Revision of splicing variants in the DMD gene

Background: Pathogenic variants in the dystrophin (DMD) gene lead to X-linked recessive Duchenne muscular dystrophy (DMD) and Becker muscular dystrophy (BMD). Nucleotide variants that affect splicing are a known cause of hereditary diseases. However, their representation in the public genomic variation databases is limited due to the low accuracy of their interpretation, especially if they are located within exons. The analysis of splicing variants in the DMD gene is essential both for understanding the underlying molecular mechanisms of the dystrophinopathies' pathogenesis and selecting suitable therapies for patients. Results: Using deep in silico mutagenesis of the entire DMD gene sequence and subsequent SpliceAI splicing predictions, we identified 7,948 DMD single nucleotide variants that could potentially affect splicing, 863 of them were located in exons. Next, we analyzed over 1,300 disease-associated DMD SNVs previously reported in the literature (373 exonic and 956 intronic) and intersected them with SpliceAI predictions. We predicted that ~95% of the intronic and ~10% of the exonic reported variants could actually affect splicing. Interestingly, the majority (75%) of patient-derived intronic variants were located in the AG-GT terminal dinucleotides of the introns, while these positions accounted for only 13% of all intronic variants predicted in silico. Of the 97 potentially spliceogenic exonic variants previously reported in patients with dystrophinopathy, we selected 38 for experimental validation. For this, we developed and tested a minigene expression system encompassing 27 DMD exons. The results showed that 35 (19 missense, 9 synonymous, and 7 nonsense) of the 38 DMD exonic variants tested actually disrupted splicing. We compared the observed consequences of splicing changes between variants leading to severe Duchenne and milder Becker muscular dystrophy and showed a significant difference in their distribution. This finding provides extended insights into relations between molecular consequences of splicing variants and the clinical features. Conclusions: Our comprehensive bioinformatics analysis, combined with experimental validation, improves the interpretation of splicing variants in the DMD gene. The new insights into the molecular mechanisms of pathogenicity of exonic single nucleotide variants contribute to a better understanding of the clinical features observed in patients with Duchenne and Becker muscular dystrophy. ### Competing Interest Statement The authors have declared no competing interest.