Some genetic and treatment-related factors are risk factors for inhibitor development in patients with hemophilia A (PwHA). However, the genotype distribution of the factor VIII gene ( F8 ) and genetic impact on inhibitor development in Japanese PwHA remain unknown. In 2007, the Japan Hemophilia Inhibitor Study 2 (J-HIS2) was organized to establish a nationwide registry system for hemophiliacs and to elucidate risk factors for inhibitor development, designed for prospective investigation following a retrospective study (J-HIS1) which had already finished. Patients, newly diagnosed after January 2007, were enrolled in J-HIS2 and followed up for inhibitor development and clinical environments since 2008 onward. In the present study, F8 genotypes of PwHA were investigated in the patients recruited from the J-HIS2 cohort as well as those with inhibitor from the J-HIS1 cohort. F8 variants identified in 59 PwHA with inhibitor in J-HIS1 were: 20 intron-22 inversions, 5 intron-1 inversions, 9 large deletions, 4 nonsense, 8 missense, 11 small in/del, and 2 splice-site variants. F8 variants identified in 267 (67 with inhibitor) PwHA in J-HIS2 were: 76(28) intron-22 inversions, 3(2) intron-1 inversion, 1(0) duplication, 8(5) large deletions, 21(7) nonsense, 109(7) missense, 40(11) small in/del, and 9(7) splice-site variants. Forty variants were novel. The cumulative inhibitor incidence rate in the severe group with null changes was 42.4% (95% confidence interval [CI]: 33.7-50.8), higher than that with nonnull changes (15.6% [95%CI: 6.8-27.8]), in J-HIS2. Relative risk for inhibitor development of null changes was 2.89. The spectrum of F8 genotype and genetic impact on inhibitor development in Japanese PwHA were consistent with the previous reports., Competing Interests: K.S. was an endowed assistant professor funded by CSL Behring. K.Y. teaches a course endowed by Takeda Co. Ltd. T.K. received research funding from Chugai Pharmaceutical Co., Ltd. and Bayer AG, and a lecture reward from Chugai Pharmaceutical Co., Ltd., Takeda Co. Ltd., Novo Nordisk A/S, Sanofi S.A., Bayer A/G, and Sysmex Corporation. K.N. has received grants from Takeda Co. Ltd. and Sanofi S.A., and research funding from Chugai Pharmaceutical Co., Ltd., F. Hoffmann-La Roche Ltd., Bayer A/G, Novo Nordisk A/S, KM Biologics, and also honoraria from Takeda Co. Ltd., Bayer A/G, Novo Nordisk A/S, Sanofi S.A., CSL Behring, Chugai Pharmaceutical Co., Ltd., F. Hoffmann-La Roche Ltd. outside the submitted work. M.T. has received research funding from Chugai Pharmaceutical Co., Ltd., F. Hoffmann-La Roche Ltd., Sanofi S.A., CSL Behring, and Novo Nordisk A/S and also honoraria from Chugai Pharmaceutical Co., Ltd., CSL Behring, Bayer AG, Takeda Co. Ltd., Sanofi S.A., and Novo Nordisk A/S outside the submitted work and listed as an entity's board of directors or advisory committee member for Chugai Pharmaceutical Co., Ltd., Novo Nordisk A/S, Sanofi S.A., and Bayer AG. K.F. has received grants and personal fees from Takeda Co. Ltd. (Baxalta/Shire), Bayer, Pfizer, CSL Behring, Novo Nordisk, Sanofi S.A. (Biogen/Bioverativ), KM Biologics (Kaketsuken) and Chugai Pharmaceutical Co. LTD, and grants from Japan Blood Products Organization, personal fees from SRL Inc., LSI Medience, Roche Diagnostics, Siemens, Sekisui Medical, Fujirebio Inc., Torii Pharmaceuticals, Octapharma, Sysmex, MSD, and other from CIMIC, outside the submitted work. A.Y. has received payment for a manuscript and consulting fee from Japan Blood Products Organization, and honoraria for lectures from Takeda Co., Ltd., Bayer A/G, and Chugai Pharmaceutical Co., Ltd. A.S. has no conflict of interest. M.S. received research funding from Chugai Pharmaceutical Co., Ltd., F. Hoffmann-La Roche Ltd., Sanofi S.A., Takeda Co. Ltd., CSL Behring, KM Biologics Co., Ltd., and Novo Nordisk A/S; and consulting fee from Chugai Pharmaceutical Co., Ltd.; and payment for lectures on speaker's bureau from Chugai Pharmaceutical Co., Ltd., Sanofi S.A., Bayer AG, and Sysmex corporation; and is listed as an entity's board of directors or advisory committee member for Chugai Pharmaceutical Co., Ltd., F. Hoffmann-La Roche Ltd., BioMarin Pharmaceutical Inc., Bayer AG, and Sanofi S.A.; and is an inventor of patents related to anti-FIXa/FX bispecific antibodies., (Thieme. All rights reserved.)