1
|
Daniel MY, Ternisien C, Castet S, Falaise C, D'Oiron R, Volot F, Itzhar N, Pan-Petesch B, Jeanpierre E, Paris C, Zawadzki C, Desvages M, Dupont A, Veyradier A, Repessé Y, Babuty A, Trossaërt M, Boisseau P, Denis CV, Lenting PJ, Goudemand J, Rauch A, Susen S. Type 2N von Willebrand disease: genotype drives different bleeding phenotypes and treatment needs. J Thromb Haemost 2024:S1538-7836(24)00381-7. [PMID: 38992343 DOI: 10.1016/j.jtha.2024.06.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Revised: 05/29/2024] [Accepted: 06/17/2024] [Indexed: 07/13/2024]
Abstract
BACKGROUND Type 2 Normandy von Willebrand disease (VWD2N) is usually perceived as a mild bleeding disorder that can be treated with desmopressin (DDAVP). However, VWD2N patients can be compound heterozygous or homozygous for different variants, with p.Arg854Gln (R854Q) being the most frequent causative one. There are limited data about the impact of 2N variants on VWD2N phenotype and DDAVP response. OBJECTIVES This study aims to describe the phenotype of VWD2N, including DDAVP response, according to genotype. METHODS VWD2N patients with a complete genotype/phenotype characterization by the French reference center for VWD, including MCMDM-1VWD bleeding score, were eligible to be included in the study. Results of the DDAVP trial were also collected. RESULTS A total of 123 VWD2N patients from the French registry were included in this study. Results were stratified according to the presence (R854QPos, n = 114) or absence (R854QNeg, n = 9) of at least 1 R854Q allele. Three R854QPos subgroups were further individualized: patients homozygous (R854QHmz, n = 55), compound heterozygous for R854Q and a null allele (R854Q/3, n = 48), or compound heterozygous for R854Q and another 2N variant (R854Q/2N, n = 11). FVIII C levels were significantly lower in R854QNeg and R854Q/3 patients compared with R854QHmz ones (P < .001 and P < .0001, respectively). R854QNeg patients were diagnosed earlier due to bleeding symptoms and had a higher bleeding score than R854QPos patients (P < .001). In DDAVP trial, FVIII:C survival was lower in VWD type 2N than in type 1 patients. R854QPos patients had a heterogeneous DDAVP response, which was best predicted by baseline FVIII:C level. CONCLUSION The heterogeneous genetic background of VWD2N drives different bleeding phenotypes and response patterns to DDAVP, underlining the clinical relevance of DDAVP trial to identify patients potentially eligible to alternative therapeutic options.
Collapse
Affiliation(s)
- Mélanie Y Daniel
- Hematology and Transfusion Department, Institut National de la Santé et de la Recherche Médicale, Centre Hospitalier Universitaire de Lille, Institut Pasteur de Lille, Université de Lille, U1011-European Genomic Institute for Diabetes, Lille, France. https://twitter.com/DanielMelanieMD
| | | | - Sabine Castet
- Bordeaux University Hospital, Hemostasis Clinical Center, Bordeaux, France
| | - Céline Falaise
- Hemostasis Clinical Center, Marseille University Hospital, Assistance Publique-Hôpitaux de Marseille, Marseille, France
| | - Roseline D'Oiron
- Reference Center for Hemophilia and Rare Congenital Bleeding Disorders, Bicêtre Hospital Assistance Publique-Hôpitaux de Paris, University of Paris-Saclay and Unité Mixte de Recherche_S1176, Institut National de la Santé et de la Recherche Médicale, Le Kremlin-Bicêtre, France
| | - Fabienne Volot
- Hemostasis Clinical Center, Dijon University Hospital, Dijon, France
| | - Nathalie Itzhar
- Laboratory of Haemostasis, Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | | | - Emmanuelle Jeanpierre
- Hematology and Transfusion Department, Institut National de la Santé et de la Recherche Médicale, Centre Hospitalier Universitaire de Lille, Institut Pasteur de Lille, Université de Lille, U1011-European Genomic Institute for Diabetes, Lille, France
| | - Camille Paris
- Hematology and Transfusion Department, Institut National de la Santé et de la Recherche Médicale, Centre Hospitalier Universitaire de Lille, Institut Pasteur de Lille, Université de Lille, U1011-European Genomic Institute for Diabetes, Lille, France
| | | | | | - Annabelle Dupont
- Hematology and Transfusion Department, Institut National de la Santé et de la Recherche Médicale, Centre Hospitalier Universitaire de Lille, Institut Pasteur de Lille, Université de Lille, U1011-European Genomic Institute for Diabetes, Lille, France
| | - Agnès Veyradier
- Laboratory of Haemostasis, Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Yohann Repessé
- Laboratory and Clinical Hemostasis, Caen University Hospital, Caen, France
| | - Antoine Babuty
- Haemostasis Clinical Center, Nantes University Hospital, Nantes, France
| | - Marc Trossaërt
- Haemostasis Clinical Center, Nantes University Hospital, Nantes, France
| | - Pierre Boisseau
- Service de Génétique Médicale, Centre Hospitalier Universitaire de Nantes, Nantes, France
| | - Cécile V Denis
- Hémostase Inflammation Thrombose U1176, Institut National de la Santé et de la Recherche Médicale, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Peter J Lenting
- Hémostase Inflammation Thrombose U1176, Institut National de la Santé et de la Recherche Médicale, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Jenny Goudemand
- Hematology and Transfusion, Lille University Hospital, Lille, France
| | - Antoine Rauch
- Hematology and Transfusion Department, Institut National de la Santé et de la Recherche Médicale, Centre Hospitalier Universitaire de Lille, Institut Pasteur de Lille, Université de Lille, U1011-European Genomic Institute for Diabetes, Lille, France
| | - Sophie Susen
- Hematology and Transfusion Department, Institut National de la Santé et de la Recherche Médicale, Centre Hospitalier Universitaire de Lille, Institut Pasteur de Lille, Université de Lille, U1011-European Genomic Institute for Diabetes, Lille, France.
| |
Collapse
|
2
|
Favaloro EJ, Mohammed S, Vong R, Pasalic L. Laboratory Testing for von Willebrand Factor: Factor VIII Binding for the Diagnosis or Exclusion of Type 2N von Willebrand Disease: An Update. Methods Mol Biol 2023; 2663:679-691. [PMID: 37204745 DOI: 10.1007/978-1-0716-3175-1_45] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
von Willebrand factor (VWF) is a large adhesive plasma protein that expresses several functional activities. One of these activities is to bind coagulation factor VIII (FVIII) and to protect it from degradation. Deficiency of, and/or defects in, VWF can give rise to a bleeding disorder called von Willebrand disease (VWD). The defect in VWF that affects its ability to bind to and protect FVIII is captured within type 2N VWD. In these patients, FVIII is produced normally; however, plasma FVIII quickly degrades as it is not bound to and protected by VWF. These patients phenotypically resemble those with hemophilia A, where instead, FVIII is produced in lower amount. Both hemophilia A and 2N VWD patients therefore present with reduced levels of plasma FVIII relative to VWF level. However, therapy differs, since patients with hemophilia A are given FVIII replacement products, or FVIII mimicking products; instead, patients with 2N VWD require VWF replacement therapy, since FVIII replacement will only be effective for a short term, given this replacement product will quickly degrade in the absence of functional VWF. Thus, 2N VWD needs to be differentiated from hemophilia A. This can be achieved by genetic testing or by use of a VWF:FVIII binding assay. The current chapter provides a protocol for the performance of a commercial VWF:FVIII binding assay.
Collapse
Affiliation(s)
- Emmanuel J Favaloro
- School of Medical Sciences, Faculty of Medicine and Health University of Sydney, Westmead Hospital, Westmead, NSW, Australia.
- School of Dentistry and Medical Sciences, Faculty of Science and Health, Charles Sturt University, Wagga, Wagga, NSW, Australia.
| | - Soma Mohammed
- Department of Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead Hospital, Westmead, NSW, Australia
| | - Ronny Vong
- Department of Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead Hospital, Westmead, NSW, Australia
| | - Leonardo Pasalic
- Department of Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead Hospital, Westmead, NSW, Australia
- Sydney Centres for Thrombosis and Haemostasis, Westmead, NSW, Australia
- Westmead Clinical School, Sydney University, Westmead, NSW, Australia
| |
Collapse
|
3
|
Sacco M, Lancellotti S, Branchini A, Tardugno M, Testa MF, Lunghi B, Bernardi F, Pinotti M, Giusti B, Castaman G, De Cristofaro R. The p.P1127S pathogenic variant lowers von Willebrand factor levels through higher affinity for the macrophagic scavenger receptor LRP1: Clinical phenotype and pathogenic mechanisms. J Thromb Haemost 2022; 20:1818-1829. [PMID: 35596664 PMCID: PMC9545986 DOI: 10.1111/jth.15765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 04/28/2022] [Accepted: 05/17/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND The index case is a 21-year-old Italian woman with a mild hemorrhagic syndrome and von Willebrand factor antigen (VWF:Ag) = 34.3 U/dl, VWF recombinant glycoprotein Ib (VWF:GpIbR) = 32.8 U/dl, and factor VIII (FVIII) = 55.3 IU/dl. AIMS The aim of this study is to characterize from a genetic and biochemical standpoint this low VWF phenotype. METHODS Coagulation and biochemical methods were used to study the structural and functional pattern of VWF multimers in the index case's plasma. Recombinant wild-type and p.P1127S VWF variants were produced using human embryonic kidney (HEK)-293 cells. In addition, genetic screening was carried out to detect single nucleotide variants of some scavenger VWF/FVIII receptor genes such as CLEC4M, STAB2, and ASGR2. RESULTS Genetic investigation revealed that the index case inherited from her mother the heterozygous missense mutation c.3379C > T (VWF exon 25), causing the p.P1127S substitution in the VWF D'D3 domain. The index case was also homozygous for the scavenger receptor ASGR2 c.-95 CC-genotype. Desmopressin normalized the VWF level of the patient, although its clearance was faster (t1/2 = 6.7 h) than in normal subjects (t1/2 = 12 ± 0.7 h). FVIII-VWF interaction, A Disintegrin And Metalloprotease with ThromboSpondin type 1 motif-13 levels, ristocetin-induced-platelet-aggregation, and VWF multimeric pattern were normal. The p.P1127S variant was normally synthesized and secreted by HEK-293 cells, and molecular modeling predicts a conformational change showing higher affinity for the macrophagic scavenger receptor lipoprotein receptor-related protein 1 (LRP1), as also experimentally verified. CONCLUSIONS The p.P1127S variant may cause a low VWF phenotype, stemming from an increased VWF affinity for the scavenger receptor LRP1 and, consequently, an accelerated clearance of VWF.
Collapse
Affiliation(s)
- Monica Sacco
- Dipartimento di Medicina e Chirurgia TraslazionaleFacoltà di Medicina e Chirurgia “Agostino Gemelli,” Università Cattolica S. CuoreRomaItaly
| | - Stefano Lancellotti
- Servizio Malattie Emorragiche e TromboticheFondazione Policlinico Universitario “A. Gemell” IRCCSRomaItaly
| | - Alessio Branchini
- Dipartimento di Scienze della Vita e BiotecnologieUniversità di FerraraFerraraItaly
| | - Maira Tardugno
- Dipartimento di Medicina e Chirurgia TraslazionaleFacoltà di Medicina e Chirurgia “Agostino Gemelli,” Università Cattolica S. CuoreRomaItaly
| | | | - Barbara Lunghi
- Dipartimento di Scienze della Vita e BiotecnologieUniversità di FerraraFerraraItaly
| | - Francesco Bernardi
- Dipartimento di Scienze della Vita e BiotecnologieUniversità di FerraraFerraraItaly
| | - Mirko Pinotti
- Dipartimento di Scienze della Vita e BiotecnologieUniversità di FerraraFerraraItaly
| | - Betti Giusti
- Dipartimento di Medicina Sperimentale e ClinicaUniversità di FirenzeFirenzeItaly
- Laboratorio Genetico Molecolare Avanzato, SOD Malattie AterotromboticheAzienda Ospedaliero‐ Universitaria “Careggi"FirenzeItaly
| | - Giancarlo Castaman
- Dipartimento di Oncologia, Centro Malattie Emorragiche e della CoagulazioneOspedale Universitario “Careggi”FirenzeItaly
| | - Raimondo De Cristofaro
- Dipartimento di Medicina e Chirurgia TraslazionaleFacoltà di Medicina e Chirurgia “Agostino Gemelli,” Università Cattolica S. CuoreRomaItaly
- Servizio Malattie Emorragiche e TromboticheFondazione Policlinico Universitario “A. Gemell” IRCCSRomaItaly
| |
Collapse
|
4
|
Khaliq S. Diagnostic Challenges in Children With Congenital Bleeding Disorders: A Developing Country Perspective. Am J Clin Pathol 2021; 156:1149-1154. [PMID: 34125163 DOI: 10.1093/ajcp/aqab073] [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: 11/14/2022] Open
Abstract
OBJECTIVES To assess the frequency and characteristics of children with inherited bleeding disorders that were initially misdiagnosed, leading to inappropriate disease management. METHODS This study was conducted at the Haematology/Pathology Department of Fauji Foundation Hospital, Rawalpindi, Pakistan, from August 2014 to August 2018. Children who were diagnosed with an inherited bleeding disorder but did not respond to initial therapy were reevaluated. RESULTS In total, 62 children were diagnosed with a bleeding disorder. Of these, 27 were diagnosed with an inherited bleeding disorder and 35 with an acquired bleeding disorder. Of the 27 children with inherited bleeding disorders, 18% (n = 5) were misdiagnosed and treated inappropriately. The median age of the misdiagnosed patients was 9 years (range, 5-13 years). Three patients with Bernard-Soulier syndrome had been misdiagnosed as having immune thrombocytopenic purpura, 1 patient with von Willebrand disease had been misdiagnosed as having hemophilia A, and 1 patient with haemophilia B had been misdiagnosed as having hemophilia A. CONCLUSIONS There are chances of misdiagnosis and improper or invasive management if comprehensive laboratory evaluation and a thorough clinical evaluation are not performed in children with congenital bleeding disorders.
Collapse
Affiliation(s)
- Sehar Khaliq
- Foundation University Medical College/Foundation University Islamabad, Islamabad, Pakistan
| |
Collapse
|
5
|
Pérez-Rodríguez A, Batlle J, Pinto JC, Corrales I, Borràs N, Garcia-Martínez I, Cid AR, Bonanad S, Parra R, Mingot-Castellano ME, Navarro N, Altisent C, Pérez-Montes R, Moretó A, Herrero S, Soto I, Mosteirín NF, Jiménez-Yuste V, Jacob ADA, Fontanes E, Mateo J, Quismondo NC, Batlle F, Vidal F, López-Fernández MF. Type 2N VWD: Conclusions from the Spanish PCM-EVW-ES project. Haemophilia 2021; 27:1007-1021. [PMID: 34494337 DOI: 10.1111/hae.14405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 08/17/2021] [Accepted: 08/22/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Type 2N von Willebrand disease (VWD) is characterized by a decreased affinity of von Willebrand factor (VWF) for factor VIII (FVIII). Abnormal binding of FVIII to VWF (VWF:FVIIIB), results in low FVIII plasma levels, which can lead to a misdiagnosis of mild haemophilia A. Accurate diagnosis of type 2N VWD is essential for appropriate genetic counselling and therapy. This disease can be distinguished from haemophilia A by in vitro assays (measurement VWF:FVIIIB activity) and/or genetic analysis. AIM To identify the current challenges in the diagnosis and treatment of this type of VWD and provide an in-depth description of the phenotypes and mutations identified. RESULTS Twenty-eight patients had at least one type 2N mutation, and 13 of these had a type 2N mutation combined with other variations. Three type 2N mutations were detected: p.Arg816Trp, p.Arg854Gln, and p.Arg763Ser. Two of these are the most frequently described mutations worldwide. This mutational spectrum differs from the broad spectrum seen in neighbouring France, where at least eight distinct 2N mutations have been found. In the PCM-EVW-ES cohort, 11 asymptomatic type 2N carriers with borderline FVIII plasma levels would probably have been excluded if the evaluation had been based on clinical and laboratory data only. Likewise, three patients with a severe phenotype would have been classified as homozygous for a 2N mutation if only the phenotype study had been performed. CONCLUSION The high detection yield and affordability of next-generation sequencing support the use of this technology as a first-line diagnostic tool in this setting.
Collapse
Affiliation(s)
| | - Javier Batlle
- Complexo Hospitalario Universitario A Coruña, INIBIC, A Coruña, Spain
| | - Joana Costa Pinto
- Complexo Hospitalario Universitario A Coruña, INIBIC, A Coruña, Spain
| | - Irene Corrales
- Haematology Service, Banc de Sang i Teixits (BST), Barcelona, Spain.,Vall d'Hebron Institut de Recerca, Universitat Autònoma de Barcelona (VHIR-UAB), Barcelona, Spain
| | - Nina Borràs
- Haematology Service, Banc de Sang i Teixits (BST), Barcelona, Spain.,Vall d'Hebron Institut de Recerca, Universitat Autònoma de Barcelona (VHIR-UAB), Barcelona, Spain
| | - Iris Garcia-Martínez
- Haematology Service, Banc de Sang i Teixits (BST), Barcelona, Spain.,Vall d'Hebron Institut de Recerca, Universitat Autònoma de Barcelona (VHIR-UAB), Barcelona, Spain
| | - Ana Rosa Cid
- Haematology Service, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Santiago Bonanad
- Haematology Service, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Rafael Parra
- Vall d'Hebron Institut de Recerca, Universitat Autònoma de Barcelona (VHIR-UAB), Barcelona, Spain.,Haematology Service, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | | | - Nira Navarro
- Haematology Service, Hospital Universitario Dr. Negrín, Las Palmas de Gran Canaria, Spain
| | - Carmen Altisent
- Haematology Service, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Rocío Pérez-Montes
- Haematology Service, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Ana Moretó
- Haematology Service, Hospital Universitario Cruces, Barakaldo, Spain
| | - Sonia Herrero
- Haematology Service, Hospital Universitario de Guadalajara, Guadalajara, Spain
| | - Inmaculada Soto
- Haematology Service, Hospital Universitario Central de Asturias, Oviedo, Spain
| | | | | | - Aurora de Andrés Jacob
- Haematology Service, Complexo Hospitalario Universitario Santiago de Compostela, Santiago, Spain
| | - Emilia Fontanes
- Haematology Service, Hospital Universitario Lucus Augusti, Lugo, Spain
| | - José Mateo
- Haematology Service, Hospital Sta Creu i St Pau, Barcelona, Spain
| | | | - Fernando Batlle
- Haematology Service, Lapisoft Projects S.A., A Coruña, Spain
| | - Francisco Vidal
- Haematology Service, Banc de Sang i Teixits (BST), Barcelona, Spain.,Vall d'Hebron Institut de Recerca, Universitat Autònoma de Barcelona (VHIR-UAB), Barcelona, Spain.,Haematology Service, CIBER de Enfermedades Cardiovasculares (CIBERCV)
| | | | -
- Complexo Hospitalario Universitario A Coruña, INIBIC, A Coruña, Spain
| |
Collapse
|
6
|
ASH ISTH NHF WFH 2021 guidelines on the diagnosis of von Willebrand disease. Blood Adv 2021; 5:280-300. [PMID: 33570651 DOI: 10.1182/bloodadvances.2020003265] [Citation(s) in RCA: 226] [Impact Index Per Article: 75.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 10/23/2020] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND von Willebrand disease (VWD) is the most common inherited bleeding disorder known in humans. Accurate and timely diagnosis presents numerous challenges. OBJECTIVE These evidence-based guidelines of the American Society of Hematology (ASH), the International Society on Thrombosis and Haemostasis (ISTH), the National Hemophilia Foundation (NHF), and the World Federation of Hemophilia (WFH) are intended to support patients, clinicians, and other health care professionals in their decisions about VWD diagnosis. METHODS ASH, ISTH, NHF, and WFH established a multidisciplinary guideline panel that included 4 patient representatives and was balanced to minimize potential bias from conflicts of interest. The Outcomes and Implementation Research Unit at the University of Kansas Medical Center (KUMC) supported the guideline-development process, including performing or updating systematic evidence reviews up to 8 January 2020. The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients. The panel used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, including GRADE Evidence-to-Decision frameworks, to assess evidence and make recommendations, which were subsequently subject to public comment. RESULTS The panel agreed on 11 recommendations. CONCLUSIONS Key recommendations of these guidelines include the role of bleeding-assessment tools in the assessment of patients suspected of VWD, diagnostic assays and laboratory cutoffs for type 1 and type 2 VWD, how to approach a type 1 VWD patient with normalized levels over time, and the role of genetic testing vs phenotypic assays for types 2B and 2N. Future critical research priorities are also identified.
Collapse
|
7
|
Seidizadeh O, Peyvandi F, Mannucci PM. Von Willebrand disease type 2N: An update. J Thromb Haemost 2021; 19:909-916. [PMID: 33497541 DOI: 10.1111/jth.15247] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 01/13/2021] [Accepted: 01/14/2021] [Indexed: 12/18/2022]
Abstract
Quantitative or qualitative defects of von Willebrand factor (VWF) are responsible for the most common inherited bleeding disorder, von Willebrand disease (VWD). Type 2N VWD is an uncommon recessive disorder that results from gene mutations located in the region coding for the binding site of VWF for factor VIII (FVIII). This narrative review describes the pathophysiology, diagnostic procedures and treatment as well as the molecular biology of type 2N VWD. Although other VWF-dependent functions like binding to platelets and collagen are preserved, FVIII plasma levels are low due to the rapid clearance of this moiety in the absence or reduction of its binding to VWF. The diagnosis of type 2N should be considered in patients with low FVIII coagulant activity (FVIII:C) and disproportionally higher VWF antigen, especially when they present with an autosomal recessive pattern of inheritance. Because an accurate diagnosis is essential for genetic counseling and optimal treatment, type 2N must be distinguished from mild/moderate hemophilia A and its carrier state. This differential diagnosis can be obtained by using the laboratory assay of the FVIII binding capacity of VWF (VWF:FVIIIB) or analysis of the FVIII binding site on the VWF gene.
Collapse
Affiliation(s)
- Omid Seidizadeh
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Milan, Italy
| | - Flora Peyvandi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Pier Mannuccio Mannucci
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Milan, Italy
| |
Collapse
|
8
|
Seidi Zadeh O, Ahmadinejad M, Amoohossein B, Homayoun S. Are Iranian patients with von Willebrand disease type 2N properly differentiated from hemophilia A and do they receive appropriate treatment? Blood Coagul Fibrinolysis 2020; 31:382-386. [PMID: 32815913 DOI: 10.1097/mbc.0000000000000932] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
: The defect function of the von Willebrand factor (VWF) in carrying factor VIII (FVIII) leads to von Willebrand disease type 2N (VWD 2N) which could be easily misdiagnosed as hemophilia A. Differentiating of VWD 2N from hemophilia A is crucial for patient treatment and genetic counseling. As a retrospective study, we aimed to evaluate the current diagnostic work-up of Iranian patients with mild/moderate deficiency of FVIII levels and the possibility of misdiagnosis of VWD 2N as hemophilia A. All patients who referred to the reference coagulation laboratory at the Iranian Blood Transfusion Organization in a 10-months period for bleeding diathesis work-up with the request of FVIII activity level were included. Clinical and laboratory phenotypes including International Society on Thrombosis and Hemostasis - Bleeding Assessment Tool, FVIII activity, VWF antigen, VWF ristocetin cofactor, and FVIII binding capacity of VWF were assessed on suspected cases for VWD 2N. In total, the results of 896 patients for investigation of VWD 2N were evaluated and five new patients were identified within unrelated families with abnormal VWF:FVIIIB levels. Four were heterozygous for VWD 2N and one homozygous whom all were misdiagnosed as hemophilia A and underwent inappropriate treatments. The median bleeding score of the VWD 2N population was nine (4-13). In Iran, probably a significant number of VWD 2N patients are misdiagnosed as hemophilia A due to insufficient test panel for subtyping of von Willebrand disease. This study also emphasized the need for inclusion of the VWF:FVIIIB in suspected hemophilia A to achieve an optimal treatment strategy.
Collapse
Affiliation(s)
- Omid Seidi Zadeh
- Blood Transfusion Research Center, High Institute for Research and Education in Transfusion Medicine, Tehran, Iran
| | | | | | | |
Collapse
|
9
|
Noncanonical type 2B von Willebrand disease associated with mutations in the VWF D'D3 and D4 domains. Blood Adv 2020; 4:3405-3415. [PMID: 32722784 DOI: 10.1182/bloodadvances.2020002334] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 06/22/2020] [Indexed: 11/20/2022] Open
Abstract
We observed a 55-year-old Italian man who presented with mucosal and cutaneous bleeding. Results of his blood analysis showed low levels of von Willebrand factor (VWF) antigen and VWF activity (both VWF ristocetin cofactor and VWF collagen binding), mild thrombocytopenia, increased ristocetin-induced platelet aggregation, and a deficiency of high-molecular-weight multimers, all typical phenotypic hallmarks of type 2B von Willebrand disease (VWD). The analysis of the VWF gene sequence revealed heterozygous in cis mutations: (1) c.2771G>A and (2) c.6532G>T substitutions in the exons 21 and 37, respectively. The first mutation causes the substitution of an Arg residue with a Gln at position 924, in the D'D3 domain. The second mutation causes an Ala to Ser substitution at position 2178 in the D4 domain. The patient's daughter did not present the same fatherly mutations but showed only the heterozygous polymorphic c.3379C>T mutation in exon 25 of the VWF gene causing the p.P1127S substitution, inherited from her mother. The in vitro expression of the heterozygous in cis VWF mutant rVWFWT/rVWF924Q-2178S confirmed and recapitulated the ex vivo VWF findings. Molecular modeling showed that these in cis mutations stabilize a partially stretched and open conformation of the VWF monomer. Transmission electron microscopy and atomic force microscopy showed in the heterozygous recombinant form rVWFWT/rVWF924Q-2178S a stretched conformation, forming strings even under static conditions. Thus, the heterozygous in cis mutations 924Q/2178S promote conformational transitions in the VWF molecule, causing a type 2B-like VWD phenotype, despite the absence of typical mutations in the A1 domain of VWF.
Collapse
|
10
|
Favaloro EJ, Pasalic L, Curnow J. Laboratory tests used to help diagnose von Willebrand disease: an update. Pathology 2016; 48:303-18. [DOI: 10.1016/j.pathol.2016.03.001] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Revised: 03/15/2016] [Accepted: 03/20/2016] [Indexed: 10/21/2022]
|
11
|
Rapid discrimination of the phenotypic variants of von Willebrand disease. Blood 2016; 127:2472-80. [PMID: 26917779 DOI: 10.1182/blood-2015-11-664680] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Accepted: 02/15/2016] [Indexed: 11/20/2022] Open
Abstract
Approximately 20% to 25% of patients with von Willebrand disease (VWD) have a qualitative defect of the von Willebrand factor (VWF) protein activities. Variant VWD typically is classified as type 1C, 2A, 2B, 2M, or 2N depending on the VWF activity defect. Traditionally, diagnosis has relied on multiple clinical laboratory assays to assign VWD phenotype. We developed an enzyme-linked immunosorbent assay (ELISA) to measure the various activities of VWF on a single plate and evaluated 160 patient samples enrolled in the Zimmerman Program for the Molecular and Clinical Biology of von Willebrand Disease with type 2 VWD. Using linear discriminate analysis (LDA), this assay was able to identify type 1C, 2A, 2B, 2M, or 2N VWD with an overall accuracy of 92.5% in the patient study cohort. LDA jackknife analysis, a statistical resampling technique, identified variant VWD with an overall accuracy of 88.1%, which predicts the assay's performance in the general population. In addition, this assay demonstrated correlation with traditional clinical laboratory VWF assays. The VWF multiplex activity assay may be useful as a same-day screening assay when considering the diagnosis of variant VWD in an individual patient.
Collapse
|
12
|
van Meegeren MER, Mancini TL, Schoormans SCM, van Haren BJT, van Duren C, Diekstra A, Laros-van Gorkom BAP, Brons PPT, Simons A, Hoefsloot L, van Heerde WL. Clinical phenotype in genetically confirmed von Willebrand disease type 2N patients reflects a haemophilia A phenotype. Haemophilia 2015. [DOI: 10.1111/hae.12733] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- M. E. R. van Meegeren
- Hemophilia Treatment Center; Radboud University Medical Center; Nijmegen The Netherlands
| | - T. L. Mancini
- Unit Thrombosis Hemostasis; Laboratory of Hematology; Department of Laboratory Medicine; Radboud University Medical Center; Nijmegen The Netherlands
| | - S. C. M. Schoormans
- Unit Thrombosis Hemostasis; Laboratory of Hematology; Department of Laboratory Medicine; Radboud University Medical Center; Nijmegen The Netherlands
| | - B. J. T. van Haren
- Unit Thrombosis Hemostasis; Laboratory of Hematology; Department of Laboratory Medicine; Radboud University Medical Center; Nijmegen The Netherlands
| | - C. van Duren
- Unit Thrombosis Hemostasis; Laboratory of Hematology; Department of Laboratory Medicine; Radboud University Medical Center; Nijmegen The Netherlands
| | - A. Diekstra
- Department of Human Genetics; Radboud University Medical Center; Nijmegen The Netherlands
| | - B. A. P. Laros-van Gorkom
- Hemophilia Treatment Center; Radboud University Medical Center; Nijmegen The Netherlands
- Department of Hematology; Radboud University Medical Center; Nijmegen The Netherlands
| | - P. P. T. Brons
- Hemophilia Treatment Center; Radboud University Medical Center; Nijmegen The Netherlands
- Department of Pediatrics; Radboud University Medical Center; Nijmegen The Netherlands
| | - A. Simons
- Department of Human Genetics; Radboud University Medical Center; Nijmegen The Netherlands
| | - L. Hoefsloot
- Department of Human Genetics; Radboud University Medical Center; Nijmegen The Netherlands
| | - W. L. van Heerde
- Hemophilia Treatment Center; Radboud University Medical Center; Nijmegen The Netherlands
- Department of Pediatrics; Radboud University Medical Center; Nijmegen The Netherlands
| |
Collapse
|
13
|
|
14
|
Boylan B, Rice AS, De Staercke C, Eyster ME, Yaish HM, Knoll CM, Bean CJ, Miller CH. Evaluation of von Willebrand factor phenotypes and genotypes in Hemophilia A patients with and without identified F8 mutations. J Thromb Haemost 2015; 13:1036-42. [PMID: 25780857 PMCID: PMC4512234 DOI: 10.1111/jth.12902] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Indexed: 12/01/2022]
Abstract
BACKGROUND Hemophilia A (HA) is an X-linked bleeding disorder caused by a deficiency in factor VIII (FVIII). von Willebrand disease (VWD) is characterized by a quantitative or qualitative defect in von Willebrand factor (VWF). Patients with VWD with severely low VWF or VWD Type 2N (VWD2N), a VWD subtype distinguished by defective VWF binding to FVIII, may have reduced FVIII levels secondary to their VWD. These patients superficially resemble patients with HA and pose a potential for misdiagnosis. OBJECTIVES To investigate the unexplained cause of bleeding in HA patients without known FVIII mutations by assessing plasma VWF antigen (VWF:Ag), FVIII binding capacities and VWF genotypes. PATIENTS/METHODS Thirty-seven of 1027 patients with HA studied as part of the Hemophilia Inhibitor Research Study lacked identifiable F8 mutations. These patients (cases) and 73 patients with identified F8 mutations (controls) were evaluated for VWF:Ag, a patient's VWF capacity to bind FVIII (VWF:FVIIIB) and VWF sequence. RESULTS Four cases had VWF:Ag < 3 IU dL(-1) and VWF mutations consistent with Type 3 VWD. Six cases and one control were heterozygous for mutations previously reported to cause Type 1 VWD (VWD1) (n = five cases and one control) or predicted to be deleterious by Polyphen2 and SIFT prediction tools (n = 1 case). One control had VWF:Ag < 30 IU dL(-1) and seven patients (four cases and three controls), including two cases who were heterozygous for a known VWD2N mutation, had reduced VWF:FVIIIB. CONCLUSIONS These data emphasize that some patients diagnosed with HA require VWF assessments in order to achieve a comprehensive diagnosis and an optimal treatment strategy.
Collapse
Affiliation(s)
- Brian Boylan
- Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Anne S. Rice
- Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Christine De Staercke
- Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - M. Elaine Eyster
- Department of Medicine, Division of Hematology and Oncology, Pennsylvania State University College of Medicine, Hershey, Pennsylvania
| | - Hassan M. Yaish
- Department of Pediatrics, Division of Hematology/Oncology, University of Utah School of Medicine, Salt Lake City, Utah
| | - Christine M. Knoll
- Center for Cancer and Blood Disorders, Phoenix Children's Hospital, Phoenix, Arizona
| | - Christopher J. Bean
- Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Connie H. Miller
- Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | | |
Collapse
|
15
|
Widemann A, Pasero C, Arnaud L, Poullin P, Loundou AD, Choukroun G, Sanderson F, Lacroix R, Sabatier F, Coppo P, Dignat-George F, Kaplanski G. Circulating endothelial cells and progenitors as prognostic factors during autoimmune thrombotic thrombocytopenic purpura: results of a prospective multicenter French study. J Thromb Haemost 2014; 12:1601-9. [PMID: 25088020 DOI: 10.1111/jth.12681] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2014] [Accepted: 07/06/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND Autoimmune thrombotic thrombocytopenic purpura (AI-TTP) is characterized by an excess of circulating ultralarge von Willebrand factor (VWF) caused by anti-ADAMTS-13 autoantibodies. Animal studies, however, have shown that endothelial cell activation may also be an important trigger of AI-TTP. OBJECTIVES To prospectively study circulating biomarkers of endothelial lesion and activation, such as circulating endothelial cells (CECs), soluble P-selectin (sP-selectin), or VWF, and of endothelial repair, such as circulating progenitor cells (CPCs) and endothelial progenitor cells (EPCs), in AI-TTP, in relation to disease severity and prognosis. RESULTS Twenty-two patients were included in this study. CEC (P < 0.01), VWF (P < 0.05) and sP-selectin (P < 0.01) levels were significantly increased during crisis, and returned to baseline levels during remission. Both CEC (P < 0.05) and sP-selectin (P < 0.05) levels were significantly higher in patients who died or developed neurologic sequelae. CPC levels were substantially increased during the acute phase of the disease (P < 0.001), and returned to baseline levels during remission. Among CPCs, EPC levels were also increased during crisis (P < 0.05) and significantly decreased during remission. Patients who received < 16 plasma exchanges (PEs) had significantly higher EPC counts (P < 0.05) than those who needed more numerous PEs to obtain remission, suggesting that initial EPC counts may be associated with faster endothelial repair. CONCLUSION The profile of circulating endothelial markers shows massive endothelial activation and repair/remodeling during AI-TTP, and suggests that CECs and EPCs may be promising prognostic biomarkers of the disease.
Collapse
Affiliation(s)
- A Widemann
- Vascular Research Center of Marseille, Inserm, UMRS_1076, Aix-Marseille Université, Marseille, France
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
16
|
Skipwith CG, Haberichter SL, Gehrand A, Zheng XL. Compromised shear-dependent cleavage of type 2N von Willebrand factor variants by ADAMTS13 in the presence of factor VIII. Thromb Haemost 2013; 110:202-4. [PMID: 23636243 DOI: 10.1160/th13-01-0053] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2013] [Accepted: 04/03/2013] [Indexed: 11/05/2022]
|