A method for the study of antihaemophilic globulin inhibitors with reference to six cases

International Council for Standardization in Haematology recommendations for laboratory measurement of factor VIII and FIX type I inhibitors

This guidance document has been prepared on behalf of the International Council for Standardisation in Hematology. The aim of the document is to provide guidance and recommendations on the measurement of factor VIII (FVIII) and factor IX (FIX) inhibitors. After an introduction on the clinical background and relevance of factor VIII and factor IX inhibitor testing, the following aspects of laboratory testing are included: screening for inhibitors, assay principle, sample requirements, testing requirements and interpretation, quality assurance, interferences and recent developments. This guidance document focusses on recommendations for a standardised procedure for the laboratory measurement of FVIII and FIX type I inhibitors. The recommendations are based on published data in peer-reviewed literature and expert opinion.

Methods for anti-factor VIII antibody levels in haemophilia A patients - validation of a multiplex immunoassay and comparability with assays measuring non-neutralising and neutralising antibodies (inhibitors)

INTRODUCTION

The development of neutralising (inhibitors) and non-neutralising antibodies (NNAs) is a complication to factor replacement therapy in haemophilia. The diagnostic methods available lack standardisation, have high inter-laboratory variation, and false-negative as well as false-positive results may affect treatment. Both functional inhibitors and NNAs may be detected with higher reproducibility, sensitivity and specificity using the immunological Luminex xMAP-based fluorescence-immunoassay (xFLI).

AIM

Validation of our xFLI and comparability with enzyme-linked immunosorbent assay (ELISA) and chromogenic Nijmegen-Bethesda assay (CBA) for anti-FVIII antibodies in haemophilia A (HA) patients.

METHODS

The xFLI method was developed with full-length and B-domain deleted factor coupled to magnetic beads, optimised and validated for performance characteristics. Comparability with ELISA and CBA was evaluated in HA patient samples (n = 112), serial samples in six inhibitor patients and reference interval and decision-limits in healthy donors (n = 44).

RESULTS

The intra- and inter-assay precision (CV%) for the xFLI method was below 6% and detection limit (LLOQ) .084 ng/mL (NovoEight). All ELISA-positive samples were positive with either Advate or NovoEight. Additionally, 10.7%-14.3% were xFLI-positive and ELISA-negative. All but one CBA-positive sample was above 3SD with xFLI; one was between 2 and 3SD. 29.1% were xFLI-positive and CBA negative. The overall concordance between xFLI and ELISA was 82.1% and xFLI and CBA 77.9%.

CONCLUSION

The anti-FVIII antibody xFLI method is adaptable to clinical practice and more sensitive and reproducible than ELISA and CBA. Actual NNA titers are determined to both full-length and B-domain deleted FVIII. The xFLI is thus valuable for confirmation of all anti-FVIII antibodies.

The rapid Bethesda assay is equivalent to the standard Bethesda assay for detection of factor IX inhibitors in patients with severe haemophilia B

INTRODUCTION

The time-dependent nature of factor VIII (FVIII) inhibitors is well described, and the standard FVIII Bethesda assay used to measure inhibitors incorporates a 2-hour incubation. Despite case reports and reviews describing the immediate-acting nature of factor IX (FIX) inhibitors, many coagulation laboratories continue to use a traditional prolonged incubation for FIX Bethesda assays. To our knowledge, a comprehensive evaluation of the FIX Bethesda assay without incubation has not been reported.

AIM

The goal of this study was to evaluate the performance of a rapid FIX Bethesda (ie no incubation) compared with the standard Bethesda assay (2-hour incubation).

METHODS

The analysis used a Bethesda assay configured for either immediate testing or a 2-hour incubation. Samples from 14 haemophilia B patients with inhibitors and 9 non-human controls were tested.

RESULTS

The two assays yielded similar performance overall. The average per cent difference in inhibitor titre between the rapid and standard FIX Bethesda assay was -3% (range -15% to +13%; P = .175) for patient samples and -2% (range -17% to +14%; P = .376) for controls.

CONCLUSION

The rapid Bethesda assay showed good agreement with the standard Bethesda assay for determination of inhibitor levels in patients with severe haemophilia B. The rapid assay allows for faster assessment of inhibitors in patients with severe haemophilia B and has the potential to improve the ability of the coagulation laboratory to perform testing from a logistical viewpoint. Further studies involving larger numbers of patients would be important to confirm our findings.

Laboratory testing for factor VIII and IX inhibitors in haemophilia: A review

Inhibitors are antibodies directed against haemophilia treatment products which interfere with their function. Factor VIII (FVIII) inhibitors in haemophilia A and factor IX (FIX) inhibitors in haemophilia B are significant clinically when they require a change in a patient's treatment regimen. Their persistence may increase morbidity and mortality. Multiple laboratory tests are now available for detecting and understanding inhibitors in haemophilia. Inhibitors are traditionally measured by their interference in clotting or chromogenic factor assays. They may also be detected using immunologic assays, such as enzyme-linked immunosorbent assay or fluorescence immunoassay. Anti-FVIII or anti-FIX antibodies of IgG4 subclass best correlate with the presence of functional inhibitors. Improvements in inhibitor measurement have been recently introduced. Preanalytical heat treatment of patient specimens allows testing of patients without delaying treatment. Use of chromogenic and immunologic assays may aid in identification of false-positive results, which are frequent among low-titre inhibitors. Validated reagent substitutions can be used to reduce assay cost. New methods for defining assay positivity and reporting low-titre inhibitors have been suggested. Challenges remain in the areas of quality control, assay standardization, monitoring of patients undergoing immune tolerance induction therapy and testing in the presence of modified and novel treatment products.

Comparison of clot-based, chromogenic and fluorescence assays for measurement of factor VIII inhibitors in the US Hemophilia Inhibitor Research Study

BACKGROUND

Detection and validation of inhibitors (antibodies) to hemophilia treatment products are important for clinical care, evaluation of product safety and assessment of population trends.

METHODS

Centralized monitoring for factor VIII (FVIII) inhibitors was conducted for patients in the Hemophilia Inhibitor Research Study using a previously reported modified Nijmegen-Bethesda clotting assay (NBA), a chromogenic Bethesda assay (CBA) and a novel fluorescence immunoassay (FLI).

RESULTS

NBA and CBA were performed on 1005 specimens and FLI on 272 specimens. CBA was negative on 880/883 specimens (99.7%) with Nijmegen-Bethesda units (NBU) < 0.5 and positive on 42/42 specimens (100%) with NBU ≥ 2.0 and 43/80 specimens (53.8%) with NBU 0.5-1.9. Among specimens with positive NBA and negative CBA, 58.1% were FLI negative, 12.9% had evidence of lupus anticoagulant, and 35.5% had non-time-dependent inhibition. CBA and FLI were positive on 72.4% and 100% of 1.0-1.9 NBU specimens and 43.1% and 50.0% of 0.5-0.9 NBU specimens. FLI detected antibodies in 98.0% of CBA-positive and 81.6% of NBA-positive specimens (P = 0.004). Among 21 new inhibitors detected by NBA, five (23.8%) with 0.7-1.3 NBU did not react in CBA or FLI. Among previously positive patients with 0.5-1.9 NBU, 7/25 (28%) were not CBA or FLI positive. FLI was positive on 36/169 NBU-negative specimens (21.3%).

CONCLUSIONS

FVIII specificity could not be demonstrated by CBA or FLI for 26% of inhibitors of 0.5-1.9 NBU; such results must be interpreted with caution. Low titer inhibitors detected in clot-based assays should always be repeated, with consideration given to evaluating their reactivity with FVIII using more specific assays.

Factor VIII inhibitors: a 50-year perspective

Inhibitors of factor VIII (FVIII) have been studied for more than 50 years, but diagnostic and therapeutic challenges remain. To describe the features that distinguish alloantibodies from autoantibodies, list predisposing factors, and review methods for tolerance induction and autoantibody suppression. Review of key articles published during the past half-century that have advanced knowledge in this field. Alloantibodies generally bind to the A2 or C2 domains of FVIII and disrupt the formation of the FVIII-FIX complex. They exhibit type 1 reaction kinetics, are saturable by FVIII, and display anamnesis. In contrast, autoantibodies usually bind to the C2 domain of FVIII, interfering with phospholipid and von Willebrand factor binding. They have type-2 kinetics and are poorly neutralized by FVIII. Repeated exposures to FVIII induce tolerance in 70-80% of haemophiliacs with inhibitors, whereas drugs that deplete B-lymphocytes restore self-tolerance to FVIII in a similar percentage of non-haemophiliacs. Future work should focus on improving assays that detect and quantify inhibitors, examining the pathophysiology of inhibitor formation using contemporary immunologic tools, and investigating new treatment modalities. These should include agents to control bleeding with less thrombotic risk, more specific immunomodulating drugs to curtail antibody formation, and, for haemophilia patients, genetic therapies to provide FVIII resistant to or protected from inactivation by inhibitors.

Laboratory assessment of factor VIII inhibitor titer: the North American Specialized Coagulation Laboratory Association experience

Quantification of inhibitory antibodies against infused factor VIII (FVIII) has an important role in the management of patients with hemophilia A. This article summarizes results from the largest North American FVIII inhibitor proficiency testing challenge conducted to date. Test samples, 4 negative and 4 positive (1-3 Bethesda units [BU]/mL), were distributed by the ECAT Foundation in conjunction with the North American Specialized Coagulation Laboratory Association and analyzed by 38 to 42 laboratories in 2006 and 2007. Whereas laboratories were able to distinguish between the absence and presence of low-titer FVIII inhibitors, the intralaboratory coefficient of variation was high (30%-42%) for inhibitor-positive samples, and the definition of lower detection limits of the assay was variable (0-1 BU/mL). Most laboratories performed the Bethesda assay with commercially supplied buffered normal pooled plasma in a 1:1 mix with patient plasma. These data provide information for the development of consensus guidelines to improve FVIII inhibitor quantification.

Laboratory issues in bleeding disorders

The clinical history of the patient and of his/her relatives is the most important tool for making correct diagnosis of inherited or acquired bleeding disorders. Several attempts have been made by clinicians to evaluate the sensitivity and specificity of bleeding symptoms. Specific and detailed questionnaires have been designed to quantify the bleeding tendency of patients with von Willebrand's disease (VWD) and a bleeding score has been calculated. VWD is considered the most frequent inherited bleeding disorder according to population studies: however, due to the complexity of its diagnosis, the number of patients with correct diagnosis of VWD in many developing countries is relatively low and most cases remain still under- or misdiagnosed. Once bleeding history is carefully evaluated by means of a bleeding score, the laboratory workout should be organized to find out the specific defect of haemostasis responsible for bleeding. Since factors involved in haemostasis are many, the correct approach must include first level screening tests with the aim to identify the abnormal phase of haemostasis involved: then, second level tests should be focused on the specific factors within the abnormal step of haemostasis. Among many other acquired bleeding disorders related to clinical conditions or to the use of drugs, the acquired inhibitors of haemostasis are rare but should be immediately characterized by appropriate laboratory tests because they can be often life-threatening for the patients.

Factor VIII inhibitors in haemophiliacs: a single-centre experience over 34 years, 1964-97

A retrospective study of the natural history of factor VIII inhibitors in haemophilia A patients experienced in a single comprehensive haemophilia centre over three decades is reported. 431 haemophilia A patients of all severities have been followed-up for a total of 5626 patient-years. The frequency of inhibitors was 10% in the severe haemophilia A patients and 37% occurred in children <10 years. The majority of the patients received several products before developing the inhibitors. 59% of patients had <50 exposure days and 48% were high responders (>5 BU). An 8-year (1987-95) inhibitor-free period was seen during which all previously untreated patients were treated with an intermediate-purity factor VIII concentrate. A moderate haemophiliac with a missense mutation that has not been described in association with inhibitor is reported. Six HIV-positive patients preserved their antibody response to factor VIII even at the advanced stage of their disease.

A circulating anticoagulant occurring after temporal arteritis and controlled by corticosteroid therapy

A case is described in which a circulating anticoagulant, inhibiting antihaemophilic globulin, developed following temporal arteritis. The circulating anticoagulant disappeared with steroid therapy, reappearing when steroids were withdrawn. Permanent maintenance therapy appears necessary in this case to prevent haemorrhagic manifestations.

A CIRCULATING ANTICOAGULANT INHIBITING ANTIHAEMOPHILIC GLOBULIN

A circulating anticoagulant inhibiting antihaemophilic globulin (A.H.G.) is described in an otherwise healthy 70-year-old woman, and the therapeutic response to steroids is discussed. The nature and pathogenesis of the anticoagulant remain obscure, but its properties and behaviour do not support an autoimmune aetiology.

Some complications of the therapy of hemorrhagic disorders

The principal mode for treating disorders of hemostasis is correction of the patient's functional defect by transfusions of appropriate fractions of normal plasma or transfusions of platelets. Two major complications of such therapy are the transmission of infectious diseases, particularly hepatitis and the acquired immune deficiency syndrome (AIDS), and the development of antibodies against clotting factors that are deficient in the patient's plasma. Measures that reduce the occurrence of infection include careful selection of donors, fractionation of plasma with the help of monoclonal antibodies, and treatment of plasma or its fractions with heat or with virus-inactivating organic solvents. No technique of preparing or administering blood or its components can prevent the emergence of antibodies against clotting factors. Desensitization by repeated infusions of antigen, for example, antihemophilic factor, however, appears to result in remission in some patients.

Variable inactivation of human factor VIII from different sources by human factor VIII inhibitors

The source of human factor VIIII (FVIII) had a marked effect on the inhibitory activity of a panel of eight human FVIII inhibitors. Use of conventional FVIII concentrates gave lower inhibitor titres whereas a monoclonal antibody purified FVIII concentrate gave titres similar to or greater than those with plasma. Addition of phospholipid (PL) protected highly purified FVIII against inhibition. The content of PL-bound FVIII in concentrates may account for the observed differences.

Haemophiliacs with factor VIII inhibitors in Finland: prevalence, incidence and outcome

Twenty-five of the 139 Finnish patients (18.0%) with severe haemophilia A alive in 1960 or born later have or have had an inhibitor against factor VIII. 19 of the 110 patients alive have an inhibitor and the current prevalence is 17.3%. The incidence of new inhibitors was 10.3 per thousand patient years for the observation period starting from 1960, median 16 years. The age dependent cumulative risk of developing an inhibitor was 22% at the age of 10. There have been no deaths from bleeding since 1976, which has resulted in a marked decrease in mortality. The annual death rate of patients with inhibitors was 5.8 per thousand years of life in 1980-89 compared to 41.7 in the previous decade. The recent progress in the modalities for treatment of bleedings has markedly improved the outcome of patients with factor VIII inhibitors.

Fibrinogen Baltimore III: congenital dysfibrinogenemia with a shortened gamma-subunit

An abnormal fibrinogen has been found in an asymptomatic Negro female. Clinical laboratory findings were normal, except for a prolonged thrombin time which was corrected by addition of calcium. Fibrinopeptide release by thrombin and crosslinking by factor XIII also occurred normally, but fibrin monomer polymerization was delayed. Sodium dodecylsulfate-polyacrylamide gel electrophoresis disclosed that 50% of the gamma-subunits migrated with an apparent Mr of 45,500, approximately 1,500 Da smaller than normal. The evidence suggests that an internal sequence of 10-15 residues is missing from the gamma-subunit of the abnormal fibrinogen.

Management of patients with factor VIII inhibitors

In summary, while a great deal of information has accumulated concerning the properties and natural history of F VIII inhibitors, management remains frustrating and controversial. While bleeding episodes in those who are low responders can be treated with F VIII concentrates, treatment of bleeding in high responders is often much more difficult. Current therapeutic options include F VIII concentrates of human or porcine origin in high dosage, and PCC or APCC. The choice of treatment depends on the patient's current inhibitor concentration, the type and severity of bleeding, product availability, and the preference of the medical personnel involved. However, none of the available therapeutic modalities work as well as F VIII in a hemophiliac without an inhibitor. Perhaps more promising are the immune tolerance regimens that have been developed and are now being modified and fine tuned by a number of investigators. Such regimens have reportedly eradicated F VIII inhibitors in some hemophiliacs, and have converted others from high responders to low responders, in whom bleeding episodes can be effectively treated with conventional doses of F VIII. In contrast to the F VIII inhibitors developing in hemophiliacs, those developing in nonhemophiliacs can often be eradicated with corticosteroids or immunosuppressive drugs, either alone or in combination with F VIII. Not all respond to such approaches and serious hemorrhage may still occur. Treatment of bleeding episodes has included the use of human or porcine F VIII, APCC and, in two instances, DDAVP.

Acquired factor VIII deficiency in an elderly woman on tamoxifen

A case is presented and acquired factor VIII deficiency is discussed. The studied patient was elderly and had cancer of left breast, cancer of the head of the pancreas, history of blood transfusions, and was on tamoxifencitrate therapy for breast cancer. Any one of the above factors could have been responsible for production of factor VIII deficiency.

Frequency and clinical and transfusional significance of rheumatoid factor in patients with haemophilia and von Willebrand's disease

Using a solid-phase radioimmunoassay for IgM rheumatoid factor, increased levels were found in 24% or 82 patients with haemophilia A, in 4 of 11 patients with haemophilia B, in 2 of 11 patients with haemophilia A with inhibitors and in 4 of 12 with von Willebrand's disease. The levels of rheumatoid factor increased significantly (p less than 0.02) after factor VIII concentrate or cryoprecipitate transfusions. No clinical or transfusional side effects could be attributed in these patients in relation to the presence of rheumatoid factor.

[Different proportions of factor VIII and factor VIII inhibitors in their antigen-antibody complexes]

We examined the physico-chemical properties of factor VIII inhibitors in two patients. There is no stoichiometric mixture of factor VIII and factor VIII inhibitor since one polyvalent factor VIII particle can be bound by various numbers of factor VIII inhibitor particles. The balance between free factor VIII and inhibitor and their antigen-antibody complexes cannot be explained by the homogeneous natural law of mass action. A patient with classical hemophilia A exhibited an inhibitor which shows conformity with the Poisson distribution as far as the portion of free factor VIII activity is concerned. The spontaneously occurring inhibitor showed a different binding characteristic to factor VIII. We demonstrated here that the Freundlich's adsorption isotherme is effective for a spontaneous factor VIII inhibitor. During follow up qualitative and quantitative changes of both inhibitor types were observed. We assume that the change of property of inhibitor in hemophiliacs is due to a stronger binding to factor VIII and of the spontaneous inhibitor to a poorer fit of antigen and antibody.

Immunoradiometric assay of inhibitors of antihaemophilic factor A

An immunoradiometric assay (IRMA) for determination of antibodies against f. VIII:C in haemophilia A was developed. The assay was based on competitive binding of radiolabelled anti-VIII:C and antibodies in the test material to immobilized VIII:C. Fifteen haemophiliacs with known inhibitors were investigated with the new method and with a conventional neutralization test. In 3 cases the inhibitors were detected only with the IRMA and in the other 12 there was good agreement between the inhibitor levels found with the two methods. It was also possible to demonstrate the antibodies in three non-haemophilic patients with acquired inhibitors. The IRMA, which can detect the antibodies down to a concentration of 0.02 inhibitor units per ml, is more sensitive than conventional neutralization tests and is thus of practical importance in the investigation of patients with low inhibitor titres.

Changes in the life expectancy of patients with severe haemophilia A in Finland in 1930-79

Important advances have been made in the treatment of haemophilia during the past 30 years. We have analysed the data of all the known 163 patients with severe haemophilia A living in Finland in 1930-79 in order to study changes in the prognosis of severe haemophilia A. During the period of 50 years the mean age at death of the patients has increased from 7.8 years in 1930-39 to 25.5 years in 1970-79 and the annual death rate has markedly decreased in all age groups. The decline has been greatest in patients under 10 years of age. In this age group the annual death rate decreased from over 50 per thousand in 1930-39 and 1940-49 to 4.8 per thousand in 1970-79. The prognosis of patients with inhibitors has remained poor, however. Five of the six deaths during the last decade occurred in patients with inhibitors. The overall annual death rate of patients without inhibitors was only 1.2 per thousand in 1970-79, suggesting that at the present time the life expectancy of patients who do not develop inhibitors does not markedly differ from that of the general male population.

Precipitating anti-VIII:C antibodies in two patients with haemophilia A

IgG from the plasmas of two haemophilia A patients with anti-VIII:CAg antibodies (1000 and 200 u/ml) was isolated and labelled with 125I. The specific labelled anti-VIII:CAg IgG was further purified by binding to and elution from immobilized factor VIII/von Willebrand factor (F.VIII/vWF). When studied by immunodiffusion and autoradiography, both antibodies gave a precipitin line with normal plasma, serum, cryoprecipitate, purified F.VIII/vWF and the plasmas of two patients with haemophilia A+. No precipitin line was observed with the plasmas of 11 patients with haemophilia A- or four patients with severe von Willebrand's disease. Levels of VIII:CAg obtained by radioelectroimmunoassay were in agreement with those obtained by immunoradiometric assay. This study demonstrates that, contrary to previous evidence, human anti-VIII:CAg antibodies are precipitating as well as neutralizing when studied by highly sensitive techniques.

Immunoabsorption in an extracorporeal plasma perfusion system: in vitro studies

A rechargeable plasma perfusion system developed to remove IgG immunoglobulins is described. Partially purified protein A was covalently bonded on two separate carriers, Sepharose 6MB and carboxyl acrylic beads. Plasma from a patient with IgG multiple myeloma was perfused through the Sepharose-protein A column, and this resulted in a maximum removal of 177% of the estimated removal capacity of the column. Plasma from the same source was perfused through the acrylic bead-protein A column and yielded an average of 220% of the estimated removal capacity of the column. In addition, plasma from a normal subject and from six patients with various autoimmune diseases was perfused through the Sepharose-protein A column, and varying percent removal was obtained. A detailed procedure for covalent coupling of purified protein A to carboxylated acrylic beads is also given.

Plasma exchange and human factor VIII concentrate in managing haemophilia A with factor VIII inhibitors

Plasma exchanges were combined with human factor VIII concentrate therapy in the treatment of major bleeding episodes in five patients with haemophilia A and factor VIII inhibitors. All patients had a good clinical response to combined treatment. Inhibitor levels showed satisfactory falls before rapid secondary increases of inhibitor levels took place. A sixth patient with von Willebrand's disease and a factor VIII clotting activity inhibitor was successfully prepared for operation using plasma exchange. Postoperative haemostasis and healing were normal. In two patients the plasma exchanges were relatively more effective than the administered human factor VIII in reducing the levels of factor VIII inhibitor. Combined plasma exchange and human factor VIII treatment may offer a rapidly effective means of reducing factor VIII inhibitor levels in this group of patients, together with significant saving of costs.

Case report: successful treatment of an idiopathic acquired factor VIII inhibitor with unusual features

A patient with an idiopathic acquired factor VIII inhibitor is described. Unusual features of this patient's illness were measurable factor VIII (4 to greater than 20%) despite the presence of inhibitor, and continued spontaneous bleeding despite these factor VIII levels. Successful treatment on both a short-term and a long-term basis--with neutralizing doses of human factor VIII concentrate and with chlorambucil, respectively--is reported. It is concluded that in patients with this type of inhibitor factor VIII, assays may not provide a reliable prediction of the potential for bleeding and that chlorambucil therapy warrants further study.

Factor VII and fibrinolytic response to deamino-8-D-argenine vasopressin in normal subjects and dissociate response in some patients with haemophilia and von Willebrand's disease

Deamino-8-D-argenine vasopressin (DDAVP) was given by intravenous infusion to normal subjects, haemophiliacs and patients with von Willebrand's disease (vWd) and the factor VIII and plasminogen activator response was studied. In normal subjects and most patients with mild haemophilia and mild (intermediate) von Willebrand's disease there was an increase in plasminogen activator and all factor VIII related activities. In patients with mild vWd the prolonged bleeding time was shortened by DDAVP despite only a modest rise in factor VIII related Ristocetin cofactor activity (VIIIR:RiCoF). Sub-groups of patients have been characterized in whom atypical responses was observed. In two brothers with clinically severe haemophilia, but with 5--6 u/dl procoagulant factor VIII (VIIIC), there was an increase in VIIIC but no rise of the corresponding antigen, suggesting increased release of an antigenically abnormal poorly functioning molecule. A patient with intermediate vWd was studied in whom neither DDAVP, adrenaline infusion, nor venous occlusion resulted in an increase in either plasminogen activator or factor VIII related antigen (VIIRAg), although there was a significant increase in VIIIC. In a further patient with severe vWd, DDAVP failed to elicit any plasminogen activator or VIII response. The results obtained from these two patients suggested that in some individuals the presumed endothelial cell abnormality in vWd may be more extensive than a defect in VIIIRAg synthesis. Sub-groups of patients have been identified for whom treatment with factor VIII concentrates would be more appropriate than DDAVP prior to minor surgery.

An immunoradiometric assay for procoagulant factor VIII antigen: results in haemophilia, von Willebrand's disease and fetal plasma and serum

An immunoradiometric assay (IRMA) has been developed based on the inhibitor which arose in a polytransfused severe haemophiliac. The two-site IRMA measures antigens closely associated with the procoagulant parts of the factor VIII complex, which are termed FVIIC antigens or FVIIICAG. FVIIICAG was present in normal plasma and also, at a slightly lower concentration, in normal serum. In 37 patients with haemophilia A, 36 had FVIIICAG levels of less than 10% of the normal plasma pool. In patients with von Willebrand's disease the levels of FVIIIC and FVIIICAG were in good agreement, both before and after treatment with cryoprecipitate or DDAVP. FVIIICAG was relatively stable in plasma at 37 degrees C and could also be detected in cord and fetal serum. The assay is of potential value for detecting reduced levels of factor VIII, for carrier detection and for the prenatal diagnosis of haemophilia.

Acquired von Willebrand's syndrome and Ehlers-Danlos syndrome presenting with gastro-intestinal bleeding

The clinical and laboratory findings in a patient with severe gastro-intestinal bleeding and the Ehlers-Danlos syndrome are described. Coagulation studies and a lack of history of previous haemorrhage were consistent with a diagnosis of acquired von Willebrand's syndrome. His response to treatment with blood transfusion, Factor VIII, cimetidine, tranexamic acid and cyclophosphamide is described. Family studies revealed other members with Ehlers-Danlos syndrome but normal coagulation.

Factor XII deficiency with systemic lupus erythematosus. Biological implications

A patient with Factor XII (Hageman) deficiency and fulminant systemic lupus erythematosus is presented. The Factor XII deficiency was noted prior to the onset of clinical systemic lupus erythematosus and persisted throughout the patient's course without associated hemorrhagic manifestations. There was no evidence for a circulating anticoagulant. The patient had a rapidly progressive fatal course unresponsive to corticosteroid therapy. Factor XII levels did not increase during therapy with steroids. Despite absence of Hageman factor, evidence for activation of complement by the classic pathway and thromboembolic phenomenon was observed. The role of Factor XII in coagulation and inflammatory pathways and the influence of the factor deficiency on the course of the patient's illness are discussed.

Synthesis of procoagulant factor VIII, factor VIII related antigen and other coagulation factors by the isolated perfused rat liver

The synthesis of factor VIII and other coagulation factors has been studied using an isolated, perfused rat liver. Synthetic function of the liver was validated by adding [35S]L-methionine to the perfusion medium and performing two-dimensional crossed immunoelectrophoresis and autoradiography on samples obtained during perfusion. Progressive incorporation of radioactivity into plasma proteins was demonstrated. This was inhibited by cycloheximide. Coagulation factor assays demonstrated synthesis of factors II, IX and X and of factor V and procoagulant factor VIII (VIIIC). Synthesis of factor VIII related antigen (VIIIRAg), measured in an immunoradiometric assay, was not significantly demonstrated. Addition of warfarin to the perfusion medium inhibited the synthesis of factors II, IX and X but not of factors V and VIII. Cycloheximide completely inhibited synthesis of all coagulation factors but actinomycin acted only after a latent period. Reticuloendothelial cell blockade was attempted by adding ethionine to the perfusion medium or by administration of Indian ink to the donor animals prior to removal of the livers. In these instances synthesis of factor V and factor VIIIC was inhibited but not that of factors II, IX and X. The results confirmed the functional capacity of the isolated liver for synthesizing proteins and the vitamin K dependent coagulation factors, and suggested similar kinetic features for the synthesis of factors V and VIIIC. Failure to detect significant VIIIRAg synthesis in these experiments is consistent with the hypothesis that this protein is released by vascular endothelial cells throughout the body and is activated or joined to VIIIC or stimulates its production in the liver.