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Rassoulzadegan M, Ala F, Jazebi M, Enayat MS, Tabibian S, Shams M, Bahraini M, Dorgalaleh A. Molecular and clinical profile of type 2 von Willebrand disease in Iran: a thirteen-year experience. Int J Hematol 2020; 111:535-543. [PMID: 31939074 DOI: 10.1007/s12185-019-02814-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 12/25/2019] [Accepted: 12/25/2019] [Indexed: 01/23/2023]
Abstract
Type 2 von Willebrand disease (VWD) is the most common congenital bleeding disorder, with variable bleeding tendency and a complex laboratory phenotype. In the current study, we report the clinical and molecular profile of a large number of Iranian patients with type 2 VWD. All exons, intron-exon boundaries, and untranslated regions were sequenced by Sanger sequencing for direct mutation detection. All identified mutations were confirmed in family members and by relevant bioinformatics studies. A total of 136 patients with type 2 VWD were diagnosed, including 42 (30.9%), 32 (23.6%), 38 (27.9%), and 24 (17.6%) patients with type 2A, type 2B, type 2M, and type 2N, respectively. Epistaxis (49%), gum bleeding (30.2%), ecchymosis (23.2%), and menorrhagia (16.3%) were the most common clinical presentations, while miscarriage (2.3%) and umbilical cord bleeding (0.8%) were the rarest. Thirty mutations were identified within the VWF gene, nine (30%) being novel, with p.Arg1379Cys (n = 20), p.Val1316Met (n = 13), p.Arg1597Trp (n = 13), p.Arg1374Cys (n = 10), p.Ser1506Leu (n = 10), and p.Arg1308Cys (n = 9) the most common. Type 2 VWD is a hemorrhagic disorder with variable bleeding tendency and a heterogeneous molecular basis in patients in Iran.
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Affiliation(s)
| | - Fereydoun Ala
- Iranian Comprehensive Hemophilia Care Centre, Tehran, Iran
| | | | | | - Shadi Tabibian
- Department of Hematology and Blood Transfusion, Faculty of Allied Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Mahmood Shams
- Department of Medical Laboratory, Faculty of Paramedical Science, Babol University of Medical Science, Babol, Iran
| | - Mehran Bahraini
- Department of Hematology and Blood Transfusion, Faculty of Allied Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Akbar Dorgalaleh
- Department of Hematology and Blood Transfusion, Faculty of Allied Medicine, Iran University of Medical Sciences, Tehran, Iran.
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3
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Kalaska B, Miklosz J, Kamiński K, Swieton J, Jakimczuk A, Yusa SI, Pawlak D, Nowakowska M, Szczubiałka K, Mogielnicki A. Heparin-Binding Copolymer as a Complete Antidote for Low-Molecular-Weight Heparins in Rats. J Pharmacol Exp Ther 2020; 373:51-61. [PMID: 31937564 DOI: 10.1124/jpet.119.262931] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 01/09/2020] [Indexed: 11/22/2022] Open
Abstract
Bleeding resulting from the application of low-molecular-weight heparins (LMWHs) may be treated with protamine sulfate, but this treatment lacks efficiency; its action against antifactor Xa activity is limited to ∼60%. Moreover, protamine sulfate can cause life-threatening hypersensitivity reactions. We developed diblock heparin-binding copolymer (HBC), which can neutralize the anticoagulant activity of parenteral anticoagulants. In the present study, we explored the safety profile of HBC and its potential to reverse enoxaparin, nadroparin, dalteparin, and tinzaparin in human plasma and at in vivo conditions. HBC-LMWH complexes were characterized using zeta potential, isothermal titration calorimetry, and dynamic light scattering. The rat cardiomyocytes and human endothelial cells were used for the assessment of in vitro toxicity. Male Wistar rats were observed for up to 4 days after HBC administration for clinical evaluation, gross necropsy, and biochemistry and histopathological analysis. Rats were treated with LMWHs alone or followed by short-time intravenous infusion of HBC, and bleeding time and antifactor Xa activity were measured. HBC completely reversed antifactor Xa activity prolonged in vitro by all LMWHs with an optimal weight ratio of 2.5:1. The complexes of HBC-LMWHs were below 5 µm. We observed no effects on the viability of cardiovascular cells treated with HBC at concentrations up to 0.05 mg/ml. Single doses up to 20 mg/kg of HBC were well tolerated by rats. HBC completely reversed the effects of LMWHs on bleeding time and antifactor Xa activity in vivo after 20 minutes and retained ∼80% and ∼60% of reversal activity after 1 and 2 hours, respectively. Well-documented efficacy and safety of HBC both in vitro and in vivo make this polymer a promising candidate for LMWHs reversal. SIGNIFICANCE STATEMENT: Over the last decade, there has been significant progress in developing antidotes for the reversal of anticoagulants. Until now, there has been no effective and safe treatment for patients with severe bleeding under low-molecular-weight heparin therapy. Based on our in vitro and in vivo studies, heparin-binding copolymer seems to be a promising candidate for neutralizing all clinically relevant low-molecular-weight heparins.
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Affiliation(s)
- Bartlomiej Kalaska
- Department of Pharmacodynamics, Medical University of Bialystok, Bialystok, Poland (B.K., J.M., J.S., A.J., D.P., A.M.); Faculty of Chemistry, Jagiellonian University, Krakow, Poland (K.K., M.N., K.S.); and Department of Applied Chemistry, Graduate School of Engineering, University of Hyogo, Himeji, Hyogo, Japan (S.-I.Y.)
| | - Joanna Miklosz
- Department of Pharmacodynamics, Medical University of Bialystok, Bialystok, Poland (B.K., J.M., J.S., A.J., D.P., A.M.); Faculty of Chemistry, Jagiellonian University, Krakow, Poland (K.K., M.N., K.S.); and Department of Applied Chemistry, Graduate School of Engineering, University of Hyogo, Himeji, Hyogo, Japan (S.-I.Y.)
| | - Kamil Kamiński
- Department of Pharmacodynamics, Medical University of Bialystok, Bialystok, Poland (B.K., J.M., J.S., A.J., D.P., A.M.); Faculty of Chemistry, Jagiellonian University, Krakow, Poland (K.K., M.N., K.S.); and Department of Applied Chemistry, Graduate School of Engineering, University of Hyogo, Himeji, Hyogo, Japan (S.-I.Y.)
| | - Justyna Swieton
- Department of Pharmacodynamics, Medical University of Bialystok, Bialystok, Poland (B.K., J.M., J.S., A.J., D.P., A.M.); Faculty of Chemistry, Jagiellonian University, Krakow, Poland (K.K., M.N., K.S.); and Department of Applied Chemistry, Graduate School of Engineering, University of Hyogo, Himeji, Hyogo, Japan (S.-I.Y.)
| | - Aleksandra Jakimczuk
- Department of Pharmacodynamics, Medical University of Bialystok, Bialystok, Poland (B.K., J.M., J.S., A.J., D.P., A.M.); Faculty of Chemistry, Jagiellonian University, Krakow, Poland (K.K., M.N., K.S.); and Department of Applied Chemistry, Graduate School of Engineering, University of Hyogo, Himeji, Hyogo, Japan (S.-I.Y.)
| | - Shin-Ichi Yusa
- Department of Pharmacodynamics, Medical University of Bialystok, Bialystok, Poland (B.K., J.M., J.S., A.J., D.P., A.M.); Faculty of Chemistry, Jagiellonian University, Krakow, Poland (K.K., M.N., K.S.); and Department of Applied Chemistry, Graduate School of Engineering, University of Hyogo, Himeji, Hyogo, Japan (S.-I.Y.)
| | - Dariusz Pawlak
- Department of Pharmacodynamics, Medical University of Bialystok, Bialystok, Poland (B.K., J.M., J.S., A.J., D.P., A.M.); Faculty of Chemistry, Jagiellonian University, Krakow, Poland (K.K., M.N., K.S.); and Department of Applied Chemistry, Graduate School of Engineering, University of Hyogo, Himeji, Hyogo, Japan (S.-I.Y.)
| | - Maria Nowakowska
- Department of Pharmacodynamics, Medical University of Bialystok, Bialystok, Poland (B.K., J.M., J.S., A.J., D.P., A.M.); Faculty of Chemistry, Jagiellonian University, Krakow, Poland (K.K., M.N., K.S.); and Department of Applied Chemistry, Graduate School of Engineering, University of Hyogo, Himeji, Hyogo, Japan (S.-I.Y.)
| | - Krzysztof Szczubiałka
- Department of Pharmacodynamics, Medical University of Bialystok, Bialystok, Poland (B.K., J.M., J.S., A.J., D.P., A.M.); Faculty of Chemistry, Jagiellonian University, Krakow, Poland (K.K., M.N., K.S.); and Department of Applied Chemistry, Graduate School of Engineering, University of Hyogo, Himeji, Hyogo, Japan (S.-I.Y.)
| | - Andrzej Mogielnicki
- Department of Pharmacodynamics, Medical University of Bialystok, Bialystok, Poland (B.K., J.M., J.S., A.J., D.P., A.M.); Faculty of Chemistry, Jagiellonian University, Krakow, Poland (K.K., M.N., K.S.); and Department of Applied Chemistry, Graduate School of Engineering, University of Hyogo, Himeji, Hyogo, Japan (S.-I.Y.)
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Nava T, Dubé E, Gauthier J, Vézina C, Bonnefoy A, Lillicrap D, Rivard GE. Challenges in diagnosis of von Willebrand disease in the presence of combined mutations of different genes. Haemophilia 2019; 25:e113-e117. [PMID: 30690834 DOI: 10.1111/hae.13686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 11/07/2018] [Accepted: 01/03/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Tiago Nava
- Centre d'hémostase pédiatrique et adulte du CHU Sainte-Justine, Montreal University, Montréal, Quebec, Canada.,Division of Pediatric Hematology-Oncology, University Hospital of Geneva, Geneva, Switzerland
| | - Evemie Dubé
- Centre d'hémostase pédiatrique et adulte du CHU Sainte-Justine, Montreal University, Montréal, Quebec, Canada
| | - Julie Gauthier
- Centre d'hémostase pédiatrique et adulte du CHU Sainte-Justine, Montreal University, Montréal, Quebec, Canada
| | - Catherine Vézina
- Montreal Children's Hospital, McGill University, Montréal, Quebec, Canada
| | - Arnaud Bonnefoy
- Centre d'hémostase pédiatrique et adulte du CHU Sainte-Justine, Montreal University, Montréal, Quebec, Canada
| | - David Lillicrap
- Department of Medicine, Department of Pathology and Molecular Medicine, Queen's University, Kingston, Ontario, Canada
| | - Georges-Etienne Rivard
- Centre d'hémostase pédiatrique et adulte du CHU Sainte-Justine, Montreal University, Montréal, Quebec, Canada
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Dzeshka MS, Pastori D, Lip GYH. Direct oral anticoagulant reversal: how, when and issues faced. Expert Rev Hematol 2017; 10:1005-1022. [PMID: 28901221 DOI: 10.1080/17474086.2017.1379896] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
INTRODUCTION The number of atrial fibrillation (AF) patients requiring thrombo-prophylaxis with oral anticoagulation is greatly increasing. The introduction of non-vitamin K oral anticoagulants (NOACs) in addition to standard therapy with dose-adjusted warfarin has increased the therapeutic options for AF patients. Despite a generally better safety profile of the NOACs, the risk of major bleedings still persists, and the management of serious bleeding is a clinical challenge. Areas covered: In the current review, risk of major bleeding in patients taking NOACs and general approaches to manage bleeding depending on severity, with a particular focus on specific reversal agents, are discussed. Expert commentary: Due to short half-life of NOACs compared to warfarin, discontinuation of drug, mechanical compression, and volume substitution are considered to be sufficient measures in most of bleeding cases. In case of life-threatening bleeding or urgent surgery, hemostasis can be achieved with non-specific reversal agents (prothrombin complex concentrates) in patients treated with factor Xa inhibitor until specific antidotes (andexanet α and ciraparantag) will receive approval. Thus far, idarucizumab has been the only reversal agent approved for dabigatran.
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Affiliation(s)
- Mikhail S Dzeshka
- a Institute of Cardiovascular Sciences , University of Birmingham , Birmingham , UK.,b Grodno State Medical University , Grodno , Belarus
| | - Daniele Pastori
- a Institute of Cardiovascular Sciences , University of Birmingham , Birmingham , UK.,c Department of Internal Medicine and Medical Specialties , Sapienza University of Rome , Rome , Italy
| | - Gregory Y H Lip
- a Institute of Cardiovascular Sciences , University of Birmingham , Birmingham , UK.,d Aalborg Thrombosis Research Unit, Department of Clinical Medicine , Aalborg University , Aalborg , Denmark
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Quiroga T, Goycoolea M, Belmont S, Panes O, Aranda E, Zúñiga P, Pereira J, Mezzano D. Quantitative impact of using different criteria for the laboratory diagnosis of type 1 von Willebrand disease. J Thromb Haemost 2014; 12:1238-43. [PMID: 24796601 DOI: 10.1111/jth.12594] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2013] [Accepted: 04/26/2014] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Only ± 50% of patients with type 1 von Willebrand disease (VWD) have recognized molecular defects and diagnosis still rests on demonstrating low plasma von Willebrand factor (VWF) protein/function. However, no generalized consensus exists regarding the type and number of VWF variables that should be considered for diagnosis. AIM To compare the quantitative impact of four different criteria to diagnose type 1 VWD. METHODS We tested four laboratory criteria on 4298 laboratory studies during a 5-year period. The first was the National Heart, Lung, and Blood Institute recommendation, which diagnoses type 1 VWD with plasma VWF antigen (VWF:Ag) and VWF ristocetin cofactor (VWF:RCo) < 30 IU dL(-1) and possible VWD/'low VWF' with values between 30 and 50 IU dL(-1) . Second, diagnosis was established when two of three variables, VWF:Ag, VWF:RCo, VWF collagen binding assay (VWF:CB), were ≤ 2.5th percentile. Diagnostic criterion for possible VWD/'low VWF' using percentiles was also described. The third criterion (European Group on von Willebrand Disease, EUVWD), uses a plasma level of VWF:RCo (or VWF:CB) ≤ 40 IU dL(-1) for diagnosis. Finally, the Zimmerman Program for the Molecular and Clinical Biology of VWD (ZPMCBVWD) diagnoses VWD if VWF:Ag or VWF:RCo are ≤ 40 IU dL(-1) . RESULTS The three assays had high correlation and excellent agreement at levels < 120 IU dL(-1) . The National Heart, Lung, and Blood Institute recommendation was followed to diagnose 122 (2.8%) patients with type 1 VWD and 704 (16.4%) with possible VWD/'low VWF.' Using percentiles, the diagnosis of type 1 VWD increased to 280 (6.5%) patients; 169 (3.9%) patients had possible VWD and 180 (4.2%) patients had 'low VWF.' Diagnoses using EUVWD and ZPMCBVWD criteria increased to 339 (7.9%) and 357 (8.3%) patients, respectively. DISCUSSION Identical data, analyzed using different criteria, led to almost three-fold difference (2.8-8.3%) in diagnostic rate. This increase is mostly explained by increasing the cut-off values of VWF measurements from < 30 to ≈ 40 IU dL(-1) . Further refinement of the laboratory diagnosis of type 1 VWD is a priority.
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Affiliation(s)
- T Quiroga
- Department of Clinical Laboratory, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
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