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Dorgalaleh A. Novel Insights into Heterozygous Factor XIII Deficiency. Semin Thromb Hemost 2024; 50:200-212. [PMID: 36940714 DOI: 10.1055/s-0043-1764471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2023]
Abstract
The prevalence and clinical significance of heterozygous factor XIII (FXIII) deficiency has long been debated, with controversial reports emerging since 1988. In the absence of large epidemiologic studies, but based on a few studies, a prevalence of 1 per 1,000 to 5,000 is estimated. In southeastern Iran, a hotspot area for the disorder, a study of more than 3,500 individuals found an incidence of 3.5%. Between 1988 and 2023, a total of 308 individuals were found with heterozygous FXIII deficiency, of which molecular, laboratory, and clinical presentations were available for 207 individuals. A total of 49 variants were found in the F13A gene, most of which were missense (61.2%), followed by nonsense (12.2%) and small deletions (12.2%), most occurring in the catalytic domain (52.1%) of the FXIII-A protein and most frequently in exon 4 (17%) of the F13A gene. This pattern is relatively similar to homozygous (severe) FXIII deficiency. In general, heterozygous FXIII deficiency is an asymptomatic condition without spontaneous bleeding tendency, but it can lead to hemorrhagic complications in hemostatic challenges such as trauma, surgery, childbirth, and pregnancy. Postoperative bleeding, postpartum hemorrhage, and miscarriage are the most common clinical manifestations, while impaired wound healing has been rarely reported. Although some of these clinical manifestations can also be observed in the general population, they are more common in heterozygous FXIII deficiency. While studies of heterozygous FXIII deficiency conducted over the past 35 years have shed light on some of the ambiguities of this condition, further studies on a large number of heterozygotes are needed to answer the major questions related to heterozygous FXIII deficiency.
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Sharma R, Jamwal M, Singh N, Sharma P, Bansal D, Trehan A, Malhotra P, Jain A, Ahluwalia J, Das R, Kumar N. Genetic Spectrum in F13A1 Detected by Next-Generation Sequencing Among North Indian Patients with FXIII Deficiency. Indian J Hematol Blood Transfus 2023; 39:276-283. [PMID: 37006978 PMCID: PMC10064406 DOI: 10.1007/s12288-022-01579-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 09/02/2022] [Indexed: 11/05/2022] Open
Abstract
Purpose The study aimed to explore the molecular defects underlying FXIII deficiency. Materials and Methods Sixteen unrelated cases were enrolled based on the indication of the urea clot solubility test and Factor XIII-A antigen levels. Cases were further subjected to targeted next-generation sequencing (custom gene panel: F7, F8, VWF, F9, F13A1, F13B). The pathogenic/likely pathogenic variants were validated by Sanger sequencing in the patients and family members. Results Mean age of referral to our center was 27.2 years (8 week-67 years). Consanguinity was found in only one of the 16 cases and 9 cases presented in infancy. The most common symptoms were skin bleeds (69%) and umbilical cord bleed (50%). The clot solubility test was positive in 12, inconclusive in 1, and normal in 3. Mean FXIII-A levels were 15.7 IU/dL (range 0.6 to 49.5 IU/dL). Pathogenic/likely pathogenic variants in F13A1 were found in 11 (69%). Nine cases (82%) were homozygous, and two were compound heterozygous. Total eleven variants were found of which four were missense (c.1226G>A; c.998C>T; c.631G>C; c.2134A>C); three deletion (c.521delG; c.742delA; c.1405_1408delCAAA); two nonsense (c.1112G>A; c.1127G>A) and two splice site (c.1909-1G>C; c.2045G>A). No probably pathogenic variant was found in the F13B. Conclusion Inherited FXIII deficiency with bleeding is associated with genetic defects in predominantly the F13A1 gene. A variety of variants were seen in this cohort. A nonsense variant c.1127G>A found in three of our cases seems to be recurrent. This data will contribute to designing functional studies and antenatal testing in affected families. Supplementary Information The online version contains supplementary material available at 10.1007/s12288-022-01579-1.
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Affiliation(s)
- Ritika Sharma
- Department of Hematology, Postgraduate Institute of Medical Education and Research, 160012 Chandigarh, India
| | - Manu Jamwal
- Department of Hematology, Postgraduate Institute of Medical Education and Research, 160012 Chandigarh, India
| | - Namrata Singh
- Department of Hematology, Postgraduate Institute of Medical Education and Research, 160012 Chandigarh, India
| | - Prashant Sharma
- Department of Hematology, Postgraduate Institute of Medical Education and Research, 160012 Chandigarh, India
| | - Deepak Bansal
- Department of Pediatrics (Hematology-Oncology Unit), Postgraduate Institute of Medical Education and Research, 160012 Chandigarh, India
| | - Amita Trehan
- Department of Pediatrics (Hematology-Oncology Unit), Postgraduate Institute of Medical Education and Research, 160012 Chandigarh, India
| | - Pankaj Malhotra
- Department of Clinical Hematology and Medical Oncology, Postgraduate Institute of Medical Education and Research, 160012 Chandigarh, India
| | - Arihant Jain
- Department of Clinical Hematology and Medical Oncology, Postgraduate Institute of Medical Education and Research, 160012 Chandigarh, India
| | - Jasmina Ahluwalia
- Department of Hematology, Postgraduate Institute of Medical Education and Research, 160012 Chandigarh, India
| | - Reena Das
- Department of Hematology, Postgraduate Institute of Medical Education and Research, 160012 Chandigarh, India
| | - Narender Kumar
- Department of Hematology, Postgraduate Institute of Medical Education and Research, 160012 Chandigarh, India
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Javed H, Singh S, Urs SUR, Oldenburg J, Biswas A. Genetic landscape in coagulation factor XIII associated defects – Advances in coagulation and beyond. Blood Rev 2022; 59:101032. [PMID: 36372609 DOI: 10.1016/j.blre.2022.101032] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 10/26/2022] [Accepted: 10/28/2022] [Indexed: 11/06/2022]
Abstract
Coagulation factor XIII (FXIII) acts as a fine fulcrum in blood plasma that maintains the balance between bleeding and thrombosis by covalently crosslinking the pre-formed fibrin clot into an insoluble one that is resistant to premature fibrinolysis. In plasma, FXIII circulates as a pro-transglutaminase complex composed of the dimeric catalytic FXIII-A encoded by the F13A1 gene and dimeric carrier/regulatory FXIII-B subunits encoded by the F13B gene. Growing evidence accumulated over decades of exhaustive research shows that not only does FXIII play major roles in both pathological extremes of hemostasis i.e. bleeding and thrombosis, but that it is, in fact, a pleiotropic protein with physiological roles beyond coagulation. However, the current FXIII genetic-epidemiological literature is overwhelmingly derived from the bleeding pathology associated with its deficiency. In this article we review the current clinical, functional, and molecular understanding of this fascinating multifaceted protein, especially putting into the same perspective its genetic landscape.
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Ejaz M, Saleem A, Ali N, Tariq F. Factor XIII deficiency with intracranial haemorrhage. BMJ Case Rep 2019; 12:e228682. [PMID: 31451452 PMCID: PMC6720766 DOI: 10.1136/bcr-2018-228682] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/31/2019] [Indexed: 11/04/2022] Open
Abstract
A 5-year-old girl presented to paediatric emergency with fever and seizures for a short duration. At first, meningitis was suspected and management was started empirically. There was no improvement in the clinical condition of the patient and investigations revealed spontaneous intracranial haemorrhage (ICH) secondary to factor XIII deficiency. The child was transfused cryoprecipitate and managed conservatively for ICH. She became asymptomatic and was kept on monthly cryoprecipitate transfusions. This case report summarises factor XIII deficiency in ICH which was not suspected initially, but diagnosed later on after CT scan head and factor XIII assay. This report also highlights events occurring during its management.
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Affiliation(s)
- Muzamil Ejaz
- Pediatrics, Dow Medical College, Dow University of Health Sciences, Dr Ruth KM Pfau Civil Hospital, Karachi, Pakistan
| | - Ayesha Saleem
- Pediatrics, Dow Medical College, Dow University of Health Sciences, Dr Ruth KM Pfau Civil Hospital, Karachi, Pakistan
| | - Nimrah Ali
- Pediatrics, Dow Medical College, Dow University of Health Sciences, Dr Ruth KM Pfau Civil Hospital, Karachi, Pakistan
| | - Fizza Tariq
- Pediatrics, Dow Medical College, Dow University of Health Sciences, Dr Ruth KM Pfau Civil Hospital, Karachi, Pakistan
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Li B, Billur R, Maurer MC, Kohler HP, Raddatz Müller P, Alberio L, Schroeder V. Proline 36 of the Factor XIII Activation Peptide Plays a Crucial Role in Substrate Recognition and Zymogen Activation. Thromb Haemost 2018; 118:2037-2045. [PMID: 30419598 DOI: 10.1055/s-0038-1675600] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
The activation peptide of blood coagulation factor XIII (AP-FXIII) has important functions in stabilizing the FXIII-A2 dimer and regulating FXIII activation. Contributions of many of its 37 amino acids to these functions have been described. However, the role of proline 36, which is adjacent to the thrombin cleavage site at Arg37, has not yet been studied in detail. We approached this question when we came across a patient with congenital FXIII deficiency in whom we detected a novel Pro36Ser mutation. We expressed the mutant FXIII-A Pro36Ser protein in Chinese hamster ovary cells and found that this mutation does not influence FXIII-A expression but significantly inhibits proteolytic activation by thrombin. The enzymatic transglutaminase activity is not affected as it can be induced in the presence of high Ca2+ concentrations. We performed nuclear magnetic resonance analysis to investigate AP-FXIII-thrombin interactions, which showed that the mutant Ser36 peptide binds less well to the thrombin surface than the native Pro36 peptide. The Arg37 at the P1 position still makes strong interactions with the active site cleft but the P4-P2 residues (34VVS36) appear to be less well positioned to contact the neighbouring thrombin active site region. In conclusion, we have characterized a novel mutation in AP-FXIII representing only the fourth case of the rare FXIII-A type II deficiency. This case served as a perfect in vivo model to shed light on the crucial role of Pro36 in the proteolytic activation of FXIII-A. Our results contribute to the understanding of structure-function relationship in FXIII.
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Affiliation(s)
- Bojun Li
- Experimental Haemostasis Group, Department for BioMedical Research, University of Bern, Bern, Switzerland
| | - Ramya Billur
- Department of Chemistry, University of Louisville, Louisville, Kentucky, United States
| | - Muriel C Maurer
- Department of Chemistry, University of Louisville, Louisville, Kentucky, United States
| | - Hans P Kohler
- Experimental Haemostasis Group, Department for BioMedical Research, University of Bern, Bern, Switzerland
| | - Pascale Raddatz Müller
- Division of Haematology and Central Haematology Laboratory, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Lorenzo Alberio
- Division of Haematology and Central Haematology Laboratory, Lausanne University Hospital, Lausanne, Switzerland.,Faculté de Biologie et Médecine, University of Lausanne, Lausanne, Switzerland
| | - Verena Schroeder
- Experimental Haemostasis Group, Department for BioMedical Research, University of Bern, Bern, Switzerland
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Li B, Borhany M, Abid M, Kohler HP, Schroeder V. Identification of a novel nonsense mutation leading to congenital factor XIII deficiency. Thromb Res 2018; 165:83-85. [PMID: 29604433 DOI: 10.1016/j.thromres.2018.03.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Revised: 02/13/2018] [Accepted: 03/26/2018] [Indexed: 11/18/2022]
Affiliation(s)
- Bojun Li
- Experimental Haemostasis Group, Department for BioMedical Research, University of Bern, Bern, Switzerland
| | - Munira Borhany
- Department of Haematology, Haemostasis & Thrombosis, National Institute of Blood Disease and Bone Marrow Transplantation (NIBD), Karachi, Pakistan
| | - Madiha Abid
- Department of Haematology, Haemostasis & Thrombosis, National Institute of Blood Disease and Bone Marrow Transplantation (NIBD), Karachi, Pakistan
| | - Hans P Kohler
- Experimental Haemostasis Group, Department for BioMedical Research, University of Bern, Bern, Switzerland; Department of Medicine, Inselgruppe, Tiefenauspital, Bern, Switzerland
| | - Verena Schroeder
- Experimental Haemostasis Group, Department for BioMedical Research, University of Bern, Bern, Switzerland.
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Ivaškevičius V, Biswas A, Garly ML, Oldenburg J. Comparison ofF13A1gene mutations in 73 patients treated with recombinant FXIII-A2. Haemophilia 2017; 23:e194-e203. [DOI: 10.1111/hae.13233] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/10/2017] [Indexed: 11/28/2022]
Affiliation(s)
- V. Ivaškevičius
- Institute of Experimental Haematology and Transfusion Medicine; University Hospital Bonn; Bonn Germany
| | - A. Biswas
- Institute of Experimental Haematology and Transfusion Medicine; University Hospital Bonn; Bonn Germany
| | | | - J. Oldenburg
- Institute of Experimental Haematology and Transfusion Medicine; University Hospital Bonn; Bonn Germany
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Autoimmune acquired factor XIII deficiency due to anti-factor XIII/13 antibodies: A summary of 93 patients. Blood Rev 2016; 31:37-45. [PMID: 27542511 DOI: 10.1016/j.blre.2016.08.002] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 07/14/2016] [Accepted: 08/02/2016] [Indexed: 11/22/2022]
Abstract
Autoimmune acquired factor XIII (F13) deficiency or autoimmune hemophilia-like disease (hemorrhaphilia) resulted from the generation of anti-F13 antibodies (AH13) is a severe bleeding disorder that occurs mainly in the elderly. Although rare, the number of patients diagnosed with AH13 has recently increased. To improve understanding of this disease, the author summarized 93 ever reported/diagnosed AH13 cases. About 50% of cases were idiopathic. In the remaining half of the patients, autoimmune diseases and malignancies were the most common underlying diseases. Intramuscular and subcutaneous bleeding were the most frequently reported symptoms. Hemorrhage was the cause of death in 13 patients. In 4 patients, the diagnosis was established after hemorrhagic death. Therefore, physicians/hematologists must raise the awareness of AH13 as a life-threatening disease. Most patients were treated with F13 concentrates to arrest bleeding and with prednisolone and cyclophosphamide to eradicate anti-F13 autoantibodies. AH13 cases tend to become chronic and intractable and require close follow-up over an extended period.
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Blood coagulation factor XIII and factor XIII deficiency. Blood Rev 2016; 30:461-475. [PMID: 27344554 DOI: 10.1016/j.blre.2016.06.002] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Revised: 06/01/2016] [Accepted: 06/10/2016] [Indexed: 11/20/2022]
Abstract
Factor XIII (FXIII) is a multifunctional pro-γ-transglutaminase that, in addition to its well-known role in hemostasis, has a crucial role in angiogenesis, maintenance of pregnancy, wound healing, bone metabolism, and even cardio protection. FXIII deficiency (FXIIID) is a rare bleeding disorder (RBD) with an estimated incidence of one per two million that is accompanied by life-threatening bleeding such as umbilical cord bleeding, recurrent spontaneous miscarriage, and intracranial hemorrhage (ICH). Today, the disease is successfully managed by FXIII concentrate and recombinant FXIII for prophylaxis, management of minor and major bleeding, treatment of ICH, and successful delivery in women with recurrent pregnancy loss. Molecular analysis of patients with FXIIID revealed a wide spectrum of mutations, most frequently missense mutations in the FXIII-A subunit, with a few recurrent mutations observed worldwide. In vitro expression studies revealed that most of the missense mutations cause intracellular instability of the FXIII protein and, subsequently, FXIIID.
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Handrkova H, Borhany M, Schroeder V, Fatima N, Hussain A, Shamsi T, Kohler HP. Identification of two novel missense mutations causing severe factor XIII deficiency. Haemophilia 2015; 21:e253-e256. [PMID: 25832324 DOI: 10.1111/hae.12663] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/04/2015] [Indexed: 11/26/2022]
Affiliation(s)
- H Handrkova
- University Clinic of Haematology, Haemostasis Research Laboratory, University Hospital of Bern, Bern, Switzerland; Department of Clinical Research, University of Bern, Bern, Switzerland
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