1
|
Casini A, Gebhart J. How to investigate mild to moderate bleeding disorders and bleeding disorder of unknown cause. Int J Lab Hematol 2024; 46 Suppl 1:27-33. [PMID: 38454298 DOI: 10.1111/ijlh.14266] [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: 01/16/2024] [Accepted: 02/28/2024] [Indexed: 03/09/2024]
Abstract
A bleeding tendency is one of the most common complaints observed by hematologists. It is challenging to differentiate a clinically insignificant bleeding from a bleeding phenotype that requires hemostatic evaluation and medical intervention. A thorough review of personal and familial history, objective assessment of bleeding severity using a bleeding assessment tool, and a focused physical examination are critical to correctly identifying suspected patients with mild to moderate bleeding disorders (MBDs). A basic laboratory work-up should be performed in all patients referred for a bleeding tendency. If a hemostatic abnormality is found such as evidence of von Willebrand disease, a platelet function disorder, or a coagulation factor deficiency, more extensive testing should be performed to further characterize the bleeding disorder. Conversely, if all results are normal the patient is considered to have bleeding disorder of unknown cause (BDUC). For patients with BDUC, further evaluation may include non-routine testing to look for rare bleeding disorders not detected by routine hemostasis tests, such as thrombomodulin-associated coagulopathy, tissue factor pathway inhibitor-related bleeding disorder, hyperfibrinolytic-bleeding disorders or impaired tissue factor production. In this review, we summarize the stepwise diagnostic procedure in MBDs and provide some insights into the biological features of BDUC.
Collapse
Affiliation(s)
- Alessandro Casini
- Division of Angiology and Hemostasis, University Hospitals of Geneva, Geneva, Switzerland
| | - Johanna Gebhart
- Department of Medicine I, Division of Hematology and Hemostaseology, Medical University Vienna, Austria
| |
Collapse
|
2
|
Bang HI, Lee JY, Kim HY, Shin S, Nam MH, Kim IS, Kim JM, Yoon JH, Shin MG, Hwang SM, Kong SY. Coagulation Testing in Real-World Setting: Insights From a Comprehensive Survey. Clin Appl Thromb Hemost 2024; 30:10760296241228239. [PMID: 38321776 PMCID: PMC10851719 DOI: 10.1177/10760296241228239] [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: 09/04/2023] [Revised: 12/18/2023] [Accepted: 01/07/2024] [Indexed: 02/08/2024] Open
Abstract
The objective of this survey was to gain a real-world perspective on coagulation testing by evaluating the availability of various coagulation laboratory tests, assessing specific analytic and postanalytic steps in clinical laboratories in Korea.Participants were surveyed using a 65-question questionnaire specifically focused on their coagulation testing practices related to prothrombin time (PT), activated partial thromboplastin time (aPTT), plasma-mixing studies, lupus anticoagulant (LA) tests, platelet function tests, coagulation factor assays, and the composition of hemostasis and thrombosis test panels. The survey was performed between July and September 2022.The survey achieved a 77.9% (81 of 104) response rate. PT or aPTT tests were performed directly at all participating institutions, followed by D-dimer and fibrinogen tests, platelet function test, and plasma-mixing studies in order of frequency. Variations existed in the performance of mixing test and LA assessment. Patterns of coagulating testing differed depending on the size of the hospital. The survey revealed that most laboratories conducted coagulation tests following the international guidelines such as Clinical Laboratory Standards Institute guidelines and the Korean Laboratory Certification system. However, some coagulation tests, including mixing test and LA tests, are yet to be standardized in Korea.Continuous education on coagulation test methods and internal and external quality control are required to encourage laboratories to enhance the performance of coagulation testing.
Collapse
Affiliation(s)
- Hae In Bang
- Department of Laboratory Medicine, Soonchunhyang University Seoul Hospital, Seoul, The Republic of Korea
| | - Ja Young Lee
- Department of Laboratory Medicine, Inje University Busan Paik Hospital, Busan, The Republic of Korea
| | - Hyun-Young Kim
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, The Republic of Korea
| | - Saeam Shin
- Department of Laboratory Medicine, Yonsei University College of Medicine, Seoul, The Republic of Korea
| | - Myung Hyun Nam
- Department of Laboratory Medicine, Korea University Anam Hospital, Seoul, The Republic of Korea
| | - In-Suk Kim
- Department of Laboratory Medicine, Pusan National University Yangsan Hospital, Yangsan, The Republic of Korea
| | - Ji Myung Kim
- Department of Laboratory Medicine, Chungnam National University College of Medicine, Daejeon, The Republic of Korea
| | - Jong-Hyun Yoon
- Department of Laboratory Medicine, Seoul National University Boramae Medical Center, Seoul, The Republic of Korea
| | - Myung-Geun Shin
- Department of Laboratory Medicine, Chonnam National University Medical School and Chonnam National University Hwasun Hospital, Hwasun, The Republic of Korea
| | - Sang Mee Hwang
- Department of Laboratory Medicine, Seoul National University Bundang Hospital, Seongnam, The Republic of Korea
| | - Sun-Young Kong
- Department of Laboratory Medicine, National Cancer Center Hospital, Goyang, The Republic of Korea
| |
Collapse
|
3
|
Babuty A, Debord C, Drillaud N, Eveillard M, Trossaert M, Ternisien C, Sigaud M, Cador E, Béné MC, Fouassier M. Prothrombin consumption as an indicator of hemorrhagic phenotype in mild platelet function disorders. Eur J Haematol 2023; 111:787-795. [PMID: 37553915 DOI: 10.1111/ejh.14079] [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: 05/17/2023] [Revised: 07/28/2023] [Accepted: 07/31/2023] [Indexed: 08/10/2023]
Abstract
BACKGROUND The bleeding risk of patients with mild platelet function disorders is difficult to assess and their phenotype remains ill-explored. AIM This study was designed to establish a comprehensive biological phenotype of patients with mild platelet function disorders. METHODS Twenty patients were included with persistent abnormal light transmission aggregometry (LTA). The ISTH bleeding assessment tool (ISTH-BAT) was assessed to identify laboratory analyses associated with an abnormal hemorrhagic score. RESULTS The majority of patients had defects that might affect Gαi protein signaling pathways or minor abnormalities. No LTA nor flow cytometry parameters were associated with an above-normal hemorrhagic score. However, prothrombin consumption, which corresponds to the ratio of serum residual factor II to plasma residual factor II, was significantly higher (p = .006) in the abnormal ISTH-BAT group (mean = 14%, SD = 6) compared with the normal ISTH-BAT group (mean = 8%, SD 4). Prothrombin consumption was significantly associated with ISTH-BAT score (r = .5287, IC 95% 0.0986-0.7924, p = .0165). CONCLUSION In this group of patients, there was an association between a pathological bleeding score and increased prothrombin consumption. This test could be used as an additional indicator of platelet function abnormality liable to be related to bleeding risk.
Collapse
Affiliation(s)
- Antoine Babuty
- Nantes Université, CHU Nantes, Service d'Hématologie Biologique, Nantes, France
- Nantes Université, CHU Nantes, Centre de Ressource et de Compétence-Maladies Hémorragiques Constitutionnelles, Nantes, France
| | - Camille Debord
- Nantes Université, CHU Nantes, Service d'Hématologie Biologique, Nantes, France
| | - Nicolas Drillaud
- Nantes Université, CHU Nantes, Service d'Hématologie Biologique, Nantes, France
- Nantes Université, CHU Nantes, Centre de Ressource et de Compétence-Maladies Hémorragiques Constitutionnelles, Nantes, France
| | - Marion Eveillard
- Nantes Université, CHU Nantes, Service d'Hématologie Biologique, Nantes, France
| | - Marc Trossaert
- Nantes Université, CHU Nantes, Service d'Hématologie Biologique, Nantes, France
- Nantes Université, CHU Nantes, Centre de Ressource et de Compétence-Maladies Hémorragiques Constitutionnelles, Nantes, France
| | - Catherine Ternisien
- Nantes Université, CHU Nantes, Service d'Hématologie Biologique, Nantes, France
- Nantes Université, CHU Nantes, Centre de Ressource et de Compétence-Maladies Hémorragiques Constitutionnelles, Nantes, France
| | - Marianne Sigaud
- Nantes Université, CHU Nantes, Service d'Hématologie Biologique, Nantes, France
- Nantes Université, CHU Nantes, Centre de Ressource et de Compétence-Maladies Hémorragiques Constitutionnelles, Nantes, France
| | - Emmanuelle Cador
- Nantes Université, CHU Nantes, Service d'Hématologie Biologique, Nantes, France
| | - Marie C Béné
- Nantes Université, CHU Nantes, Service d'Hématologie Biologique, Nantes, France
| | - Marc Fouassier
- Nantes Université, CHU Nantes, Service d'Hématologie Biologique, Nantes, France
- Nantes Université, CHU Nantes, Centre de Ressource et de Compétence-Maladies Hémorragiques Constitutionnelles, Nantes, France
| |
Collapse
|
4
|
Mathews N, Tasneem S, Hayward CPM. Rare inherited coagulation and fibrinolytic defects that challenge diagnostic laboratories. Int J Lab Hematol 2023. [PMID: 37211424 DOI: 10.1111/ijlh.14084] [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: 03/01/2023] [Accepted: 04/12/2023] [Indexed: 05/23/2023]
Abstract
BACKGROUND Coagulation factors, anticoagulants, and fibrinolytic proteins are important for hemostasis, and mutations affecting these proteins causes some rare inherited bleeding disorders that are particularly challenging to diagnose. AIMS This review provides current information on rare inherited bleeding disorders that are difficult to diagnose. MATERIAL & METHODS A review of the literature was conducted for up to date information on rare and difficult to diagnose bleeding disorders. RESULTS Some rare bleeding disorders cause an inherited deficiency of multiple coagulation factors (F), such as combined FV and FVIII deficiency and familial vitamin K-dependent clotting factor deficiency. Additionally, congenital disorders of glycosylation can affect a variety of procoagulant and anticoagulant proteins and also platelets. Some bleeding disorders reflect mutations with unique impairments in the procoagulant/anticoagulant balance, including those caused by F5 mutations that secondarily increase the plasma levels of tissue factor pathway inhibitor as well as THBD mutations that increase functional thrombomodulin in plasma or cause a consumptive coagulopathy due to thrombomodulin deficiency. Some bleeding disorders accelerate fibrinolysis due to loss-of-function mutations in SERPINE1 and SERPINF2 or in the case of Quebec platelet disorder, a duplication mutation that rewires PLAU and selectively increases expression in megakaryocytes, resulting in a unique platelet-dependent gain-of-function defect in fibrinolysis. DISCUSSION Current information on rare and difficult to diagnose bleeding disorders indicates they have unique clinical and laboratory features, and pathogenic characteristics to consider for diagnostic evaluation. CONCLUSION Laboratories and clinicians should consider rare inherited disorders, and difficult to diagnose conditions, in their strategy for diagnosing bleeding disorders.
Collapse
Affiliation(s)
- Natalie Mathews
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
- Hamilton Regional Laboratory Medicine Program, Hamilton, Ontario, Canada
| | - Subia Tasneem
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Catherine P M Hayward
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
- Hamilton Regional Laboratory Medicine Program, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| |
Collapse
|
5
|
Pruthi RK. Testing strategies used in the diagnosis of rare inherited bleeding disorders. Expert Rev Hematol 2023:1-15. [PMID: 37144355 DOI: 10.1080/17474086.2023.2211257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
INTRODUCTION Rare Bleeding Disorders have a low population prevalence and may not be recognized by most clinicians. In addition, knowledge gaps of the indicated laboratory tests and their availability add to the potential for delayed diagnosis or misdiagnosis. The lack of widely available commercial, regulatory body approved esoteric tests limit them to reference laboratories, thus limiting easy access for patients. AREAS COVERED A literature search of Pubmed, Medline, Embase and review of international society guidelines was performed. Additional references from published articles were reviewed. A patient-centered approach to recognition and evaluation of RBD is discussed. EXPERT OPINION Recognition of RBD relies on obtaining a detailed patient personal and family hemostatic history. Inquiry into a history of involvement of other organ systems is important and if present should lead to suspicion of an inherited platelet disorder or a variant of Ehlers Danlos Syndrome. Multiple factors contribute to the complexity of development of efficient algorithms for diagnostic testing. Limitations in diagnostic sensitivity and specificity of screening tests, diagnostic tests, and esoteric tests further compound the complexity of establishing a diagnosis. Educational efforts focusing on clinician awareness of RBDs and available testing options are vital for optimal management of such patients.
Collapse
Affiliation(s)
- Rajiv K Pruthi
- Mayo Comprehensive Hemophilia Center, Division of Hematology, Department of Internal Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA
| |
Collapse
|
6
|
Heubel-Moenen FCJI, Ansems LEM, Verhezen PWM, Wetzels RJH, van Oerle RGM, Straat RJMHE, Megy K, Downes K, Henskens YMC, Beckers EAM, Joore MA. Effectiveness and costs of a stepwise versus an all-in-one approach to diagnose mild bleeding disorders. Br J Haematol 2023; 200:792-801. [PMID: 36444397 DOI: 10.1111/bjh.18570] [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: 07/15/2022] [Revised: 11/04/2022] [Accepted: 11/08/2022] [Indexed: 12/02/2022]
Abstract
The diagnostic work-up of patients referred to the haematologist for bleeding evaluation is performed in a stepwise way: bleeding history and results of screening laboratory tests guide further diagnostic evaluation. This can be ineffective, time-consuming and burdensome for patients. To improve this strategy, the initial laboratory investigation can be extended. In a model-based approach, effectiveness and costs of a conventional stepwise versus a newly proposed all-in-one diagnostic approach for bleeding evaluation were evaluated and compared, using data from an observational patient cohort study, including adult patients referred for bleeding evaluation. In the all-in-one approach, specialized platelet function tests, coagulation factors, and fibrinolysis tests were included in the initial investigation. Final diagnosis, hospital resource use and costs and patient burden were compared. A total of 150 patients were included. Compared to the stepwise approach, in the all-in-one approach, 19 additional patients reached a diagnosis and patient burden was lower, but total costs per patient were higher [€359, 95% bootstrapped confidence interval (BCI) 283-518, p = 0.001]. For bleeding evaluation of patients referred to the haematologist, an all-in-one diagnostic approach has a higher diagnostic yield and reduces patient burden, at a higher cost. This raises the question what costs justify the diagnosis of a bleeding disorder and a less burdensome diagnostic strategy.
Collapse
Affiliation(s)
- Floor C J I Heubel-Moenen
- Department of Hematology, Internal Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Loes E M Ansems
- Department of Hematology, Internal Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Paul W M Verhezen
- Central Diagnostic Laboratory, Unit for Hemostasis and Transfusion, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Rick J H Wetzels
- Central Diagnostic Laboratory, Unit for Hemostasis and Transfusion, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Rene G M van Oerle
- Central Diagnostic Laboratory, Unit for Hemostasis and Transfusion, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Ron J M H E Straat
- Central Diagnostic Laboratory, Unit for Hemostasis and Transfusion, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Karyn Megy
- National Institute for Health Research (NIHR) BioResource, Cambridge University Hospitals NHS Foundation, Cambridge Biomedical Campus, Cambridge, UK.,Department of Haematology, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK
| | - Kate Downes
- National Institute for Health Research (NIHR) BioResource, Cambridge University Hospitals NHS Foundation, Cambridge Biomedical Campus, Cambridge, UK.,Department of Haematology, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK.,Cambridge University Hospitals Genomic Laboratory, Cambridge University Hospitals Foundation Trust, Cambridge Biomedical Campus, UK
| | - Yvonne M C Henskens
- Central Diagnostic Laboratory, Unit for Hemostasis and Transfusion, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Erik A M Beckers
- Department of Hematology, Internal Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Manuela A Joore
- Department of Clinical Epidemiology and Medical Technology Assessment (KEMTA), Maastricht University Medical Centre+, CAPHRI Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
| |
Collapse
|
7
|
Pandey A, Verma R, Eikelboom J, Verma S. Factor XI inhibitors: what should clinicians know. Curr Opin Cardiol 2023; 38:88-93. [PMID: 36718618 DOI: 10.1097/hco.0000000000001015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
PURPOSE OF REVIEW Factor XI (FXI) inhibitors were developed to address unmet needs and limitations of current anticoagulants and are currently being studied in several indications. In this paper, we review the rationale for the development of these agents and summarize what clinicians should know about drugs that target FXI. RECENT FINDINGS Patients with FXI deficiency may have a lower risk of venous thromboembolism and cardiovascular events and have a variable but generally mild bleeding diathesis. FXI has been proposed as a target for anticoagulants due to the potential for reduction in thrombosis with a lower risk of bleeding than current anticoagulant agents. Several classes of drugs that target FXI are under development, of which three classes (small molecule inhibitors, antisense oligonucleotides and monoclonal antibodies) have been studied in Phase II trials. At least three large Phase III trial programs are planned or are underway, and will study the efficacy and safety of FXI inhibitors in tens of thousands of patients across a variety of indications including atrial fibrillation, stroke and cancer-associated venous thromboembolism. SUMMARY FXI inhibitors were developed with the hope of attenuating thrombosis with reduced bleeding/impairment of haemostasis. These agents have shown promise in preliminary trials with a low rate of bleeding. Ongoing Phase III investigations will inform the utility of these agents in clinical practice.
Collapse
Affiliation(s)
| | - Raj Verma
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | | | | |
Collapse
|
8
|
Dave RG, Geevar T, Chellaiya GK, Mammen JJ, Vijayan R, Samuel A, Gowri M, Nair SC. Stability and utility of flow cytometric platelet activation tests: A modality to bridge the gap between diagnostic demand and supply. Platelets 2022; 33:1043-1051. [DOI: 10.1080/09537104.2022.2042232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Rutvi Gautam Dave
- Department of Transfusion Medicine and Immunohematology, Christian Medical College Vellore, Vellore, India
| | - Tulasi Geevar
- Department of Transfusion Medicine and Immunohematology, Christian Medical College Vellore, Vellore, India
| | | | - Joy John Mammen
- Department of Transfusion Medicine and Immunohematology, Christian Medical College Vellore, Vellore, India
| | - Ramya Vijayan
- Department of Transfusion Medicine and Immunohematology, Christian Medical College Vellore, Vellore, India
| | - Ashok Samuel
- Department of Transfusion Medicine and Immunohematology, Christian Medical College Vellore, Vellore, India
| | - Mahasampath Gowri
- Department of Biostatistics, Christian Medical College Vellore, Vellore, India
| | - Sukesh Chandran Nair
- Department of Transfusion Medicine and Immunohematology, Christian Medical College Vellore, Vellore, India
| |
Collapse
|
9
|
Pezeshkpoor B, Oldenburg J, Pavlova A. Experiences in Routine Genetic Analysis of Hereditary Hemorrhagic, Thrombotic, and Platelet Disorders. Hamostaseologie 2022; 42:S5-S12. [PMID: 35226963 DOI: 10.1055/a-1726-4793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
Hemostasis is a complex and tightly regulated system that attempts to maintain a homeostatic balance to permit normal blood flow, without bleeding or thrombosis. Hemostasis reflects the subtle balance between procoagulant and anticoagulant factors in the pathways of primary hemostasis, secondary hemostasis, and fibrinolysis. The major components in this interplay include the vascular endothelium, platelets, coagulation factors, and fibrinolytic factors. After vessel wall injury, the subendothelium is exposed to the blood stream, followed by rapid activation of platelets via collagen binding and von Willebrand factor-mediated platelet adhesion to the damaged vessel wall through platelet glycoprotein receptor Ib/IX/V. Activated platelets change their shape, release bioactive molecules from their granules, and expose negatively charged phospholipids on their surface. For a proper function of this process, an adequate number of functional platelets are required. Subsequently, a rapid generation of sufficient amounts of thrombin begins; followed by activation of the coagulation system and its coagulation factors (secondary hemostasis), generating fibrin that consolidates the platelet plug. To maintain equilibrium between coagulation and anticoagulation, the naturally occurring anticoagulants such as protein C, protein S, and antithrombin keep this process in balance. Deficiencies (inherited or acquired) at any level of this fine-tuned system result in pathologic bleedings or increased hypercoagulability states leading to thrombosis. This review will focus on genetic diagnosis of inherited bleeding, thrombotic, and platelet disorders, discussing strengths and limitations of existing diagnostic settings and genetic tools and highlight some important considerations necessary for clinical application.
Collapse
Affiliation(s)
- B Pezeshkpoor
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Medical Faculty, University of Bonn, Bonn, Germany.,Center for Rare Diseases Bonn (ZSEB), University Clinic Bonn, Bonn, Germany
| | - J Oldenburg
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Medical Faculty, University of Bonn, Bonn, Germany.,Center for Rare Diseases Bonn (ZSEB), University Clinic Bonn, Bonn, Germany
| | - A Pavlova
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Medical Faculty, University of Bonn, Bonn, Germany.,Center for Rare Diseases Bonn (ZSEB), University Clinic Bonn, Bonn, Germany
| |
Collapse
|
10
|
Tony S, Mevada R, Al Rawas A, Wali Y, Elshinawy M. Rare inherited coagulation disorders in young children in Oman. Pediatr Hematol Oncol 2022; 39:48-61. [PMID: 34016020 DOI: 10.1080/08880018.2021.1928801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Background: Rare coagulation disorders represent 3-5% of all inherited coagulation deficiencies and are usually inherited as autosomal recessive. Oman has high rate of consanguineous marriages; we aimed to study the prevalence, presentation and management in affected Omani children. Materials and Methods: Retrospective study in pediatric patients with rare coagulation disorders in a tertiary hospital in Oman from 2009 to 2020. Results: Rare coagulation disorders were diagnosed in 79 patients (39 males/40 females), aged 1 day to 13 years, accounting for 24.7% (79/319) of all children with inherited coagulation disorders; remainder included patients with hemophilia and von Willebrand disease. FXI deficiency was most common with prevalence of 39.2%, followed by fibrinogen disorders 32.9%, FVII 18.9%, FV 5%, FXIII 2.5%, and FX deficiencies 1.2%. Manifestations ranged from mild to serious to rare/atypical; presentation at birth, ruptured-hemorrhagic ovarian cyst, splenic laceration-rupture, and sight-threatening retrobulbar-intraocular hemorrhage. Intracranial hemorrhage (ICH) occurred in 9/79 patients, it was initial mode of presentation in seven of them. Global developmental delay as a complication occurred in three. Standardized treatment strategies were used with prophylaxis initiation early in life in severely affected children. Conclusions: This ethnic group demonstrated unique features in terms of: heterogenous/atypical presentations; severe manifestations in moderate phenotype hypofibrinogenemia; clinical severity and laboratory phenotype correlation in FV deficiency; poor association between factor activity level and bleeding severity in FVII deficiency and severe bleeding tendency despite moderate laboratory phenotype in FXIII deficiency. We recommend multicenter collaboration to identify the genotype-phenotype correlation and therapeutic options of such rare, yet serious disorders.
Collapse
Affiliation(s)
- Surekha Tony
- Pediatric Hematology Oncology Unit, Department of Child Health, Sultan Qaboos University Hospital, Oman
| | | | - Abdulhakim Al Rawas
- Pediatric Hematology Oncology Unit, Department of Child Health, Sultan Qaboos University Hospital, Oman
| | - Yasser Wali
- Pediatric Hematology Oncology Unit, Department of Child Health, Sultan Qaboos University Hospital, Oman
| | - Mohamed Elshinawy
- Pediatric Hematology Oncology Unit, Department of Child Health, Sultan Qaboos University Hospital, Oman.,Department of Pediatrics, Faculty of Medicine, University of Alexandria, Alexandria, Egypt
| |
Collapse
|
11
|
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.
Collapse
|
12
|
Zeng Z, Nallan Chakravarthula T, Muralidharan C, Hall A, Linnemann AK, Alves NJ. Fluorescently conjugated annular fibrin clot for multiplexed real-time digestion analysis. J Mater Chem B 2021; 9:9295-9307. [PMID: 34698753 DOI: 10.1039/d1tb02088a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Impaired fibrinolysis has long been considered as a risk factor for venous thromboembolism. Fibrin clots formed at physiological concentrations are promising substrates for monitoring fibrinolytic performance as they offer clot microstructures resembling in vivo. Here we introduce a fluorescently labeled fibrin clot lysis assay which leverages a unique annular clot geometry assayed using a microplate reader. A physiologically relevant fibrin clotting formulation was explored to achieve high assay sensitivity while minimizing labeling impact as fluorescence isothiocyanate (FITC)-fibrin(ogen) conjugations significantly affect both fibrin polymerization and fibrinolysis. Clot characteristics were examined using thromboelastography (TEG), turbidity, scanning electron microscopy, and confocal microscopy. Sample fibrinolytic activities at varying plasmin, plasminogen, and tissue plasminogen activator (tPA) concentrations were assessed in the present study and results were compared to an S2251 chromogenic assay. The optimized physiologically relevant clot substrate showed minimal reporter-conjugation impact with nearly physiological clot properties. The assay demonstrated good reproducibility, wide working range, kinetic read ability, low limit of detection, and the capability to distinguish fibrin binding-related lytic performance. In combination with its ease for multiplexing, it also has applications as a convenient platform for assessing patient fibrinolytic potential and screening thrombolytic drug activities in personalized medical applications.
Collapse
Affiliation(s)
- Ziqian Zeng
- Department of Emergency Medicine, Indiana University School of Medicine, 635 Barnhill Dr Rm. 2063, Indianapolis, IN 46202, USA. .,Weldon School of Biomedical Engineering, Purdue University, West Lafayette, IN 47907, USA
| | - Tanmaye Nallan Chakravarthula
- Department of Emergency Medicine, Indiana University School of Medicine, 635 Barnhill Dr Rm. 2063, Indianapolis, IN 46202, USA. .,Weldon School of Biomedical Engineering, Purdue University, West Lafayette, IN 47907, USA
| | - Charanya Muralidharan
- Department of Biochemistry & Molecular Biology, Indiana University School of Medicine, Indianapolis, IN 46202, USA.,Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Abigail Hall
- Department of Emergency Medicine, Indiana University School of Medicine, 635 Barnhill Dr Rm. 2063, Indianapolis, IN 46202, USA.
| | - Amelia K Linnemann
- Department of Biochemistry & Molecular Biology, Indiana University School of Medicine, Indianapolis, IN 46202, USA.,Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Nathan J Alves
- Department of Emergency Medicine, Indiana University School of Medicine, 635 Barnhill Dr Rm. 2063, Indianapolis, IN 46202, USA. .,Weldon School of Biomedical Engineering, Purdue University, West Lafayette, IN 47907, USA.,Department of Biochemistry & Molecular Biology, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| |
Collapse
|
13
|
Thomas W, Downes K, Evans G, Gidley G, Lowe G, MacDonald S, Obaji S, O'Donnell JS, Palmer B, Pinto F, Desborough M. Current practice and registration patterns among United Kingdom Haemophilia Centre Doctors' Organisation centers for patients with unclassified bleeding disorders. J Thromb Haemost 2021; 19:2738-2743. [PMID: 34382329 DOI: 10.1111/jth.15492] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 08/02/2021] [Accepted: 08/06/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Bleeding of unknown cause (BUC) and unclassified bleeding disorders (UBD) are increasingly recognized. There is no guidance on diagnosis and management. OBJECTIVES To examine UK haemophilia centre registration patterns and current practice for UBD patients. METHODS In a two-step process, the UK National Haemophilia Database (NHD) was reviewed for registration patterns of UBD patients and a survey of UK haemophilia centers was conducted (January/February 2021) to capture current practice for diagnosis and management of patients with UBD. RESULTS/DISCUSSION Overall, registrations with the NHD for UBD patients has sharply risen from 2012 to 2020 and in 2019 accounted for 2.65% of registered patients. For the survey, the response rate was 52/67 (78%). Practice was widely variable; 35/52 (67%) centers register UBD; among these 35 centers, terminology included UBD (28 centers), undiagnosed bleeding disorder (four centers), and BUC (three centers); 34/52 (65%) centers use a formal bleeding assessment tool. For management of dental extraction and high bleeding risk surgery in a fictional UBD patient we found that tranexamic acid was widely used; however, beyond this a variety of hemostatic products were advised including blood products, recombinant factor VIIa/prothrombin complex concentrate, and desmopressin. There was general consensus (≈90%) on avoiding regional anesthesia in pregnancy, but no agreement on the need for fetal precautions to avoid bleeding at delivery (50% would advise these). There was a disparity of opinion on chemical thromboprophylaxis, and management of patients without prior hemostatic challenges and offspring of these patients. CONCLUSION This study provides a snapshot of current practice and real-world data in this area. Future studies need to address the gaps in evidence.
Collapse
Affiliation(s)
- Will Thomas
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Kate Downes
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | | | - Gill Lowe
- University Hospitals Birmingham, Birmingham, UK
| | | | | | - James S O'Donnell
- Irish Centre for Vascular Biology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Ben Palmer
- UK National Haemophilia Database, Manchester, UK
| | | | | |
Collapse
|
14
|
Devreese KMJ. Thrombin generation measured by two platforms in patients with a bleeding tendency: Reply. J Thromb Haemost 2021; 19:2899-2901. [PMID: 34668300 DOI: 10.1111/jth.15522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 09/05/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Katrien M J Devreese
- Coagulation Laboratory, Department of Laboratory Medicine, University Hospital Ghent, Ghent, Belgium
- Department of Diagnostic Sciences, Ghent University, Ghent, Belgium
| |
Collapse
|
15
|
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.
Collapse
|
16
|
Cornette M, Monteyne T, De Kesel PM, Devreese KMJ. Thrombin generation measured by two platforms in patients with a bleeding tendency. J Thromb Haemost 2021; 19:1460-1471. [PMID: 33724649 DOI: 10.1111/jth.15292] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 03/11/2021] [Accepted: 03/12/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND Mild to moderate bleeding disorders are a diagnostic challenge. Many patients remain undiagnosed despite thorough and repeated laboratory testing. Thrombin generation (TG) is an overall assay measuring the functionality of the hemostatic system and may be a useful tool in diagnosing patients with bleeding tendency. OBJECTIVES We examined the added value of TG in patients with mild bleeding tendency with and without diagnosis after classical laboratory testing. Further, we investigated the role of different expressions of results, between-method variation, and reference ranges. METHODS TG of patients and controls was measured in parallel by two TG platforms (ST Genesia and calibrated automated thrombogram [CAT]). All TG parameters in patient and control groups were compared by statistical analysis (Mann-Whitney U tests) including visual representation with box-and-whisker plots. Results were expressed as normalized ratios (ST Genesia and CAT) or corrected values (ST Genesia). Reference intervals were calculated to which patient results were compared. We studied lot-to-lot reagent variability for both platforms. RESULTS In 62.7% (ST Genesia) to 69.5% (CAT) of patients undiagnosed with a traditional laboratory work-up, abnormal TG parameters (lag time and endogenous thrombin potential expressed as normalized ratio and/or corrected value) were detected. In the group of previously diagnosed patients, abnormal parameters were found in 58.1% of patients for both TG assays. No relevant lot-to-lot reagent variability was observed. CONCLUSIONS Adding TG helps with diagnosing patients with mild bleeding disorder. TG seems a promising tool in diagnosis of bleeding tendency, but further evaluation is necessary before application in diagnostic laboratory testing.
Collapse
Affiliation(s)
- Margot Cornette
- Coagulation Laboratory, Department of Laboratory Medicine, University Hospital Ghent, Ghent, Belgium
| | - Tinne Monteyne
- Coagulation Laboratory, Department of Laboratory Medicine, University Hospital Ghent, Ghent, Belgium
| | - Pieter M De Kesel
- Coagulation Laboratory, Department of Laboratory Medicine, University Hospital Ghent, Ghent, Belgium
| | - Katrien M J Devreese
- Coagulation Laboratory, Department of Laboratory Medicine, University Hospital Ghent, Ghent, Belgium
- Department of Diagnostic Sciences, Ghent University, Ghent, Belgium
| |
Collapse
|
17
|
[Hematoma in lipedema: from cutaneous origin or defect of coagulation?]. Wien Med Wochenschr 2020; 171:48-52. [PMID: 33301076 DOI: 10.1007/s10354-020-00792-9] [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: 08/28/2020] [Accepted: 11/12/2020] [Indexed: 10/22/2022]
Abstract
Lipedema is a widespread in concern of etiology partially unknown disease especially in women. In many cases it is accompanied by bleeding complications. Our current work focuses on possible coagulation disorders as potential sources of such bleeding complications. Since only a minority of our patients showed a coagulation defect it is suggestive that the main underlying reason for bleeding in lipedema is of cutaneous origin what may only be forwarded by simultaneously existing coagulation disorders.
Collapse
|
18
|
van der Vorm LN, Huskens D, Florin L, De Kesel P, Roest M, de Laat B, Devreese KM. Active von Willebrand Factor in patients with a bleeding diathesis. THROMBOSIS UPDATE 2020. [DOI: 10.1016/j.tru.2020.100001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
|
19
|
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.
Collapse
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
| |
Collapse
|
20
|
Huskens D, Li L, Florin L, de Kesel P, de Laat B, Roest M, Devreese KMJ. Flow cytometric analysis of platelet function to improve the recognition of thrombocytopathy. Thromb Res 2020; 194:183-189. [PMID: 32788114 DOI: 10.1016/j.thromres.2020.06.037] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 06/02/2020] [Accepted: 06/22/2020] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Light transmission aggregometry (LTA) is the gold standard for diagnosing bleeding disorders. Although LTA is laborious, requires large volumes of blood and is relatively insensitive to small changes in platelet function, there is still no competing alternative approach to replace LTA for the diagnosis of platelet bleeding disorders. MATERIALS AND METHODS This study investigates the correlation between flow cytometry-based whole blood platelet activation test (WB-PACT) and LTA and whether WB-PACT is of additional value for the identification of bleeding disorders. In total, 161 patients with suspected bleeding diathesis were tested. RESULTS A correlation of 0.41 between LTA and WB-PACT was found, and there was agreement between tests in 62% of cases (κ = 0.23). The WB-PACT is of additional value to LTA to detect platelet function disorders (PFD) as 10 patients with elevated bleeding score (BS) were detected with WB-PACT, 4 with LTA and 7 patients were positive with both tests. Interestingly, in contrast to LTA, WB-PACT has an additional option to detect VWF disfunctions. CONCLUSION WB-PACT may have added value for the routine diagnostic work-up in patients who need to have platelet function tested.
Collapse
Affiliation(s)
- Dana Huskens
- Synapse Research Institute, Maastricht, the Netherlands; Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, the Netherlands.
| | - Li Li
- Synapse Research Institute, Maastricht, the Netherlands; Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Lisa Florin
- Coagulation Laboratory, Department of Laboratory Medicine, Ghent University Hospital, Ghent, Belgium
| | - Pieter de Kesel
- Coagulation Laboratory, Department of Laboratory Medicine, Ghent University Hospital, Ghent, Belgium
| | - Bas de Laat
- Synapse Research Institute, Maastricht, the Netherlands; Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Mark Roest
- Synapse Research Institute, Maastricht, the Netherlands; Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Katrien M J Devreese
- Coagulation Laboratory, Department of Laboratory Medicine, Ghent University Hospital, Ghent, Belgium; Department of Diagnostic Sciences, Ghent University, Ghent, Belgium
| |
Collapse
|
21
|
Foti F, Sica S, Alma E, De Cristofaro R, Mores N, Vetrugno G. Sudden nasal bleeding and brodifacoum: A case of accidental exposure or attempted homicide? Leg Med (Tokyo) 2020; 47:101772. [PMID: 32771937 DOI: 10.1016/j.legalmed.2020.101772] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 07/15/2020] [Accepted: 07/31/2020] [Indexed: 11/29/2022]
Abstract
A 50-year-old man was admitted to the emergency department with abrupt massive epistaxis. An accurate anamnesis and physical evaluation could not reveal any other anomalies, while coagulation tests showed potentially life threatening prolonged prothrombin time, with activated partial thromboplastin and thrombin time, with fibrinogen and antithrombin III within limits. Despite the prompt pharmacological and compressive local treatment, bleeding continued and the patient was therefore hospitalized. Highly specific coagulation and toxicological testing-among others high-performance liquid chromatography assessment on plasma-were performed, leading to the unexpected identification of brodifacoum. Police and criminal justice authorities revealed the source of exposure to brodifacoum after several months of investigation, residing in his everyday life. Brodifacoum is a long-lasting anticoagulant, acting as a vitamin K antagonist, and belongs to the family of superwarfarins. Brodifacoum use is authorized as rodenticide in many countries worldwide, but has been reported as cause of severe coagulopathies in humans, both intentional or involuntary, even consumed as a contaminant of herbal drugs, such as cannabis. The original contribution of this case to the knowledges of human brodifacoum intoxication resides in the multidisciplinary approach and the collaborative interplay of clinical and toxicology experts as well as judicial authorities.
Collapse
Affiliation(s)
- Federica Foti
- Risk Management Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.
| | - Simona Sica
- Unit of Vascular Surgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome-Università Cattolica del Sacro Cuore, Rome, Italy
| | - Eleonora Alma
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome - Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Raimondo De Cristofaro
- Servizio Malattie Emorragiche e Trombotiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome-Università Cattolica S. Cuore, Rome, Italy
| | - Nadia Mores
- Unit of Pharmacovigilance, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome-Università Cattolica del Sacro Cuore, Rome, Italy
| | - Giuseppe Vetrugno
- Risk Management Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Department of Healthcare Surveillance and Bioethics, Section of Legal Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
| |
Collapse
|
22
|
Srivastava A. Diagnosis of haemophilia and other inherited bleeding disorders ‐ Is a new paradigm needed? Haemophilia 2020; 27 Suppl 3:14-20. [DOI: 10.1111/hae.14042] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 04/29/2020] [Accepted: 04/30/2020] [Indexed: 12/15/2022]
Affiliation(s)
- Alok Srivastava
- Department of Haematology Christian Medical College Vellore India
| |
Collapse
|
23
|
George TI. Evolution of the International Journal of Laboratory Hematology. Int J Lab Hematol 2020; 42 Suppl 1:6-7. [DOI: 10.1111/ijlh.13203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Accepted: 03/23/2019] [Indexed: 11/28/2022]
|
24
|
Ilich A, Noubouossie DF, Henderson M, Ellsworth P, Betbadal KF, Campello E, Meeks S, Dunn A, Park MS, Pawlinski R, Simioni P, Shapiro A, Key NS. Development and application of global assays of hyper- and hypofibrinolysis. Res Pract Thromb Haemost 2020; 4:46-53. [PMID: 31989084 PMCID: PMC6971323 DOI: 10.1002/rth2.12275] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Revised: 09/03/2019] [Accepted: 09/10/2019] [Indexed: 01/01/2023] Open
Abstract
Numerous methods for evaluation of global fibrinolytic activity in whole blood or plasma have been proposed, with the majority based on tissue-type plasminogen activator (t-PA) addition to initiate fibrinolysis. We propose that such an approach is useful to reveal hypofibrinolysis, but t-PA concentrations should be kept to a minimum. In this paper, we describe a low-concentration t-PA plasma turbidity assay to evaluate several congenital factor deficiencies, including plasminogen activator inhibitor-1 (PAI-1) and plasminogen deficiency, as well as hemophilia A and B. In addition, we demonstrate a threshold dependency on endogenous PAI-1 levels. To assess endogenous hyperfibrinolysis, we suggest that assays that avoid t-PA addition are preferable, with assays based on euglobulin fractionation remaining a viable choice. We describe a euglobulin fraction clot lysis time (ECLT) assay with spectrophotometric readout and other modifications, and evaluate it as a tool to measure hyperfibrinolysis in inherited clotting factor deficiency states. We demonstrate that the ECLT is predominantly driven by residual amounts of PAI-1, t-PA, and α2-antiplasmin. These assays should be further evaluated for the detection of hypo- or hyperfibrinolysis in acquired thrombotic or hemorrhagic disorders.
Collapse
Affiliation(s)
- Anton Ilich
- Department of MedicineUniversity of North CarolinaChapel HillNorth Carolina
| | | | - Michael Henderson
- Department of MedicineUniversity of North CarolinaChapel HillNorth Carolina
| | - Patrick Ellsworth
- Department of MedicineUniversity of North CarolinaChapel HillNorth Carolina
| | | | - Elena Campello
- Thrombotic and Hemorrhagic Diseases UnitDepartment of MedicineUniversity of PadovaPadovaItaly
| | - Shannon Meeks
- Department of PediatricsEmory UniversityAflac Cancer and Blood Disorders CenterChildren’s Healthcare of AtlantaAtlantaGeorgia
| | - Amy Dunn
- Nationwide Children’s HospitalColumbusOhio
| | - Myung S. Park
- Trauma, Critical Care and General SurgeryMayo ClinicRochesterMinnesota
| | - Rafal Pawlinski
- Department of MedicineUniversity of North CarolinaChapel HillNorth Carolina
| | - Paolo Simioni
- Thrombotic and Hemorrhagic Diseases UnitDepartment of MedicineUniversity of PadovaPadovaItaly
| | - Amy Shapiro
- Indiana Hemophilia and Thrombosis CenterIndianapolisIndiana
| | - Nigel S. Key
- Department of Pathology and Laboratory MedicineUniversity of North CarolinaChapel HillNorth Carolina
| |
Collapse
|
25
|
Gooijer K, Rondeel JMM, van Dijk FS, Harsevoort AGJ, Janus GJM, Franken AAM. Bleeding and bruising in Osteogenesis Imperfecta: International Society on Thrombosis and Haemostasis bleeding assessment tool and haemostasis laboratory assessment in 22 individuals. Br J Haematol 2019; 187:509-517. [PMID: 31304589 DOI: 10.1111/bjh.16097] [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: 03/13/2019] [Accepted: 05/21/2019] [Indexed: 11/29/2022]
Abstract
Osteogenesis imperfecta (OI) is characterized by susceptibility to bone fractures. Other symptoms, such as easy bruising and bleeding complications during surgery necessitating transfusions, have also been reported. The aim of the cross-sectional pilot study was to assess the bleeding and bruising tendency in OI patients and to screen for possible underlying haematological disorders. Bleeding tendency was investigated using the International Society on Thrombosis and Haemostasis bleeding assessment tool (ISTH-BAT) in 22 adult OI patients. Laboratory testing was performed to investigate for bleeding disorders or abnormal coagulation. Four patients [OI type 1(n = 3), OI type 4(n = 1)] had a bleeding score (BS) fitting with a bleeding tendency, but without test results pointing to a coagulopathy. Two patients [OI type 1(n = 1), OI type 3 (n = 1)] without a bleeding tendency according to the BS had increased fibrinolysis. This is the second largest study to date addressing bleeding tendency in OI and the first study to use ISTH-BAT and elaborate laboratory testing for coagulopathies. Four patients had an increased bleeding tendency. However, laboratory testing demonstrated no bleeding disorder or abnormal coagulation. Increased fibrinolysis was demonstrated in two patients without bleeding tendency on BS. Vascular fragility as a cause of bleeding tendency in OI has been suggested earlier. Further research on bleeding tendency in OI is important.
Collapse
Affiliation(s)
- Koert Gooijer
- Expert Centre for adults with Osteogenesis Imperfecta, Isala Hospital, Zwolle, The Netherlands
| | - Jan M M Rondeel
- Department of Clinical Chemistry, Isala Hospital, Zwolle, The Netherlands
| | - Fleur S van Dijk
- Expert Centre for adults with Osteogenesis Imperfecta, Isala Hospital, Zwolle, The Netherlands.,North West Thames Regional Genetics Service, Ehlers-Danlos Syndrome National Diagnostic Service London, North West Health Care University NHS Trust, Harrow, Middlesex, UK
| | - Arjan G J Harsevoort
- Expert Centre for adults with Osteogenesis Imperfecta, Isala Hospital, Zwolle, The Netherlands
| | - Guus J M Janus
- Expert Centre for adults with Osteogenesis Imperfecta, Isala Hospital, Zwolle, The Netherlands
| | - Anton A M Franken
- Expert Centre for adults with Osteogenesis Imperfecta, Isala Hospital, Zwolle, The Netherlands
| |
Collapse
|
26
|
Hayward CPM, Moffat KA, Brunet J, Carlino SA, Plumhoff E, Meijer P, Zehnder JL. Update on diagnostic testing for platelet function disorders: What is practical and useful? Int J Lab Hematol 2019; 41 Suppl 1:26-32. [PMID: 31069975 DOI: 10.1111/ijlh.12995] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 02/07/2019] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Platelet function disorders (PFD) are an important group of bleeding disorders that require validated and practical laboratory strategies for diagnosis. METHODS This review summarizes the authors' experiences, current literature, and an international survey to evaluate the practices of diagnostic laboratories that offer tests for PFD. RESULTS Blood counts, blood film review, and aggregation tests are the most commonly performed investigations for PFD and help determine whether there is thrombocytopenia and/or defective platelet function due to a variety of causes. The performance characteristics of tests for PFD, and the level of evidence that these tests detect bleeding problems, are important issues to determine where tests are useful for diagnostic or correlative purposes, or research only uses. Platelet aggregation assays, and quantitative analysis of platelet dense granule numbers, are tests with good performance characteristics that detect abnormalities associated with increased bleeding in a significant proportion of individuals referred for PFD investigations. Lumiaggregometry estimates of platelet adenosine triphosphate release show greater variability which limits the diagnostic usefulness. Diagnostic laboratories report that fiscal and other constraints, including a lack of high-quality evidence, limit their ability to offer an expanded test menu for PFD. CONCLUSION PFD are clinically important bleeding disorders that remain challenging for diagnostic laboratories to investigate. While some PFD tests are well validated for diagnostic purposes, gaps in scientific evidence and resource limitations influence diagnostic laboratory decisions on which PFD tests to offer.
Collapse
Affiliation(s)
- Catherine P M Hayward
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada.,Department of Medicine, McMaster University, Hamilton, Ontario, Canada.,Hamilton Regional Laboratory Medicine Program, Hamilton, Ontario, Canada
| | - Karen A Moffat
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada.,Hamilton Regional Laboratory Medicine Program, Hamilton, Ontario, Canada
| | - Justin Brunet
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Stephen A Carlino
- Hamilton Regional Laboratory Medicine Program, Hamilton, Ontario, Canada
| | | | - Piet Meijer
- ECAT Foundation, Voorschoten, The Netherlands
| | - James L Zehnder
- Departments of Pathology and Medicine, Stanford University, Stanford, California
| |
Collapse
|
27
|
Navred K, Martin M, Ekdahl L, Zetterberg E, Andersson NG, Strandberg K, Norstrom E. A simplified flow cytometric method for detection of inherited platelet disorders-A comparison to the gold standard light transmission aggregometry. PLoS One 2019; 14:e0211130. [PMID: 30673773 PMCID: PMC6343919 DOI: 10.1371/journal.pone.0211130] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Accepted: 01/08/2019] [Indexed: 12/30/2022] Open
Abstract
Background Flow cytometric platelet activation has emerged as an alternative diagnostic test for inherited platelet disorders. It is, however, labor intensive and few studies have directly compared the performance of flow cytometric platelet activation (PACT) to light transmission aggregometry (LTA). The aims of this study were 1/ to develop a simplified flow cytometric platelet activation assay using microtiter plates and 2/ to correlate the outcome to gold standard method LTA, and to clinical bleeding assessment tool scores (BAT score). Methods The PACT method was developed in microtiter plates using adenosine diphosphate (ADP), collagen-derived peptide (CRP-XL) and thrombin receptor activator for peptide 6 (TRAP-6) as agonists. Antibodies against GPIIb-IIIa activation epitope (PAC1), P-selectin (CD62P) and lysosome-associated membrane glycoprotein 3 (LAMP3; CD63) were used as platelet activation markers. Sixty-six patients referred to the coagulation unit for bleeding symptoms were included in this single-center observational study. Platelet activation was determined by PACT and LTA. The results of both methods were correlated to BAT score. Results A two-by-two analysis using Cohen’s kappa analysis gave moderate agreement between LTA and PACT (82%, kappa = 0.57), when PACT analysis with ADP and CRP-XL was compared to LTA. Using LTA as reference method, positive predictive value was 70% and negative predictive value was 87%. A substantial number of patients had high BAT score and normal LTA and PACT results. Patients with abnormal LTA or PACT results had higher BAT score than patients with normal results, but the difference was not significant. Conclusions The performance in microtiter plates simplified the PACT method and enabled analysis of more patients at the same time. Our results indicate that with modification of the current PACT assay, a higher negative predictive value can be obtained. Furthermore, with comparable result to LTA the PACT could be used as a screening assay for inherited platelet disorders.
Collapse
Affiliation(s)
- Kristoffer Navred
- Coagulation Laboratory, Department of Clinical Chemistry, Division of Laboratory Medicine, Skåne County Council, Malmö, Sweden
| | - Myriam Martin
- Coagulation Laboratory, Department of Clinical Chemistry, Division of Laboratory Medicine, Skåne County Council, Malmö, Sweden
| | - Lina Ekdahl
- Coagulation Laboratory, Department of Clinical Chemistry, Division of Laboratory Medicine, Skåne County Council, Malmö, Sweden
| | - Eva Zetterberg
- Department of Haematology, Coagulation Unit, Skåne University Hospital, Lund, Sweden
| | | | - Karin Strandberg
- Coagulation Laboratory, Department of Clinical Chemistry, Division of Laboratory Medicine, Skåne County Council, Malmö, Sweden
| | - Eva Norstrom
- Department of Translational Medicine, Lund University, Skåne County Council, Malmö, Sweden
- * E-mail:
| |
Collapse
|