1
|
Zhang K, Qin L, Xu F, Ye L, Wen M, Pan J, Yang L, Wang M, Xie H. The spectrum of factor XI deficiency in Southeast China: four recurrent variants can explain most of the deficiencies. Orphanet J Rare Dis 2024; 19:224. [PMID: 38835089 DOI: 10.1186/s13023-024-03235-5] [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: 02/13/2024] [Accepted: 05/27/2024] [Indexed: 06/06/2024] Open
Abstract
BACKGROUND Factor XI (FXI) deficiency is an autosomal hemorrhagic disorder characterized by reduced plasma FXI levels. Multiple ancestral variants in the F11 gene have been identified in Ashkenazi Jews and other selected European populations. However, there are few reports of predominant variants in Chinese and/or East Asian populations. The aim of this study is to characterize the genotypes and phenotypes of FXI deficiency and identify the predominant variants. RESULTS Of the 41 FXI-deficient patients, 39 exhibited severe FXI defects, considerably more than those with partial defects. The APTT levels showed a negative correlation with FXI activity levels (coefficient=-0.584, P < .001). Only nine patients experienced mild bleeding, including one partially defective patient and eight severely defective patients. The majority of patients were referred for preoperative screenings (n = 22) and checkups (n = 14). Genetic analysis revealed that 90% of the patients had genetic defects, with 2, 16, and 19 cases of heterozygous, homozygous, and compound heterozygous patients, respectively. Seventeen variants were detected in the F11 gene (6 novel), including eleven missense variants, four nonsense variants, and two small deletions scattered throughout the F11. Of the 11 missense variants, six have not yet been studied for in vitro expression. Protein modeling analyses indicated that all of these variants disrupted local structural stability by altering side-chain orientation and hydrogen bonds. Nine variants, consisting of three missense and six null variants, were detected with a frequency of two or more. The highest allele frequency was observed in p.Q281* (21.25%), p.W246* (17.50%), p.Y369* (12.50%), and p.L442Cfs*8 (12.50%). The former two were variants specific to East Asia, while the remaining two were southeast China-specific variants. CONCLUSION Our population-based cohort demonstrated that no correlation between the level of FXI activity and the bleeding severity in FXI deficiency. Additionally, the prevalence of FXI deficiency may have been underestimated. The nonsense p.Q281* was the most common variant in southeast China, suggesting a possible founder effect.
Collapse
Affiliation(s)
- Ke Zhang
- Department of Clinical Laboratory, Key Laboratory of Clinical Laboratory Diagnosis and Translational Research of Zhejiang Province, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China
| | - Langyi Qin
- Department of Clinical Laboratory, Key Laboratory of Clinical Laboratory Diagnosis and Translational Research of Zhejiang Province, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China
| | - Fei Xu
- Department of Clinical Laboratory, Key Laboratory of Clinical Laboratory Diagnosis and Translational Research of Zhejiang Province, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China
| | - Longying Ye
- Department of Clinical Laboratory, Key Laboratory of Clinical Laboratory Diagnosis and Translational Research of Zhejiang Province, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China
| | - Mengzhen Wen
- Department of Clinical Laboratory, Key Laboratory of Clinical Laboratory Diagnosis and Translational Research of Zhejiang Province, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China
| | - Jingye Pan
- Department of Intensive Care Unit, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China
| | - Lihong Yang
- Department of Clinical Laboratory, Key Laboratory of Clinical Laboratory Diagnosis and Translational Research of Zhejiang Province, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China
| | - Mingshan Wang
- Department of Clinical Laboratory, Key Laboratory of Clinical Laboratory Diagnosis and Translational Research of Zhejiang Province, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China.
| | - Haixiao Xie
- Department of Clinical Laboratory, Key Laboratory of Clinical Laboratory Diagnosis and Translational Research of Zhejiang Province, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China.
| |
Collapse
|
2
|
Barg AA, Livnat T, Kenet G. Factor XI deficiency: phenotypic age-related considerations and clinical approach towards bleeding risk assessment. Blood 2024; 143:1455-1464. [PMID: 38194679 DOI: 10.1182/blood.2023020721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 12/22/2023] [Accepted: 12/29/2023] [Indexed: 01/11/2024] Open
Abstract
ABSTRACT Factor XI (FXI) deficiency is a rare bleeding disorder that presents complex challenges in patient assessment and bleeding risk management. Despite generally causing mild to moderate bleeding symptoms, clinical manifestations can vary, and bleeding tendency does not always correlate with FXI plasma levels or genotype. Our manuscript delves into the age-related nuances of FXI deficiency across an individual's lifespan. We emphasize issues faced by specific groups, including neonates and females of reproductive age experiencing abnormal uterine bleeding and postpartum hemorrhage. Older patients present unique challenges and concerns related to the management of bleeding as well as thrombotic complications. The current assortment of diagnostic laboratory assays shows limited success in predicting bleeding risk in the perisurgical setting of patients with FXI deficiency. This review explores the intricate interplay between individual bleeding profiles, surgical sites, and FXI activity levels. We also evaluate the accuracy of existing laboratory assays in predicting bleeding and discuss the potential role of investigational global assays in perioperative assessment. Furthermore, we outline our suggested diagnostic approach to refine treatment strategies and decision making. Available treatment options are presented, including antifibrinolytics, replacement products, and recombinant activated FVII. Finally, we discuss promising nonreplacement therapies for the treatment of rare bleeding disorders that can potentially address the challenges faced when managing FXI deficiency-related bleeding complications.
Collapse
Affiliation(s)
- Assaf Arie Barg
- National Hemophilia Center, Coagulation Unit and Amalia Biron Research Institution of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, Israel; and Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tami Livnat
- National Hemophilia Center, Coagulation Unit and Amalia Biron Research Institution of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, Israel; and Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gili Kenet
- National Hemophilia Center, Coagulation Unit and Amalia Biron Research Institution of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, Israel; and Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| |
Collapse
|
3
|
Zhang X, Lewandowska M, Aldridge M, Iglay K, Wolford E, Shapiro A. Global epidemiology of factor XI deficiency: A targeted review of the literature and foundation reports. Haemophilia 2023; 29:423-434. [PMID: 36367760 DOI: 10.1111/hae.14687] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 10/03/2022] [Accepted: 10/15/2022] [Indexed: 11/13/2022]
Abstract
INTRODUCTION Hereditary factor XI (FXI) deficiency is a rare coagulation disorder that may result in excessive bleeding requiring intervention to restore haemostasis. AIM The aim of this review was to report the current knowledge of the worldwide incidence and prevalence of FXI deficiency. METHODS A targeted PubMed search using terms related to FXI deficiency was conducted to identify studies published from April 2002 through April 2022. A manual search supplemented the electronic search. Studies were eligible for data abstraction if they reported population-based incidence proportions/rates or prevalence proportions for FXI deficiency. RESULTS The electronic and manual searches returned 253 publications. After applying exclusion criteria, seven publications were included in the analysis, including a global report from the World Federation of Haemophilia (WFH). Six publications provided information on the prevalence of FXI deficiency that included 74 countries and regions. The estimated prevalence of FXI in the WFH report ranged from 0/100,000 in several countries to 55.85/100,000 individuals in the United Kingdom. Prevalence estimates in the PubMed findings ranged from .1 to 246.2/1,000,000 inhabitants with varying methods of case identification and time periods of analysis. One study estimated the incidence of FXI deficiency in Yecla, Spain at 2% of blood donors and .09% of hospital inpatients/outpatients with activated partial thromboplastin time (aPTT) tests. CONCLUSION FXI deficiency is rare across the world, but additional steps could be taken to improve incidence and prevalence estimation, for example, development of a consistent FXI deficiency definition and incorporating genetic testing into a clinical routine to better identify and characterise cases.
Collapse
Affiliation(s)
- Xinruo Zhang
- CERobs Consulting, LLC., Wrightsville Beach, North Carolina, USA
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | | | - Molly Aldridge
- CERobs Consulting, LLC., Wrightsville Beach, North Carolina, USA
| | - Kristy Iglay
- CERobs Consulting, LLC., Wrightsville Beach, North Carolina, USA
| | - Eric Wolford
- Bio Products Laboratory, Ltd., Elstree, Hertfordshire, UK
| | - Amy Shapiro
- Indiana Hemophilia and Thrombosis Center, Indianapolis, Indiana, USA
| |
Collapse
|
4
|
De Mazancourt P, Harroche A, Pouymayou K, Sigaud M, Falaise C, Stieltjes N, Castet SM, Tardy B, Zawadzki C, Goudemand J, Dargaud Y. Reinvestigation of unidentified causative variants in FXI-deficient patients: Focus on gene segment deletions. Haemophilia 2023; 29:248-255. [PMID: 36195107 DOI: 10.1111/hae.14666] [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: 04/29/2022] [Revised: 07/06/2022] [Accepted: 09/08/2022] [Indexed: 01/28/2023]
Abstract
INTRODUCTION Data on failure to identify the molecular mechanism underlying FXI deficiency by Sanger analysis and the contribution of gene segment deletions are almost inexistent. AIMS AND METHODS Prospective and retrospective analysis was conducted on FXI-deficient patients' DNA via Next Generation Sequencing (NGS), or Sanger sequencing and Multiplex Probe Ligation-dependent Assay (MLPA) to detect cryptic causative gene variants or gene segment deletions. RESULTS Sanger analysis or NGS enabled us to identify six severe and one partial (median activity 41 IU/dl) FXI deficient index cases with deletions encompassing exons 11-15, the whole gene, or both. After Sanger sequencing, retrospective evaluation using MLPA detected seven additional deletion cases in apparently homozygous cases in non-consanguineous families, or in previously unsolved FXI-deficiency cases. Among the 504 index cases with a complete genetic investigation (Sanger/MLPA, or NGS), 23 remained unsolved (no abnormality found [n = 14] or rare intronic variants currently under investigation, [n = 9]). In the 481 solved cases (95% efficiency), we identified F11 gene-deleted patients (14 cases; 2.9%). Among these, whole gene deletion accounted for four heterozygous cases, exons 11-15 deletion for five heterozygous and three homozygous ones, while compound heterozygous deletion and isolated exon 12 deletion accounted for one case each. CONCLUSION Given the high incidence of deletions in our population (2.9%), MLPA (or NGS with a reliable bioinformatic pipeline) should be systematically performed for unsolved FXI deficiencies or apparently homozygous cases in non-consanguineous families.
Collapse
Affiliation(s)
- Philippe De Mazancourt
- Laboratory of Molecular Biology, Ambroise Pare Hospital, GHU APHP Paris-Saclay, Boulogne-Billancourt, France.,UMR1179, Versailles St-Quentin University, Boulogne-Billancourt, France
| | - Annie Harroche
- Department of Hematology, Hospital Necker-Enfants Malades, GHU AP-HP, Centre - Université de Paris, Paris, France
| | - Katia Pouymayou
- Laboratory of Hematology, La Timone Hospital, APHM, Marseille, France
| | - Marianne Sigaud
- Ressources and Competence Center for Constitutional Bleeding Disorders - CRC-MHC, Nantes University Hospital, Nantes, France
| | - Céline Falaise
- Department of Pediatric Hematology, Immunology, and Oncology, La Timone Children's Hospital, APHM, Marseille, France
| | - Natalie Stieltjes
- Ressources and Competence Center for Constitutional Bleeding Disorders - CRC-MHC, Cochin Hospital, GHU AP-HP, Centre - Université de Paris, Paris, France
| | - Sabine-Marie Castet
- Department of Biological Hematology, CHU Bordeaux-GH Pellegrin, Bordeaux, France
| | - Brigitte Tardy
- Department of Hematology, CHU Nord, Saint Etienne, France
| | | | - Jenny Goudemand
- Department of Hematology, Biology-Pathology Center, CHU, Lille, France
| | - Yesim Dargaud
- Clinical Haemostasis Unit, Louis Pradel Heart Hospital, Lyon, France
| |
Collapse
|
5
|
Dorgalaleh A, Bahraini M, Shams M, Parhizkari F, Dabbagh A, Naderi T, Fallah A, Fazeli A, Ahmadi SE, Samii A, Daneshi M, Heydari F, Tabibian S, Tavasoli B, Noroozi-Aghideh A, Tabatabaei T, Gholami MS. Molecular basis of rare congenital bleeding disorders. Blood Rev 2022; 59:101029. [PMID: 36369145 DOI: 10.1016/j.blre.2022.101029] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 09/26/2022] [Accepted: 10/23/2022] [Indexed: 11/11/2022]
Abstract
Rare bleeding disorders (RBDs), including factor (F) I, FII, FV, FVII, combined FV and FVIII (CF5F8), FXI, FXIII and vitamin-K dependent coagulation factors (VKCF) deficiencies, are a heterogeneous group of hemorrhagic disorder with a variable bleeding tendency. RBDs are due to mutation in underlying coagulation factors genes, except for CF5F8 and VKCF deficiencies. FVII deficiency is the most common RBD with >330 variants in the F7 gene, while only 63 variants have been identified in the F2 gene. Most detected variants in the affected genes are missense (>50% of all RBDs), while large deletions are the rarest, having been reported in FVII, FX, FXI and FXIII deficiencies. Most were located in the catalytic and activated domains of FXI, FX, FXIII and prothrombin deficiencies. Understanding the proper molecular basis of RBDs not only can help achieve a timely and cost-effective diagnosis, but also can help to phenotype properties of the disorders.
Collapse
|
6
|
Kuder H, Dickeson SK, Brooks MB, Kehl A, Müller E, Gailani D, Giger U. A Common Missense Variant Causing Factor XI Deficiency and Increased Bleeding Tendency in Maine Coon Cats. Genes (Basel) 2022; 13:792. [PMID: 35627175 PMCID: PMC9140718 DOI: 10.3390/genes13050792] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 04/22/2022] [Accepted: 04/26/2022] [Indexed: 02/05/2023] Open
Abstract
Hereditary factor XI (FXI) deficiency is characterized as an autosomal mild to moderate coagulopathy in humans and domestic animals. Coagulation testing revealed FXI deficiency in a core family of Maine Coon cats (MCCs) in the United States. Factor XI-deficient MCCs were homozygous for a guanine to adenine transition resulting in a methionine substitution for the highly conserved valine-516 in the FXI catalytic domain. Immunoblots detected FXI of normal size and quantity in plasmas of MCCs homozygous for V516M. Some FXI-deficient MCCs experienced excessive post-operative/traumatic bleeding. Screening of 263 MCCs in Europe revealed a mutant allele frequency of 0.232 (23.2%). However, V516M was not found among 100 cats of other breeds. Recombinant feline FXI-M516 (fFXI-M516) expressed ~4% of the activity of wild-type fFXI-V516 in plasma clotting assays. Furthermore, fFXIa-M516 cleaved the chromogenic substrate S-2366 with ~4.3-fold lower catalytic efficacy (kcat/Km) than fFXIa-V516, supporting a conformational alteration of the protease active site. The rate of FIX activation by fFXIa-M516 was reduced >3-fold compared with fFXIa-V516. The common missense variant FXI-V516M causes a cross-reactive material positive FXI deficiency in MCCs that is associated with mild-moderate bleeding tendencies. Given the prevalence of the variant in MCCs, genotyping is recommended prior to invasive procedures or breeding.
Collapse
Affiliation(s)
- Henrike Kuder
- Vetsuisse Faculty, University of Zürich, Winterthurerstrasse 260, CH-8057 Zurich, Switzerland;
- Laboklin GmbH & Co. KG (Labogen), Steubenstrasse 4, D-97688 Bad Kissingen, Germany; (A.K.); (E.M.)
| | - S. Kent Dickeson
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, 1301 Medical Center Dr, Nashville, TN 37232, USA; (S.K.D.); (D.G.)
| | - Marjory B. Brooks
- Comparative Coagulation Laboratory, Cornell University, 240 Farrier Road, Ithaca, NY 14853, USA;
| | - Alexandra Kehl
- Laboklin GmbH & Co. KG (Labogen), Steubenstrasse 4, D-97688 Bad Kissingen, Germany; (A.K.); (E.M.)
| | - Elisabeth Müller
- Laboklin GmbH & Co. KG (Labogen), Steubenstrasse 4, D-97688 Bad Kissingen, Germany; (A.K.); (E.M.)
| | - David Gailani
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, 1301 Medical Center Dr, Nashville, TN 37232, USA; (S.K.D.); (D.G.)
| | - Urs Giger
- Vetsuisse Faculty, University of Zürich, Winterthurerstrasse 260, CH-8057 Zurich, Switzerland;
| |
Collapse
|
7
|
Barg AA, Levy-Mendelovich S, Budnik I, Mandel-Shorer N, Dardik R, Avishai E, Brutman-Barazani T, Ifrah AD, Oren-Malek L, Yacobovich J, Gilad O, Nakav S, Fruchtman Y, Revel-Vilk S, Miskin H, Kenet G. Pediatric severe factor XI deficiency: A multicenter study. Pediatr Blood Cancer 2022; 69:e29545. [PMID: 34957695 DOI: 10.1002/pbc.29545] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 11/21/2021] [Accepted: 12/02/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Factor XI (FXI) deficiency is a rare autosomal recessive bleeding disorder. Only scarce publications address its clinical features in children. The increased prevalence of FXI deficiency in Israel enabled data collection for this large multicenter cohort study. OBJECTIVE Some hemostatic challenges may be unique or more common in children, such as bleeding in the neonatal period or trauma-related injury. The current study was designed to explore the potential impact of these differences in children with severe FXI deficiency. METHODS Medical files of all children with FXI level under 15% followed at five tertiary centers were evaluated. The retrieved data comprised demographic and clinical characteristics, including bleeding episodes, surgical interventions, treatment strategies, as well as laboratory features. RESULTS Sixty children, whose median age at diagnosis was 4.2 years and their median FXI level was 4%, were included. Three children experienced triggered intracranial hemorrhage (ICH) and two children had major bleeds. No bleeding complications occurred in surgeries in which hemostatic treatment consisting mostly of tranexamic acid or fresh frozen plasma was applied (n = 45). In contrast, excessive bleeding was noted in 25% of surgical procedures performed without hemostatic preparation (p = .002). CONCLUSION This study's findings confirm the generally favorable outcome of this rare bleeding disorder, with no spontaneous bleeds or cases of perinatal ICH. Nonetheless, proper diagnosis and adequate hemostasis in the surgical setting are imperative. Unlike previous studies in adults, our pediatric study suggests an association between the severity of FXI deficiency and bleeding tendency.
Collapse
Affiliation(s)
- Assaf Arie Barg
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,The Israeli National Hemophilia Center, Thrombosis Unit and Amalia Biron Research Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, Israel
| | - Sarina Levy-Mendelovich
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,The Israeli National Hemophilia Center, Thrombosis Unit and Amalia Biron Research Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, Israel
| | - Ivan Budnik
- Department of Pathophysiology, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Noa Mandel-Shorer
- Department of Paediatric Haematology-Oncology, Ruth Rappaport Children's Hospital, Rambam Health Care Campus, Technion-Israel Institute of Technology, Haifa, Israel
| | - Rima Dardik
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,The Israeli National Hemophilia Center, Thrombosis Unit and Amalia Biron Research Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, Israel
| | - Einat Avishai
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,The Israeli National Hemophilia Center, Thrombosis Unit and Amalia Biron Research Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, Israel
| | - Tami Brutman-Barazani
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,The Israeli National Hemophilia Center, Thrombosis Unit and Amalia Biron Research Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, Israel
| | - Aviya Dvir Ifrah
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,The Israeli National Hemophilia Center, Thrombosis Unit and Amalia Biron Research Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, Israel
| | - Liat Oren-Malek
- Department of Paediatric Haematology-Oncology, Ruth Rappaport Children's Hospital, Rambam Health Care Campus, Technion-Israel Institute of Technology, Haifa, Israel
| | - Joanne Yacobovich
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Paediatric Haematology Oncology, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - Oded Gilad
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Paediatric Haematology Oncology, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - Sigal Nakav
- The Coagulation Laboratory, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
| | - Yariv Fruchtman
- Paediatric Haemato-Oncology Department, Saban Paediatric Medical Center, Soroka University Medical Center, Beer-Sheva, Israel
| | - Shoshana Revel-Vilk
- Paediatric Haematology Oncology Unit, Shaare Zedek Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Hagit Miskin
- Paediatric Haematology Oncology Unit, Shaare Zedek Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Gili Kenet
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,The Israeli National Hemophilia Center, Thrombosis Unit and Amalia Biron Research Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, Israel
| |
Collapse
|
8
|
Dhaha Y, El Borgi W, Elmahmoudi H, Achour M, Fekih Salem S, Ben Lakhal F, Meddeb B, Gouider E. Factor XI deficiency: About 20 cases and literature review. LA TUNISIE MEDICALE 2022; 100:60-65. [PMID: 35822334 PMCID: PMC9002864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
INTRODUCTION Factor XI deficiency is a rare coagulation disorder with variable bleeding manifestations. AIM To evaluate the correlation between the degree of factorXI deficiency and the clinical expression of the disease. METHODS Retrospective study, spanning 10 years from January 1, 2010 to December 31, 2019, concerning patients followed at the Hemophilia Center at Aziza Othmana Hospital in Tunis. The data were collected from the medical records. The determination of PT, APTT, fibrinogen level and coagulation factors are performed by coagulometric technique on STA® compact / ACL TOP®. FactorXI deficiency was confirmed on two different samples. Statistical analysis of the clinical-biological correlation was performed using the chi-square test. The significance level was 0.05. RESULTS Twenty patients were collected. The mean age of discovery was 25 years with a sex ratio (M/F) =0.33. The circumstances of discovery were incidental in 14 patients. A family history of bleeding was reported in 30% of cases. Eight patients underwent surgery, six of whom had a simple postoperative course. The APTT was prolonged and isolated in 75% of cases. The hemostasis test was normal in 5 cases. The average FactorXI level was 24%. The tendency to bleed did not seem to be correlated with FactorXI levels. CONCLUSION Prospective multicenter studies including molecular study would be necessary to better elucidate this rare disorder.
Collapse
Affiliation(s)
- Yosra Dhaha
- 1- Service d’hématologie biologique CHU Aziza Othmena / Faculté de Médecine de Sousse
| | - Wijdène El Borgi
- 2- Service d’hématologie biologique CHU Aziza Othmena / Faculté de médecine de Tunis
| | - Hajer Elmahmoudi
- 3- Service d’hématologie biologique CHU Aziza Othmena / Faculté des Sciences Tunis
| | - Mariem Achour
- 4- Service d’hématologie clinique. CHU Aziza Othmana. Faculté de médecine de Tunis
| | - Sarra Fekih Salem
- 5- Service d’hématologie biologique. CHU Aziza Othmana. Faculté de Pharmacie de Monastir
| | - Fatma Ben Lakhal
- 2- Service d’hématologie biologique CHU Aziza Othmena / Faculté de médecine de Tunis
| | - Balkis Meddeb
- 4- Service d’hématologie clinique. CHU Aziza Othmana. Faculté de médecine de Tunis
| | - Emna Gouider
- 2- Service d’hématologie biologique CHU Aziza Othmena / Faculté de médecine de Tunis
| |
Collapse
|
9
|
Harris VA, Lin W, Perkins SJ. Analysis of 272 Genetic Variants in the Upgraded Interactive FXI Web Database Reveals New Insights into FXI Deficiency. TH OPEN 2021; 5:e543-e556. [PMID: 35059554 PMCID: PMC8763576 DOI: 10.1055/a-1683-8605] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 10/27/2021] [Indexed: 12/18/2022] Open
Abstract
Coagulation Factor XI (FXI) is a plasma glycoprotein composed of four apple (Ap) domains and a serine protease (SP) domain. FXI circulates as a dimer and activates Factor IX (FIX), promoting thrombin production and preventing excess blood loss. Genetic variants that degrade FXI structure and function often lead to bleeding diatheses, commonly termed FXI deficiency. The first interactive FXI variant database underwent initial development in 2003 at
https://www.factorxi.org
. Here, based on a much improved FXI crystal structure, the upgraded FXI database contains information regarding 272 FXI variants (including 154 missense variants) found in 657 patients, this being a significant increase from the 183 variants identified in the 2009 update. Type I variants involve the simultaneous reduction of FXI coagulant activity (FXI:C) and FXI antigen levels (FXI:Ag), whereas Type II variants result in decreased FXI:C yet normal FXI:Ag. The database updates now highlight the predominance of Type I variants in FXI. Analysis in terms of a consensus Ap domain revealed the near-uniform distribution of 81 missense variants across the Ap domains. A further 66 missense variants were identified in the SP domain, showing that all regions of the FXI protein were important for function. The variants clarified the critical importance of changes in surface solvent accessibility, as well as those of cysteine residues and the dimer interface. Guidelines are provided below for clinicians who wish to use the database for diagnostic purposes. In conclusion, the updated database provides an easy-to-use web resource on FXI deficiency for clinicians.
Collapse
Affiliation(s)
- Victoria A. Harris
- Research Department of Structural and Molecular Biology, University College London, London, United Kingdom
| | - Weining Lin
- Research Department of Structural and Molecular Biology, University College London, London, United Kingdom
| | - Stephen J. Perkins
- Research Department of Structural and Molecular Biology, University College London, London, United Kingdom
| |
Collapse
|
10
|
Exploring the global landscape of genetic variation in coagulation factor XI deficiency. Blood 2017; 130:e1-e6. [DOI: 10.1182/blood-2017-04-780148] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 06/12/2017] [Indexed: 12/16/2022] Open
Abstract
Key Points
Exome-data analysis revealed that FXI deficiency is from 2 to 20 times more frequent than expected in most populations. Exome-data analysis evidenced novel recurrent and ethnic-specific mutations other than the well-known type II and type III defects.
Collapse
|
11
|
Wiewel-Verschueren S, Mulder AB, Meijer K, Mulder R. Factor 11 single-nucleotide variants in women with heavy menstrual bleeding. J OBSTET GYNAECOL 2017; 37:912-918. [PMID: 28609141 DOI: 10.1080/01443615.2017.1312303] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
In a previous study it was shown that lower factor XI (FXI) levels in women with heavy menstrual bleeding (HMB). Our aim was to determine the single-nucleotide variants (SNVs) in the F11 gene in women with HMB. In addition, an extensive literature search was performed to determine the clinical significance of each SNV. Patients referred for HMB (PBAC-score >100) were included. With direct sequencing analysis of all 15 exons and flanking introns of the F11 gene, 29 different non-structural SNVs were detected in 49 patients with HMB. Interestingly, most of these SNVs have previously been associated with venous thrombosis instead of bleeding. These findings have not helped to elucidate the molecular basis of HMB. They also question the specificity of previously reported F11 variations in patients with thrombosis. More studies are needed to explain the lower FXI levels seen in patients with HMB. IMPACT STATEMENT Women with mild deficiencies of factor XI (FXI) (< 70%) are prone to excessive bleeding during menstruation. Bleeding manifestations are not well correlated with plasma FXI levels and bleeding episodes can vary widely among patients with similar low FXI levels. In a previous study we showed that women with heavy menstrual bleeding (HMB) had normal, but on average, lower levels of FXI than controls. In light of these findings, we performed F11 gene analysis to determine the single-nucleotide variants (SNVs) in women with HMB and performed an extensive literature search to determine the clinical significance of each SNV. By direct sequencing analysis of the F11 gene we found 29 different non-structural SNVs in 49 women with heavy menstrual bleeding. Remarkably, a number of these SNVs have previously been implicated in thrombosis. These findings have not helped to elucidate the molecular basis of lower FXI levels in HMB. They also question the specificity of previously reported F11 variations in patients with thrombosis. More studies are needed to explain the lower FXI levels seen in patients with HMB.
Collapse
Affiliation(s)
- Sophie Wiewel-Verschueren
- a Division of Thrombosis and Haemostasis, Department of Hematology , University of Groningen, University Medical Center Groningen , Groningen , The Netherlands.,b Department of Obstetrics and Gynaecology , University of Groningen, University Medical Center Groningen , Groningen , The Netherlands
| | - André B Mulder
- c Department of Laboratory Medicine , University of Groningen, University Medical Center Groningen , Groningen , The Netherlands
| | - Karina Meijer
- a Division of Thrombosis and Haemostasis, Department of Hematology , University of Groningen, University Medical Center Groningen , Groningen , The Netherlands
| | - René Mulder
- c Department of Laboratory Medicine , University of Groningen, University Medical Center Groningen , Groningen , The Netherlands
| |
Collapse
|
12
|
|
13
|
Abstract
INTRODUCTION Inherited fXI deficiency has been an enigma since its discovery in 1953. The variable and relatively mild symptoms in patients with even the most severe form of the disorder seem out of step with the marked abnormalities in standard clotting assays. Indeed, the contribution of factor XI to hemostasis in an individual is not adequately assessed by techniques available in modern clinical laboratories. AREAS COVERED We discuss clinical studies, genetic/genomic analyses, and advances in laboratory medicine that are reshaping our views on the role of factor XI in pathologic coagulation. We review how the disorder associated with factor XI deficiency has contributed to changes in blood coagulation models, and discuss the complex genetics of the deficiency state and its relationship to bleeding. Finally, we cover new laboratory approaches that may distinguish deficient patients who are prone to bleeding from those without such predisposition. Expert commentary: Advances in understanding the biology of factor XI have led to modifications in treatment of factor XI-deficient patients. Factor replacement is used more judiciously, and alternative approaches are gaining favor. In the future, better laboratory tests may allow us to target therapy to those patients who would benefit most.
Collapse
Affiliation(s)
- Allison P Wheeler
- a Department of Pathology, Microbiology and Immunology , Vanderbilt University , Nashville , TN , USA.,b The Department of Pediatrics , Vanderbilt University , Nashville , TN , USA
| | - David Gailani
- a Department of Pathology, Microbiology and Immunology , Vanderbilt University , Nashville , TN , USA.,c The Department of Medicine , Vanderbilt University , Nashville , TN , USA
| |
Collapse
|
14
|
Molecular basis and bleeding manifestations of factor XI deficiency in 11 Turkish families. Blood Coagul Fibrinolysis 2015; 26:63-8. [DOI: 10.1097/mbc.0000000000000185] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
|
15
|
Mumford AD, Ackroyd S, Alikhan R, Bowles L, Chowdary P, Grainger J, Mainwaring J, Mathias M, O'Connell N. Guideline for the diagnosis and management of the rare coagulation disorders: a United Kingdom Haemophilia Centre Doctors' Organization guideline on behalf of the British Committee for Standards in Haematology. Br J Haematol 2014; 167:304-26. [PMID: 25100430 DOI: 10.1111/bjh.13058] [Citation(s) in RCA: 198] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Andrew D Mumford
- School of Cellular and Molecular Medicine, University of Bristol, Bristol, UK
| | | | | | | | | | | | | | | | | |
Collapse
|
16
|
Choi SJ, Kim J, Lee KA, Choi JR, Yoo J. Cys482Trp missense mutation in the coagulation factor XI gene (F11) in a Korean patient with factor XI deficiency. Ann Lab Med 2014; 34:332-5. [PMID: 24982842 PMCID: PMC4071194 DOI: 10.3343/alm.2014.34.4.332] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2013] [Revised: 09/16/2013] [Accepted: 01/29/2014] [Indexed: 11/19/2022] Open
Affiliation(s)
- Seung Jun Choi
- Department of Laboratory Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea. ; Department of Laboratory Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Juwon Kim
- Department of Laboratory Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Kyung-A Lee
- Department of Laboratory Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jong Rak Choi
- Department of Laboratory Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jongha Yoo
- Department of Laboratory Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea. ; Department of Laboratory Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| |
Collapse
|
17
|
Kamoun F, Sfaihi L, Wali M, Kamoun T, Hachicha M. [An uncommon cause of hematemesis in children: factor XI deficiency]. Arch Pediatr 2014; 21:296-8. [PMID: 24461936 DOI: 10.1016/j.arcped.2013.12.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2013] [Revised: 07/18/2013] [Accepted: 12/06/2013] [Indexed: 11/17/2022]
Abstract
Congenital factor XI deficiency, also called hemophilia C, is a rare coagulation disorder that is particularly common in Ashkenazi Jews. Individuals with factor XI deficiency may or may not have a mild bleeding tendency, which is typically provoked by surgery or trauma. We report the case of a 5.5-year-old girl who presented with abdominal pain, vomiting, and hematemesis. Biological tests showed a prolonged activated partial thromboplastin time (aPTT) of 113 s (control=29 s) caused by a constitutional factor Xl deficiency (2.7%). The progression was spontaneously favorable.
Collapse
Affiliation(s)
- F Kamoun
- Service de pédiatrie, hôpital Hédi-Chaker, 3029 Sfax, Tunisie; Faculté de médecine de Sfax, Sfax, Tunisie.
| | - L Sfaihi
- Service de pédiatrie, hôpital Hédi-Chaker, 3029 Sfax, Tunisie; Faculté de médecine de Sfax, Sfax, Tunisie
| | - M Wali
- Service de pédiatrie, hôpital Hédi-Chaker, 3029 Sfax, Tunisie; Faculté de médecine de Sfax, Sfax, Tunisie
| | - T Kamoun
- Service de pédiatrie, hôpital Hédi-Chaker, 3029 Sfax, Tunisie; Faculté de médecine de Sfax, Sfax, Tunisie
| | - M Hachicha
- Service de pédiatrie, hôpital Hédi-Chaker, 3029 Sfax, Tunisie; Faculté de médecine de Sfax, Sfax, Tunisie
| |
Collapse
|
18
|
Functional investigation of a venous thromboembolism GWAS signal in a promoter region of coagulation factor XI gene. Mol Biol Rep 2014; 41:2015-9. [PMID: 24420855 DOI: 10.1007/s11033-014-3049-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2013] [Accepted: 01/04/2014] [Indexed: 12/31/2022]
Abstract
Coagulation factor XI (FXI) is essential for normal function of the intrinsic pathway of blood coagulation. A nucleotide variant (rs3756008) in the promoter region of the FXI gene was recently reported for association with venous thromboembolism. This study aimed to examine promoter activity of the rs3756008 or other variants linked with it. Luciferase assay was analyzed with minigenes including haplotypes (AA with frequency of 0.62 and TG with frequency of 0.38) of 2 completely linked nucleotide variants (rs3756008 and rs3756009) in 5'-upstream region of the FXI gene. While their expression did not differ in hepatic cell (P > 0.05), the major haplotype (AA) made a significantly more expression (P < 0.05) than the minor haplotype (TG) in human embryonic kidney 293 cells. Further luciferase analysis with additional haplotypes (artificial; TA, AG) revealed that the large expression was caused by the major allele of rs3756008 (P < 0.05), but not by that of rs3756009 (P > 0.05). We suggested that the minor allele of rs3756008 in the promoter of FXI gene could reduce its expression in kidney.
Collapse
|
19
|
A family with factor-XI deficiency due to a compound heterozygosis between Gln 47 Pro (new mutation) in exon 3 and Leu 619 Pro in exon 15. Blood Coagul Fibrinolysis 2013; 25:191-5. [PMID: 24121361 DOI: 10.1097/mbc.0b013e3283641935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
A new factor XI mutation (Gln 47 Pro) has been found in combination with another known mutation (Leu 619 Pro) in a female patient with FXI deficiency and a moderate bleeding tendency. FXI activity and antigen in the proposita were 2% activity and less than 5% of normal, respectively. The parents are not consanguineous and are asymptomatic. The father is heterozygote for the new mutation whereas the mother is heterozygote for the known mutation. Other family members are heterozygotes for either one of the two mutations. The new mutation is not a polymorphism as it was not found in the population of the area. The geographical area, north-east of Italy, of the present family is the same area where a cluster of another new mutation (Ile 436 Lys) was recently reported. No relation was found between the present family and those with the previous mutation.
Collapse
|
20
|
Castaman G, Giacomelli SH, Caccia S, Riccardi F, Rossetti G, Dragani A, Giuffrida AC, Biasoli C, Duga S. The spectrum of factor XI deficiency in Italy. Haemophilia 2013; 20:106-13. [PMID: 24112640 DOI: 10.1111/hae.12257] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/26/2013] [Indexed: 11/29/2022]
Abstract
Factor XI (FXI) deficiency is a rare inherited bleeding disorder invariably caused by mutations in the FXI gene. The disorder is rather frequent in Ashkenazi Jews, in whom around 98% of the abnormal alleles is represented by Glu117X and Phe283Leu mutations. A wide heterogeneity of causative mutations has been previously reported in a few FXI deficient patients from Italy. In this article, we enlarge the knowledge on the genetic background of FXI deficiency in Italy. Over 4 years, 22 index cases, eight with severe deficiency and 14 with partial deficiency, have been evaluated. A total of 21 different mutations in 30 disease-associated alleles were identified, 10 of which were novel. Among them, a novel Asp556Gly dysfunctional mutation was also identified. Glu117X was also detected, as previously reported from other patients in Italy, while again Phe283Leu was not identified. A total of 34 heterozygous relatives were also identified. Bleeding tendency was present in very few cases, being inconsistently related to the severity of FXI deficiency in plasma. In conclusion, at variance with other populations, no single major founder effect is present in Italian patients with FXI deficiency.
Collapse
Affiliation(s)
- G Castaman
- Department of Cell Therapy and Hematology, Hemophilia and Thrombosis Center, San Bortolo Hospital, Vicenza, Italy
| | | | | | | | | | | | | | | | | |
Collapse
|
21
|
Abstract
Inherited factor XI (FXI) deficiency, also called Hemophilia C, is an uncommon autosomal recessive disorder, which is associated with a variable bleeding tendency that usually manifests after trauma or surgery. This concise report reviews current knowledge regarding the pathogenesis, genetics, diagnosis, clinical manifestations and management of this inherited bleeding disorder.
Collapse
Affiliation(s)
- Massimo Franchini
- Servizio di Immunoematologia e Trasfusione - Centro Emofilia, Azienda Ospedaliera di Verona, Italy
| | | | | |
Collapse
|
22
|
Peretz H, Salomon O, Mor-Cohen R, Usher S, Zucker M, Zivelin A, Seligsohn U. Type I mutation in the F11 gene is a third ancestral mutation which causes factor XI deficiency in Ashkenazi Jews. J Thromb Haemost 2013; 11:724-30. [PMID: 23332144 DOI: 10.1111/jth.12137] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2012] [Accepted: 01/09/2013] [Indexed: 12/21/2022]
Abstract
BACKGROUND Factor XI (FXI) deficiency is one of the most frequent inherited disorders in Ashkenazi Jews (AJ). Two predominant founder mutations termed type II (p.Glu117Stop) and type III (p.Phe283Leu) account for most cases. OBJECTIVES To present clinical aspects of a third FXI mutation, type I (c.1716 + 1G>A), which is also prevalent in AJ and to discern a possible founder effect. METHODS Bleeding manifestations, FXI levels and origin of members of 13 unrelated families harboring the type I mutation were determined. In addition, eight intragenic and five extragenic polymorphisms were analyzed in patients with a type I mutation, in 16 unrelated type II homozygotes, in 23 unrelated type III homozygotes and in Ashkenazi Jewish controls. Analysis of these polymorphisms enabled haplotype analysis and estimation of the age of the type I mutation. RESULTS Four of 16 type I heterozygotes (25%) and 6 of 12 (50%) compound heterozygotes for type I mutation (I/II and I/III), or a type I homozygote had bleeding manifestations. Haplotype analysis disclosed that like type II and type III mutations, the type I is also an ancestral mutation. An age estimate revealed that the type I mutation occurred approximately 600 years ago. The geographic distribution of affected families suggested that there was a distinct origin of the type I mutation in Eastern Europe. CONCLUSIONS The rather rare type I mutation in the FXI gene is a third founder mutation in AJ.
Collapse
Affiliation(s)
- H Peretz
- Clinical Biochemistry Laboratory, Sourasky Medical Center, Tel Aviv, Israel.
| | | | | | | | | | | | | |
Collapse
|
23
|
Bicocchi MP, Rosano C, Acquila M. Genetic analysis in FXI deficient patients from northwestern Italy: three novel and one recurrent mutation. Eur J Haematol 2013; 90:351-3. [DOI: 10.1111/ejh.12072] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Maria Patrizia Bicocchi
- Haematology and Oncology Department Haemophilia and Thrombosis Centre; Giannina Gaslini Institute; Genova; Italy
| | - Camillo Rosano
- Biopolimers and Proteomics Unit IRCCS AOU San Martino - IST National Institute for Cancer Research; Genova; Italy
| | - Maura Acquila
- Haematology and Oncology Department Haemophilia and Thrombosis Centre; Giannina Gaslini Institute; Genova; Italy
| |
Collapse
|
24
|
He R, Chen D, He S. Factor XI: hemostasis, thrombosis, and antithrombosis. Thromb Res 2011; 129:541-50. [PMID: 22197449 DOI: 10.1016/j.thromres.2011.11.051] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2011] [Revised: 11/28/2011] [Accepted: 11/29/2011] [Indexed: 10/14/2022]
Abstract
Coagulation factor FXI (FXI), a plasma serine protease zymogen, has important roles in both intrinsic and extrinsic coagulation pathways and bridges the initiation and amplification phases of plasmatic hemostasis. Recent studies have provided new insight into the molecular structure and functional features of FXI and have demonstrated distinct structural and biological differences between activated factor XII (FXIIa)-mediated FXI activation and tissue factor/thrombin-mediated FXI activation. The former is important in thrombosis; the latter is more essential in hemostasis. Activated partial thromboplastin tine (aPTT) artificially reflects FXIIa-initiated intrinsic coagulation pathway in vitro. Conversely, FXIIa-inhibited diluted thromboplastin time assay may reflect tissue factor/thrombin-mediated FXI activation in vivo. Further explication of the genetic mutations of FXI deficiency has improved the understanding of the structure-function relationship of FXI. Besides its procoagulant activity, the antifibrinolytic activity of FXI was well documented in a wealth of literature. Finally, the new emerging concept of inhibiting FXI as a novel antithrombotic approach with an improved benefit-risk ratio has been supported through observations from human FXI deficiency and various animal models. Large- and small-molecule FXI inhibitors have shown promising antithrombotic effects. The present review summarizes the recent advancements in the molecular physiology of FXI and the molecular pathogenesis of FXI deficiency and discusses the evidence and progress of FXI-targeting antithrombotics development.
Collapse
Affiliation(s)
- Rong He
- Division of Hematopathology, Mayo Clinic, Rochester, Minnesota 55905, USA.
| | | | | |
Collapse
|
25
|
Girolami A, Scarparo P, Bonamigo E, Santarossa L, Cristiani A, Moro S, Lombardi AM. A cluster of factor XI-deficient patients due to a new mutation (Ile 436 Lys) in northeastern Italy*. Eur J Haematol 2011; 88:229-36. [DOI: 10.1111/j.1600-0609.2011.01723.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
26
|
|
27
|
Kim J, Song J, Lyu CJ, Kim YR, Oh SH, Choi YC, Yoo JH, Choi JR, Kim H, Lee KA. Population-specific spectrum of the F11 mutations in Koreans: evidence for a founder effect. Clin Genet 2011; 82:180-6. [DOI: 10.1111/j.1399-0004.2011.01732.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
28
|
Abstract
Factor XI (FXI) deficiency is a rare autosomal bleeding disease associated with genetic defects in the FXI gene. It is a heterogeneous disorder with variable tendency in bleeding and variable causative FXI gene mutations. It is characterized as a cross-reacting material-negative (CRM-) FXI deficiency due to decreased FXI levels or cross-reacting material-positive (CRM+) FXI deficiency due to impaired FXI function. Increasing number of mutations has been reported in FXI mutation database, and most of the mutations are affecting serine protease (SP) domain of the protein. Functional characterization for the mutations helps to better understand the molecular basis of FXI deficiency. Prevalence of the disease is higher in certain populations such as Ashkenazi Jews. The purpose of this review is to give an overview of the molecular basis of congenital FXI deficiency.
Collapse
Affiliation(s)
- Ergul Berber
- Department of Molecular Biology and Genetics, Halic University, Istanbul, Turkey.
| |
Collapse
|
29
|
Hopmeier P. Faktor XI. Hamostaseologie 2010. [DOI: 10.1007/978-3-642-01544-1_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
|
30
|
Abstract
Factor XI (FXI) deficiency is an autosomal recessive injury-related bleeding tendency, which is common in Jews particularly of Ashkenazi origin. To date, 152 mutations in the FXI gene have been reported with four exhibiting founder effects in specific populations, Glu117stop in Ashkenazi and Iraqi Jews and Arabs, Phe283Leu in Ashkenazi Jews, Cys38Arg in Basques, and Cys128stop in the United Kingdom. Severe FXI deficiency does not confer protection against acute myocardial infarction, but is associated with a reduced incidence of ischemic stroke. Inhibitors to FXI develop in one-third of patients with very severe FXI deficiency following exposure to blood products. Therapy for prevention of bleeding during surgery in patients with severe FXI deficiency consists of plasma, factor XI concentrates, fibrin glue and antifibrinolytic agents. In patients with an inhibitor to FXI, recombinant factor VIIa is useful.
Collapse
Affiliation(s)
- U Seligsohn
- Amalia Biron Research Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, Israel.
| |
Collapse
|
31
|
Prospective analysis of factor XI deficiencies in the Marseilles area identified four novel mutations among 12 consecutive unrelated families. Blood Coagul Fibrinolysis 2009; 20:84-8. [DOI: 10.1097/mbc.0b013e32831bc51c] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
32
|
Castaman G, Giacomelli SH, Habart D, Asselta R, Duga S, Rodeghiero F. Factor XI gene mutations in factor XI deficient patients of the Czech Republic. Am J Hematol 2008; 83:916-9. [PMID: 18839438 DOI: 10.1002/ajh.21286] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Factor XI (FXI) deficiency is an autosomal inherited coagulation disorder characterized by bleeding symptoms mainly associated with injury or surgery. Although most of the FXI gene mutations in Ashkenazi Jews are represented by the Glu117stop or Phe283Leu mutations, considerable genetic heterogeneity has been reported in other populations. We report here the genotypic characterization of four families with severe inherited FXI deficiency from the Czech Republic. Seven different gene mutations (three novel) were identified, thus, excluding the existence of a major founder effect in this population. Interestingly, both Glu117stop and Phe283Leu were detected once, further demonstrating the occurrence of these mutations also outside the Jewish populations. In conclusion, we confirm that FXI deficiency in non-Jewish populations is because of different gene mutations; however, the presence of the Glu117stop and Phe283Leu mutations suggests that genetic testing in FXI-deficient patients can start with these two point mutations.
Collapse
Affiliation(s)
- Giancarlo Castaman
- Department of Hematology and Hemophilia and Thrombosis Center, San Bortolo Hospital, Vicenza, Italy.
| | | | | | | | | | | |
Collapse
|
33
|
Severe factor XI deficiency in a Korean woman with a novel missense mutation (Val498Met) and duplication G mutation in exon 13 of the F11 gene. Blood Coagul Fibrinolysis 2008; 19:679-83. [DOI: 10.1097/mbc.0b013e32830ef8f9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
34
|
Abstract
Factor IX is a key component of the plasma system that forms a fibrin clot at a site of vascular injury. Activation of factor IX by factor XIa is required in certain situations to prevent bleeding from premature clot degradation. Factor XIa is a coagulation protease comprised of two identical subunits. The biochemical and physiologic implications of this unusual structural feature are being actively investigated. Congenital factor XI deficiency causes a mild-to-moderate bleeding disorder, with hemorrhage typically involving the oral/nasal cavities and the urinary tract. Current treatment recommendations take this tissue-specific bleeding pattern into account and target factor replacement to certain types of procedures and clinical situations. Results from animal models and human population studies indicate that factor XI contributes to thromboembolic disease. This protease may therefore be a legitimate therapeutic target.
Collapse
Affiliation(s)
- Stephen B Smith
- Department of Pathology, Vanderbilt University, 777 Preston Research Building, 2220 Pierce Ave, Nashville, TN 37232-6307, USA
| | - David Gailani
- Division of Hematology/Oncology, Vanderbilt University, 777 Preston Research Building, 2220 Pierce Avenue, Nashville, TN 37232-6307, USA, Tel.: +1 615 936 1505, Fax: +1 615 936 3853,
| |
Collapse
|
35
|
Karimi M, Jafari H, Lahsaeizadeh S, Afrasiabi A, Akbari A, Dehbozorgian J, Ardeshiri R, Guella I, Asselta R, Peyvandi F. Factor XI deficiency in Southern Iran: identification of a novel missense mutation. Ann Hematol 2008; 88:359-63. [DOI: 10.1007/s00277-008-0595-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2007] [Accepted: 08/08/2008] [Indexed: 10/21/2022]
|
36
|
Duncan EM, Casey GJ, Fenech MP, Lerda NV, Casey CR, Rodgers SE, Lee SH, Chunilal S, Robinson K, Lloyd JV. Partial and severe factor XI deficiency in South Australia and the usefulness of factor XI mutation analysis for diagnosis. Pathology 2008; 40:401-6. [DOI: 10.1080/00313020801911462] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
|
37
|
Abstract
Although factor XI (FXI) deficiency has a particularly high incidence in Ashkenazi Jews, it is now frequently diagnosed in other ethnic groups. This review gives an overview of the basic pathophysiology, clinical manifestations, and management of FXI deficiency. The correlation between FXI levels and the bleeding phenotype is much less clear than in the haemophilias, and consequently the bleeding risk can be difficult to predict. Two well-characterized mutations in the F11 gene are responsible for the majority of Jewish cases, but new mutations are becoming increasingly recognized. The publication of the crystal structure has greatly enhanced our understanding of the structure-function relationship in FXI. The impact of recent studies on our understanding of the role of FXI in coagulation is discussed.
Collapse
Affiliation(s)
- K Gomez
- Haemophilia Centre and Thrombosis Unit, Royal Free Hospital, Hampstead, London, UK.
| | | |
Collapse
|
38
|
Induction of an inhibitor antibody to factor XI in a patient with severe inherited factor XI deficiency by Rh immune globulin. Blood 2008; 111:1306-8. [DOI: 10.1182/blood-2007-08-108449] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
AbstractIn this paper, we report an inhibitor antibody to factor XI (FXI) in a woman with severe inherited FXI deficiency, induced by FXI present in an Rh immune globulin preparation. The patient is homozygous for the Glu117Stop mutation, associated with a FXI level of less than 1 U/dL. Unlike all previously described patients with severe FXI deficiency and an inhibitor, the patient had never been exposed to blood products. Following 3 injections of Rh immune globulin during pregnancy, she developed an inhibitor to FXI (8 Bethesda units) that was shown to bind specifically to FXI and inhibit factor IX cleavage by purified FXIa. The administered Rh immune globulin and 2 other similar products were shown to contain FXI. Clinicians should be aware of the potential for immunization of severely FXI-deficient patients by FXI present in Rh immune globulin preparations.
Collapse
|
39
|
Bozzao C, Rimoldi V, Asselta R, Landau M, Ghiotto R, Tenchini ML, De Cristofaro R, Castaman G, Duga S. A novel factor XI missense mutation (Val371Ile) in the activation loop is responsible for a case of mild type II factor XI deficiency. FEBS J 2007; 274:6128-38. [DOI: 10.1111/j.1742-4658.2007.06134.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
40
|
Girolami A, Ruzzon E, Tezza F, Scandellari R, Vettore S, Girolami B. Arterial and venous thrombosis in rare congenital bleeding disorders: a critical review. Haemophilia 2007; 12:345-51. [PMID: 16834733 DOI: 10.1111/j.1365-2516.2006.01299.x] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
A thorough review of the literature and of personal files has allowed the gathering of 81 patients with rare congenital bleeding disorders and thrombotic phenomena. Sixteen of these patients had congenital afibrinogenemia, eight involved factor V deficiency, 20 factor VII defects, 33 factor XI deficiencies and only one, a factor XIII defect. Altogether 42 patients showed arterial thrombosis (myocardial infarction [MI] in 28 cases; ischemic stroke in 4; arterial occlusion in 8; 2 patients with disseminated intravascular coagulation (DIC)). Ages varied between 13 and 74. Twenty-two patients were males and 16 females. In four cases, sex was not reported. There were three fatalities: two after a MI and one because of heart failure. With regard to venous thrombosis: 9 patients had pulmonary embolism, 15 patients had deep vein thrombosis, 9 patients had both pulmonary embolism and deep vein thrombosis; 1 patient had superficial vein thrombosis, whereas, 5 cases had an unusual site venous thrombosis (two portal systems, two cerebral sinuses, one inferior vena cava) for a total of 39 cases. Age varied between 3 and 86. In this case, 20 patients were males and 17 were females. In two cases, sex was not reported. There were three fatalities: two because of pulmonary embolism and one because of inferior vena cava thrombosis. The fact that thrombosis has never been described in patients with factor II or factor X seems to underscore the central antithrombotic role that these two factors have in the coagulation system.
Collapse
Affiliation(s)
- A Girolami
- University of Padua Medical School, Department of Medical and Surgical Sciences, Padua, Italy.
| | | | | | | | | | | |
Collapse
|
41
|
Peyvandi F, Jayandharan G, Chandy M, Srivastava A, Nakaya SM, Johnson MJ, Thompson AR, Goodeve A, Garagiola I, Lavoretano S, Menegatti M, Palla R, Spreafico M, Tagliabue L, Asselta R, Duga S, Mannucci PM. Genetic diagnosis of haemophilia and other inherited bleeding disorders. Haemophilia 2006; 12 Suppl 3:82-9. [PMID: 16684001 DOI: 10.1111/j.1365-2516.2006.01263.x] [Citation(s) in RCA: 91] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Inherited deficiencies of plasma proteins involved in blood coagulation generally lead to lifelong bleeding disorders, whose severity is inversely proportional to the degree of factor deficiency. Haemophilia A and B, inherited as X-linked recessive traits, are the most common hereditary hemorrhagic disorders caused by a deficiency or dysfunction of blood coagulation factor VIII (FVIII) and factor IX (FIX). Together with von Willebrand's disease, a defect of primary haemostasis, these X-linked disorders include 95% to 97% of all the inherited deficiencies of coagulation factors. The remaining defects, generally transmitted as autosomal recessive traits, are rare with prevalence of the presumably homozygous forms in the general population of 1:500,000 for FVII deficiency and 1 in 2 million for prothrombin (FII) and factor XIII (FXIII) deficiency. Molecular characterization, carrier detection and prenatal diagnosis remain the key steps for the prevention of the birth of children affected by coagulation disorders in developing countries, where patients with these deficiencies rarely live beyond childhood and where management is still largely inadequate. These characterizations are possible by direct or indirect genetic analysis of genes involved in these diseases, and the choice of the strategy depends on the effective available budget and facilities to achieve a large benefit. In countries with more advanced molecular facilities and higher budget resources, the most appropriate choice in general is a direct strategy for mutation detection. However, in countries with limited facilities and low budget resources, carrier detection and prenatal diagnosis are usually performed by linkage analysis with genetic markers. This article reviews the genetic diagnosis of haemophilia, genetics and inhibitor development, genetics of von Willebrand's disease and of rare bleeding disorders.
Collapse
Affiliation(s)
- F Peyvandi
- Department of Medicine and Medical Specialities, IRCCS Maggiore Hospital, Mangiagalli and Regina Elena Foundation, Luigi Villa Foundation, University of Milan, Milan, Italy.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
42
|
Salomon O, Zivelin A, Livnat T, Seligsohn U. Inhibitors to Factor XI in Patients With Severe Factor XI Deficiency. Semin Hematol 2006; 43:S10-2. [PMID: 16427373 DOI: 10.1053/j.seminhematol.2005.11.018] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Factor XI (FXI) deficiency is a rare bleeding disorder that may arise from any of a number of missense, nonsense, splice site, insertion, and deletion mutations within the FXI gene. Severely affected patients are at considerable risk of developing inhibitors to FXI and, although spontaneous bleeding is uncommon in such patients, bleeding after surgery or trauma can be severe. As treatment with fresh frozen plasma (FFP) or FXI concentrates is ineffective in patients with inhibitors, other therapies must be sought. Traditionally, such patients have been treated with various agents and methods, including plasma exchange, cyclophosphamide, intravenous immunoglobulin, and prothrombin complex concentrates. However, emerging data indicate that recombinant activated factor VII (rFVIIa; NovoSeven, Novo Nordisk, Bagsvaerd, Denmark) may also be effective in FXI deficiency with inhibitors. Further work is required to determine the optimal dosing schedules of the agent in this indication.
Collapse
Affiliation(s)
- Ophira Salomon
- Amalia Biron Research Institute of Thrombosis and Hemostasis, Chaim Sheba Medical Center, Tel Hashomer, Israel.
| | | | | | | |
Collapse
|
43
|
Fujikawa K. Historical perspective of factor XI. Thromb Res 2005; 115:441-50. [PMID: 15792673 DOI: 10.1016/j.thromres.2004.10.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2004] [Revised: 10/25/2004] [Accepted: 10/27/2004] [Indexed: 11/27/2022]
Affiliation(s)
- Kazuo Fujikawa
- Department of Biochemistry, University of Washington, Seattle Washington 98195, USA.
| |
Collapse
|
44
|
Saunders RE, O'Connell NM, Lee CA, Perry DJ, Perkins SJ. Factor XI deficiency database: an interactive web database of mutations, phenotypes, and structural analysis tools. Hum Mutat 2005; 26:192-8. [PMID: 16086308 DOI: 10.1002/humu.20214] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Factor XI (FXI) is the zymogen of a serine protease enzyme in the intrinsic pathway of blood coagulation and is an important factor in the creation of a stable fibrin clot. Deficiency of FXI leads to an injury-related bleeding disorder and is remarkable for the lack of correlation between bleeding symptoms and FXI coagulant activity (FXI:C). The FXI protein is composed of five domains: four tandem repeat domains of approximately 80 residues known as Apple (Ap) domains, and the catalytic serine protease (Sp) domain. A total of 65 mutations throughout the FXI gene (F11) have been reported in FXI deficient patients. An interactive web database of these mutations has been created (www.FactorXI.org) that integrates the phenotypic data with genetic data and structural homology models for the five FXI domains. The database provides a central repository for all reported genetic alterations within F11. With the use of recently developed visualization tools, each mutation can be highlighted on the structural models of the FXI domains together with an appropriate survey of patient data, such as FXI:C levels and FXI antigen levels. The database also enables new F11 mutations to be interpreted. The interactive design of this database will lead to a more comprehensive comparative understanding of the genetic factors that influence bleeding risk.
Collapse
Affiliation(s)
- Rebecca E Saunders
- Department of Biochemistry and Molecular Biology, University College London, London, United Kingdom
| | | | | | | | | |
Collapse
|
45
|
Hill M, McLeod F, Franks H, Gordon B, Dolan G. Genetic analysis in FXI deficiency: six novel mutations and the use of a polymerase chain reaction-based test to define a whole gene deletion. Br J Haematol 2005; 129:825-9. [PMID: 15953011 DOI: 10.1111/j.1365-2141.2005.05536.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The genetic basis of factor XI (FXI) deficiency was investigated in 30 patients from 13 different families of non-Jewish origin. Twelve different mutations were detected (including six novel changes), seven missense mutations and three mutations leading to null alleles. Haplotype analysis suggested a large gene deletion in one family. We confirmed the presence of a recently reported Alu-mediated FXI gene deletion. An unrelated patient with severe deficiency was shown to be compound heterozygous for A412V and this whole gene deletion. We suggest that this recurrent gene deletion should be included in the genetic analysis of FXI deficiency.
Collapse
Affiliation(s)
- Marian Hill
- Department of Clinical Chemistry, University Hospital, Queens Medical Centre, Nottingham, UK.
| | | | | | | | | |
Collapse
|
46
|
Abstract
AbstractDeficiencies of coagulation factors other than factor VIII and factor IX that cause bleeding disorders are inherited as autosomal recessive traits and are rare, with prevalences in the general population varying between 1 in 500 000 and 1 in 2 million for the homozygous forms. As a consequence of the rarity of these deficiencies, the type and severity of bleeding symptoms, the underlying molecular defects, and the actual management of bleeding episodes are not as well established as for hemophilia A and B. We investigated more than 1000 patients with recessively inherited coagulation disorders from Italy and Iran, a country with a high rate of recessive diseases due to the custom of consanguineous marriages. Based upon this experience, this article reviews the genetic basis, prevalent clinical manifestations, and management of these disorders. The steps and actions necessary to improve the condition of these often neglected patients are outlined.
Collapse
Affiliation(s)
- Pier Mannuccio Mannucci
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Department of Internal Medicine and Dermatology/IRCCS, Maggiore Hospital, University of Milan, Via Pace 9, 20122 Milan, Italy.
| | | | | |
Collapse
|
47
|
Bolton-Maggs PHB, Perry DJ, Chalmers EA, Parapia LA, Wilde JT, Williams MD, Collins PW, Kitchen S, Dolan G, Mumford AD. The rare coagulation disorders - review with guidelines for management from the United Kingdom Haemophilia Centre Doctors' Organisation. Haemophilia 2004; 10:593-628. [PMID: 15357789 DOI: 10.1111/j.1365-2516.2004.00944.x] [Citation(s) in RCA: 399] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
The rare coagulation disorders are heritable abnormalities of haemostasis that may present significant difficulties in diagnosis and management. This review summarizes the current literature for disorders of fibrinogen, and deficiencies of prothrombin, factor V, FV + VIII, FVII, FX, the combined vitamin K-dependent factors, FXI and FXIII. Based on both collective clinical experience and the literature, guidelines for management of bleeding complications are suggested with specific advice for surgery, spontaneous bleeding, management of pregnancy and the neonate. We have chosen to include a section on Ehlers-Danlos Syndrome because haematologists may be consulted about bleeding manifestations in such patients.
Collapse
Affiliation(s)
- P H B Bolton-Maggs
- Department of Clinical Haematology, Manchester Royal Infirmary, Manchester, UK.
| | | | | | | | | | | | | | | | | | | |
Collapse
|