponding author
- McDonnell, Nazli B.
- Atwal, Paldeep S.
- ORCID
- Venue
- The American Journal of Human Genetics
- Publisher
- Elsevier BV
- Published
- 2018-04
- Volume
- 102
- Issue
- 4
- Pages
- 696-705
- ISSN
- 0002-9297 (ISSN-L)
- PMC
- PMC5985336
- OpenAlex
- W2795052789
- Cited by
- 176
- References
- 33
- Citations by year
- 2026: 13 · 2025: 30 · 2024: 25 · 2023: 26 · 2022: 14 · 2021: 20 · 2020: 23 · 2019: 24 · 2018: 1
- FWCI
- 10.26
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Licence
- Locations
- The American Journal of Human Genetics (publishedVersion)
- Europe PMC (PubMed Central) (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- King Abdullah University of Science and Technology Repository (King Abdullah University of Science and Technology) (submittedVersion)
- Funders
- American Heart Association (14GRNT18690001)
- National Institutes of Health (HL078869S1, HL078869)
- National Institute on Aging (03-AG-N330, 2003-086, 11-AG-N079)
- Boston University
- Mayo Clinic
- Topics
- Life Sciences › Biochemistry, Genetics and Molecular Biology › Genetics › Connective tissue disorders research
- Life Sciences › Biochemistry, Genetics and Molecular Biology › Genetics › Dermatological and Skeletal Disorders
- Life Sciences › Biochemistry, Genetics and Molecular Biology › Genetics › Genomics and Rare Diseases
- Keywords
- AEBP1, Ehlers-Danlos syndrome, collagen self-assembly, collagen fibrils, connective tissue diseases, compound heterozygosity, splice site mutation, discoidin domain, collagen polymerization, wound healing, joint laxity, skin collagen, fibroblast proliferation
- MeSH terms
- Protein Domains, Adult, Alleles, Amino Acid Sequence, Carboxypeptidases, Child, Child, Preschool, Collagen, Connective Tissue, Ehlers-Danlos Syndrome, Female, Fibroblasts, Humans, Male, Mutation, Repressor Proteins, RNA, Messenger, Skin, Young Adult
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