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de Kovel MS, Escuriola-Ettingshausen C, Königs C, Ranta S, Fischer K. Bleeding phenotype according to factor level in 825 children with nonsevere hemophilia: data from the PedNet cohort. J Thromb Haemost 2024:S1538-7836(24)00322-2. [PMID: 38866249 DOI: 10.1016/j.jtha.2024.05.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 05/21/2024] [Accepted: 05/28/2024] [Indexed: 06/14/2024]
Abstract
BACKGROUND Information on bleeding phenotype in nonsevere hemophilia may be used to determine target factor levels for prophylaxis or gene therapy in severe hemophilia. OBJECTIVES To assess the association between endogenous factor level and bleeding phenotype in children with nonsevere (factor [F]VIII/FIX activity 1%-25%) hemophilia A (HA) and B without prophylaxis. METHODS Data on annualized bleeding rate (ABR), annualized joint bleeding rate (AJBR), and onset of bleeding were extracted from the international PedNet cohort including children born since 2000. Mean ABR and AJBR were modeled and compared according to FVIII/FIX endogenous activity (1%-2%, 3%-5%, 6%-10%, 11%-15%, 16%-20%, and 21%-25%) using negative binomial regression. Onset of bleeding was analyzed using Kaplan-Meier survival curves. RESULTS Eight hundred twenty-five children (40% with moderate hemophilia; 87% with HA) with median follow-up of 7.4 years/child were included. The median age at onset of bleeding and median bleeding rates changed with increasing endogenous activity. From endogenous FVIII 1% to 2% to 21% to 25%, the age at onset of bleeding changed from a median of 1.4 to 14.2 years, ABR from 1.6 to 0.1/y, and AJBR from 0.5 to 0.0/y. From endogenous FIX 1% to 2% to 16% to 25%, the onset of bleeding changed from a median of 1.7 to 6.1 years, ABR from 0.5 to 0.1/y, and AJBR from 0.1 to 0.0/y. The negative correlation between AJBR and factor level was most strongly pronounced up to a factor level of 6% in HA and hemophilia B. CONCLUSION Endogenous factor activity of >5% was identified as a threshold to significantly lower joint bleeding rate, while FVIII levels >15% and FIX levels >10% were sufficient to achieve the goal of 0 bleeds in this pediatric cohort.
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Affiliation(s)
| | | | - Christoph Königs
- Goethe University Frankfurt, University Hospital, Department of Paediatrics and Adolescent Medicine, Clinical and Molecular Hemostasis, Frankfurt, Germany
| | - Susanna Ranta
- Pediatric Coagulation Unit, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Kathelijn Fischer
- Center for Benign Haematology, Thrombosis and Haemostasis Van Creveldkliniek, University Medical Center Utrecht, Utrecht, The Netherlands
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Arvanitakis A, Jepsen C, Andersson NG, Baghaei F, Astermark J. Primary prophylaxis implementation and long-term joint outcomes in Swedish haemophilia A patients. Haemophilia 2024; 30:671-677. [PMID: 38575549 DOI: 10.1111/hae.15013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Revised: 03/21/2024] [Accepted: 03/26/2024] [Indexed: 04/06/2024]
Abstract
INTRODUCTION Primary prophylaxis is the gold standard in severe haemophilia A (SHA) but time to escalate the prophylaxis regimen varies. AIM Assess prophylaxis implementation and long-term joint health outcomes in SHA with primary prophylaxis. METHODS Adult male patients born after 1980, with SHA on primary prophylaxis, started before the age of 3 years and second joint bleed, and no history of FVIII inhibitors, were enrolled. Repeated joint-health examinations were performed with HJHS or HEAD-US; VERITAS-PRO assessed adherence. RESULTS Thirty patients were enrolled with, at inclusion, median age 33.5 years, annualized bleed rate and joint bleed rate 0, and FVIII consumption 4232 IU/kg/year, respectively. The median age was 1.2 years, at prophylaxis start once weekly with a median FVIII dose of 47.7 IU/kg, and 1.7 years, by the time escalation to a final regimen had occurred, with a median infusion frequency of thrice weekly and FVIII dose 41.7 IU/kg, respectively. Older age correlated with later transition to escalated prophylaxis (p < .001). Longer time to escalated prophylaxis correlated to more bleeds (p < .001). Median HJHS increased slowly, reaching 4 at 35-40 years. HJHS at 15-20 years correlated with higher HJHS afterwards. Median total HEAD-US score was 1 and correlated with HJHS (p < .001). Median VERITAS-PRO score was 36, indicating good treatment adherence. CONCLUSION Primary prophylaxis is effective but does not completely prevent the gradual development of arthropathy in SHA. Joint assessments with HJHS should start at an early age, as they correlate with arthropathy in later life. Prophylaxis escalation should proceed expeditiously to prevent bleeds.
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Affiliation(s)
- Alexandros Arvanitakis
- Department of Translational Medicine, Lund University, Malmö, Sweden
- Department of Haematology, Oncology and Radiation Physics, Skåne University Hospital, Malmö, Sweden
| | - Caroline Jepsen
- Region Västra Götaland, Sahlgrenska University Hospital, Department of Medicine, Coagulation Centre, Gothenburg, Sweden
| | - Nadine G Andersson
- Department for Paediatric Haematology and Oncology, Children's Hospital, Skåne University Hospital, Malmö, Sweden
- Department of Clinical Sciences, Paediatrics, Lund University, Malmö, Sweden
| | - Fariba Baghaei
- Region Västra Götaland, Sahlgrenska University Hospital, Department of Medicine, Coagulation Centre, Gothenburg, Sweden
| | - Jan Astermark
- Department of Translational Medicine, Lund University, Malmö, Sweden
- Department of Haematology, Oncology and Radiation Physics, Skåne University Hospital, Malmö, Sweden
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van Heel DA, Foppen W, Fischer K. Arthropathy on X-rays in 363 persons with hemophilia: long-term development, and impact of birth cohort and inhibitor status. Res Pract Thromb Haemost 2024; 8:102355. [PMID: 38496709 PMCID: PMC10941006 DOI: 10.1016/j.rpth.2024.102355] [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: 09/13/2023] [Revised: 01/13/2024] [Accepted: 02/09/2024] [Indexed: 03/19/2024] Open
Abstract
Background Arthropathy following repeated bleeding is common in persons with hemophilia. Since the introduction of prophylaxis, treatment has intensified and joint health has improved. However, data on the long-term development of arthropathy are still scant. Objectives To evaluate long-term arthropathy development since the introduction of prophylaxis according to birth cohort, hemophilia severity, and inhibitor status. Methods This single-center historic cohort study included persons with severe and moderate hemophilia A and hemophilia B born between 1935 and 2005. Arthropathy on X-rays was evaluated using the Pettersson score. Patient and joint characteristics were studied per birth cohort (<1970, 1970-1980, 1981-1990, and >1990) and compared according to hemophilia severity. The distribution of affected joints and cumulative incidence of arthropathy were analyzed. The association of Pettersson score with birth cohort and inhibitor characteristics was explored using multivariable regression analyses adjusted for age at evaluation. Results In total, 1064 X-rays of 363 patients were analyzed. Of persons with severe hemophilia (n = 317, 87.3%), 244 (77.0%) developed arthropathy. Prophylaxis was started at younger ages over time, from a median of 18 to 2.1 years, and concomitantly, arthropathy decreased in consecutive birth cohorts. Ankles were most commonly affected in 188 of 258 (72.9%) patients. Persons with moderate hemophilia (n = 46, 12.7%) had a lower risk of arthropathy (27/46 [58.7%]), but a reduction over time was less pronounced. In the multivariable analyses, birth cohort and age at evaluation were predictors for the development of arthropathy, while inhibitor status showed no association. Conclusion The development and severity of arthropathy have decreased over the past decades. However, patients have remained at risk for developing arthropathy, especially in their ankles.
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Affiliation(s)
- Dayna A.M. van Heel
- Center of Expertise for Benign Haematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Wouter Foppen
- Department of Radiology and Nuclear Medicine, Division of Imaging and Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Kathelijn Fischer
- Center of Expertise for Benign Haematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
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Leuci A, Dargaud Y. Blood-Induced Arthropathy: A Major Disabling Complication of Haemophilia. J Clin Med 2023; 13:225. [PMID: 38202232 PMCID: PMC10779541 DOI: 10.3390/jcm13010225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 12/19/2023] [Accepted: 12/28/2023] [Indexed: 01/12/2024] Open
Abstract
Haemophilic arthropathy (HA) is one of the most serious complications of haemophilia. It starts with joint bleeding, leading to synovitis which, in turn, can cause damage to the cartilage and subchondral bone, eventually inducing degenerative joint disease. Despite significant improvements in haemophilia treatment over the past two decades and recent guidelines from ISTH and WFH recommending FVIII trough levels of at least 3 IU/dL during prophylaxis, patients with haemophilia still develop joint disease. The pathophysiology of HA is complex, involving both inflammatory and degenerative components. Early diagnosis is key for proper management. Imaging can detect joint subclinical changes and influence prophylaxis. Magnetic resonance imagining (MRI) and ultrasound are the most frequently used methods in comprehensive haemophilia care centres. Biomarkers of joint health have been proposed to determine osteochondral joint deterioration, but none of these biomarkers has been validated or used in clinical practice. Early prophylaxis is key in all severe haemophilia patients to prevent arthropathy. Treatment is essentially based on prophylaxis intensification and chronic joint pain management. However, there remain significant gaps in the knowledge of the mechanisms responsible for HA and prognosis-influencing factors. Better understanding in this area could produce more effective interventions likely to ultimately prevent or attenuate the development of HA.
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Affiliation(s)
- Alexandre Leuci
- UR4609 Hemostasis & Thrombosis Research Unit, Faculté de Médecine Lyon Est, Université Claude Bernard Lyon 1, 69008 Lyon, France;
| | - Yesim Dargaud
- UR4609 Hemostasis & Thrombosis Research Unit, Faculté de Médecine Lyon Est, Université Claude Bernard Lyon 1, 69008 Lyon, France;
- Unité d’Hémostase Clinique—Centre de Référence de l’Hémophilie, Hôpital Louis Pradel Hospices Civils de Lyon, 69002 Lyon, France
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Mizoguchi Y, Tani C, Aizawa M, Tomioka K, Shimomura M, Nishimura S, Matsubara Y, Iwaki D, Tanaka K, Kawaguchi H, Nakashima Y, Mikami Y, Okada S, Kobayashi M. Age-specific incidence of joint disease in paediatric patients with haemophilia: A single-centre real-world outcome based on consecutive US examination. Haemophilia 2023; 29:1359-1365. [PMID: 37639381 DOI: 10.1111/hae.14848] [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: 03/27/2023] [Revised: 08/06/2023] [Accepted: 08/10/2023] [Indexed: 08/31/2023]
Abstract
INTRODUCTION Joint health is one of the most important factors contributing to a healthy life in patients with haemophilia. Recent study revealed that starting early prophylaxis was not enough to prevent joint disease in most paediatric patients with haemophilia. AIM In this study, we aimed to determine the age-specific incidence of acute joint disease during childhood at single haemophilia treatment centre (HTC). METHOD The joint health in 48 patients was evaluated based on consecutive US testing for 5 years at annual multidisciplinary comprehensive care. RESULTS During the study period, 23 patients (47.9%) had no joint disease since the initial examination, whereas 13 patients (27.0%) showed development from negative to positive findings. The incidence of joint disease increased with age: 0% in preschool, 5.3% in elementary school, 14.3% in junior high school and 35% beyond high school age. Among the 13 patients who developed joint disease, two experienced acquired synovitis that resolved during the follow-up period. Statistical analysis revealed that the patients who routinely underwent follow-up by the HTC exhibited a significantly lower incidence of joint disease than did those followed up at other institutions (p < .001). CONCLUSION These results indicated that close check-up, including routine joint examination using US as well as frequent assessment of pharmacokinetic profile at the HTC, might play an important role in avoiding joint disease among paediatric patients with haemophilia.
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Affiliation(s)
- Yoko Mizoguchi
- Department of Pediatrics, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
| | - Chihiro Tani
- Department of Diagnostic Radiology, Hiroshima University Hospital, Hiroshima, Japan
| | - Mika Aizawa
- Graduate School of Advanced Science and Engineering, Hiroshima University, Hiroshima, Japan
| | - Keita Tomioka
- Department of Pediatrics, Hiroshima Prefectural Rehabilitation Center, Hiroshima, Japan
| | - Maiko Shimomura
- Department of Pediatrics, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
| | - Shiho Nishimura
- Department of Pediatrics, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, Japan
| | - Yoshiko Matsubara
- Department of Diagnostic Radiology, Hiroshima University Hospital, Hiroshima, Japan
| | - Daisuke Iwaki
- Division of Rehabilitation, Department of Clinical Practice and Support, Hiroshima University Hospital, Hiroshima, Japan
| | - Kiyoto Tanaka
- Department of Pediatrics, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
| | - Hiroshi Kawaguchi
- Department of Pediatrics, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
| | - Yuko Nakashima
- Collaborative Research laboratory of Musculoskeletal Ultrasound in Medicine, Hiroshima University Hospital, Hiroshima, Japan
| | - Yukio Mikami
- Department of Rehabilitation Medicine, Hiroshima University Hospital, Hiroshima, Japan
| | - Satoshi Okada
- Department of Pediatrics, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
| | - Masao Kobayashi
- Japanese Red Cross, Chugokushikoku Block Blood Center, Hiroshima, Japan
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