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Mehic D, Assinger A, Gebhart J. Utility of Global Hemostatic Assays in Patients with Bleeding Disorders of Unknown Cause. Hamostaseologie 2024. [PMID: 38950624 DOI: 10.1055/a-2330-9112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/03/2024] Open
Abstract
Bleeding disorder of unknown cause (BDUC) is a diagnosis of exclusion after exhaustive evaluation of plasmatic coagulation and platelet function. This review explores the utility of global hemostatic assays as confirmatory tests and in elucidating the pathophysiology of BDUC. Unlike traditional hemostatic tests that focus on coagulation factors, global assays are conducted both in plasma and also whole blood. These assays provide a more comprehensive understanding of the cell-based model of coagulation, aid in the identification of plasmatic factor abnormalities that may reduce hemostatic capacity, and allow for the assessment of impaired platelet-endothelial interactions under shear stress, as well as hyperfibrinolytic states. While clinical tests such as skin bleeding time and global assays such as PFA-100 exhibit limited diagnostic capacity, the role of viscoelastic testing in identifying hemostatic dysfunction in patients with BDUC remains unclear. Thrombin generation assays have shown variable results in BDUC patients; some studies demonstrate differences compared with healthy controls or reference values, whereas others question its clinical utility. Fibrinolysis assessment in vitro remains challenging, with studies employing euglobulin clot lysis time, plasma clot lysis time, and fluorogenic plasmin generation yielding inconclusive or conflicting results. Notably, recent studies suggest that microfluidic analysis unveils shear-dependent platelet function defects in BDUC patients, undetected by conventional platelet function assays. Overall, global assays might be helpful for exploring underlying hemostatic impairments, when conventional hemostatic laboratory tests yield no results. However, due to limited data and/or discrepant results, further research is needed to evaluate the utility of global assays as screening tools.
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Affiliation(s)
- Dino Mehic
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Alice Assinger
- Institute of Vascular Biology and Thrombosis Research, Centre of Physiology and Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Johanna Gebhart
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
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2
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Baker RI, Choi P, Curry N, Gebhart J, Gomez K, Henskens Y, Heubel-Moenen F, James P, Kadir RA, Kouides P, Lavin M, Lordkipanidze M, Lowe G, Mumford A, Mutch N, Nagler M, Othman M, Pabinger I, Sidonio R, Thomas W, O'Donnell JS. Standardization of definition and management for bleeding disorder of unknown cause: communication from the SSC of the ISTH. J Thromb Haemost 2024; 22:2059-2070. [PMID: 38518896 DOI: 10.1016/j.jtha.2024.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 02/08/2024] [Accepted: 03/08/2024] [Indexed: 03/24/2024]
Abstract
In many patients referred with significant bleeding phenotype, laboratory testing fails to define any hemostatic abnormalities. Clinical practice with respect to diagnosis and management of this patient cohort poses significant clinical challenges. We recommend that bleeding history in these patients should be objectively assessed using the International Society on Thrombosis and Haemostasis (ISTH) bleeding assessment tool. Patients with increased bleeding assessment tool scores should progress to hemostasis laboratory testing. To diagnose bleeding disorder of unknown cause (BDUC), normal complete blood count, prothrombin time, activated partial thromboplastin time, thrombin time, von Willebrand factor antigen, von Willebrand factor function, coagulation factors VIII, IX, and XI, and platelet light transmission aggregometry should be the minimum laboratory assessment. In some laboratories, additional specialized hemostasis testing may be performed to identify other rare causes of bleeding. We recommend that patients with a significant bleeding phenotype but normal laboratory investigations should be registered with a diagnosis of BDUC in preference to other terminology. Global hemostatic tests and markers of fibrinolysis demonstrate variable abnormalities, and their clinical significance remains uncertain. Targeted genomic sequencing examining candidate hemostatic genes has a low diagnostic yield. Underlying BDUC should be considered in patients with heavy menstrual bleeding since delays in diagnosis often extend to many years and negatively impact quality of life. Treatment options for BDUC patients include tranexamic acid, desmopressin, and platelet transfusions.
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Affiliation(s)
- Ross I Baker
- Western Australia Centre for Thrombosis and Haemostasis, Murdoch University, Perth, Australia; Clinical Research Unit, Perth Blood Institute, Perth, Australia; Hollywood Hospital Haemophilia Centre, Haematology Academic Unit, Perth, Australia; Irish-Australian Blood Collaborative Network, Dublin, Ireland and Perth, Australia.
| | - Philip Choi
- Haematology Department, The Canberra Hospital, Canberra, Australia; Division of Genome Sciences and Cancer, John Curtin School of Medical Research, Australian National University, Canberra, Australia
| | - Nicola Curry
- Department of Clinical Haematology, Haemophilia & Thrombosis Centre, Oxford University Hospitals National Health Service Foundation Trust, Oxford, United Kingdom; Radcliffe Department of Medicine, Oxford University, Oxford, United Kingdom
| | - Johanna Gebhart
- Department of Medicine, Division of Hematology and Hemostaseology, Medical University Vienna, Vienna, Austria
| | - Keith Gomez
- Katharine Dormandy Haemophilia Centre and Thrombosis Unit, Royal Free London National Health Service Foundation Trust, London, United Kingdom
| | - Yvonne Henskens
- Central Diagnostic Laboratory, Maastricht University Medical Centre, Maastricht, The Netherlands; Department of Biochemistry, Institute for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
| | - Floor Heubel-Moenen
- Department of Hematology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Paula James
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Rezan Abdul Kadir
- Department of Obstetrics and Gynaecology, Katharine Dormandy Haemophilia and Thrombosis Centre, The Royal Free National Health Service Hospital, London, United Kingdom; Institute for Women's Health, University College, London, United Kingdom
| | - Peter Kouides
- Mary M. Gooley Hemophilia Center, Rochester, New York, USA
| | - Michelle Lavin
- Irish-Australian Blood Collaborative Network, Dublin, Ireland and Perth, Australia; National Coagulation Centre, St. James's Hospital, Dublin, Ireland; Irish Centre for Vascular Biology, School of Pharmacy & Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Marie Lordkipanidze
- Research Center, Montreal Heart Institute, Montreal, Quebec, Canada; Faculty of Pharmacy, Université de Montréal, Montreal, Quebec, Canada
| | - Gillian Lowe
- West Midlands Adult Comprehensive Care Haemophilia Centre, University Hospitals Birmingham National Health Service Foundation Trust, Birmingham, United Kingdom
| | - Andrew Mumford
- School of Cellular and Molecular Medicine, University of Bristol, Bristol, United Kingdom
| | - Nicola Mutch
- Aberdeen Cardiovascular and Diabetes Centre, Institute of Medical Sciences, School of Medicine, United Kingdom; Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, United Kingdom
| | - Michael Nagler
- Department of Clinical Chemistry, Inselspital, Bern University Hospital, Bern, Switzerland; Department of Clinical Chemistry, Inselspital University Hospital Bern, Bern, Switzerland
| | - Maha Othman
- Department of Biomedical and Molecular Sciences, School of Medicine, Queen's University, Kingston, Ontario, Canada; School of Baccalaureate Nursing, St Lawrence College, Kingston, Ontario, Canada; Clinical Pathology Department, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Ingrid Pabinger
- Department of Medicine, Division of Hematology and Hemostaseology, Medical University Vienna, Vienna, Austria
| | - Robert Sidonio
- Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Will Thomas
- Department of Haematology, Cambridge University Hospitals National Health Service Foundation Trust, Cambridge, United Kingdom
| | - James S O'Donnell
- Irish-Australian Blood Collaborative Network, Dublin, Ireland and Perth, Australia; National Coagulation Centre, St. James's Hospital, Dublin, Ireland; Irish Centre for Vascular Biology, School of Pharmacy & Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
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3
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Monard A, Thomas W, Heubel-Moenen F. Bleeding disorders of unknown cause; the role of physiological anticoagulants. Thromb Res 2024; 237:216-217. [PMID: 38423879 DOI: 10.1016/j.thromres.2024.02.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 02/23/2024] [Indexed: 03/02/2024]
Affiliation(s)
- Amaury Monard
- Department of Internal Medicine - Haematology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Will Thomas
- Department of Haematology, Cambridge University Hospitals NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge CB2 0QQ, UK
| | - Floor Heubel-Moenen
- Department of Internal Medicine - Haematology, Maastricht University Medical Center, Maastricht, the Netherlands.
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Bareille M, Lecompte T, Mullier F. Assessment of the individual determinants of two fibrinolysis assays, GFC and ECLT in platelet-depleted plasma and derived euglobulin fraction respectively. Thromb Res 2023; 230:33-36. [PMID: 37633059 DOI: 10.1016/j.thromres.2023.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 08/01/2023] [Accepted: 08/11/2023] [Indexed: 08/28/2023]
Affiliation(s)
- Marion Bareille
- Université catholique de Louvain, CHU UCL Namur, Hematology Laboratory, Yvoir, Belgium.
| | - Thomas Lecompte
- Université de Lorraine, Nancy, France; Université de Namur, Department of Pharmacy, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), Namur, Belgium
| | - François Mullier
- Université catholique de Louvain, CHU UCL Namur, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), Hematology Laboratory, Yvoir, Belgium
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Zafarani A, Ghodratnia E, Amirzargar MR, Mahmoudi M, Taghavi-Farahabadi M, Tavangar F, Abdolkarimi B, Tabibian S. Bleeding disorder of unknown cause: Results from Iranian study. Transfus Apher Sci 2023; 62:103730. [PMID: 37295973 DOI: 10.1016/j.transci.2023.103730] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 05/07/2023] [Accepted: 05/18/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND Definite diagnosis of patients with mild to moderate bleeding is challenging. Some studies reported that even more than 50% of their patients remained undiagnosed which is classified as a Bleeding disorder of unknown cause (BDUC). This study aims to document the clinical characteristics and proportion of patients with BDUC in the Iranian Comprehensive Hemophilia Care Center (ICHCC) one of the referral centers for diagnosis of congenital bleeding disorder in Iran. METHODS This study was conducted on 397 patients who were referred with a bleeding manifestation to ICHCC from 2019 to 2022. Demographic and laboratory data were documented for all patients. Bleeding questionnaires including ISTH-Bleeding Assessment tool (ISTH-BAT) and the Molecular and Clinical Markers for the Diagnosis and Management of Type 1 (MCMDM-1 (ISTH-BAT, MCMDM-1, and the Pictorial Bleeding Assessment Chart (PBLAC) were filled out for all patients. The data were analyzed by the statistical package for social science (SPSS version 22, SPSS, Chicago, Illinois, USA). RESULTS BDUC was diagnosed in 200 patients and 197 patients reached the final diagnosis. Hemophilia, von Willebrand disease (VWD), factor (F) VII deficiency, and platelet functional disorders (PFDs) were confirmed in 54, 49, 34, and 15 of the patients, respectively. No significant difference was found in bleeding scores between patients with BDUC and those with confirmed disease. In contrast, after setting cut-off (ISTH-BAT for males ≥ 4 and females ≥ 6 and MCMDM-1 for males ≥ 3 and females ≥ 5) clinically significant difference was found. There was no association between having a positive consanguineous marriage and setting a diagnosis; however, significant associations were seen for having a positive family history of bleeding. Age (OR =0.977, 95% CI.965-0.989), gender (BDUC female, 151/200; final diagnosis female, 95/197) (OR=3.3, 95% CI 2.16-5.06), family history (OR = 3.19, 95% CI 1.99-5.11), and consanguineous marriage (OR=1.59, 95% CI 1.03-2.45) were considered as a risk factor for categorizing the patients with BDUC or final diagnosis. CONCLUSION The findings are mainly in line with previous studies about BDUC patients. The large number of patients with BDUC underlines the incompleteness of available routine laboratory tests and shows the necessity of progress in the development of reliable diagnostic tools to identify underlying bleeding disorders.
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Affiliation(s)
- Alireza Zafarani
- Department of Hematology and Blood Banking, Faculty of Allied Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Elnaz Ghodratnia
- Department of Hematology and Blood Banking, Faculty of Allied Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Mohammad Reza Amirzargar
- Department of Hematology and Blood Banking, Faculty of Allied Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Mohammad Mahmoudi
- Department of Immunology, Faculty of Allied Medicine، Iran University of Medical Sciences, Tehran, Iran
| | - Mahsa Taghavi-Farahabadi
- Department of Immunology, Faculty of Allied Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Fatemeh Tavangar
- Transfusion Research Center, High Institute for Research and Education in Transfusion Medicine, Tehran, Iran
| | - Babak Abdolkarimi
- Pediatric Hematology-Oncology, Lorestan University of Medical Sciences, Khoramabad, Iran.
| | - Shadi Tabibian
- Iranian Comprehensive Hemophilia Care Center, Tehran, Iran.
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Thomas W. The natural history of bleeding disorder of unknown cause. J Thromb Haemost 2023; 21:1747-1749. [PMID: 37330263 DOI: 10.1016/j.jtha.2023.03.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 03/22/2023] [Indexed: 06/19/2023]
Affiliation(s)
- Will Thomas
- Haemophilia and Thrombophilia Centre, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom.
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Mehic D, Neubauer G, Janig F, Kaider A, Ay C, Pabinger I, Gebhart J. Risk factors for future bleeding in patients with mild bleeding disorders: longitudinal data from the Vienna Bleeding Biobank. J Thromb Haemost 2023; 21:1757-1768. [PMID: 36924834 DOI: 10.1016/j.jtha.2023.03.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 02/15/2023] [Accepted: 03/05/2023] [Indexed: 03/18/2023]
Abstract
BACKGROUND The future bleeding risk, especially after hemostatic challenges, and thus the requirement for hemostatic treatment in patients with mild-to-moderate bleeding disorders (MBDs) is largely unknown. OBJECTIVES This study aimed to prospectively examine the recurrence of bleeding symptoms and clinical risk factors for future bleeding in patients with MBD, including patients with bleeding disorder of unknown cause (BDUC). METHODS Bleeding symptoms of patients with MBD included in the Vienna Bleeding Biobank were re-evaluated at in-person follow-up visits or by mail. RESULTS In total, 392 patients, including 62.8% with BDUC, were investigated for the recurrence of bleeding events. During the follow-up time of median (IQR) 4.3 years (2.6-6.7), 72% of patients had at least 1 bleeding event. Most persistent bleeding manifestations were hematomas (n = 146/245, 59.6%) and bleeding from small wounds (n = 69/141, 48.9%), followed by epistaxis (n = 42/132, 31.8%), oral mucosal bleeding (n = 26/87, 29.9%), and joint bleeding (n = 7/14, 50.0%). Patients with previous postinterventional bleeding had a significantly increased risk for bleeding events after surgery (n = 33/114, 29.0 %) or tooth extraction (n = 16/39, 41.0%). A high bleeding score (OR [95% CI], 1.14 [1.05 to 2.94], per 1 unit) and follow-up time (OR [95% CI], 1.23 [1.12 to 1.36], per 1 year) were independently associated with any bleeding event. For bleeding after hemostatic challenges, blood group O (OR, 3.17 [1.57 to 6.40]), previous postsurgical bleeding (OR, 2.40 [1.06 to 5.46]), and an established diagnosis (OR, 2.07 [1.04 to 4.10]) were independent risk factors. CONCLUSION Patients with MBD have a high risk for recurrent bleeding. This encourages prophylactic hemostatic treatment in patients with MBD, particularly when they face hemostatic challenges.
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Affiliation(s)
- Dino Mehic
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria; Institute of Vascular Biology and Thrombosis Research, Centre of Physiology and Pharmacology, Medical University of Vienna, Vienna, Austria. https://twitter.com/dino_mehic
| | - Georg Neubauer
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Florian Janig
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Alexandra Kaider
- Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Cihan Ay
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria. https://twitter.com/Cihan_Ay_MD
| | - Ingrid Pabinger
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Johanna Gebhart
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria.
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8
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Valke LLFG, Meijer D, Nieuwenhuizen L, Laros‐van Gorkom BAP, Blijlevens NMA, Heerde WL, Schols SEM. Fibrinolytic assays in bleeding of unknown cause: Improvement in diagnostic yield. Res Pract Thromb Haemost 2022; 6:e12681. [PMID: 35316940 PMCID: PMC8922970 DOI: 10.1002/rth2.12681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 01/28/2022] [Accepted: 01/31/2022] [Indexed: 11/11/2022] Open
Abstract
Introduction Aim Methods Results Discussion
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Affiliation(s)
- Lars L. F. G. Valke
- Department of Hematology Radboud University Medical Center Nijmegen The Netherlands
- Hemophilia Treatment Center Nijmegen‐Eindhoven‐Maastricht The Netherlands
| | - Danielle Meijer
- Department of Laboratory Medicine Laboratory of Hematology Radboud University Medical Center Nijmegen The Netherlands
| | - Laurens Nieuwenhuizen
- Hemophilia Treatment Center Nijmegen‐Eindhoven‐Maastricht The Netherlands
- Department of Hematology Maxima Medical Center Veldhoven The Netherlands
| | - Britta A. P. Laros‐van Gorkom
- Department of Hematology Radboud University Medical Center Nijmegen The Netherlands
- Hemophilia Treatment Center Nijmegen‐Eindhoven‐Maastricht The Netherlands
| | | | - Waander L. Heerde
- Hemophilia Treatment Center Nijmegen‐Eindhoven‐Maastricht The Netherlands
- Enzyre BV Novio Tech Campus Nijmegen The Netherlands
| | - Saskia E. M. Schols
- Department of Hematology Radboud University Medical Center Nijmegen The Netherlands
- Hemophilia Treatment Center Nijmegen‐Eindhoven‐Maastricht The Netherlands
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9
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How I treat. Bleeding Disorder of Unknown Cause (BDUC). Blood 2021; 138:1795-1804. [PMID: 34398949 DOI: 10.1182/blood.2020010038] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 08/10/2021] [Indexed: 11/20/2022] Open
Abstract
Recent studies have demonstrated that only 30% of patients referred for assessment of a possible bleeding tendency will eventually be diagnosed with a mild bleeding disorder (MBD) such as von Willebrand disease (VWD) or platelet function defect (PFD). Rather, the majority of such patients will be diagnosed with Bleeding Disorder of Unknown Cause (BDUC). There remains an important unmet need to define consensus regarding the clinical and laboratory criteria necessary for a formal BDUC diagnosis. Nevertheless, BDUC already accounts for more than 10% of patients registered in some Haemophilia Comprehensive Care centres. Accumulating recent data suggest that BDUC is also being diagnosed with increasing frequency. Increased BAT scores are widely utilized to differentiate significant from trivial symptoms in patients with mucocutaneous bleeding. Objective assessment of bleeding phenotype using a standardised bleeding assessment tool (BAT) therefore represents a fundamental first step in the diagnosis of BDUC. Since BDUC is a diagnosis by exclusion, accurate quantification of bleeding phenotype is critical as this will be the primary determinant upon which a diagnosis of BDUC is reached. Importantly, BAT scores suggest that patients with BDUC display bleeding phenotypes comparable to those seen in patients with VWD or PFD respectively. Despite the prevalence of BDUC, diagnosis and management of these patients commonly pose significant clinical dilemmas. In this manuscript, we consider these challenges in the context of a number of typical case studies, discuss the available evidence and outline our approach to the management of these patients.
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Mohammed BAB. Alpha 2-antiplasmin deficiency in a Sudanese child: a case report. J Med Case Rep 2021; 15:238. [PMID: 33957960 PMCID: PMC8103643 DOI: 10.1186/s13256-021-02813-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 03/22/2021] [Indexed: 11/19/2022] Open
Abstract
Background The plasma serine protease inhibitor alpha 2-antiplasmin (α2-AP, otherwise known as α2-plasmin inhibitor) is a rapid-acting plasmin inhibitor recently found in human plasma, which seems to have a significant role in the regulation of in vivo fibrinolysis. Congenital deficiency of α2-AP is extremely uncommon. Case presentation We report here a case of absolute deficiency of α2-AP in an 11-year-old Sudanese boy, who had a lifelong intermittent hemorrhagic tendency (gum bleeding, epistaxis, and exaggerated bleeding after trauma). Coagulation tests including prothrombin time, partial thromboplastin time, thrombin time, bleeding time, platelet count, clot retraction test, antithrombin, and factor VIII levels were within normal limits. Hepatic function tests and complete blood count were also normal. The main interesting finding in this patient was that the whole blood clot lysis was extremely fast, completed within 5–8 hours. The second abnormal finding is that the euglobulin clot lysis time was short. Nevertheless, the concentration of α2-AP in the patient's plasma was 0.2 IU/ml (reference range is 0.80–1.20 IU/ml). The addition of pooled plasma (with normal α2-AP) to the patient's whole blood corrected the accelerated fibrinolysis. Conclusion The study showed that α2-AP deficiency resulted in uninhibited fibrinolysis that caused the hemorrhagic tendency in this patient. Thus, this report demonstrates the significant role of α2-AP in coagulation.
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Mehic D, Pabinger I, Ay C, Gebhart J. Fibrinolysis and bleeding of unknown cause. Res Pract Thromb Haemost 2021; 5:e12511. [PMID: 34027290 PMCID: PMC8117813 DOI: 10.1002/rth2.12511] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 02/21/2021] [Accepted: 03/10/2021] [Indexed: 12/04/2022] Open
Abstract
Patients with bleeding of unknown cause (BUC) present with a variety of mild to moderate bleeding symptoms, but no hemostatic abnormalities can be found. Hyperfibrinolysis is rarely evaluated as the underlying cause for bleeding in clinical practice, and well-established global assays for abnormal fibrinolysis are lacking. Few patients with definitive fibrinolytic disorders, including α2-antiplasmin deficiency, plasminogen activator inhibitor 1 deficiency, or Quebec platelet disorder, have been reported. This review aims to summarize data on established fibrinolytic disorders and to discuss assessments of fibrinolysis in prior bleeding cohorts. Furthermore, we review available global tests with the potential to measure fibrinolysis, such as turbidity fibrin clot assays and rotational thromboelastometry, and their relevance in the workup of patients with BUC. We conclude that, due to the lack of adequate global tests, hyperfibrinolysis might be an underdiagnosed cause for a bleeding disorder. The diagnosis of hyperfibrinolytic bleeding disorders would improve patient care as effective treatment with antifibrinolytic agents is available.
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Affiliation(s)
- Dino Mehic
- Clinical Division of Hematology and HemostaseologyDepartment of Medicine IMedical University of ViennaViennaAustria
| | - Ingrid Pabinger
- Clinical Division of Hematology and HemostaseologyDepartment of Medicine IMedical University of ViennaViennaAustria
| | - Cihan Ay
- Clinical Division of Hematology and HemostaseologyDepartment of Medicine IMedical University of ViennaViennaAustria
| | - Johanna Gebhart
- Clinical Division of Hematology and HemostaseologyDepartment of Medicine IMedical University of ViennaViennaAustria
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12
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Assessing Plasmin Generation in Health and Disease. Int J Mol Sci 2021; 22:ijms22052758. [PMID: 33803235 PMCID: PMC7963172 DOI: 10.3390/ijms22052758] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 02/20/2021] [Accepted: 03/05/2021] [Indexed: 12/13/2022] Open
Abstract
Fibrinolysis is an important process in hemostasis responsible for dissolving the clot during wound healing. Plasmin is a central enzyme in this process via its capacity to cleave fibrin. The kinetics of plasmin generation (PG) and inhibition during fibrinolysis have been poorly understood until the recent development of assays to quantify these metrics. The assessment of plasmin kinetics allows for the identification of fibrinolytic dysfunction and better understanding of the relationships between abnormal fibrin dissolution and disease pathogenesis. Additionally, direct measurement of the inhibition of PG by antifibrinolytic medications, such as tranexamic acid, can be a useful tool to assess the risks and effectiveness of antifibrinolytic therapy in hemorrhagic diseases. This review provides an overview of available PG assays to directly measure the kinetics of plasmin formation and inhibition in human and mouse plasmas and focuses on their applications in defining the role of plasmin in diseases, including angioedema, hemophilia, rare bleeding disorders, COVID-19, or diet-induced obesity. Moreover, this review introduces the PG assay as a promising clinical and research method to monitor antifibrinolytic medications and screen for genetic or acquired fibrinolytic disorders.
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13
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Thomas W, Downes K, Desborough MJR. Bleeding of unknown cause and unclassified bleeding disorders; diagnosis, pathophysiology and management. Haemophilia 2020; 26:946-957. [PMID: 33094877 DOI: 10.1111/hae.14174] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 09/03/2020] [Accepted: 09/21/2020] [Indexed: 12/24/2022]
Abstract
Bleeding of unknown cause (BUC), also known as unclassified bleeding disorders (UBD), has been defined as a clear bleeding tendency in the presence of normal haemostatic tests. There are challenges in the diagnosis and management of these patients. BUC/UBD encompasses a heterogenous group of disorders which may include undiagnosed rare monogenic diseases, polygenic reasons for bleeding; and patients without a clear bleeding disorder but with a previous bleeding event. Nevertheless, these patients may have heavy menstrual bleeding or be at risk of bleeding when undergoing surgical procedures, or childbirth; optimizing haemostasis and establishing a mode of inheritance is important to minimize morbidity. The bleeding score has been used to clinically assess and describe these patients, but its value remains uncertain. In addition, accurate distinction between normal and pathological bleeding remains difficult. Several studies have investigated cohorts of these patients using research haemostasis tests, including thrombin generation and fibrinolytic assays, yet no clear characteristics have consistently emerged. Thus far, detailed genetic analysis of these patients has not been fruitful in unravelling the cause of bleeding. There is a need for standardization of diagnosis and management guidelines for these patients. This review gives an overview of this field with some suggestions for future research.
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Affiliation(s)
- Will Thomas
- Department of Haematology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Kate Downes
- East Midlands and East of England Genomic Laboratory Hub, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.,Department of Haematology, University of Cambridge, Cambridge, UK
| | - Michael J R Desborough
- Haemostasis and Thrombosis Centre, Guy's and St Thomas' Hospital NHS Foundation Trust, London, UK
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MacDonald S, Wright A, Beuche F, Downes K, Besser M, Symington E, Kelly A, Thomas W. Characterization of a large cohort of patients with unclassified bleeding disorder; clinical features, management of haemostatic challenges and use of global haemostatic assessment with proposed recommendations for diagnosis and treatment. Int J Lab Hematol 2019; 42:116-125. [DOI: 10.1111/ijlh.13124] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 09/27/2019] [Accepted: 10/28/2019] [Indexed: 12/30/2022]
Affiliation(s)
- Stephen MacDonald
- Department of Haematology Cambridge University Hospitals NHS Foundation Trust Cambridge UK
| | - Alfie Wright
- School of Clinical Medicine University of Cambridge Cambridge UK
| | | | - Kate Downes
- Department of Haematology University of Cambridge Cambridge UK
- NIHR BioResource‐Rare Diseases Cambridge University Hospitals NHS Foundation Trust Cambridge UK
- NHS Blood and Transplant Cambridge Biomedical Campus Cambridge UK
| | - Martin Besser
- Department of Haematology Cambridge University Hospitals NHS Foundation Trust Cambridge UK
| | - Emily Symington
- Department of Haematology Cambridge University Hospitals NHS Foundation Trust Cambridge UK
| | - Anne Kelly
- Department of Haematology Cambridge University Hospitals NHS Foundation Trust Cambridge UK
| | - Will Thomas
- Department of Haematology Cambridge University Hospitals NHS Foundation Trust Cambridge UK
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15
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Fundamentals for a Systematic Approach to Mild and Moderate Inherited Bleeding Disorders: An EHA Consensus Report. Hemasphere 2019; 3:e286. [PMID: 31942541 PMCID: PMC6919472 DOI: 10.1097/hs9.0000000000000286] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 07/08/2019] [Accepted: 07/15/2019] [Indexed: 01/05/2023] Open
Abstract
Healthy subjects frequently report minor bleedings that are frequently ‘background noise’ of normality rather than a true disorder. Nevertheless, unexpected or unusual bleeding may be alarming. Thus, the distinction between normal and pathologic bleeding is critical. Understanding the underlying pathologic mechanism in patients with an excessive bleeding is essential for their counseling and treatment. Most of these patients with significant bleeding will result affected by non-severe inherited bleeding disorders (BD), collectively denominated mild or moderate BD for their relatively benign course. Unfortunately, practical recommendations for the management of these disorders are still lacking due to the current state of fragmented knowledge of pathophysiology and lack of a systematic diagnostic approach. To address this gap, an International Working Group (IWG) was established by the European Hematology Association (EHA) to develop consensus-based guidelines on these disorders. The IWG agreed that grouping these disorders by their clinical phenotype under the single category of mild-to-moderate bleeding disorders (MBD) reflects current clinical practice and will facilitate a systematic diagnostic approach. Based on standardized and harmonized definitions a conceptual unified framework is proposed to distinguish normal subjects from affected patients. The IWG proposes a provisional comprehensive patient-centered initial diagnostic approach that will result in classification of MBD into distinct clinical-pathological entities under the overarching principle of clinical utility for the individual patient. While we will present here a general overview of the global management of patients with MBD, this conceptual framework will be adopted and validated in the evidence-based, disease-specific guidelines under development by the IWG.
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Hofer S, Ay C, Rejtö J, Wolberg AS, Haslacher H, Koder S, Pabinger I, Gebhart J. Thrombin-generating potential, plasma clot formation, and clot lysis are impaired in patients with bleeding of unknown cause. J Thromb Haemost 2019; 17:1478-1488. [PMID: 31177606 PMCID: PMC6851858 DOI: 10.1111/jth.14529] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 05/16/2019] [Accepted: 06/03/2019] [Indexed: 01/11/2023]
Abstract
BACKGROUND In a large proportion of patients with a mild to moderate bleeding tendency no diagnosis can be established (bleeding of unknown cause, BUC). OBJECTIVES To investigate possible dysfunctions in thrombin generation and plasma clot formation and lysis in patients with BUC from the Vienna Bleeding Biobank (VIBB). PATIENTS AND METHODS Thrombin generation and plasma clot properties of 382 BUC patients were compared to those of 100 healthy controls and 16 patients with factor VIII (FVIII) activity ≤50%. RESULTS Thrombin generation was significantly impaired in BUC patients compared to healthy controls, exhibiting a prolonged lag time and time to peak and decreased maximum thrombin generation, velocity index, and area under the curve (AUC). The assessment of clot formation and lysis in BUC patients revealed a lower clot formation rate (Vmax), resulting in a longer TTP, increased absorbance (ΔAbs), and a shorter clot lysis time (CLT) than in healthy controls. Comparing patients with FVIII activity ≤ 50% to those with BUC, parameters of thrombin generation and clot formation and lysis were either stronger or comparably impaired. Bleeding severity did not correlate with parameters of thrombin generation, clot formation, or clot lysis. CONCLUSION Patients with BUC have an impaired hemostatic capacity reflected by a lower thrombin-generation potential, a lower clot formation rate, increased clot turbidity, and shorter clot lysis time, which might contribute to their increased bleeding tendency. Assays monitoring these parameters can alert physicians of hemostatic impairment and should be considered in situations where traditional hemostatic lab tests fail to reveal the clinical bleeding tendency.
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Affiliation(s)
- Stefanie Hofer
- Clinical Division of Hematology and HemostaseologyDepartment of Medicine IMedical University of ViennaViennaAustria
| | - Cihan Ay
- Clinical Division of Hematology and HemostaseologyDepartment of Medicine IMedical University of ViennaViennaAustria
| | - Judit Rejtö
- Clinical Division of Hematology and HemostaseologyDepartment of Medicine IMedical University of ViennaViennaAustria
| | - Alisa S. Wolberg
- Department of Pathology and Laboratory MedicineUniversity of North Carolina at Chapel HillChapel HillNorth Carolina
| | - Helmuth Haslacher
- Department of Laboratory MedicineMedical University of ViennaViennaAustria
| | - Silvia Koder
- Clinical Division of Hematology and HemostaseologyDepartment of Medicine IMedical University of ViennaViennaAustria
| | - Ingrid Pabinger
- Clinical Division of Hematology and HemostaseologyDepartment of Medicine IMedical University of ViennaViennaAustria
| | - Johanna Gebhart
- Clinical Division of Hematology and HemostaseologyDepartment of Medicine IMedical University of ViennaViennaAustria
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17
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Mezzano D, Quiroga T. Diagnostic challenges of inherited mild bleeding disorders: a bait for poorly explored clinical and basic research. J Thromb Haemost 2019; 17:257-270. [PMID: 30562407 DOI: 10.1111/jth.14363] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Indexed: 01/10/2023]
Abstract
The best-known inherited mild bleeding disorders (MBDs), i.e. type 1 von Willebrand disease (VWD), platelet function disorders (PFDs), and mild to moderate clotting factor deficiencies, are characterized clinically by mucocutaneous bleeding, and, although they are highly prevalent, still pose difficult diagnostic problems. These include establishing the pathological nature of bleeding, and the uncertainties surrounding the clinical relevance of laboratory results. Furthermore, the high frequency of bleeding symptoms in the normal population and the subjective appraisal of symptoms by patients or parents makes elucidating the pathological nature of bleeding difficult. Standardized bleeding assessment tools and semiquantitative bleeding scores (BSs) help to discriminate normal from abnormal bleeding. However, as most MBDs have similar bleeding patterns, for example, bleeding sites, frequency, and severity, BSs are of little help for diagnosing specific diseases. Global tests of primary hemostasis (bleeding time; PFA-100/200) lack sensitivity and, like BSs, are not disease-specific. Problems with the diagnosis of type 1 VWD and PFD include assay standardization, uncertain definition of von Willebrand factor cut-off levels, and the lack of universal diagnostic criteria for PFD. Regarding clotting factor deficiencies, the bleeding thresholds of some coagulation factors, such as factor VII and FXI, are highly variable, and may lead to misinterpretation of the clinical relevance of mild to moderate deficiencies. Remarkably, a large proportion of MBDs remain undiagnosed even after comprehensive and repeated laboratory testing. These are tentatively considered to represent bleeding of undefined cause, with clinical features indistinguishable from those of classical MBD; the pathogenesis of this is probably multifactorial, and unveiling these mechanisms should constitute a fertile source of translational research.
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Affiliation(s)
- D Mezzano
- Department of Hematology-Oncology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - T Quiroga
- Clinical Laboratory, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
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18
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Vries MJ, van der Meijden PE, Kuiper GJ, Nelemans PJ, Wetzels RJ, van Oerle RG, Lancé MD, ten Cate H, Henskens YM. Preoperative screening for bleeding disorders: A comprehensive laboratory assessment of clinical practice. Res Pract Thromb Haemost 2018; 2:767-777. [PMID: 30349896 PMCID: PMC6178633 DOI: 10.1002/rth2.12114] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 04/22/2018] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Patients with mild bleeding disorders are at risk of perioperative bleeding, but screening for these disorders remains challenging. OBJECTIVES We aimed to assess the prevalence of hemostatic abnormalities in patients with and without reported bleeding symptoms on a preoperative questionnaire, consisting of guideline-proposed questions, and appraised the diagnostic value of several screening modalities for the identification of patients with hemostatic abnormalities. METHODS In this observational study, 240 patients with and 95 patients without bleeding symptoms on the preoperative questionnaire were included. Patients with known bleeding disorders, antithrombotic drugs, thrombocytopenia, and anemia were excluded. Preoperatively, all patients underwent elaborate hemostatic testing. Hemostatic abnormalities were defined as coagulation, vWF, or fibrinolysis factor levels below reference range and platelet function defects. Screening modalities included the ISTH Bleeding Assessment Tool (ISTH-BAT), PT, aPTT, TT, Euglobulin Lysis Time (ELT), and Platelet Function Analyser (PFA). RESULTS In 21 of 240 (8.8%) patients reporting bleeding symptoms, hemostatic abnormalities were found, including 7 reduced coagulation factor levels, 10 platelet function abnormalities, and 4 reduced vWF levels. In comparison, 10 of 95 (10.5%) patients not reporting bleeding symptoms had abnormalities. The ISTH-BAT could not identify patients with abnormalities, while PT, aPTT, TT, ELT, and PFA had high specificity but low sensitivity to detect abnormalities. CONCLUSIONS The prevalence of hemostatic abnormalities in both patients with and without reported bleeding symptoms was 9%-10%. This suggests that the guideline-based questionnaire cannot differentiate between patients with and without abnormalities, while the discriminative power of the screening modalities is also limited.
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Affiliation(s)
- Minka J. Vries
- Laboratory for Clinical Thrombosis and HaemostasisDepartment of BiochemistryCardiovascular Research Institute MaastrichtMaastricht UniversityMaastrichtThe Netherlands
| | - Paola E. van der Meijden
- Laboratory for Clinical Thrombosis and HaemostasisDepartment of BiochemistryCardiovascular Research Institute MaastrichtMaastricht UniversityMaastrichtThe Netherlands
- Thrombosis Expertise CentreMaastricht University Medical CentreMaastrichtThe Netherlands
| | - Gerhardus J. Kuiper
- Department of AnaesthesiologyMaastricht University Medical CentreMaastrichtThe Netherlands
| | - Patricia J. Nelemans
- Department of EpidemiologySchool for Public Health and Primary CareMaastricht University Medical CentreMaastrichtThe Netherlands
| | - Rick J. Wetzels
- Central Diagnostic LaboratoryMaastricht University Medical CentreMaastrichtThe Netherlands
| | - René G. van Oerle
- Laboratory for Clinical Thrombosis and HaemostasisDepartment of BiochemistryCardiovascular Research Institute MaastrichtMaastricht UniversityMaastrichtThe Netherlands
- Central Diagnostic LaboratoryMaastricht University Medical CentreMaastrichtThe Netherlands
| | - Marcus D. Lancé
- Department of AnaesthesiologyMaastricht University Medical CentreMaastrichtThe Netherlands
| | - Hugo ten Cate
- Laboratory for Clinical Thrombosis and HaemostasisDepartment of BiochemistryCardiovascular Research Institute MaastrichtMaastricht UniversityMaastrichtThe Netherlands
- Thrombosis Expertise CentreMaastricht University Medical CentreMaastrichtThe Netherlands
| | - Yvonne M. Henskens
- Laboratory for Clinical Thrombosis and HaemostasisDepartment of BiochemistryCardiovascular Research Institute MaastrichtMaastricht UniversityMaastrichtThe Netherlands
- Central Diagnostic LaboratoryMaastricht University Medical CentreMaastrichtThe Netherlands
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19
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Saes JL, Schols SEM, van Heerde WL, Nijziel MR. Hemorrhagic disorders of fibrinolysis: a clinical review. J Thromb Haemost 2018; 16:S1538-7836(22)02207-3. [PMID: 29847021 DOI: 10.1111/jth.14160] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Indexed: 12/28/2022]
Abstract
Hyperfibrinolytic bleeding can be caused by a deficiency of one of the inhibitors of fibrinolysis (plasminogen activator inhibitor type 1 [PAI-1] or α2-antiplasmin [α2-AP]), or an excess of one of the activators of fibrinolysis: tissue-type plasminogen activator or urokinase-type plasminogen activator. This review focuses on the clinical implications of these disorders. The bleeding phenotype of fibrinolytic disorders is characterized by delayed bleeding after trauma, surgery and dental procedures. Bleeding in areas of high fibrinolytic activity is also common, such as menorrhagia and epistaxis. Patients with α2-AP deficiency present with the most severe bleeding episodes. Recently, it was discovered that hyperfibrinolytic disorders are associated with a high rate of obstetric complications such as miscarriage and preterm birth, especially in PAI-1 deficient patients. Hyperfibrinolytic disorders are probably underdiagnosed because of lack of knowledge and lack of accurate diagnostic tests. A substantial part of the large group of patients diagnosed as 'bleeding of unknown origin' could actually have a hyperfibrinolytic disorder. In the case of a high index of suspicion (i.e. because of a positive family history, recurrent bleeding or uncommon type of bleeding such as an intramedullary hematoma), further testing should not be withheld because of normal results of standard hemostatic screening assays. Timely diagnosis is important because these disorders can generally be treated well with antifibrinolytic agents.
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Affiliation(s)
- J L Saes
- Department of Hematology, Radboud University Medical Center, Nijmegen, the Netherlands
- Haemophilia Treatment Center, Nijmegen-Eindhoven-Maastricht, the Netherlands
| | - S E M Schols
- Department of Hematology, Radboud University Medical Center, Nijmegen, the Netherlands
- Haemophilia Treatment Center, Nijmegen-Eindhoven-Maastricht, the Netherlands
| | - W L van Heerde
- Haemophilia Treatment Center, Nijmegen-Eindhoven-Maastricht, the Netherlands
| | - M R Nijziel
- Department of Hematology, Catharina Hospital, Eindhoven, the Netherlands
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20
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Gebhart J, Hofer S, Panzer S, Quehenberger P, Sunder-Plassmann R, Hoermann G, Eigenbauer E, Haslacher H, Kepa S, Kyrle PA, Eichinger S, Knöbl P, Eischer L, Mannhalter C, Ay C, Pabinger I. High proportion of patients with bleeding of unknown cause in persons with a mild-to-moderate bleeding tendency: Results from the Vienna Bleeding Biobank (VIBB). Haemophilia 2018; 24:405-413. [PMID: 29388750 DOI: 10.1111/hae.13422] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/28/2017] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Data on clinical characteristics and the prevalence of underlying coagulopathies in patients with mild-to-moderate bleeding disorders (MBDs) are scarce. AIM We established the Vienna Bleeding Biobank (VIBB) to characterize and thoroughly investigate Austrian patients with MBDs. RESULTS Four hundred eighteen patients (female = 345, 82.5%) were included. A platelet function defect (PFD) was diagnosed in 26 (6.2%) and a possible PFD in 30 (7.2%) patients. Eight patients (1.9%) were diagnosed with von Willebrand disease (VWD) (type 1 n = 6; type 2 n = 2), and 29 patients had low VWF (30-50 IU/dL). Deficiencies in factor VIII, IX, XI or XIII were found in 11 (2.6%), 3 (0.7%), 3 (0.7%) and 1 patient(s), 2 patients had dysfibrinogenaemia, and further 2 had possible PFD and FXI deficiency. Probable causal mutations were detected in 8 of 11 patients with FVIII deficiency, 2 of 3 patients with FIX deficiency and 2 of 8 patients with VWD. Three hundred three patients (72.5%) had normal results in the coagulation assays and were categorized as patients with bleeding of unknown cause (BUC). The bleeding score did not differ between patients with and without established diagnosis. A diagnosis of a bleeding disorder was more frequently made in men than in women (49.3% vs 22.9%). Male sex (OR 3.55, 95% CI: 2.02-6.22; P < .001) and blood group 0 (OR 1.86, 95% CI: 1.17-2.94; P = .008) were independently associated with diagnosis of a bleeding disorder. CONCLUSION The high rate of patients with BUC despite in-depth haemostatic assessment underlines the incompleteness of available routine laboratory tests. Males with MBDs were more likely to be diagnosed with an established bleeding disorder than females.
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Affiliation(s)
- J Gebhart
- Department of Medicine I, Clinical Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna, Austria
| | - S Hofer
- Department of Medicine I, Clinical Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna, Austria
| | - S Panzer
- Department of Blood Group Serology and Transfusion Medicine, Medical University of Vienna, Vienna, Austria
| | - P Quehenberger
- Department of Laboratory Medicine, Division of Medical and Chemical Laboratory Diagnostics, Medical University of Vienna, Vienna, Austria
| | - R Sunder-Plassmann
- Department of Laboratory Medicine, Division of Medical and Chemical Laboratory Diagnostics, Medical University of Vienna, Vienna, Austria
| | - G Hoermann
- Department of Laboratory Medicine, Division of Medical and Chemical Laboratory Diagnostics, Medical University of Vienna, Vienna, Austria
| | - E Eigenbauer
- IT-Systems and Communications, Medical University of Vienna, Vienna, Austria
| | - H Haslacher
- Department of Laboratory Medicine, Division of Medical and Chemical Laboratory Diagnostics, Medical University of Vienna, Vienna, Austria
| | - S Kepa
- Department of Medicine I, Clinical Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna, Austria
| | - P A Kyrle
- Department of Medicine I, Clinical Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna, Austria
| | - S Eichinger
- Department of Medicine I, Clinical Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna, Austria
| | - P Knöbl
- Department of Medicine I, Clinical Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna, Austria
| | - L Eischer
- Department of Medicine I, Clinical Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna, Austria
| | - C Mannhalter
- Department of Laboratory Medicine, Division of Medical and Chemical Laboratory Diagnostics, Medical University of Vienna, Vienna, Austria
| | - C Ay
- Department of Medicine I, Clinical Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna, Austria
| | - I Pabinger
- Department of Medicine I, Clinical Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna, Austria
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