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Seidizadeh O, Baronciani L, Lillicrap D, Peyvandi F. Application of genetic testing for the diagnosis of von Willebrand disease. J Thromb Haemost 2024:S1538-7836(24)00288-5. [PMID: 38762018 DOI: 10.1016/j.jtha.2024.05.006] [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: 01/12/2024] [Revised: 04/13/2024] [Accepted: 05/08/2024] [Indexed: 05/20/2024]
Abstract
von Willebrand disease (VWD) is the most frequent inherited bleeding disorder, with an estimated symptomatic prevalence of 1 per 1000 in the general population. VWD is characterized by defects in the quantity, quality, or multimeric structure of von Willebrand factor (VWF), a glycoprotein being hemostatically essential in circulation. VWD is classified into 3 principal types: low VWF/type 1 with partial quantitative deficiency of VWF, type 3 with virtual absence of VWF, and type 2 with functional abnormalities of VWF, being classified as 2A, 2B, 2M, and 2N. A new VWD type has been officially recognized by the ISTH SSC on von Willebrand factor which has also been discussed by the joint ASH/ISTH/NHF/WFH 2021 guidelines (ie, type 1C), indicating patients with quantitative deficiency due to an enhanced VWF clearance. With the advent of next-generation sequencing technologies, the process of genetic diagnosis has substantially changed and improved accuracy. Therefore, nowadays, patients with type 3 and severe type 1 VWD can benefit from genetic testing as much as type 2 VWD. Specifically, genetic testing can be used to confirm or differentiate a VWD diagnosis, as well as to provide genetic counseling. The focus of this manuscript is to discuss the current knowledge on VWD molecular pathophysiology and the application of genetic testing for VWD diagnosis.
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Affiliation(s)
- Omid Seidizadeh
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy. https://twitter.com/OmidSeidi
| | - Luciano Baronciani
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - David Lillicrap
- Department of Pathology and Molecular Medicine, Queen's University, Kingston, Ontario, Canada. https://twitter.com/DavidLillicrap
| | - Flora Peyvandi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy.
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Seidizadeh O, Ciavarella A, Baronciani L, Boggio F, Ballardini F, Cozzi G, Colpani P, Pagliari MT, Novembrino C, Siboni SM, Peyvandi F. Clinical and Laboratory Presentation and Underlying Mechanism in Patients with Low VWF. Thromb Haemost 2024; 124:340-350. [PMID: 37799090 DOI: 10.1055/a-2186-6362] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/07/2023]
Abstract
BACKGROUND Low von Willebrand factor (VWF) refers to subjects with plasma levels of 30 to 50 IU/dL. The mechanism of low VWF is poorly understood. We chose to determine the clinical presentation, laboratory phenotype, and underlying mechanisms of low VWF. MATERIAL AND METHODS We included 250 patients characterized with low VWF. The International Society on Thrombosis and Haemostasis Bleeding Assessment Tool (ISTH-BAT) was used to assess clinical symptoms. To determine the underlying mechanisms of low VWF, we used as markers the VWF propeptide (VWFpp) assay and FVIII:C/VWF:Ag ratio for VWF synthesis and the VWFpp/VWF:Ag ratio for VWF clearance. Results were compared with those of 120 healthy controls. Cases with abnormal screening tests were further evaluated for coagulation factor levels and platelet disorders. RESULTS The median age of the cohort was 35 years (range 3-85), 21% were children (n = 53), 34% were adult males (n = 85), and 45% (n = 112) were adult females. According to the ISTH-BAT, abnormal bleeding was found in 35% of children, 47% of males, and 49% of females. No association was found between VWF activity levels and ISTH-BAT. Patients showed an overall decreased VWF synthesis/secretion and an enhanced VWF clearance was identified in 33% of them. In 89 patients (36%), there were other hemostasis-related defects, but there was no difference in the ISTH-BAT between the two groups. CONCLUSION Our findings indicate that reduced VWF synthesis/secretion and enhanced VWF clearance are major mechanisms of low VWF levels. Patients with low VWF have significant bleeding manifestations. While other hemostasis defects occurred together with low VWF, this combination did not exacerbate clinical symptoms.
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Affiliation(s)
- Omid Seidizadeh
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Alessandro Ciavarella
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Luciano Baronciani
- Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
| | - Federico Boggio
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | | | - Giovanna Cozzi
- Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
| | - Paola Colpani
- Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
| | - Maria Teresa Pagliari
- Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
| | - Cristina Novembrino
- Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
| | - Simona Maria Siboni
- Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
| | - Flora Peyvandi
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
- Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
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Owaidah T, Alharbi M, Mandourah M, Saleh M, Almusa A, Alnounou R, Alzahrani H, Khogeer H. Clinical and laboratory presentation of von Willebrand disease: Experience from a single center in KSA. J Taibah Univ Med Sci 2022; 18:413-419. [PMID: 37102076 PMCID: PMC10124135 DOI: 10.1016/j.jtumed.2022.10.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Revised: 09/17/2022] [Accepted: 10/18/2022] [Indexed: 11/16/2022] Open
Abstract
Objectives This study was aimed at assessing the clinical presentations and laboratory findings among patients diagnosed with vWD at a Saudi tertiary care unit. Methods This retrospective study included 189 patients with vWD who were followed up in our unit over 4 years. Clinical and laboratory data were collected and analyzed in SPSS. Results The median age of the study cohort was 30 years (range 11 months-56 years). The cohort had a female preponderance, with 32.30% males and 66.70% females. Bleeding from different sites was observed, mostly from the joints and muscles (23.90%), followed by the mucus membranes (14.60%), genitourinary areas (7.70%), ecchymoses (2.80%), and gastrointestinal areas (2.80%). A total of 48% of participants presented with more than one type of bleeding. A total of 105 (58.01%) participants had type 1; 29 (16.02%) had type 2; and 47 (25.96%) had type 3 vWD. Blood tests indicated the following mean value: hemoglobin, 116 ± 25.60 gm/L; ferritin, 75.80 ± 166.80 μg/L (median 28.5); vWAg, 0.40 ± 0.27IU/ml; and vWD:RCo, 0.32 ± 0.20IU/dL. The partial thromboplastin time was prolonged in 49.20% and normal in 50.80% of participants. Platelet function analysis values were prolonged in 92.90% and normal in 7.10% of participants. Comparative analysis of the O-type and non-O blood type showed that blood type O was significantly correlated with factor VIII (p-value = 0.013), vWF:RCo (p-value = 0.004), and vWF:Ag (p-value = 0.019). Conclusion Joint and muscle bleeds were the most common clinical presentations in our cohort. Although type 1 vWD was most prevalent in our cohort, we observed a comparatively higher prevalence of type 3, possibly because of ethnic differences or referral bias. We found a significant difference between O and non-O blood type regarding FVIII and vWF:Ag, and observed a more pronounced difference for vWD activity measuresd by vWF:RCo with blood type O being the systematic factor.
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Affiliation(s)
- Tarek Owaidah
- Department of Pathology and Laboratory Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, KSA
- Department of Haematology and Transfusion Medicine, Alfaisal University, Riyadh, KSA
- Corresponding address: Consultant Hematology and Transfusion Medicine, Alfaisal University, Riyadh 11211, KSA.
| | - Muhammed Alharbi
- Department of Pathology and Laboratory Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, KSA
| | - Mohammed Mandourah
- Department of Haematology and Transfusion Medicine, Alfaisal University, Riyadh, KSA
| | - Mahasen Saleh
- Department of Paediatric Haematology Oncology, King Faisal Specialist Hospital and Research Centre, Riyadh, KSA
| | - Abdulrahman Almusa
- Department of Paediatric Haematology Oncology, King Faisal Specialist Hospital and Research Centre, Riyadh, KSA
| | - Randa Alnounou
- Department of Pathology and Laboratory Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, KSA
| | - Hazza Alzahrani
- Adult Hematology/HSCT, Oncology Centre, King Faisal Specialist Hospital and Research Center Riyadh, KSA
| | - Haithm Khogeer
- Adult Hematology/HSCT, Oncology Centre, King Faisal Specialist Hospital and Research Center Riyadh, KSA
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Cryptogenic oozers and bruisers. Hematology 2021; 2021:85-91. [DOI: 10.1182/hematology.2021000236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Bleeding disorders with normal, borderline, or nondiagnostic coagulation tests represent a diagnostic challenge. Disorders of primary hemostasis can be further evaluated by additional platelet function testing modalities, platelet electron microscopy, repeat von Willebrand disease testing, and specialized von Willebrand factor testing beyond the usual initial panel. Secondary hemostasis is further evaluated by coagulation factor assays, and factor XIII assays are used to diagnose disorders of fibrin clot stabilization. Fibrinolytic disorders are particularly difficult to diagnose with current testing options. A significant number of patients remain unclassified after thorough testing; most unclassified patients have a clinically mild bleeding phenotype, and many may have undiagnosed platelet function disorders. High-throughput genetic testing using large gene panels for bleeding disorders may allow diagnosis of a larger number of these patients in the future, but more study is needed. A logical laboratory workup in the context of the clinical setting and with a high level of expertise regarding test interpretation and limitations facilitates a diagnosis for as many patients as possible.
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Atiq F, Wuijster E, de Maat MP, Kruip MJ, Cnossen MH, Leebeek FW. Criteria for low von Willebrand factor diagnosis and risk score to predict future bleeding. J Thromb Haemost 2021; 19:719-731. [PMID: 33370487 PMCID: PMC7986755 DOI: 10.1111/jth.15227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 12/01/2020] [Accepted: 12/18/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Important diagnostic and clinical aspects of moderately reduced von Willebrand factor (VWF) levels are still unknown. There is no clear evidence which cutoff value (0.50 vs 0.60 IU/ml) should be used to diagnose "low VWF." Also, the incidence of bleeding after the diagnosis has been made, and risk factors for bleeding are unknown yet. OBJECTIVES To investigate the incidence of postsurgical bleeding, postpartum hemorrhage (PPH), and traumatic and spontaneous bleeding after low VWF diagnosis, and to develop a risk score to predict future bleeding. METHODS We performed a cohort study in patients with historically lowest VWF levels of 0.31 to 0.60 IU/ml. Clinical data of patients were retrospectively collected. RESULTS We included 439 patients with low VWF. During a follow-up of 6.3 ± 3.7 years, 259 surgical procedures, 81 deliveries, and 109 spontaneous and traumatic bleeding episodes were reported. The incidence of postsurgical bleeding was 2.7%, whereas 10% of deliveries was complicated by PPH. Overall, 65 patients (14.8%) had bleeding requiring treatment, which was not different between patients with historically lowest VWF levels of 0.31-0.50 and 0.51-0.60 IU/ml (p = .154). Age <18 years, abnormal bleeding score at diagnosis, and being referred for bleeding symptoms at the time of diagnosis were independent risk factors for bleeding during follow-up, and therefore included in the risk score. CONCLUSIONS The cutoff value of low VWF diagnosis should be set at 0.60 IU/ml. Furthermore, a risk score is developed to identify individuals with a high risk for bleeding after low VWF diagnosis.
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Affiliation(s)
- Ferdows Atiq
- Department of HematologyErasmus MCUniversity Medical Center RotterdamRotterdamThe Netherlands
| | - Esmee Wuijster
- Department of HematologyErasmus MCUniversity Medical Center RotterdamRotterdamThe Netherlands
| | - Moniek P.M. de Maat
- Department of HematologyErasmus MCUniversity Medical Center RotterdamRotterdamThe Netherlands
| | - Marieke J.H.A. Kruip
- Department of HematologyErasmus MCUniversity Medical Center RotterdamRotterdamThe Netherlands
| | - Marjon H. Cnossen
- Department of Pediatric HematologyErasmus MC‐Sophia Children’s HospitalUniversity Medical Center RotterdamRotterdamThe Netherlands
| | - Frank W.G. Leebeek
- Department of HematologyErasmus MCUniversity Medical Center RotterdamRotterdamThe Netherlands
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Naderi M, Malek F, Miri Aliabad G, Behnampoor M, Karimi M, De Sanctis V. Congenital Bleeding Disorders amid the COVID-19 pandemic: Open questions and recommendations. ACTA BIO-MEDICA : ATENEI PARMENSIS 2020; 91:e2020028. [PMID: 32921723 PMCID: PMC7716957 DOI: 10.23750/abm.v91i3.10203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Accepted: 07/11/2020] [Indexed: 11/23/2022]
Abstract
This article reviews the current knowledges of congenital bleeding disorders (CBD) amid the COVID-19 pandemic. It appears that CBD is not associated with higher risk of getting COVID-19 and so the prevalence of COVID-19 among them seems not higher compared to the general population. In absence of specific therapeutic recommendations, it is essential to make a correct assessment of the risk of haemorrhage/thrombosis. Based on expert opinion, strategies for outpatient management include adherence to prescribed regimens, telemedicine, and communication about COVID-19 in patients with CBD. More data should be also collected to better characterize the impact of COVID-19 on patients with CBD. The current findings encourage further studies to determine the prevalence of SARS-CoV2 infection in CBD patients to understand more fully the burden of this novel pathogen and to develop adequate preventive measures against this infection.
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Affiliation(s)
- Majid Naderi
- Genetics of Non-Communicable Disease Research Center, Zahedan University of Medical Sciences, Zahedan, Iran,.
| | - Fatemeh Malek
- Pediatric Congenital Hematologic Disorders Research Center, Research Institute for Children's Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | | | - Mahammad Behnampoor
- Department of ediatrics, Zahedan University of Medical Sciences, Zahedan, Iran.
| | - Mehran Karimi
- Hematology Research Center, Shiraz University of Medical Sciences,.
| | - Vincenzo De Sanctis
- Pediatric and Adolescent Outpatient Clinic, Quisisana Hospital, Ferrara, Italy.
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Fogarty H, Doherty D, O'Donnell JS. New developments in von Willebrand disease. Br J Haematol 2020; 191:329-339. [PMID: 32394456 DOI: 10.1111/bjh.16681] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 03/30/2020] [Accepted: 04/01/2020] [Indexed: 12/19/2022]
Abstract
Von Willebrand disease (VWD) constitutes the most common inherited human bleeding disorder. It is associated with a mucocutaneous bleeding phenotype that can significantly impact upon quality of life. Despite its prevalence and associated morbidity, the diagnosis and subclassification of VWD continue to pose significant clinical challenges. This is in part attributable to the fact that plasma von Willebrand factor (VWF) levels vary over a wide range in the normal population, together with the multiple different physiological functions played by VWF in vivo. Over recent years, substantial progress has been achieved in elucidating the biological roles of VWF. Significant advances have also been made into defining the pathophysiological mechanisms underpinning both quantitative and qualitative VWD. In particular, several new laboratory assays have been developed that enable more precise assessment of specific aspects of VWF activity. In the present review, we discuss these recent developments in the field of VWD diagnosis, and consider how these advances can impact upon clinical diagnostic algorithms for use in routine clinical practice. In addition, we review some important recent advances pertaining to the various treatment options available for managing patients with VWD.
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Affiliation(s)
- Helen Fogarty
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland.,National Coagulation Centre, St James's Hospital, Dublin, Ireland
| | - Dearbhla Doherty
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - James S O'Donnell
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland.,National Coagulation Centre, St James's Hospital, Dublin, Ireland.,National Children's Research Centre, Our Lady's Children's Hospital Crumlin, Dublin, Ireland
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Favaloro EJ. Utility of the platelet function analyser (PFA-100/200) for exclusion or detection of von Willebrand disease: A study 22 years in the making. Thromb Res 2020; 188:17-24. [PMID: 32036157 DOI: 10.1016/j.thromres.2020.01.029] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Revised: 01/04/2020] [Accepted: 01/31/2020] [Indexed: 11/16/2022]
Abstract
INTRODUCTION von Willebrand disease (VWD) is the most common inherited bleeding disorder and may alternatively arise as an acquired condition (AVWS). These represent deficiency and/or defects in von Willebrand factor (VWF). Closure times (CTs) obtained from the platelet function analyser (PFA) are highly sensitive to both VWD/AVWS. The current study has evaluated the utility of the PFA-100/-200 to exclude or detect laboratory identified VWD. MATERIALS AND METHODS An evaluation of the success or otherwise of prospective PFA testing to help exclude or detect VWD using data from a locally maintained database. This database contains patient information, results of PFA testing, results of VWF testing, platelet count and hematocrit, and additional information, for a current total of 3678 entries representing over 2 decades of testing. RESULTS According to selection criteria, a total of 142 samples were identified as derived from patients with VWD. All but one of these were also identified to have abnormal PFA CTs. Additional data sets of patients with 'low VWF' (n = 137), or borderline normal VWF (n = 163) were also identified, as well as patients with thrombocytopenia and/or low hematocrit (n = 487). In these cohorts, PFA CTs were often (but not always) abnormal. There was a strong association between VWF test parameter values and PFA CTs. Additional study samples comprised cases with normal VWF parameters but prolonged CTs (n = 594), as well as cases with normal VWF and normal CTs (n = 1292), permitting calculation of sensitivity of abnormal PFA for VWD (99.3%), as well as specificity (68.5%), negative predictive value (99.9%) and positive predictive value (19.2%), for a prevalence of 7.0%. Comparatively, normal PFA CTs were better able to exclude VWD than normal test results for individual VWF parameters. CONCLUSION This study reports on an evaluation of PFA CTs for identification or exclusion of VWD. In our dataset, representing over 22 years of experience, normal PFA CTs were able to predict absence of VWD with higher sensitivity than individual VWF test results.
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Affiliation(s)
- Emmanuel J Favaloro
- Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead Hospital, Westmead, NSW, Australia; Sydney Centres for Thrombosis and Haemostasis Research, Westmead Hospital, Westmead, NSW, Australia.
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Oliver S, Vanniasinkam T, Mohammed S, Vong R, Favaloro EJ. Semi-automated von Willebrand factor multimer assay for von Willebrand disease: Further validation, benefits and limitations. Int J Lab Hematol 2019; 41:762-771. [PMID: 31508897 DOI: 10.1111/ijlh.13107] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 07/31/2019] [Accepted: 08/21/2019] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Accurate diagnosis of von Willebrand disease (VWD) enables effective patient management. von Willebrand factor (VWF) multimer analysis provides useful information regarding VWF multimer structure, thereby aiding VWD subtyping and management; however, historically technically challenging assays have had limited utility. This study evaluates the Sebia Hydrasys Hydragel-11 semi-automated VWF multimer assay and further validates the Hydragel-5 gel system, as primarily pertaining to VWD diagnostics and monitoring of therapy. METHODS Provisionally diagnosed (via a reference assay test panel) archived patient samples and prospective test patient samples, including those undergoing desmopressin trial or therapy monitoring, along with commercial and in-house control material and various external quality assessment (EQA) samples, were analysed. VWF multimers were evaluated for presence, loss or partial loss of high molecular weight (HMWM) and intermediate molecular weight (IMWM) multimers by both visual inspection and densitometric scanning, and comparison with reference assay results. RESULTS All anticipated multimer patterns were reproduced, with patients generally showing multimer profiles matching expected patterns according to VWD type based on reference test panel 'diagnosis'. Occasional discrepancies were resolved by retesting. The increase in plasma VWF following desmopressin therapy was also clearly demonstrated. Multimer profiles of EQA samples complemented reference test panel results and matched EQA targets. There were some 'technical' limitations noted. CONCLUSION This easy to use, standardised, semi-automated multimer analysis system can demonstrate the multimer profile of VWD patients, thus representing an additional laboratory tool for improved diagnosis, thereby facilitating appropriate patient management.
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Affiliation(s)
- Susan Oliver
- Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead Hospital, Westmead, NSW, Australia
| | - Thiru Vanniasinkam
- School of Biomedical Science, Charles Sturt University, Wagga Wagga, NSW, Australia
| | - Soma Mohammed
- Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead Hospital, Westmead, NSW, Australia
| | - Ronny Vong
- Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead Hospital, Westmead, NSW, Australia
| | - Emmanuel J Favaloro
- Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead Hospital, Westmead, NSW, Australia.,Sydney Centres for Thrombosis and Haemostasis, Westmead Hospital, Westmead, NSW, Australia
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Manderstedt E, Nilsson R, Lind-Halldén C, Ljung R, Astermark J, Halldén C. Targeted re-sequencing of F8, F9 and VWF: Characterization of Ion Torrent data and clinical implications for mutation screening. PLoS One 2019; 14:e0216179. [PMID: 31026269 PMCID: PMC6485758 DOI: 10.1371/journal.pone.0216179] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 04/15/2019] [Indexed: 12/11/2022] Open
Abstract
Mutations are not identified in ~5% of hemophilia A and 10–35% of type 1 VWD patients. The bleeding tendency also varies among patients carrying the same causative mutation, potentially indicating variants in additional genes modifying the phenotype that cannot be identified by routine single-gene analysis. The F8, F9 and VWF genes were analyzed in parallel using an AmpliSeq strategy and Ion Torrent sequencing. Targeting all exonic positions showed an average read depth of >2000X and coverage close to 100% in 24 male patients with known disease-causing mutations. Discrimination between reference alleles and alternative/indel alleles was adequate at a 25% frequency threshold. In F8, F9 and VWF there was an absolute majority of all reference alleles at allele frequencies >95% and the average alternative allele and indel frequencies never reached above 10% and 15%, respectively. In VWF, 4–5 regions showed lower reference allele frequencies; in two regions covered by the pseudogene close to the 25% cut-off for reference alleles. All known mutations, including indels, gross deletions and substitutions, were identified. Additional VWF variants were identified in three hemophilia patients. The presence of additional mutations in 2 out of 16 (12%) randomly selected hemophilia patients indicates a potential mutational contribution that may affect the disease phenotype and counseling in these patients. Parallel identification of disease-causing mutations in all three genes not only confirms the deficiency, but differentiates phenotypic overlaps and allows for correct genetic counseling.
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Affiliation(s)
- Eric Manderstedt
- Department of Environmental Science and Bioscience, Kristianstad University, Kristianstad, Sweden
| | - Rosanna Nilsson
- Department of Environmental Science and Bioscience, Kristianstad University, Kristianstad, Sweden
- * E-mail:
| | - Christina Lind-Halldén
- Department of Environmental Science and Bioscience, Kristianstad University, Kristianstad, Sweden
| | - Rolf Ljung
- Department of Clinical Sciences–Pediatrics and Malmö Center for Thrombosis and Hemostasis, Skåne University Hospital, Malmö, Sweden
| | - Jan Astermark
- Department for Hematology Oncology and Radiation Physics, Center for Thrombosis and Hemostasis, Skåne University Hospital, Malmö, Sweden
| | - Christer Halldén
- Department of Environmental Science and Bioscience, Kristianstad University, Kristianstad, Sweden
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Topf HG, Strasser ER, Breuer G, Rascher W, Rauh M, Fahlbusch FB. Closing the gap - detection of clinically relevant von Willebrand disease in emergency settings through an improved algorithm based on rotational Thromboelastometry. BMC Anesthesiol 2019; 19:10. [PMID: 30630422 PMCID: PMC6329185 DOI: 10.1186/s12871-018-0672-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 12/26/2018] [Indexed: 01/25/2023] Open
Abstract
Background Hemorrhage and blood loss are still among the main causes of preventable death. Global hemostatic assays are useful point-of-care test (POCT) devices to rapidly detect cumulative effects of plasma factors and platelets on coagulation. Thromboelastography (TEG) and Thromboelastometry (ROTEM) are established methods in many anesthesiological departments for guided hemostatic treatment. However, von Willebrand disease remains undetected by standard ROTEM, especially during emergency care, despite being the most prevalent congenital hemostatic disorder. Methods In our monocentric cohort pilot study we focused on hemostatic challenges associated with von Willebrand disease. Twenty-seven patients with suspected von Willebrand disease were included. We modified the routine ROTEM assay by adding a preincubation with ristocetin and commercially available plasma-derived von Willebrand factor to identify clinically relevant von Willebrand disease (VWD). Results Addition of von Willebrand factor to the ristocetin assay of a VWD type 3 patient restored the reaction of the whole blood probe to match the response of a healthy person. Our modified ROTEM assay with ristocetin (Ricotem) showed that all high responders (n = 7) had VWD. In the low responder group (n = 16) – 10 of 16 had VWD and in the normal responder group (n = 5), 2 of 5 had mild type 1 VWD. Conclusions This new modification of the standard ROTEM assay enables the detection of otherwise unnoticed critical von Willebrand disease based on alterations in clot formation and might serve as a novel approach to reliably assess severe VWD patients by platelet-mediated blood clotting in an emergency setting. We recommend incorporating this new VWD-focused screening tool into the current ROTEM-based management algorithm of acute microvascular bleeding. Electronic supplementary material The online version of this article (10.1186/s12871-018-0672-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- H-G Topf
- Department of Pediatrics and Adolescent Medicine, University of Erlangen-Nurnberg, Loschgestr. 15, 91054, Erlangen, Germany.
| | - E R Strasser
- Department of Transfusion Medicine and Hemostasis, University of Erlangen-Nurnberg, Erlangen, Germany
| | - G Breuer
- Department of Anesthesiology, University of Erlangen-Nurnberg, Erlangen, Germany
| | - W Rascher
- Department of Pediatrics and Adolescent Medicine, University of Erlangen-Nurnberg, Loschgestr. 15, 91054, Erlangen, Germany
| | - M Rauh
- Department of Pediatrics and Adolescent Medicine, University of Erlangen-Nurnberg, Loschgestr. 15, 91054, Erlangen, Germany
| | - F B Fahlbusch
- Department of Pediatrics and Adolescent Medicine, University of Erlangen-Nurnberg, Loschgestr. 15, 91054, Erlangen, Germany
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Hayward CPM. How I investigate for bleeding disorders. Int J Lab Hematol 2018; 40 Suppl 1:6-14. [PMID: 29741250 DOI: 10.1111/ijlh.12822] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2018] [Accepted: 02/07/2018] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Laboratory investigations for bleeding disorders are warranted when an individual has a personal and/or family history of bleeding, and/or laboratory findings that suggest the possibility of an inherited or acquired bleeding disorder. METHODS This review summarizes author's experience with ordering and reporting on diagnostic investigations for common and rare bleeding disorders, with consideration of recent articles on diagnosing bleeding disorders. An updated strategy is presented for investigating common and rare, congenital and acquired bleeding disorders. RESULTS An investigation of a suspected bleeding disorder requires a practical strategy that considers the clinical problem to be investigated, the pretest probability of true-positive and false-positive findings, the investigations can be performed locally or in a reference laboratory and limit the number of blood samples required to establish a diagnosis. It is often advantageous to simultaneously test for von Willebrand disease and platelet function disorders, and for coagulation defects, including fibrinogen disorders. An investigation for rarer bleeding disorders, including those affecting factor XIII, α2 antiplasmin, and plasminogen activator inhibitor-1, is appropriate when faced with a severe congenital or acquired bleeding problem that cannot be explained by the initial diagnostic investigations. CONCLUSION An organized strategy for investigating bleeding disorders that consider important issues, confirms abnormal findings, encourages proper interpretation of the results, and provides a helpful framework for assessing both common and rare causes of bleeding.
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Affiliation(s)
- C P M Hayward
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada.,Department of Medicine, McMaster University, Hamilton, ON, Canada.,Hamilton Regional Laboratory Medicine Program, Hamilton, ON, Canada
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