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Moser MM, Schoergenhofer C, Jilma B. Progress in von Willebrand Disease Treatment: Evolution towards Newer Therapies. Semin Thromb Hemost 2024; 50:720-732. [PMID: 38331000 DOI: 10.1055/s-0044-1779485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2024]
Abstract
von Willebrand disease (VWD) is a very heterogenous disease, resulting in different phenotypes and different degrees of bleeding severity. Established therapies (i.e., desmopressin, antifibrinolytic agents, hormone therapy for heavy menstrual bleeding, and von Willebrand factor [VWF] concentrates) may work in some subtypes, but not in all patients. In recent years, progress has been made in improving the diagnosis of VWD subtypes, allowing for more specific therapy. The impact of VWD on women's daily lives has also come to the fore in recent years, with hormone therapy, tranexamic acid, or recombinant VWF as treatment options. New treatment approaches, including the replacement of lacking factor VIII (FVIII) function, may work in those subgroups affected by severe FVIII deficiency. Reducing the clearance of VWF is an alternative treatment pathway; for example, rondaptivon pegol is a VWFA1 domain-binding aptamer which not only improves plasma VWF/FVIII levels, but also corrects platelet counts in thrombocytopenic type 2B VWD patients. These approaches are currently in clinical development, which will be the focus of this review. In addition, half-life extension methods are also important for the improvement of patients' quality of life. Targeting specific mutations may further lead to personalized treatments in the future. Finally, a few randomized controlled trials, although relatively small, have been published in recent years, aiming to achieve a higher level of evidence in future guidelines.
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Affiliation(s)
- Miriam M Moser
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | | | - Bernd Jilma
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
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Atiq F, Blok R, van Kwawegen CB, Doherty D, Lavin M, van der Bom JG, O'Connell NM, de Meris J, Ryan K, Schols SEM, Byrne M, Heubel-Moenen FCJI, van Galen KPM, Preston RJS, Cnossen MH, Fijnvandraat K, Baker RI, Meijer K, James P, Di Paola J, Eikenboom J, Leebeek FWG, O'Donnell JS. Type 1 VWD classification revisited: novel insights from combined analysis of the LoVIC and WiN studies. Blood 2024; 143:1414-1424. [PMID: 38142407 PMCID: PMC11033584 DOI: 10.1182/blood.2023022457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 11/07/2023] [Accepted: 11/29/2023] [Indexed: 12/26/2023] Open
Abstract
ABSTRACT There is significant ongoing debate regarding type 1 von Willebrand disease (VWD) defintion. Previous guidelines recommended patients with von Willebrand factor (VWF) levels <30 IU/dL be diagnosed type 1 VWD, whereas patients with significant bleeding and VWF levels from 30 to 50 IU/dL be diagnosed with low VWF. To elucidate the relationship between type 1 VWD and low VWF in the context of age-induced increases in VWF levels, we combined data sets from 2 national cohort studies: 162 patients with low VWF from the Low VWF in Ireland Cohort (LoVIC) and 403 patients with type 1 VWD from the Willebrand in The Netherlands (WiN) studies. In 47% of type 1 VWD participants, VWF levels remained <30 IU/dL despite increasing age. Conversely, VWF levels increased to the low VWF range (30-50 IU/dL) in 30% and normalized (>50 IU/dL) in 23% of type 1 VWD cases. Crucially, absolute VWF antigen (VWF:Ag) levels and increase of VWF:Ag per year overlapped between low VWF and normalized type 1 VWD participants. Moreover, multiple regression analysis demonstrated that VWF:Ag levels in low VWF and normalized type 1 VWD patients would not have been different had they been diagnosed at the same age (β = 0.00; 95% confidence interval, -0.03 to 0.04). Consistently, no difference was found in the prevalence of VWF sequence variants; factor VIII activity/VWF:Ag or VWF propeptide/VWF:Ag ratios; or desmopressin responses between low VWF and normalized type 1 VWD patients. In conclusion, our findings demonstrate that low VWF does not constitute a discrete clinical or pathological entity. Rather, it is part of an age-dependent type 1 VWD evolving phenotype. Collectively, these data have important implications for future VWD classification criteria.
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Affiliation(s)
- Ferdows Atiq
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
- Department of Haematology, Erasmus University Medical Center-Erasmus MC, Rotterdam, The Netherlands
| | - Robin Blok
- Department of Haematology, Erasmus University Medical Center-Erasmus MC, Rotterdam, The Netherlands
| | - Calvin B. van Kwawegen
- Department of Haematology, Erasmus University Medical Center-Erasmus MC, Rotterdam, The Netherlands
| | - Dearbhla Doherty
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
- National Coagulation Centre, St James’s Hospital, Dublin, Ireland
| | - Michelle Lavin
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
- National Coagulation Centre, St James’s Hospital, Dublin, Ireland
| | - Johanna G. van der Bom
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Joke de Meris
- Netherlands Hemophilia Society, Leiden, The Netherlands
| | - Kevin Ryan
- National Coagulation Centre, St James’s Hospital, Dublin, Ireland
| | - Saskia E. M. Schols
- Department of Hematology, Radboud University Medical Center, Nijmegen and Hemophilia Treatment Center, Nijmegen-Eindhoven-Maastricht, The Netherlands
| | - Mary Byrne
- National Coagulation Centre, St James’s Hospital, Dublin, Ireland
| | | | - Karin P. M. van Galen
- Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Roger J. S. Preston
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Marjon H. Cnossen
- Department of Pediatric Hematology and Oncology, Erasmus MC, University Medical Center–Sophia Children's Hospital Rotterdam, Rotterdam, The Netherlands
| | - Karin Fijnvandraat
- Department of Pediatric Hematology, Emma Children's Hospital, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
| | - Ross I. Baker
- Western Australia Centre for Thrombosis and Haemostasis, Perth Blood Institute, Murdoch University, Perth, WA, Australia
- Irish-Australian Blood Collaborative Network, Dublin, Ireland
| | - Karina Meijer
- Department of Hematology, University Medical Center Groningen, Groningen, The Netherlands
| | - Paula James
- Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Jorge Di Paola
- Department of Pediatrics, School of Medicine, Washington University in St. Louis, St. Louis, MO
| | - Jeroen Eikenboom
- Department of Internal Medicine, Division of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Frank W. G. Leebeek
- Department of Haematology, Erasmus University Medical Center-Erasmus MC, Rotterdam, The Netherlands
| | - James S. O'Donnell
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
- National Coagulation Centre, St James’s Hospital, Dublin, Ireland
- Irish-Australian Blood Collaborative Network, Dublin, Ireland
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Kogan L, Price R, Kotchetkov R. Case report: Peri-procedural hydroxyurea helps minimize bleeding in patients with Essential Thrombocythemia associated with acquired von Willebrand syndrome. Front Oncol 2024; 14:1326209. [PMID: 38361779 PMCID: PMC10867169 DOI: 10.3389/fonc.2024.1326209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 01/15/2024] [Indexed: 02/17/2024] Open
Abstract
Background Essential Thrombocythemia is a chronic myeloproliferative neoplasm characterized by an isolated excessive production of platelets. Extreme thrombocytosis is defined by having a platelet count greater than or equal to 1,000 x 109/L, which may lead to the development of acquired von Willebrand syndrome and complications of excessive hemorrhage. Case description A 74-year-old female patient was brought in for a bone marrow examination regarding elevated platelet count. She had no history of excessive bleeding. The physical exam was unremarkable with no petechiae or hematomas. Complete blood count showed platelet count 1,491x109/L. Bone marrow aspiration and biopsy were unremarkable, however, the patient developed bleeding from the biopsy site. Local pressure and an ice pack were ineffective, so she received 20 mcg of desmopressin subcutaneously, 1 unit of fresh frozen plasma and was started on tranexamic acid 1,000 mg orally every 8 hours. She was admitted for bleeding control and had another dose of desmopressin. Blood work showed elevated partial thromboplastin time and normal international normalized ratio. Acquired von Willebrand syndrome was suspected and a sample for von Willebrand disease was sent out. The next day her bleeding continued, and her Hb decreased from 145 to 89 g/L, she became symptomatic (tachycardic) and fatigued. The coagulation profile was consistent with acquired von Willebrand syndrome. Since she continued bleeding, she received 1 unit of packed red blood cells. A high dose of hydroxyurea (3g/day) was started urgently; within 24 hours platelet count was halved, and the bleeding resolved. Blood work was repeated 24 hours later and showed normalization of partial thromboplastin time and a normal Von Willebrand profile. Conclusion Patients with extreme thrombocytosis are at high risk of bleeding due to acquired Von Willebrand Syndrome. Initiation of hydroxyurea at the time of bone marrow exam helps to control platelet count and minimizes the risk of peri-procedural hemorrhage in high-risk Essential Thrombocythemia patients with suspected acquired Von Willebrand Syndrome.
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Affiliation(s)
- Leah Kogan
- Department of Medicine, University of Limerick, Limerick, Ireland
| | - Russell Price
- Department of Pathology, Royal Victoria Regional Health Centre, Barrie, ON, Canada
| | - Rouslan Kotchetkov
- Simcoe Muskoka Regional Cancer Program, Royal Victoria Regional Health Centre, Barrie, ON, Canada
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Mert S, Kuhlmann C, Hagen CS, Kessler K, Balubaid M, Giunta RE, Wiggenhauser PS. Abdominoplasty in a Patient With Type 3 von Willebrand Disease: A Case Report. Ann Plast Surg 2024; 92:133-136. [PMID: 37962210 DOI: 10.1097/sap.0000000000003711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Abstract
ABSTRACT von Willebrand disease (vWD) is an inherited bleeding disorder that is characterized by a quantitative or qualitative deficiency of the von Willebrand factor (vWF). Type 3 is the most severe form of vWD with a near-complete absence of vWF and a significantly increased risk of excessive bleeding and hematoma during a surgical procedure. To date, no data on surgical and hemostatic management of a type 3 vWD patient undergoing body-contouring surgery has been published. We report the case of a 47-year-old woman with type 3 vWD requiring medically indicated abdominoplasty after massive weight loss due to bariatric surgery. The case was successfully managed with individualized bodyweight-adapted substitution of recombinant vWF vonicog alfa and tranexamic acid under close monitoring of vWF and factor VIII activity. For further risk stratification, we propose the multidisciplinary treatment of patients with severe vWF undergoing elective plastic surgery in specialized centers providing around-the-clock laboratory testing and access to a blood bank. In addition, strict hemostasis during surgery and early postoperative mobilization with fitted compression garments are recommended to further reduce the risk of bleeding and thromboembolic complications.
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Affiliation(s)
- Sinan Mert
- From the Division of Hand, Plastic and Aesthetic Surgery, LMU University Hospital, LMU Munich, Munich, Germany
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Bhatti MQ, Gonzalez-Fernandez E, Bhatia K, Divani AA, Di Napoli M, Hinduja A, Datta YH. Neurological Complications Associated with Hereditary Bleeding Disorders. Curr Neurol Neurosci Rep 2023; 23:751-767. [PMID: 37864642 DOI: 10.1007/s11910-023-01313-y] [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] [Accepted: 09/15/2023] [Indexed: 10/23/2023]
Abstract
PURPOSE OF REVIEW Hereditary bleeding disorders may have a wide variety of clinical presentations ranging from mild mucosal and joint bleeding to severe central nervous system (CNS) bleeding, of which intracranial hemorrhage (ICH) is the most dreaded complication. In this review, we will discuss the pathophysiology of specific hereditary bleeding disorders, namely, hemophilia A, hemophilia B, and von Willebrand disease (vWD); their clinical manifestations with a particular emphasis on neurological complications; a brief overview of management strategies pertaining to neurological complications; and a review of literature guiding treatment strategies. RECENT FINDINGS ICH is the most significant cause of morbidity and mortality in patients with hemophilia. Adequate control of bleeding with the administration of specific factors or blood products, identification of risk factors for bleeding, and maintaining optimal coagulant activity are essential for appropriately managing CNS bleeding complications in these patients. The administration of specific recombinant factors is tailored to a patient's pharmacokinetics and steady-state levels. During acute bleeding episodes, initial factor activity should be maintained between 80 and 100%. Availability of monoclonal antibody Emicizumab has revolutionized prophylactic therapies in patients with hemophilia. Management of ICH in patients with vWD involves using plasma-derived factor concentrates, recombinant von Willebrand factor, and supportive antifibrinolytic agents individualized to the type and severity of vWD. Hemophilia and vWD are the most common hereditary bleeding disorders that can predispose patients to life-threatening CNS complications-intracranial bleeds, intraspinal bleeding, and peripheral nerve syndromes. Early care coordination with a hematologist can help develop an effective prophylactic regimen to avoid life-threatening bleeding complications in these patients. Further research is needed to evaluate using emicizumab as an on-demand treatment option for acute bleeding episodes in patients with hemophilia.
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Affiliation(s)
| | | | - Kunal Bhatia
- Department of Neurology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Afshin A Divani
- Department of Neurology, University of New Mexico, Albuquerque, NM, USA.
| | - Mario Di Napoli
- Neurological Service, SS Annunziata Hospital, Sulmona, L'Aquila, Italy
| | - Archana Hinduja
- Department of Neurology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Yvonne H Datta
- Department of Medicine, Division of Hematology, Oncology, and Transplantation, University of Minnesota, Minneapolis, MN, USA
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Ocran E, Chornenki NLJ, Bowman M, Sholzberg M, James P. Gastrointestinal bleeding in von Willebrand patients: special diagnostic and management considerations. Expert Rev Hematol 2023; 16:575-584. [PMID: 37278227 DOI: 10.1080/17474086.2023.2221846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 06/01/2023] [Indexed: 06/07/2023]
Abstract
INTRODUCTION Severe and recurrent gastrointestinal (GI) bleeding caused by angiodysplasia is a significant problem in patients with von Willebrand disease (VWD) and in those with acquired von Willebrand syndrome (AVWS). At present, angiodysplasia-related GI bleeding is often refractory to standard treatment including replacement therapy with von Willebrand factor (VWF) concentrates and continues to remain a major challenge and cause of significant morbidity in patients despite advances in diagnostics and therapeutics. AREAS COVERED This paper reviews the available literature on GI bleeding in VWD patients, examines the molecular mechanisms implicated in angiodysplasia-related GI bleeding, and summarizes existing strategies in the management of bleeding GI angiodysplasia in patients with VWF abnormalities. Suggestions are made for further research directions. EXPERT OPINION Bleeding from angiodysplasia poses a significant challenge for individuals with abnormal VWF. Diagnosis remains a challenge and may require multiple radiologic and endoscopic investigations. Additionally, there is a need for enhanced understanding at a molecular level to identify effective therapies. Future studies of VWF replacement therapies using newer formulations as well as other adjunctive treatments to prevent and treat bleeding will hopefully improve care.
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Affiliation(s)
- Edwin Ocran
- Department of Medicine, Queen's University, Kingston, Canada
| | | | | | - Michelle Sholzberg
- Division of Hematology-Oncology, St. Michael's Hospital, Li Ka Shing Knowledge Institute, University of Toronto, Toronto, Canada
| | - Paula James
- Department of Medicine, Queen's University, Kingston, Canada
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Gritsch H, Schrenk G, Weinhappl N, Mellgård B, Ewenstein B, Turecek PL. Structure and Function of Recombinant versus Plasma-Derived von Willebrand Factor and Impact on Multimer Pharmacokinetics in von Willebrand Disease. J Blood Med 2022; 13:649-662. [PMID: 36405429 PMCID: PMC9673800 DOI: 10.2147/jbm.s377126] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 11/03/2022] [Indexed: 11/07/2023] Open
Abstract
BACKGROUND Recombinant von Willebrand factor (rVWF, vonicog alfa) is a purified VWF concentrate produced from Chinese hamster ovary cells. rVWF is not exposed to the VWF-cleaving protease ADAMTS13 and so is not subject to proteolytic degradation of large (L) and ultra-large (UL) VWF multimers by that enzyme. PURPOSE To compare the structure and function of rVWF with the human plasma-derived VWF [pdVWF] concentrates Haemate P®/Humate-P®, Voncento®, Wilate®/Eqwilate®, and Wilfactin®/Willfact®; to investigate the relationship between VWF multimeric pattern and VWF:ristocetin cofactor (VWF:RCo) activity through population pharmacokinetic (PK) modeling in patients with severe von Willebrand disease (VWD) treated with rVWF. METHODS Analyses included VWF:RCo activity, VWF:collagen-binding activity, VWF:platelet glycoprotein Ib receptor binding, factor VIII (FVIII) binding capacity, and VWF-mediated platelet adhesion under flow conditions. VWF multimeric structure was determined by agarose gel electrophoresis. Population PK models describing the activity-time profile of small, medium, and L/UL multimers following intravenous administration of rVWF in patients with severe VWD were developed. RESULTS Findings demonstrate that rVWF contains a non-degraded VWF multimer pattern including the UL multimers not present in pdVWF concentrates. rVWF displayed higher specific platelet-binding activity, and faster mediation of platelet adhesion to collagen under shear stress versus pdVWF concentrates. rVWF also demonstrated higher FVIII binding capacity than Haemate P®, Voncento® and Wilate®. Modeling provided evidence that VWF:RCo activity in patients with severe VWD treated with rVWF is associated with L/UL VWF multimers in the circulation. CONCLUSIONS Findings suggest that the L and UL multimers preserved in rVWF contribute to high biological activity and might be important for providing hemostatic efficacy.
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Affiliation(s)
- Herbert Gritsch
- Pharmaceutical Sciences, Baxalta Innovations GmbH, a Takeda Company, Vienna, Austria
| | - Gerald Schrenk
- Pharmaceutical Sciences, Baxalta Innovations GmbH, a Takeda Company, Vienna, Austria
| | - Nina Weinhappl
- Pharmaceutical Sciences, Baxalta Innovations GmbH, a Takeda Company, Vienna, Austria
| | - Björn Mellgård
- Rare Genetics and Hematology, Research & Development, Takeda Development Center Americas, Inc, Cambridge, MA, USA
| | - Bruce Ewenstein
- Rare Genetics and Hematology, Research & Development, Takeda Development Center Americas, Inc, Cambridge, MA, USA
| | - Peter L Turecek
- Department of Pharmaceutical Sciences, Division of Pharmacology, University of Vienna, Vienna, Austria
- Plasma Derived Therapies, Research & Development, Baxalta Innovations GmbH, a Takeda Company, Vienna, Austria
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Li X, Lu Z. Role of von Willebrand factor in the angiogenesis of lung adenocarcinoma (Review). Oncol Lett 2022; 23:198. [PMID: 35572495 PMCID: PMC9100484 DOI: 10.3892/ol.2022.13319] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 04/19/2022] [Indexed: 11/06/2022] Open
Affiliation(s)
- Xin Li
- Department of Oncology, Affiliated Hospital of Weifang Medical College, Weifang, Shandong 261053, P.R. China
| | - Zhong Lu
- Department of Oncology, Affiliated Hospital of Weifang Medical College, Weifang, Shandong 261053, P.R. China
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Ambrosini YM, Piedra‐Mora C, Jennings S, Webster CRL. Serum 25-hydroxyvitamin D and C-reactive protein and plasma von Willebrand concentrations in 23 dogs with chronic hepatopathies. J Vet Intern Med 2022; 36:966-975. [PMID: 35420222 PMCID: PMC9151486 DOI: 10.1111/jvim.16424] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 03/23/2022] [Accepted: 03/25/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Serum concentrations of 25-hydroxyvitamin D (25(OH)VD) and C-reactive protein (CRP) and von Willebrand's factor (vWF) concentration correlate with histopathologic disease grade and stage in chronic inflammatory and fibrotic hepatopathies (CH) in humans. OBJECTIVES To evaluate serum 25(OH)VD and serum CRP concentrations and plasma vWF concentration and determine if they correlate with histopathologic and biochemical variables in dog with CH. ANIMALS Twenty-three client-owned dogs with a histopathologic diagnosis of CH were prospectively enrolled. METHODS Blood samples were collected before liver biopsy. Correlations between biomarkers and clinical pathological and histopathologic variables were evaluated using Pearson's or Spearman's test. RESULTS Serum 25(OH)VD concentration (median, 213 nmol/L; range, 42-527 nmol/L) was negatively correlated with serum aspartate aminotransferase activity (AST; rho = -0.59, P < .01), polymorphonuclear neutrophil count (PMN; r = -0.46, P < .05), and positively correlated with serum albumin concentration (r = 0.69, P < .001). Serum CRP concentration (median, 7.4 μg/L; range, 1-44.9 μg/L) was positively correlated with overall histopathologic necroinflammatory activity (r = 0.78, P < .001) and fibrosis score (rho = 0.49, P < .05). Plasma vWF concentration (median, 73.3%; range, 15-141%) was positively correlated with fibrosis score (r = 0.53, P < .05) and prothrombin time (rho = 0.67, P < .01), and negatively correlated with serum albumin concentration (r = -0.73, P < .001). CONCLUSION AND CLINICAL IMPORTANCE In dogs with CH, serum 25(OH)VD concentration was negatively correlated with disease activity, whereas serum CRP concentration and plasma vWF concentration were positively correlated with histopathologic grade and stage. Our results provide preliminary evidence that these biomarkers may be useful to assess grade and stage of CH in dogs in the absence of liver biopsy.
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Affiliation(s)
- Yoko M. Ambrosini
- Washington State UniversityPullmanWashingtonUSA
- Cummings School of Veterinary Medicine at Tufts UniversityGraftonMassachusettsUSA
| | - Cesar Piedra‐Mora
- Cummings School of Veterinary Medicine at Tufts UniversityGraftonMassachusettsUSA
| | - Sam Jennings
- Cummings School of Veterinary Medicine at Tufts UniversityGraftonMassachusettsUSA
- Zoetis Reference LaboratoriesSan DiegoCaliforniaUSA
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Desmopressin response depends on the presence and type of genetic variants in patients with type 1 and type 2 von Willebrand disease. Blood Adv 2022; 6:5317-5326. [PMID: 35446929 PMCID: PMC9631688 DOI: 10.1182/bloodadvances.2021006757] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 04/04/2022] [Indexed: 11/30/2022] Open
Abstract
All type 1 VWD patients without a VWF gene variant have a complete response to desmopressin. In type 1 and type 2 VWD patients with a VWF gene variant, desmopressin response highly depends on the causative VWF gene variant.
Patients with type 1 and type 2 von Willebrand disease (VWD) can be treated with desmopressin. Although a previous study has shown that the location of the causative VWF gene variant is associated with desmopressin response in type 1 VWD, the association between variants in the VWF gene and desmopressin response is not yet fully understood. Our primary aim was to compare desmopressin response in type 1 VWD patients with and without a VWF gene variant. Secondly, we investigated whether desmopressin response depends on specific VWF gene variants in type 1 and type 2 VWD. We included 250 patients from the Willebrand in the Netherlands study: 72 type 1 without a VWF gene variant, 108 type 1 with a variant, 45 type 2A, 16 type 2M, and 9 type 2N patients. VWF gene was analyzed with ion semiconductor sequencing and Multiplex Ligation-dependent Probe Amplification. Complete response to desmopressin was observed in all type 1 VWD patients without a variant, 64.3% of type 1 patients with a variant, and 31.3% of type 2 patients (P < .001). Despite a large interindividual variability in desmopressin response, patients with the same variant had comparable desmopressin responses. For instance, in 6 type 1 patients with exon 4 to 5 deletion, mean VWF activity at 1 hour after desmopressin was 0.81 IU/mL, with a coefficient of variation of 22.9%. In conclusion, all type 1 VWD patients without a VWF gene variant respond to desmopressin. In type 1 and type 2 VWD patients with a VWF variant, desmopressin response highly depends on the VWF gene variants.
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Lekic N, Tadic B, Djordjevic V, Basaric D, Micev M, Vucelic D, Mitrovic M, Grubor N. Splenectomy for Visceral Leishmaniasis Out of an Endemic Region: A Case Report and Literature Review. Medicina (B Aires) 2022; 58:medicina58020184. [PMID: 35208507 PMCID: PMC8875283 DOI: 10.3390/medicina58020184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 01/18/2022] [Accepted: 01/20/2022] [Indexed: 11/16/2022] Open
Abstract
Visceral leishmaniasis (also known as kala-azar) is characterized by fever, weight loss, swelling of the spleen and liver, and pancytopenia. If it is not treated, the fatality rate in developing countries can be as high as 100% within 2 years. In a high risk situation for perioperative bleeding due to severe thrombocytopenia/coagulopathy, we present a rare challenge for urgent splenectomy in a patient with previously undiagnosed visceral leishmaniasis. A histologic examination of the spleen revealed a visceral leishmaniasis, and the patient was successfully treated with amphotericin B.
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Affiliation(s)
- Nebojsa Lekic
- Department for HBP Surgery, University Clinical Centre of Serbia, Clinic for Digestive Surgery, Koste Todorovica Street, No. 6, 11000 Belgrade, Serbia; (N.L.); (V.D.); (D.B.); (N.G.)
- Department for Surgery with Anesthesiology, Faculty of Medicine, University of Belgrade, Subotica No. 8, 11000 Belgrade, Serbia
| | - Boris Tadic
- Department for HBP Surgery, University Clinical Centre of Serbia, Clinic for Digestive Surgery, Koste Todorovica Street, No. 6, 11000 Belgrade, Serbia; (N.L.); (V.D.); (D.B.); (N.G.)
- Department for Surgery with Anesthesiology, Faculty of Medicine, University of Belgrade, Subotica No. 8, 11000 Belgrade, Serbia
- Correspondence: ; Tel.: +381-62-388-288
| | - Vladimir Djordjevic
- Department for HBP Surgery, University Clinical Centre of Serbia, Clinic for Digestive Surgery, Koste Todorovica Street, No. 6, 11000 Belgrade, Serbia; (N.L.); (V.D.); (D.B.); (N.G.)
| | - Dragan Basaric
- Department for HBP Surgery, University Clinical Centre of Serbia, Clinic for Digestive Surgery, Koste Todorovica Street, No. 6, 11000 Belgrade, Serbia; (N.L.); (V.D.); (D.B.); (N.G.)
- Department for Surgery with Anesthesiology, Faculty of Medicine, University of Belgrade, Subotica No. 8, 11000 Belgrade, Serbia
| | - Marjan Micev
- Department for Pathology, University Clinical Centre of Serbia, Clinic for Digestive Surgery, Koste Todorovica Street, No. 6, 11000 Belgrade, Serbia;
| | - Dragica Vucelic
- Department of Transfusion Medicine, Faculty of Medicine, University of Belgrade, Koste Todorovica Street, No. 6, 11000 Belgrade, Serbia;
| | - Milica Mitrovic
- Center for Radiology and Magnetic Resonance Imaging, University Clinical Centre of Serbia, Pasterova No. 2, 11000 Belgrade, Serbia;
| | - Nikola Grubor
- Department for HBP Surgery, University Clinical Centre of Serbia, Clinic for Digestive Surgery, Koste Todorovica Street, No. 6, 11000 Belgrade, Serbia; (N.L.); (V.D.); (D.B.); (N.G.)
- Department for Surgery with Anesthesiology, Faculty of Medicine, University of Belgrade, Subotica No. 8, 11000 Belgrade, Serbia
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12
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Approach to the Patient with Bleeding. Hematol Oncol Clin North Am 2021; 35:1039-1049. [PMID: 34535288 DOI: 10.1016/j.hoc.2021.07.001] [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: 11/21/2022]
Abstract
Approach to the patient with bleeding begins with a thorough bleeding, medical, and family history to determine the nature of bleeding and severity of bleeding symptoms. Use of a Bleeding Assessment Tool allows the clinician to obtain a comprehensive bleeding history and ultimately determine the individual bleeding score that reflects bleeding severity and is classifiable as either normal or abnormal. In the absence of significant findings within patient history or presenting symptoms clearly pointing to a specific bleeding pathology, an approach to laboratory investigation is presented that proceeds through first-line, second-line, and third-line testing.
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13
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Weyand AC, Flood VH. Von Willebrand Disease: Current Status of Diagnosis and Management. Hematol Oncol Clin North Am 2021; 35:1085-1101. [PMID: 34400042 DOI: 10.1016/j.hoc.2021.07.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Von Willebrand disease (VWD) is a common bleeding disorder, affecting male and female individuals equally, that often manifests in mucosal bleeding. VWD can be secondary to a quantitative (Type 1 and Type 3) or qualitative (Type 2) defects in Von Willebrand factor (VWF). Initial testing includes VWF antigen, as well as a platelet binding assay to differentiate between qualitative and quantitative defects. Further subtyping requires additional testing and is needed to ensure appropriate treatment. Desmopressin, antifibrinolytics, hormonal treatments for heavy menstrual bleeding, and VWF concentrates are commonly used in the treatment of VWD.
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Affiliation(s)
- Angela C Weyand
- Department of Pediatrics, University of Michigan Medical School, 1150 W. Medical Center Dr, MSRB III, Room 8220E, Ann Arbor, MI 48109, USA
| | - Veronica H Flood
- Department of Pediatrics, Medical College of Wisconsin and Versiti Blood Research Institute, Milwaukee, WI, USA; Comprehensive Center for Bleeding Disorders, 8739 Watertown Plank Road, PO Box 2178, Milwaukee, WI 53201-2178, USA.
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14
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von Willebrand factor and factor VIII levels after desmopressin are associated with bleeding phenotype in type 1 VWD. Blood Adv 2020; 3:4147-4154. [PMID: 31834934 DOI: 10.1182/bloodadvances.2019000863] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 11/07/2019] [Indexed: 12/31/2022] Open
Abstract
The bleeding phenotype of patients with type 1 von Willebrand disease (VWD) is very heterogeneous. We hypothesized that this heterogeneity may partly be explained by variability in response of von Willebrand factor (VWF) and factor VIII (FVIII) levels to stress during hemostatic challenges. We therefore investigated whether VWF and FVIII levels after administration of desmopressin, which mimic in vivo hemostatic response during hemostatic challenges, explain the heterogeneity in bleeding phenotype of patients with type 1 VWD. We performed a retrospective cohort study in 122 patients with type 1 VWD. All patients received a test dose of desmopressin shortly after diagnosis. Patients' mean age was 47 ± 14 years, and the mean Tosetto bleeding score was 10 ± 7. Higher FVIII activity during the complete time course after desmopressin administration (1, 3, and 5-6 hours), and higher VWF and FVIII levels combined at 3 hours after desmopressin administration, were associated with a lower bleeding score: β = -0.9 (-1.7; -0.1) and β = -1.2 (-1.9; -0.5), respectively, adjusted for age, sex, body mass index (BMI), and comorbidities. Patients with FVIII activity in the highest quartile 3 hours after desmopressin administration had a much lower bleeding score compared with patients in the other 3 quartiles (β = -5.1 [-8.2; -2.0]) and also had a lower chance of an abnormal bleeding score (odds ratio = 0.2 [0.1-0.5]), both adjusted for age, sex, BMI, and comorbidities. In conclusion, VWF and FVIII levels after desmopressin administration, which mimic hemostatic response to hemostatic challenges, are associated with the bleeding phenotype of patients with type 1 VWD. This may partly explain the variability in bleeding phenotype of these patients.
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15
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Fogarty H, Doherty D, O'Donnell JS. New developments in von Willebrand disease. Br J Haematol 2020; 191:329-339. [PMID: 32394456 DOI: 10.1111/bjh.16681] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 03/30/2020] [Accepted: 04/01/2020] [Indexed: 12/19/2022]
Abstract
Von Willebrand disease (VWD) constitutes the most common inherited human bleeding disorder. It is associated with a mucocutaneous bleeding phenotype that can significantly impact upon quality of life. Despite its prevalence and associated morbidity, the diagnosis and subclassification of VWD continue to pose significant clinical challenges. This is in part attributable to the fact that plasma von Willebrand factor (VWF) levels vary over a wide range in the normal population, together with the multiple different physiological functions played by VWF in vivo. Over recent years, substantial progress has been achieved in elucidating the biological roles of VWF. Significant advances have also been made into defining the pathophysiological mechanisms underpinning both quantitative and qualitative VWD. In particular, several new laboratory assays have been developed that enable more precise assessment of specific aspects of VWF activity. In the present review, we discuss these recent developments in the field of VWD diagnosis, and consider how these advances can impact upon clinical diagnostic algorithms for use in routine clinical practice. In addition, we review some important recent advances pertaining to the various treatment options available for managing patients with VWD.
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Affiliation(s)
- Helen Fogarty
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland.,National Coagulation Centre, St James's Hospital, Dublin, Ireland
| | - Dearbhla Doherty
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - James S O'Donnell
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland.,National Coagulation Centre, St James's Hospital, Dublin, Ireland.,National Children's Research Centre, Our Lady's Children's Hospital Crumlin, Dublin, Ireland
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16
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Upshaw-Schulman syndrome-associated ADAMTS13 variants possess proteolytic activity at the surface of endothelial cells and in simulated circulation. PLoS One 2020; 15:e0232637. [PMID: 32365113 PMCID: PMC7197795 DOI: 10.1371/journal.pone.0232637] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 04/17/2020] [Indexed: 12/17/2022] Open
Abstract
ADAMTS13 regulates the hemostatic activity of von Willebrand factor (VWF). Determined by static assays, proteolytic activity <10IU/dL in patient plasma, in absence of ADAMTS13 autoantibodies, indicates Upshaw-Schulman syndrome (USS); the congenital form of Thrombotic Thrombocytopenic Purpura (TTP). We have recently functionally characterized sixteen USS-associated ADAMTS13 missense variants under static conditions. Here, we used two assays under shear flow conditions to analyze the activity of those seven mutants with sufficiently high residual secretion plus two newly identified variants. One assay determines cleavage of VWF strings bound to the surface of endothelial cells. The other, light transmission aggregometry-based assay, mimics degradation of VWF-platelet complexes, which are likely to be present in the circulation during TTP bouts. We found that 100 ng/ml of all variants were able to cleave about 80–90% of VWF strings even though 5 out of 9 exhibited activity ≤1% in the state-of-the-art static assay at the same concentration. These data indicate underestimation of ADAMTS13 activity by the used static assay. In simulated circulation, two variants, with missense mutations in the vicinity of the catalytic domain, exhibited only minor residual activity while all other variants were able to effectively break down VWF-platelet complexes. In both assays, significant proteolytic activity could be observed down to 100 ng/ml ADAMTS13. It is thus intriguing to postulate that most variants would have ample activity if secretion of 10% of normal plasma levels could be achieved.
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17
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Abstract
Von Willebrand factor (VWF) and coagulation factor VIII (FVIII) circulate as a complex in plasma and have a major role in the hemostatic system. VWF has a dual role in hemostasis. It promotes platelet adhesion by anchoring the platelets to the subendothelial matrix of damaged vessels and it protects FVIII from proteolytic degradation. Moreover, VWF is an acute phase protein that has multiple roles in vascular inflammation and is massively secreted from Weibel-Palade bodies upon endothelial cell activation. Activated FVIII on the other hand, together with coagulation factor IX forms the tenase complex, an essential feature of the propagation phase of coagulation on the surface of activated platelets. VWF deficiency, either quantitative or qualitative, results in von Willebrand disease (VWD), the most common bleeding disorder. The deficiency of FVIII is responsible for Hemophilia A, an X-linked bleeding disorder. Here, we provide an overview on the role of the VWF-FVIII interaction in vascular physiology.
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Affiliation(s)
- Klytaimnistra Kiouptsi
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Langenbeckstrasse 1, Building 708, 55131, Mainz, Germany
| | - Christoph Reinhardt
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Langenbeckstrasse 1, Building 708, 55131, Mainz, Germany.
- German Center for Cardiovascular Research (DZHK), Partner Site RheinMain, Mainz, Germany.
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18
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19
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Leebeek FWG, Atiq F. How I manage severe von Willebrand disease. Br J Haematol 2019; 187:418-430. [PMID: 31498884 PMCID: PMC6899759 DOI: 10.1111/bjh.16186] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 08/16/2019] [Indexed: 12/29/2022]
Abstract
Von Willebrand disease (VWD) is the most common inherited bleeding disorder. Most patients with mild and moderate VWD can be treated effectively with desmopressin. The management of severe VWD patients, mostly affected by type 2 and type 3 disease, can be challenging. In this article we review the current diagnosis and treatment of severe VWD patients. We will also discuss the management of severe VWD patients in specific situations, such as pregnancy, delivery, patients developing alloantibodies against von Willebrand factor and VWD patients with recurrent gastrointestinal bleeding. Moreover, we review emerging treatments that may be applied in future management of patients with severe VWD.
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Affiliation(s)
- Frank W G Leebeek
- Department of Haematology, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Ferdows Atiq
- Department of Haematology, Erasmus University Medical Centre, Rotterdam, the Netherlands
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20
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Lim CC, Siow B, Choo JCJ, Chawla M, Chin YM, Kee T, Lee PH, Foo M, Tan CS. Desmopressin for the prevention of bleeding in percutaneous kidney biopsy: efficacy and hyponatremia. Int Urol Nephrol 2019; 51:995-1004. [PMID: 31028561 DOI: 10.1007/s11255-019-02155-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 04/16/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Desmopressin is used to reduce bleeding complications for kidney biopsies with azotemia but little is known about desmopressin-induced hyponatremia in these individuals. We aimed to evaluate the impact of desmopressin prophylaxis on severe hyponatremia and bleeding after kidney biopsies in individuals with renal impairment. METHOD This is a single-center retrospective cohort study of consecutive adults with serum creatinine ≥ 150 µmol/L and had ultrasound-guided percutaneous native or transplant kidney biopsies between June 2011 and July 2015. Data were retrieved from electronic medical records. Primary outcomes were the use of desmopressin prophylaxis and severe hyponatremia (serum sodium ≤ 125 mmol/L) within 7 days post-biopsy. Secondary outcome was post-biopsy bleeding. RESULTS 240 native kidney and 196 allograft biopsies were performed. Median age was 51 (IQR 42.3, 60) years and eGFR was 21.9 (12.9, 30.1) ml/min/1.73 m2. Although patients prescribed desmopressin prophylaxis (n = 226) had higher serum creatinine [279 (201, 392) vs. 187 (160, 241), p < 0.001], bleeding (15.0% vs. 13.3%, p = 0.60) was not significantly different with and without desmopressin. Severe hyponatremia occurred in 30 biopsies (6.9%) with nadir serum sodium level of 122 (119, 124) mmol/L at 3 (2, 5) days after biopsy, more frequently among those with desmopressin prophylaxis (10.7% vs. 3.0%, p = 0.002). Multi-variate analysis found that pre-biopsy serum sodium level [adjusted OR 0.80 (95% CI 0.72, 0.90), p < 0.001] and desmopressin prophylaxis [adjusted OR 4.02 (95% CI 1.58, 10.21), p = 0.003] were independently associated with severe hyponatremia after kidney biopsy. CONCLUSION Pre-biopsy desmopressin was associated with severe hyponatremia in individuals with renal impairment; hence, susceptible patients given desmopressin should be closely monitored.
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Affiliation(s)
- Cynthia C Lim
- Department of Renal Medicine, Singapore General Hospital, Academia Level 3, 20 College Road, Singapore, 169856, Singapore.
| | - Benson Siow
- Pharmacy, Singapore General Hospital, 1 Hospital Drive, Outram Road, Singapore, Singapore
| | - Jason C J Choo
- Department of Renal Medicine, Singapore General Hospital, Academia Level 3, 20 College Road, Singapore, 169856, Singapore
| | - Mayank Chawla
- Department of Renal Medicine, Singapore General Hospital, Academia Level 3, 20 College Road, Singapore, 169856, Singapore
| | - Yok Mooi Chin
- Department of Renal Medicine, Singapore General Hospital, Academia Level 3, 20 College Road, Singapore, 169856, Singapore
| | - Terence Kee
- Department of Renal Medicine, Singapore General Hospital, Academia Level 3, 20 College Road, Singapore, 169856, Singapore
| | - Puay Hoon Lee
- Pharmacy, Singapore General Hospital, 1 Hospital Drive, Outram Road, Singapore, Singapore
| | - Marjorie Foo
- Department of Renal Medicine, Singapore General Hospital, Academia Level 3, 20 College Road, Singapore, 169856, Singapore
| | - Chieh Suai Tan
- Department of Renal Medicine, Singapore General Hospital, Academia Level 3, 20 College Road, Singapore, 169856, Singapore
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21
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Riddell A, Vinayagam S, Gomez K, Laffan M, McKinnon T. Evaluation of von Willebrand factor concentrates by platelet adhesion to collagen using an in vitro flow assay. Res Pract Thromb Haemost 2019; 3:126-135. [PMID: 30656286 PMCID: PMC6332833 DOI: 10.1002/rth2.12166] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Accepted: 10/19/2018] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Von Willebrand disease (VWD) results from quantitative or qualitative deficiency of von Willebrand factor (VWF) and is treated using VWF-containing concentrates. Several studies have compared the function of various VWF containing concentrates however this has not been performed using shear based assays. OBJECTIVES To compare the platelet-capture potential of 10 commercially available, plasma-derived VWF concentrates under shear conditions. METHODS VWF containing concentrates were assessed for VWF:Ag, VWF:CB, VWF:RCo, factor VIII:C ADAMTS13 content, VWF multimeric profile and glycan content using lectin binding assays. Free-thiol content of each concentrate was investigated using MPB binding assays. An in vitro flow assay was used to determine the ability of each concentrate to mediate platelet capture to collagen. RESULTS VWF multimeric analysis revealed reduction of high molecular weight (HMW) forms in four of the concentrates (Alphante, Octanate and Haemoctin, and 8Y). The high MW multimer distribution of the remaining six concentrates (Optivate, Wilate, Fandhi, Wilfactin, Haemate P, and Voncento) was similar to the plasma control. Lectin analysis demonstrated that 8Y had increased amount of T-antigen. Although platelet capture after 5 minutes perfusion was similar for all concentrates; Alphante, Octanate, and Haemoctin, demonstrated the lowest levels of platelet capture after 60 seconds of perfusion. Free-thiol content and ADAMTS13 levels varied widely between the concentrates but was not correlated with function. CONCLUSION Alphanate, Octanate, and Haemoctin, lacked HMW multimers and had the lowest initial platelet capture levels suggesting that the presence of VWF HMW multimers are required for initial platelet deposition.
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Affiliation(s)
- Anne Riddell
- Katharine Dormandy Haemophilia Centre and Thrombosis UnitRoyal Free London NHS Foundation TrustLondonUK
| | - Saravanan Vinayagam
- Katharine Dormandy Haemophilia Centre and Thrombosis UnitRoyal Free London NHS Foundation TrustLondonUK
| | - Keith Gomez
- Katharine Dormandy Haemophilia Centre and Thrombosis UnitRoyal Free London NHS Foundation TrustLondonUK
| | - Mike Laffan
- Department of HaematologyImperial College of Science Technology and MedicineLondonUK
| | - Tom McKinnon
- Department of HaematologyImperial College of Science Technology and MedicineLondonUK
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22
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Ward FL, Tobe SW, Naimark DMJ. The Role of Desmopressin in the Management of Severe, Hypovolemic Hyponatremia: A Single-Center, Comparative Analysis. Can J Kidney Health Dis 2018; 5:2054358118761051. [PMID: 29593879 PMCID: PMC5865454 DOI: 10.1177/2054358118761051] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Accepted: 07/28/2017] [Indexed: 12/17/2022] Open
Abstract
Background The role of desmopressin (DDAVP) to prevent or treat rapid serum sodium concentration ([Na]s) correction during hyponatremia management remains unclear. Objective To assess DDAVP use during the first 48 hours of severe, hypovolemic hyponatremia management. The primary study hypothesis was that the use of DDAVP would slow the rate of [Na]s correction compared with those not receiving DDAVP. Design A retrospective, observational, comparison study. Setting A single, Canadian, tertiary center. Patients All admitted patients referred to the nephrology service for severe, hypovolemic hyponatremia ([Na]s < 125 mmol/L) over a 12-month period from November 2015. Measurements The primary outcomes measure was the [Na]s after medical management for 48 hours. The length of hospital stay was also measured. Methods Patients were grouped based on whether they received DDAVP during the first 48 hours of treatment, and [Na]s correction was compared between groups using linear regression. An exploratory, multivariable, linear regression model was used to adjust for diabetes status, active malignancy, intensive care unit (ICU) admission, and hypertonic saline administration. Results Twenty-eight patients were identified, with baseline mean [Na]s of 112.7 ± 6.6 mmol/L versus 117 ± 4.3mmol/L (P = .06) in those receiving (n = 16) and not receiving DDAVP (n = 12), respectively. The DDAVP group had a more rapid [Na]s correction on the first day compared with those not receiving DDAVP, 7.7 ± 3.8 mmol/L/d versus 5.1 ± 2.0 mmol/L/d (P = .04). On the second day, there was a similar rate of [Na]s correction between groups: 1.3 ± 4.3 mmol/L/d versus 2.6 ± 3.2 mmol/L/d (P = .39), respectively. Overall, there was no difference in [Na]s correction after 48 hours between those who received DDAVP and those who did not: 121.7 ± 7.5 mmol/L versus 124.8 ± 5.7 mmol/L (P = .24). Patients who had experienced an overcorrection were successfully treated with DDAVP (n = 5), so that no patient had an ongoing overcorrection by 48 hours. Limitations The limited sample size and lack of randomization preclude definitive conclusion on the additional benefit of DDAVP to standard care. Conclusion DDAVP appears to be safe and effective in the management of severe, hypovolemic hyponatremia, associated with similar [Na]s correction to those who did not receive DDAVP after 48 hours, despite an initial more rapid correction. A randomized trial should examine what benefit DDAVP confers in addition to standard care in the management of severe, hypovolemic hyponatremia.
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Affiliation(s)
- Frank L Ward
- Division of Nephrology, Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Sheldon W Tobe
- Division of Nephrology, Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - David M J Naimark
- Division of Nephrology, Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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23
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Advances in the diagnosis and treatment of Von Willebrand disease. Blood 2017; 130:2386-2391. [PMID: 29187375 DOI: 10.1182/blood-2017-05-782029] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Accepted: 07/30/2017] [Indexed: 12/11/2022] Open
Abstract
Von Willebrand disease (VWD) is the most common inherited bleeding disorder, yet diagnosis and management remain challenging. Development and use of bleeding assessment tools allows for improved stratification of which patients may require further assessment and which patients are most likely to require treatment of their VWD. New options for laboratory assessment of von Willebrand factor (VWF) activity include a new platelet-binding assay, the VWF:GPIbM, which is subject to less variability than the ristocetin cofactor activity assay, and collagen-binding assays that provide insight into a different function of VWF. Genetic testing may be helpful in some cases where a type 2 VWD variant is suspected but is usually not helpful in type 1 VWD. Finally, treatment options for VWD are reviewed, including the use of recombinant VWF. Despite these advances, still more work is required to improve diagnosis, treatment, and quality of life for affected patients.
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24
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Sharma R, Flood VH. Advances in the diagnosis and treatment of Von Willebrand disease. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2017; 2017:379-384. [PMID: 29222282 PMCID: PMC6142610 DOI: 10.1182/asheducation-2017.1.379] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Von Willebrand disease (VWD) is the most common inherited bleeding disorder, yet diagnosis and management remain challenging. Development and use of bleeding assessment tools allows for improved stratification of which patients may require further assessment and which patients are most likely to require treatment of their VWD. New options for laboratory assessment of von Willebrand factor (VWF) activity include a new platelet-binding assay, the VWF:GPIbM, which is subject to less variability than the ristocetin cofactor activity assay, and collagen-binding assays that provide insight into a different function of VWF. Genetic testing may be helpful in some cases where a type 2 VWD variant is suspected but is usually not helpful in type 1 VWD. Finally, treatment options for VWD are reviewed, including the use of recombinant VWF. Despite these advances, still more work is required to improve diagnosis, treatment, and quality of life for affected patients.
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Affiliation(s)
- Ruchika Sharma
- Pediatric Hematology/Oncology, Medical College of Wisconsin, Milwaukee, WI
- Blood Research Institute, BloodCenter of Wisconsin, Milwaukee, WI; and
| | - Veronica H. Flood
- Pediatric Hematology/Oncology, Medical College of Wisconsin, Milwaukee, WI
- Blood Research Institute, BloodCenter of Wisconsin, Milwaukee, WI; and
- Children’s Research Institute, Children’s Hospital of Wisconsin, Milwaukee, WI
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25
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Tischer A, Machha VR, Frontroth JP, Brehm MA, Obser T, Schneppenheim R, Mayne L, Walter Englander S, Auton M. Enhanced Local Disorder in a Clinically Elusive von Willebrand Factor Provokes High-Affinity Platelet Clumping. J Mol Biol 2017; 429:2161-2177. [PMID: 28533135 DOI: 10.1016/j.jmb.2017.05.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Revised: 05/10/2017] [Accepted: 05/15/2017] [Indexed: 12/19/2022]
Abstract
Mutation of the cysteines forming the disulfide loop of the platelet GPIbα adhesive A1 domain of von Willebrand factor (VWF) causes quantitative VWF deficiencies in the blood and von Willebrand disease. We report two cases of transient severe thrombocytopenia induced by DDAVP treatment. Cys1272Trp and Cys1458Tyr mutations identified by genetic sequencing implicate an abnormal gain-of-function phenotype, evidenced by thrombocytopenia, which quickly relapses back to normal platelet counts and deficient plasma VWF. Using surface plasmon resonance, analytical rheology, and hydrogen-deuterium exchange mass spectrometry (HXMS), we decipher mechanisms of A1-GPIbα-mediated platelet adhesion and resolve dynamic secondary structure elements that regulate the binding pathway. Constrained by the disulfide, conformational selection between weak and tight binding states of A1 takes precedence and drives normal platelet adhesion to VWF. Less restrained through mutation, loss of the disulfide preferentially diverts binding through an induced-fit disease pathway enabling high-affinity GPIbα binding and firm platelet adhesion to a partially disordered A1 domain. HXMS reveals a dynamic asymmetry of flexible and ordered regions common to both variants, indicating that the partially disordered A1 lacking the disulfide retains native-like structural dynamics. Both binding mechanisms share common structural and thermodynamic properties, but the enhanced local disorder in the disease state perpetuates high-affinity platelet agglutination, characteristic of type 2B VWD, upon DDAVP-stimulated secretion of VWF leading to transient thrombocytopenia and a subsequent deficiency of plasma VWF, characteristic of type 2A VWD.
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Affiliation(s)
- Alexander Tischer
- Division of Hematology, Departments of Internal Medicine and Biochemistry and Molecular Biology, Mayo Clinic, Rochester, MN 55905, USA
| | - Venkata R Machha
- Division of Hematology, Departments of Internal Medicine and Biochemistry and Molecular Biology, Mayo Clinic, Rochester, MN 55905, USA
| | - Juan P Frontroth
- Laboratorio de Hemostasia y Trombosis, Servicio de Hematologia y Oncologia, Hospital de Pediatria, "Prof. Dr. Juan P. Garrahan", Buenos Aires, Argentina.
| | - Maria A Brehm
- Department of Paediatric Haematology and Oncology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Tobias Obser
- Department of Paediatric Haematology and Oncology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Reinhard Schneppenheim
- Department of Paediatric Haematology and Oncology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany.
| | - Leland Mayne
- Johnson Research Foundation, Department of Biochemistry and Biophysics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - S Walter Englander
- Johnson Research Foundation, Department of Biochemistry and Biophysics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA.
| | - Matthew Auton
- Division of Hematology, Departments of Internal Medicine and Biochemistry and Molecular Biology, Mayo Clinic, Rochester, MN 55905, USA.
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26
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Acute pulmonary thromboembolism occurring during treatment with tolvaptan in a patient with autosomal-dominant polycystic kidney disease. CEN Case Rep 2017; 6:61-65. [PMID: 28509130 DOI: 10.1007/s13730-016-0245-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Accepted: 12/20/2016] [Indexed: 10/20/2022] Open
Abstract
Autosomal-dominant polycystic kidney disease (ADPKD) is the most prevalent cystic kidney disease, with approximately half of the patients reaching end-stage renal disease by the age of 60. Tolvaptan prevents renal cyst growth by inhibiting intracellular cyclic AMP and is recommended for patients with ADPKD. Reports of thrombotic complications with tolvaptan have been limited. We report a case of a 60-year-old man who developed thromboembolisms during tolvaptan treatment for ADPKD. The patient started tolvaptan in July 2014. He was brought to our hospital in February 2015 with a sudden onset of dyspnea and chest pain after 6 days of persistent watery diarrhea. Blood tests revealed enhanced coagulation and fibrinolysis, and contrast-enhanced computed tomography confirmed the presence of multiple thromboembolisms. Venous thromboembolism (VTE) with acute pulmonary and lower extremity thrombi was diagnosed, and the patient was immediately admitted. Tolvaptan was discontinued on admission, and intravenous fluid loading and monteplase were started. Subsequently, chest pain and dyspnea resolved, with thrombi resolution occurring by day 14; the patient was discharged on day 18 in stable condition. VTE was attributed to continued tolvaptan during diarrhea and dehydration; tolvaptan itself was not associated with enhanced coagulability. Dehydrated patients with ADPKD, such as the patient in this case, are at an increased risk for thrombus formation. Proper education should be provided to maintain appropriate fluid status and discontinue tolvaptan upon volume depletion.
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Park BY, Park YS. Surgery in Patients with Von Willebrand Disease : A Single Center Experience. CLINICAL PEDIATRIC HEMATOLOGY-ONCOLOGY 2017. [DOI: 10.15264/cpho.2017.24.1.43] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Bo Young Park
- Department of Pediatrics, Kyung Hee University Hospital at Gangdong, School of Medicine, Kyung Hee University, Seoul, Korea
| | - Young Shil Park
- Department of Pediatrics, Kyung Hee University Hospital at Gangdong, School of Medicine, Kyung Hee University, Seoul, Korea
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Usefulness of the second-derivative curve of activated partial thromboplastin time on the ACL-TOP coagulation analyzer for detecting factor deficiencies. Blood Coagul Fibrinolysis 2017; 27:474-6. [PMID: 26523912 PMCID: PMC4888921 DOI: 10.1097/mbc.0000000000000436] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Lavin M, O'Donnell JS. New treatment approaches to von Willebrand disease. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2016; 2016:683-689. [PMID: 27913547 PMCID: PMC6142427 DOI: 10.1182/asheducation-2016.1.683] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
von Willebrand disease (VWD) is the commonest inherited bleeding disorder and results from either a quantitative or qualitative deficiency in the plasma glycoprotein von Willebrand factor (VWF). Recent large cohort studies have significantly enhanced our understanding of the molecular mechanisms involved in the pathogenesis of VWD. In contrast, however, there have been relatively few advances in the therapeutic options available for the treatment of bleeding in patients with VWD. Established treatment options include tranexamic acid, 1-deamino-8-d-arginine vasopressin (DDAVP), and plasma-derived VWF concentrates. In addition, a recombinant VWF has also recently been developed. In this review, we focus on how recent insights into the clinical and molecular aspects underpinning VWD are already beginning to influence treatment in the clinic. For example, a number of different bleeding assessment tools (BATs) have been developed to objectively assess bleeding symptoms in patients with VWD. Interestingly, however, these BAT scores may also have an important role to play in predicting bleeding risk in VWD. Furthermore, recent studies have demonstrated that enhanced VWF clearance plays a critical role in the etiology of both type 1 and type 2 VWD. These findings have direct translational relevance with respect to the use of DDAVP in patients with VWD. As understanding of the mechanisms involved in VWD pathogenesis continues to advance, novel treatment options are likely to emerge. Critically, however, large adequately powered and stratified clinical trials will be required to address the outstanding questions that remain regarding VWD treatment optimization.
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Affiliation(s)
- Michelle Lavin
- Haemostasis Research Group, Institute of Molecular Medicine, Trinity Centre for Health Sciences, St. James's Hospital, Trinity College Dublin, Ireland
| | - James S O'Donnell
- Haemostasis Research Group, Institute of Molecular Medicine, Trinity Centre for Health Sciences, St. James's Hospital, Trinity College Dublin, Ireland
- National Centre for Hereditary Coagulation Disorders, St. James's Hospital, Dublin, Ireland; and
- Irish Centre for Vascular Biology, Royal College of Surgeons in Ireland, Dublin, Ireland
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Livesey K, Yealy DM, Li J, Moore CG, Ragni MV. Von Willebrand disease in the emergency department. Haemophilia 2015; 22:263-267. [DOI: 10.1111/hae.12841] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/21/2015] [Indexed: 12/20/2022]
Affiliation(s)
- K. Livesey
- Division Hematology/Oncology; Department of Medicine; University of Pittsburgh Medical Center; Pittsburgh PA USA
| | - D. M. Yealy
- Department of Emergency Medicine; University of Pittsburgh Medical Center; Pittsburgh PA USA
| | - J. Li
- Department of Healthy Policy and Management; Graduate School of Public Health Pittsburgh; Pittsburgh PA USA
| | - C. G. Moore
- Department of Biostatistics; Carolinas Healthcare System; Charlotte NC USA
| | - M. V. Ragni
- Division Hematology/Oncology; Department of Medicine; University of Pittsburgh Medical Center; Pittsburgh PA USA
- Hemophilia Center of Western PA; Pittsburgh PA USA
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Mooberry MJ, Key NS. Microparticle analysis in disorders of hemostasis and thrombosis. Cytometry A 2015; 89:111-22. [PMID: 25704723 DOI: 10.1002/cyto.a.22647] [Citation(s) in RCA: 87] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Revised: 01/29/2015] [Accepted: 02/03/2015] [Indexed: 01/18/2023]
Abstract
Microparticles (MPs) are submicron vesicles released from the plasma membrane of eukaryotic cells in response to activation or apoptosis. MPs are known to be involved in numerous biologic processes, including inflammation, the immune response, cancer metastasis, and angiogenesis. Their earliest recognized and most widely accepted role, however, is the ability to promote and support the process of blood coagulation. Consequently, there is ongoing interest in studying MPs in disorders of hemostasis and thrombosis. Both phosphatidylserine (PS) exposure and the presence of tissue factor (TF) in the MP membrane may account for their procoagulant properties, and elevated numbers of MPs in plasma have been reported in numerous prothrombotic conditions. To date, however, there are few data on true causality linking MPs to the genesis of thrombosis. A variety of methodologies have been employed to characterize and quantify MPs, although detection is challenging due to their submicron size. Flow cytometry (FCM) remains the most frequently utilized strategy for MP detection; however, it is associated with significant technological limitations. Additionally, preanalytical and analytical variables can influence the detection of MPs by FCM, rendering data interpretation difficult. Lack of methodologic standardization in MP analysis by FCM confounds the issue further, although efforts are currently underway to address this limitation. Moving forward, it will be important to address these technical challenges as a scientific community if we are to better understand the role that MPs play in disorders of hemostasis and thrombosis.
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Affiliation(s)
- Micah J Mooberry
- Department of Medicine, Division of Hematology/Oncology, University of North Carolina at Chapel Hill, North Carolina
| | - Nigel S Key
- Department of Medicine, Division of Hematology/Oncology, University of North Carolina at Chapel Hill, North Carolina
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Laffan MA, Lester W, O'Donnell JS, Will A, Tait RC, Goodeve A, Millar CM, Keeling DM. The diagnosis and management of von Willebrand disease: a United Kingdom Haemophilia Centre Doctors Organization guideline approved by the British Committee for Standards in Haematology. Br J Haematol 2014; 167:453-65. [PMID: 25113304 DOI: 10.1111/bjh.13064] [Citation(s) in RCA: 227] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- Mike A Laffan
- Centre for Haematology, Imperial College London, London, UK
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Abstract
Abstract
von Willebrand disease (VWD) is the most common autosomally inherited bleeding disorder. The disease represents a range of quantitative and qualitative pathologies of the adhesive glycoprotein von Willebrand factor (VWF). The pathogenic mechanisms responsible for the type 2 qualitative variants of VWF are now well characterized, with most mutations representing missense substitutions influencing VWF multimer structure and interactions with platelet GPIbα and collagen and with factor VIII. The molecular pathology of type 3 VWD has been similarly well characterized, with an array of different mutation types producing either a null phenotype or the production of VWF that is not secreted. In contrast, the pathogenetic mechanisms responsible for type 1 VWD remain only partially resolved. In the hemostasis laboratory, the measurement of VWF:Ag and VWF:RCo are key components in the diagnostic algorithm for VWD, although the introduction of direct GPIbα-binding assays may become the functional assay of choice. Molecular genetic testing can provide additional benefit, but its utility is currently limited to type 2 and 3 VWD. The treatment of bleeding in VWD involves the use of desmopressin and plasma-derived VWF concentrates and a variety of adjunctive agents. Finally, a new recombinant VWF concentrate has just completed clinical trial evaluation and has demonstrated excellent hemostatic efficacy and safety.
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von Willebrand disease: advances in pathogenetic understanding, diagnosis, and therapy. Blood 2013; 122:3735-40. [PMID: 24065240 DOI: 10.1182/blood-2013-06-498303] [Citation(s) in RCA: 122] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
von Willebrand disease (VWD) is the most common autosomally inherited bleeding disorder. The disease represents a range of quantitative and qualitative pathologies of the adhesive glycoprotein von Willebrand factor (VWF). The pathogenic mechanisms responsible for the type 2 qualitative variants of VWF are now well characterized, with most mutations representing missense substitutions influencing VWF multimer structure and interactions with platelet GPIbα and collagen and with factor VIII. The molecular pathology of type 3 VWD has been similarly well characterized, with an array of different mutation types producing either a null phenotype or the production of VWF that is not secreted. In contrast, the pathogenetic mechanisms responsible for type 1 VWD remain only partially resolved. In the hemostasis laboratory, the measurement of VWF:Ag and VWF:RCo are key components in the diagnostic algorithm for VWD, although the introduction of direct GPIbα-binding assays may become the functional assay of choice. Molecular genetic testing can provide additional benefit, but its utility is currently limited to type 2 and 3 VWD. The treatment of bleeding in VWD involves the use of desmopressin and plasma-derived VWF concentrates and a variety of adjunctive agents. Finally, a new recombinant VWF concentrate has just completed clinical trial evaluation and has demonstrated excellent hemostatic efficacy and safety.
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35
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Ben-Ami T, Revel-Vilk S. The use of DDAVP in children with bleeding disorders. Pediatr Blood Cancer 2013; 60 Suppl 1:S41-3. [PMID: 23109357 DOI: 10.1002/pbc.24335] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2012] [Accepted: 08/30/2012] [Indexed: 11/07/2022]
Abstract
Desmopressin (1-deamino-8-D-arginine vasopressin, DDAVP) has been used in children with von Willebrand disease (VWD) and Hemophilia A for almost 35 years. This treatment has substantially lowered the number of children exposed to human plasma derived products, with a good safety profile, and at very low cost. The response to DDAVP has been shown to be associated with age, baseline factor level, and genetic mutations. A DDAVP challenge test is recommended. DDAVP has also been used to prevent and treat bleeding episodes in children with platelet function defects and other disorders associated with bleeding tendency.
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Affiliation(s)
- Tal Ben-Ami
- The Pediatric Hematology/Oncology Department, Hadassah Hebrew-University Hospital, Jerusalem, Israel
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Wang L, Rosenberg JB, De BP, Ferris B, Wang R, Rivella S, Kaminsky SM, Crystal RG. In vivo gene transfer strategies to achieve partial correction of von Willebrand disease. Hum Gene Ther 2012; 23:576-88. [PMID: 22482515 DOI: 10.1089/hum.2011.238] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
von Willebrand disease (VWD), the most common hereditary coagulation disorder, results from mutations in the 52-exon gene for von Willebrand factor (VWF), which encodes an 8.4-kB cDNA. Studies with VWF cDNA plasmids have demonstrated that in vivo gene transfer to the liver will correct the coagulation dysfunction in VWF(-/-) mice, but the correction is transient. To develop gene therapy for VWF that would mediate long-term expression of the VWF cDNA in liver, we first evaluated segmental pre-mRNA trans-splicing (SPTS) with two adeno-associated virus (AAV) serotype 8 vectors, each delivering one-half of the VWF cDNA. However, although the two vectors functioned well to generate VWF multimers after infection of cells in vitro, the efficiency of SPTS was insufficient to correct the VWF(-/-) mouse in vivo. As an alternative, we assessed the ability of a lentiviral vector to transfer the intact murine VWF cDNA in vivo directly to the neonatal liver of VWF(-/-) mice, using generation of VWF multimers, bleeding time, and bleeding volume as efficacy parameters. The VWF lentivirus generated VWF multimers and partially or completely corrected the coagulation defect on a persistent basis in 33% of the treated VWF-deficient mice. On the basis of the concept that partial persistent correction with gene transfer could be beneficial in VWD patients, these observations suggest that lentiviral delivery of VWF cDNA should be explored as a candidate for gene therapy in patients with a severe form of VWD.
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Affiliation(s)
- Lan Wang
- Department of Genetic Medicine, Weill Cornell Medical College, New York, NY 10065, USA
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37
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Abstract
von Willebrand disease is a common inherited bleeding disorder characterized by excessive mucocutaneous bleeding. Characteristic bleeding symptoms include epistaxis, easy bruising, oral cavity bleeding, menorrhagia, bleeding after dental extraction, surgery, and/or childbirth, and in severe cases, bleeding into joints and soft tissues. There are three subtypes: types 1 and 3 represent quantitative variants and type 2 is a group of four qualitative variants: (1) type 2A-characterized by defective von Willebrand factor-dependent platelet adhesion because of decreased high-molecular-weight von Willebrand factor multimers, (2) type 2B-caused by pathologically increased von Willebrand factor-platelet interactions, (3) type 2M-caused by decreased von Willebrand factor-platelet interactions not based on the loss of high-molecular-weight multimers, and (4) type 2N-characterized by reduced binding of von Willebrand factor to factor VIII. The diagnosis of von Willebrand disease requires specialized assays of von Willebrand factor and/or molecular genetic testing of von Willebrand factor. Severe bleeding episodes can be prevented or controlled with intravenous infusions of virally inactivated plasma-derived clotting factor concentrates containing both von Willebrand factor and factor VIII. Depending on the von Willebrand disease type, mild bleeding episodes usually respond to intravenous or subcutaneous treatment with desmopressin, a vasopressin analog. Other treatments that can reduce symptoms include fibrinolytic inhibitors and hormones for menorrhagia.
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Bornert F, Clauss F, Gros CI, Faradji A, Schmittbuhl M, Manière MC, Feki A. Hemostatic management in pediatric patients with type I von Willebrand disease undergoing oral surgery: case report and literature review. J Oral Maxillofac Surg 2011; 69:2086-91. [PMID: 21783000 DOI: 10.1016/j.joms.2011.03.073] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2011] [Revised: 03/09/2011] [Accepted: 03/30/2011] [Indexed: 10/18/2022]
Affiliation(s)
- Fabien Bornert
- Department of Oral Medicine and Oral Surgery, University Hospital, Strasbourg, France.
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Mollet-Boudjemline A, Hubert-Buron A, Boyer-Neumann C, Aldea R, Franco D, Trioche-Eberschweiller P, Mas AE, Mabille M, Labrune P, Gajdos V. Perioperative management of hemostasis for surgery of benign hepatic adenomas in patients with glycogen storage disease type ia. JIMD Rep 2011; 1:97-106. [PMID: 23430835 DOI: 10.1007/8904_2011_23] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2010] [Revised: 12/20/2010] [Accepted: 01/27/2011] [Indexed: 12/29/2022] Open
Abstract
The development of hepatocellular adenomas in the liver of patients with glycogen storage disease type I is a well-known complication of the disease. Surgical procedures and perioperative managements described so far have reported persistent and important morbidity. We report here a series of six patients (three males and three females) who underwent hepatic resection, and we propose a new hemostatic management protocol comprising glucose infusion, corticosteroids, desmopressin, and antifibrinolytic drugs, used to prevent efficaciously hepatic hemorrhage due to glycogen storage disease (GSD) platelet dysfunction.
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Affiliation(s)
- Alix Mollet-Boudjemline
- APHP, Centre de Référence Maladies Héréditaires du Métabolisme Hépatique, Service de Pédiatrie, Hôpital Antoine Béclère, 157 Rue de la Porte de Trivaux, 92141, Clamart cedex, France,
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40
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Wang JW, Valentijn KM, de Boer HC, Dirven RJ, van Zonneveld AJ, Koster AJ, Voorberg J, Reitsma PH, Eikenboom J. Intracellular storage and regulated secretion of von Willebrand factor in quantitative von Willebrand disease. J Biol Chem 2011; 286:24180-8. [PMID: 21596755 DOI: 10.1074/jbc.m110.215194] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Several missense mutations in the von Willebrand Factor (VWF) gene of von Willebrand disease (VWD) patients have been shown to cause impaired constitutive secretion and intracellular retention of VWF. However, the effects of those mutations on the intracellular storage in Weibel-Palade bodies (WPBs) of endothelial cells and regulated secretion of VWF remain unknown. We demonstrate, by expression of quantitative VWF mutants in HEK293 cells, that four missense mutations in the D3 and CK-domain of VWF diminished the storage in pseudo-WPBs, and led to retention of VWF within the endoplasmic reticulum (ER). Immunofluorescence and electron microscopy data showed that the pseudo-WPBs formed by missense mutant C1060Y are indistinguishable from those formed by normal VWF. C1149R, C2739Y, and C2754W formed relatively few pseudo-WPBs, which were often short and sometimes round rather than cigar-shaped. The regulated secretion of VWF was impaired slightly for C1060Y but severely for C1149R, C2739Y, and C2754W. Upon co-transfection with wild-type VWF, both intracellular storage and regulated secretion of all mutants were (partly) corrected. In conclusion, defects in the intracellular storage and regulated secretion of VWF following ER retention may be a common mechanism underlying VWD with a quantitative deficiency of VWF.
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Affiliation(s)
- Jiong-Wei Wang
- Einthoven Laboratory for Experimental Vascular Medicine, Leiden University Medical Center, 2333ZA Leiden, The Netherlands
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FEDERICI AB, BARILLARI G, ZANON E, MAZZUCCONI MG, MUSSO R, TARGHETTA R, MANNUCCI PM. Efficacy and safety of highly purified, doubly virus-inactivated VWF/FVIII concentrates in inherited von Willebrand’s disease: results of an Italian cohort study on 120 patients characterized by bleeding severity score. Haemophilia 2010; 16:101-10. [DOI: 10.1111/j.1365-2516.2009.02088.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Federici AB. Prophylaxis of bleeding episodes in patients with von Willebrand's disease. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2008; 6 Suppl 2:s26-32. [PMID: 19105507 PMCID: PMC2652221 DOI: 10.2450/2008.0034-08] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Patients with severe forms of von Willebrand's disease (VWD) may have frequent haemarthroses, especially when factor VIII (FVIII) levels are below 10 U/dL, so that some of them develop target joints like patients with severe haemophilia A. Some patients have recurrent gastrointestinal bleeding, often without lesions in the gastrointestinal tract, and need treatment every day or every other day. Finally, there are children who have epistaxis frequently and severely enough to cause anaemia. In these frequent and severe bleeders, the optimal therapy may be secondary long-term prophylaxis with von Willebrand factor (VWF)/FVIII concentrates rather than on-demand treatment on the occasion of bleeding episodes. The largest experience on such prophylaxis in VWD has been in Sweden in 35 patients with severe forms of VWD. Long-term prophylaxis was also implemented in a cohort of Italian patients with VWD: prophylaxis was used in seven patients with types 3 (n = 1 ), 2A (n = 4), 2M (n = 1) and type 1 (n = 1) VWD because of recurrent gastrointestinal bleeds and in four patients with type 3 VWD because of joint bleeds. Prophylaxis prevented bleeding completely in eight patients and largely reduced hospitalisation for blood transfusions in the remaining three. The cost-effectiveness of these prophylaxis regimens versus on-demand therapy will now be investigated in one large international study
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Affiliation(s)
- Augusto B Federici
- Centro Emofilia e Trombosi Angelo Bianchi Bonomi, Fondazione IRCCS Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena, Università degli Studi di Milano, Milano, Italia.
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Carless PA, Stokes BJ, Moxey AJ, Henry DA. Desmopressin for minimising perioperative allogeneic blood transfusion. Cochrane Database Syst Rev 2004:CD001884. [PMID: 14973974 PMCID: PMC4212272 DOI: 10.1002/14651858.cd001884.pub2] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Public concerns regarding the safety of transfused blood have prompted re-consideration of the use of allogeneic (from an unrelated donor) red blood cell (RBC) transfusion, and of a range of techniques designed to minimise transfusion requirements. OBJECTIVES To examine the evidence for the efficacy of desmopressin acetate (1-deamino-8-D-arginine-vasopressin; DDAVP), in reducing perioperative blood loss and the need for red cell transfusion in patients who do not have congenital bleeding disorders. SEARCH STRATEGY Articles were identified by: computer searches of MEDLINE, EMBASE, Current Contents (to May 2003), and the Cochrane Central Register of Controlled Trials (CENTRAL) (Cochrane Library, Issue 1, 2003). References in the identified trials and review articles were searched and authors contacted to identify additional studies. SELECTION CRITERIA Controlled parallel group trials in which adult patients, scheduled for non-urgent surgery, were randomised to DDAVP, or to a control group, who did not receive the intervention. DATA COLLECTION AND ANALYSIS Trial quality was assessed using criteria proposed by Schulz et al. (Schulz 1995) and Jadad et al. (Jadad 1996). Main outcomes measured were: the number of patients exposed to allogeneic red cell transfusion, and the amount of blood transfused. Other outcomes measured were: re-operation for bleeding, blood loss, post-operative complications (thrombosis, infection, non-fatal myocardial infarction), mortality, and length of hospital stay (LOS). MAIN RESULTS Eighteen trials of DDAVP (n=1295) reported data on the number of patients transfused with allogeneic RBC transfusion. In subjects treated with DDAVP, the pooled relative risk of exposure to perioperative allogeneic RBC transfusion was 0.95 (95%CI = 0.86 to 1.06). The use of DDAVP did not significantly reduce blood loss; weighted mean difference (WMD) = -114.3ml: 95% confidence interval (95%CI) = -258.8 to 30.2ml per patient) or the volume of RBC transfused (WMD = -0.35 units: 95%CI = -0.70 to 0.01 units). In DDAVP-treated patients the relative risk of requiring re-operation due to bleeding was 0.69 (95%CI = 0.26 to 1.83). There was no statistically significant effect overall for mortality and non-fatal myocardial infarction in DDAVP-treated patients compared with control (RR = 1.72: 95%CI = 0.68 to 4.33) and (RR = 1.38: 95%CI = 0.77 to 2.50) respectively. REVIEWER'S CONCLUSIONS There is no convincing evidence that desmopressin minimises perioperative allogeneic RBC transfusion in patients who do not have congenital bleeding disorders. These data suggest that there is no benefit from using DDAVP as a means of minimising perioperative allogeneic RBC transfusion.
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Affiliation(s)
- Paul A Carless
- Discipline of Clinical Pharmacology, Faculty of Health, University of Newcastle, Newcastle, Australia
| | - Barrie J Stokes
- Discipline of Clinical Pharmacology, Faculty of Health, University of Newcastle, Newcastle, Australia
| | - Annette J Moxey
- Discipline of Clinical Pharmacology, Faculty of Health, University of Newcastle, Newcastle, Australia
| | - David A Henry
- Institute of Clinical Evaluative Sciences, Toronto, Canada
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