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Casini A, Gebhart J. How to investigate mild to moderate bleeding disorders and bleeding disorder of unknown cause. Int J Lab Hematol 2024; 46 Suppl 1:27-33. [PMID: 38454298 DOI: 10.1111/ijlh.14266] [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: 01/16/2024] [Accepted: 02/28/2024] [Indexed: 03/09/2024]
Abstract
A bleeding tendency is one of the most common complaints observed by hematologists. It is challenging to differentiate a clinically insignificant bleeding from a bleeding phenotype that requires hemostatic evaluation and medical intervention. A thorough review of personal and familial history, objective assessment of bleeding severity using a bleeding assessment tool, and a focused physical examination are critical to correctly identifying suspected patients with mild to moderate bleeding disorders (MBDs). A basic laboratory work-up should be performed in all patients referred for a bleeding tendency. If a hemostatic abnormality is found such as evidence of von Willebrand disease, a platelet function disorder, or a coagulation factor deficiency, more extensive testing should be performed to further characterize the bleeding disorder. Conversely, if all results are normal the patient is considered to have bleeding disorder of unknown cause (BDUC). For patients with BDUC, further evaluation may include non-routine testing to look for rare bleeding disorders not detected by routine hemostasis tests, such as thrombomodulin-associated coagulopathy, tissue factor pathway inhibitor-related bleeding disorder, hyperfibrinolytic-bleeding disorders or impaired tissue factor production. In this review, we summarize the stepwise diagnostic procedure in MBDs and provide some insights into the biological features of BDUC.
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Affiliation(s)
- Alessandro Casini
- Division of Angiology and Hemostasis, University Hospitals of Geneva, Geneva, Switzerland
| | - Johanna Gebhart
- Department of Medicine I, Division of Hematology and Hemostaseology, Medical University Vienna, Austria
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2
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Gooijer K, Heidsieck G, Harsevoort A, Bout D, Janus G, Franken A. Bleeding assessment in a large cohort of patients with Osteogenesis Imperfecta. Orphanet J Rare Dis 2024; 19:61. [PMID: 38347577 PMCID: PMC10860322 DOI: 10.1186/s13023-024-03054-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 01/29/2024] [Indexed: 02/15/2024] Open
Abstract
BACKGROUND Osteogenesis Imperfecta (OI) is characterised by bone fragility. Among several features, easy bruising and multiple case reports on haemorrhagic events have been reported. This paper describes the diverse manifestations of bleeding and bruising in a large cohort of 328 OI patients. The aim of this study is to provide insight in the diverse aspects and therapeutic considerations of bleedings in OI. METHODS This descriptive cohort study was conducted at the National Expert Center for adults with OI in the Netherlands. Bleeding was assessed by the validated self-bleeding assessment tool (Self-BAT) The tool was distributed among 328 adults with different clinically confirmed types of OI. RESULTS 195 of 328 invited patients (completion rate 60%) with OI type 1 (n = 144), OI type 3 (n = 17) and OI type 4 (n = 34), aged between 18 and 82 years, completed the tool. Self-BAT scores were above the normal range in 42% of all patients. For males Self-BAT scores were increased in 37% with a mean score of 3.7, ranged between 0 and 18. For females the Self-BAT scores were increased in 44% with a mean of 5.4 and a range of 0-24. No statistical differences in OI subtypes were found. CONCLUSIONS Bleeding tendency appears to be a relevant complication in OI patients as this study confirms the presumption of bleeding tendency. There are specific recommendations to clinicians who treat OI patients to consider an assessment of bleeding tendency and use potential interventions to reduce haemorrhagic complications and improve quality of life.
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Affiliation(s)
- Koert Gooijer
- Expert Center for Adults with Osteogenesis Imperfecta, Isala Hospital, Dokter van Heesweg 2, PO Box 10400, 8025 AB, Zwolle, The Netherlands.
- Department of Clinical Genetics, Amsterdam Reproduction and Development Research Institute, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands.
| | - Gabriëla Heidsieck
- Expert Center for Adults with Osteogenesis Imperfecta, Isala Hospital, Dokter van Heesweg 2, PO Box 10400, 8025 AB, Zwolle, The Netherlands
| | - Arjan Harsevoort
- Expert Center for Adults with Osteogenesis Imperfecta, Isala Hospital, Dokter van Heesweg 2, PO Box 10400, 8025 AB, Zwolle, The Netherlands
| | - Daniëlle Bout
- Expert Center for Adults with Osteogenesis Imperfecta, Isala Hospital, Dokter van Heesweg 2, PO Box 10400, 8025 AB, Zwolle, The Netherlands
| | - Guus Janus
- Expert Center for Adults with Osteogenesis Imperfecta, Isala Hospital, Dokter van Heesweg 2, PO Box 10400, 8025 AB, Zwolle, The Netherlands
| | - Anton Franken
- Expert Center for Adults with Osteogenesis Imperfecta, Isala Hospital, Dokter van Heesweg 2, PO Box 10400, 8025 AB, Zwolle, The Netherlands
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Mehic D, Pabinger I, Gebhart J. Investigating patients for bleeding disorders when most of the "usual" ones have been ruled out. Res Pract Thromb Haemost 2023; 7:102242. [PMID: 38193045 PMCID: PMC10772891 DOI: 10.1016/j.rpth.2023.102242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 10/06/2023] [Accepted: 10/12/2023] [Indexed: 01/10/2024] Open
Abstract
A State of the Art lecture titled "Investigating Patients for Bleeding Disorders When Most of the Usual Ones Have Been Ruled Out" was presented at the International Society on Thrombosis and Haemostasis Congress in 2023. Mild to moderate bleeding disorders (MBDs) in patients in whom no diagnosis of an established disorder, such as platelet function defect, von Willebrand disease, or a coagulation factor deficiency, can be identified are classified as bleeding disorders of unknown cause (BDUCs). Prospective data from the Vienna Bleeding Biobank and other studies have revealed a high proportion of BDUCs of up to 70% among patients with MBD who have a similar bleeding phenotype as other MBDs. As BDUC is a diagnosis of exclusion, the accuracy of the diagnostic workup is essential. For example, repeated testing for von Willebrand disease should be considered if von Willebrand factor values are <80 IU/dL. Current evidence does not support the clinical use of global assays such as thromboelastography, platelet function analyzer, or thrombin generation potential. Rare and novel bleeding disorders due to genetic variants in fibrinolytic factors or natural anticoagulants are rare and should only be analyzed in patients with specific phenotypes and a clear family history. In BDUC, blood group O was identified as a risk factor for increased bleeding severity and bleeding risk after hemostatic challenges. Future studies should improve the phenotypical characterization and ideally identify novel risk factors in BDUC, as a multifactorial pathogenesis is suspected. Finally, we summarize relevant new data on this topic presented during the 2023 International Society on Thrombosis and Haemostasis Congress.
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Affiliation(s)
- Dino Mehic
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Ingrid Pabinger
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Johanna Gebhart
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
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4
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Kumskova M, Flora GD, Staber J, Lentz SR, Chauhan AK. Characterization of bleeding symptoms in Ehlers-Danlos syndrome. J Thromb Haemost 2023; 21:1824-1830. [PMID: 37179130 DOI: 10.1016/j.jtha.2023.04.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 03/22/2023] [Accepted: 04/04/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND Easy bruising is included as a major or minor criterion for the classification of multiple types of Ehlers-Danlos syndrome (EDS). Despite a longstanding recognition of the association between EDS and bleeding, we still lack a definitive understanding of the frequency, severity, and types of bleeding complications in patients with EDS. OBJECTIVES To evaluate hemorrhagic symptoms using the International Society of Thrombosis and Haemostasis bleeding assessment tool (ISTH-BAT) in a cohort of patients with defined types of EDS. METHODS We utilized the ISTH-BAT to characterize hemorrhagic symptoms and their severity in a cohort of 52 patients with classical, classical-like, hypermobile, or vascular EDS and a matched group of 52 healthy control subjects. RESULTS The mean ISTH-BAT score was 0.1 for healthy subjects and 9.1 for patients with EDS (p < .0001). An abnormal ISTH-BAT score was observed in 32 of 52 (62%) patients with EDS and 0 of 52 healthy controls (p < .0001). The most frequent bleeding symptoms were bruising, muscle hematomas, menorrhagia, epistaxis, bleeding from the oral cavity, and bleeding after tooth extraction. Menorrhagia that was life-threatening or required surgery was reported in 7 of 52 (14%) patients with EDS. CONCLUSION Patients with multiple types of EDS exhibit a wide range of bleeding symptoms ranging from mild to life-threatening episodes.
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Affiliation(s)
- Mariia Kumskova
- Department of Internal Medicine, University of Iowa, Iowa City, Iowa, USA.
| | - Gagan D Flora
- Department of Internal Medicine, University of Iowa, Iowa City, Iowa, USA
| | - Janice Staber
- Stead Family Department of Pediatrics, University of Iowa, Iowa City, Iowa, USA
| | - Steven R Lentz
- Department of Internal Medicine, University of Iowa, Iowa City, Iowa, USA
| | - Anil K Chauhan
- Department of Internal Medicine, University of Iowa, Iowa City, Iowa, USA. https://twitter.com/chauhanlab
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5
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Aranda E, Iha S, Solari S, Rodríguez D, Romero V, Villarroel L, Pereira J, Panes O, Mezzano D. Serotonin secretion by blood platelets: accuracy of high-performance liquid chromatography-electrochemical technique compared with the isotopic test and use in a clinical laboratory. Res Pract Thromb Haemost 2023; 7:102156. [PMID: 37601022 PMCID: PMC10439442 DOI: 10.1016/j.rpth.2023.102156] [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: 02/14/2023] [Revised: 06/07/2023] [Accepted: 07/06/2023] [Indexed: 08/22/2023] Open
Abstract
Background Mild secretion defects are the most frequent and challenging blood platelet disorders to diagnose. Most δ-granule secretion tests lack validation, are not quantitative, or have unreliable response to weak platelet agonists. Objectives To compare platelet serotonin secretion by HPLC-electrochemical detection technique (HPLC-ECD) with the reference isotopic test (3H-5-HT), evaluating its performance in clinical laboratories. Methods The assay validation followed STARD-2015 recommendations. HPLC-ECD measured the nonsecreted serotonin remaining in platelet pellets after aggregation, comparing it with the reference 3H-5-HT assay. We studied subjects with inherited and aspirin-induced blood platelet disorders and assessed the HPLC-ECD operation for routine clinical diagnosis. Results Calibration curves were linear (R2 = 0.997), with SD for residuals of 3.91% and analytical sensitivity of 5ng/mL. Intra- and interassay imprecision bias ranged between -8.5% and 2.1% and -9% and 3.1%, respectively. Serotonin recovery and stability were >95%, and the variability range of measurements was -5.5% to 4.6%. Statistical differences detected between tests were biologically irrelevant, with bias of 1.48% (SD, 8.43) and CI agreement of -18% to 15%. Both assays distinctly detected platelet secretion induced by 10 μM epinephrine and 4 μmM adenosine diphosphate. However, HPLC-ECD is quantitative and more sensitive to low serotonin content in blood platelets. Reference cutoffs for each agonist were determined in 87 subjects. Initially, the HPLC-ECD requires relatively expensive equipment and trained operators but has remarkably cheap running costs and a turn-around time of 24-36 hours. We have used this diagnostic tool routinely for >8 years. Conclusion HPLC-ECD assay for platelet serotonin secretion is highly accurate, has advantages over the reference 3H-5-HT test, and is suitable as a clinical laboratory technique.
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Affiliation(s)
- Eduardo Aranda
- Department of Hematology-Oncology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Seiki Iha
- Department of Clinical Laboratory, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Sandra Solari
- Department of Clinical Laboratory, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - David Rodríguez
- Department of Clinical Laboratory, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Viviana Romero
- Department of Hematology-Oncology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Luis Villarroel
- Department of Public Health, School of Medicine, Pontificia Universidad Católica de Chile
| | - Jaime Pereira
- Department of Hematology-Oncology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Olga Panes
- Department of Hematology-Oncology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Diego Mezzano
- Department of Hematology-Oncology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
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6
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Mehic D, Neubauer G, Janig F, Kaider A, Ay C, Pabinger I, Gebhart J. Risk factors for future bleeding in patients with mild bleeding disorders: longitudinal data from the Vienna Bleeding Biobank. J Thromb Haemost 2023; 21:1757-1768. [PMID: 36924834 DOI: 10.1016/j.jtha.2023.03.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 02/15/2023] [Accepted: 03/05/2023] [Indexed: 03/18/2023]
Abstract
BACKGROUND The future bleeding risk, especially after hemostatic challenges, and thus the requirement for hemostatic treatment in patients with mild-to-moderate bleeding disorders (MBDs) is largely unknown. OBJECTIVES This study aimed to prospectively examine the recurrence of bleeding symptoms and clinical risk factors for future bleeding in patients with MBD, including patients with bleeding disorder of unknown cause (BDUC). METHODS Bleeding symptoms of patients with MBD included in the Vienna Bleeding Biobank were re-evaluated at in-person follow-up visits or by mail. RESULTS In total, 392 patients, including 62.8% with BDUC, were investigated for the recurrence of bleeding events. During the follow-up time of median (IQR) 4.3 years (2.6-6.7), 72% of patients had at least 1 bleeding event. Most persistent bleeding manifestations were hematomas (n = 146/245, 59.6%) and bleeding from small wounds (n = 69/141, 48.9%), followed by epistaxis (n = 42/132, 31.8%), oral mucosal bleeding (n = 26/87, 29.9%), and joint bleeding (n = 7/14, 50.0%). Patients with previous postinterventional bleeding had a significantly increased risk for bleeding events after surgery (n = 33/114, 29.0 %) or tooth extraction (n = 16/39, 41.0%). A high bleeding score (OR [95% CI], 1.14 [1.05 to 2.94], per 1 unit) and follow-up time (OR [95% CI], 1.23 [1.12 to 1.36], per 1 year) were independently associated with any bleeding event. For bleeding after hemostatic challenges, blood group O (OR, 3.17 [1.57 to 6.40]), previous postsurgical bleeding (OR, 2.40 [1.06 to 5.46]), and an established diagnosis (OR, 2.07 [1.04 to 4.10]) were independent risk factors. CONCLUSION Patients with MBD have a high risk for recurrent bleeding. This encourages prophylactic hemostatic treatment in patients with MBD, particularly when they face hemostatic challenges.
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Affiliation(s)
- Dino Mehic
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria; Institute of Vascular Biology and Thrombosis Research, Centre of Physiology and Pharmacology, Medical University of Vienna, Vienna, Austria. https://twitter.com/dino_mehic
| | - Georg Neubauer
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Florian Janig
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Alexandra Kaider
- Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Cihan Ay
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria. https://twitter.com/Cihan_Ay_MD
| | - Ingrid Pabinger
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Johanna Gebhart
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria.
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7
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Heubel-Moenen FCJI, Ansems LEM, Verhezen PWM, Wetzels RJH, van Oerle RGM, Straat RJMHE, Megy K, Downes K, Henskens YMC, Beckers EAM, Joore MA. Effectiveness and costs of a stepwise versus an all-in-one approach to diagnose mild bleeding disorders. Br J Haematol 2023; 200:792-801. [PMID: 36444397 DOI: 10.1111/bjh.18570] [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: 07/15/2022] [Revised: 11/04/2022] [Accepted: 11/08/2022] [Indexed: 12/02/2022]
Abstract
The diagnostic work-up of patients referred to the haematologist for bleeding evaluation is performed in a stepwise way: bleeding history and results of screening laboratory tests guide further diagnostic evaluation. This can be ineffective, time-consuming and burdensome for patients. To improve this strategy, the initial laboratory investigation can be extended. In a model-based approach, effectiveness and costs of a conventional stepwise versus a newly proposed all-in-one diagnostic approach for bleeding evaluation were evaluated and compared, using data from an observational patient cohort study, including adult patients referred for bleeding evaluation. In the all-in-one approach, specialized platelet function tests, coagulation factors, and fibrinolysis tests were included in the initial investigation. Final diagnosis, hospital resource use and costs and patient burden were compared. A total of 150 patients were included. Compared to the stepwise approach, in the all-in-one approach, 19 additional patients reached a diagnosis and patient burden was lower, but total costs per patient were higher [€359, 95% bootstrapped confidence interval (BCI) 283-518, p = 0.001]. For bleeding evaluation of patients referred to the haematologist, an all-in-one diagnostic approach has a higher diagnostic yield and reduces patient burden, at a higher cost. This raises the question what costs justify the diagnosis of a bleeding disorder and a less burdensome diagnostic strategy.
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Affiliation(s)
- Floor C J I Heubel-Moenen
- Department of Hematology, Internal Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Loes E M Ansems
- Department of Hematology, Internal Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Paul W M Verhezen
- Central Diagnostic Laboratory, Unit for Hemostasis and Transfusion, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Rick J H Wetzels
- Central Diagnostic Laboratory, Unit for Hemostasis and Transfusion, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Rene G M van Oerle
- Central Diagnostic Laboratory, Unit for Hemostasis and Transfusion, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Ron J M H E Straat
- Central Diagnostic Laboratory, Unit for Hemostasis and Transfusion, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Karyn Megy
- National Institute for Health Research (NIHR) BioResource, Cambridge University Hospitals NHS Foundation, Cambridge Biomedical Campus, Cambridge, UK.,Department of Haematology, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK
| | - Kate Downes
- National Institute for Health Research (NIHR) BioResource, Cambridge University Hospitals NHS Foundation, Cambridge Biomedical Campus, Cambridge, UK.,Department of Haematology, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK.,Cambridge University Hospitals Genomic Laboratory, Cambridge University Hospitals Foundation Trust, Cambridge Biomedical Campus, UK
| | - Yvonne M C Henskens
- Central Diagnostic Laboratory, Unit for Hemostasis and Transfusion, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Erik A M Beckers
- Department of Hematology, Internal Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Manuela A Joore
- Department of Clinical Epidemiology and Medical Technology Assessment (KEMTA), Maastricht University Medical Centre+, CAPHRI Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
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8
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Valke LLFG, Meijer D, Nieuwenhuizen L, Laros‐van Gorkom BAP, Blijlevens NMA, Heerde WL, Schols SEM. Fibrinolytic assays in bleeding of unknown cause: Improvement in diagnostic yield. Res Pract Thromb Haemost 2022; 6:e12681. [PMID: 35316940 PMCID: PMC8922970 DOI: 10.1002/rth2.12681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 01/28/2022] [Accepted: 01/31/2022] [Indexed: 11/11/2022] Open
Abstract
Introduction Aim Methods Results Discussion
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Affiliation(s)
- Lars L. F. G. Valke
- Department of Hematology Radboud University Medical Center Nijmegen The Netherlands
- Hemophilia Treatment Center Nijmegen‐Eindhoven‐Maastricht The Netherlands
| | - Danielle Meijer
- Department of Laboratory Medicine Laboratory of Hematology Radboud University Medical Center Nijmegen The Netherlands
| | - Laurens Nieuwenhuizen
- Hemophilia Treatment Center Nijmegen‐Eindhoven‐Maastricht The Netherlands
- Department of Hematology Maxima Medical Center Veldhoven The Netherlands
| | - Britta A. P. Laros‐van Gorkom
- Department of Hematology Radboud University Medical Center Nijmegen The Netherlands
- Hemophilia Treatment Center Nijmegen‐Eindhoven‐Maastricht The Netherlands
| | | | - Waander L. Heerde
- Hemophilia Treatment Center Nijmegen‐Eindhoven‐Maastricht The Netherlands
- Enzyre BV Novio Tech Campus Nijmegen The Netherlands
| | - Saskia E. M. Schols
- Department of Hematology Radboud University Medical Center Nijmegen The Netherlands
- Hemophilia Treatment Center Nijmegen‐Eindhoven‐Maastricht The Netherlands
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9
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Mehic D, Tolios A, Hofer S, Ay C, Haslacher H, Downes K, Haimel M, Pabinger I, Gebhart J. Thrombomodulin in patients with mild to moderate bleeding tendency. Haemophilia 2021; 27:1028-1036. [PMID: 34628704 PMCID: PMC9293080 DOI: 10.1111/hae.14433] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 08/27/2021] [Accepted: 09/26/2021] [Indexed: 11/30/2022]
Abstract
Introduction A massive increase of soluble thrombomodulin (sTM) due to variants in the thrombomodulin gene (THBD) has recently been identified as a novel bleeding disorder. Aim To investigate sTM levels and underlying genetic variants as a cause for haemostatic impairment and bleeding in a large number of patients with a mild to moderate bleeding disorder (MBD), including patients with bleeding of unknown cause (BUC). Patients and methods In 507 MBD patients, sTM levels, thrombin generation and plasma clot formation were measured and compared to 90 age‐ and sex‐matched healthy controls. In patients, genetic analysis of the THBD gene was performed. Results No difference in sTM levels between patients and controls was found overall (median ([IQR] 5.0 [3.8‐6.3] vs. 5.1 [3.7‐6.4] ng/ml, p = .762), and according to specific diagnoses of MBD or BUC, and high sTM levels (≥95th percentile of healthy controls) were not overrepresented in patients. Soluble TM levels had no impact on bleeding severity or global tests of haemostasis, including thrombin generation or plasma clot formation. In the THBD gene, no known pathogenic or novel disease‐causing variants affecting sTM plasma levels were identified in our patient cohort. Conclusion TM‐associated coagulopathy appears to be rare, as it was not identified in our large cohort of patients with MBD. Soluble TM did not arise as a risk factor for bleeding or altered haemostasis in these patients.
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Affiliation(s)
- Dino Mehic
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Alexander Tolios
- Department of Blood Group Serology and Transfusion Medicine, Medical University of Vienna, Vienna, Austria.,Institute of Vascular Biology and Thrombosis Research, Center for Physiology and Pharmacology, Medical University of Vienna, Vienna, Austria.,Institute for Artificial Intelligence and Decision Support, Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Stefanie Hofer
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Cihan Ay
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Helmuth Haslacher
- Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Kate Downes
- Department of Haematology, Cambridge Biomedical Campus, University of Cambridge, Cambridge, UK.,Cambridge Biomedical Campus, Cambridge University Hospitals Genomic Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Matthias Haimel
- CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences, Vienna, Austria.,Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases, Vienna, Austria
| | - Ingrid Pabinger
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Johanna Gebhart
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
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10
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How I treat. Bleeding Disorder of Unknown Cause (BDUC). Blood 2021; 138:1795-1804. [PMID: 34398949 DOI: 10.1182/blood.2020010038] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 08/10/2021] [Indexed: 11/20/2022] Open
Abstract
Recent studies have demonstrated that only 30% of patients referred for assessment of a possible bleeding tendency will eventually be diagnosed with a mild bleeding disorder (MBD) such as von Willebrand disease (VWD) or platelet function defect (PFD). Rather, the majority of such patients will be diagnosed with Bleeding Disorder of Unknown Cause (BDUC). There remains an important unmet need to define consensus regarding the clinical and laboratory criteria necessary for a formal BDUC diagnosis. Nevertheless, BDUC already accounts for more than 10% of patients registered in some Haemophilia Comprehensive Care centres. Accumulating recent data suggest that BDUC is also being diagnosed with increasing frequency. Increased BAT scores are widely utilized to differentiate significant from trivial symptoms in patients with mucocutaneous bleeding. Objective assessment of bleeding phenotype using a standardised bleeding assessment tool (BAT) therefore represents a fundamental first step in the diagnosis of BDUC. Since BDUC is a diagnosis by exclusion, accurate quantification of bleeding phenotype is critical as this will be the primary determinant upon which a diagnosis of BDUC is reached. Importantly, BAT scores suggest that patients with BDUC display bleeding phenotypes comparable to those seen in patients with VWD or PFD respectively. Despite the prevalence of BDUC, diagnosis and management of these patients commonly pose significant clinical dilemmas. In this manuscript, we consider these challenges in the context of a number of typical case studies, discuss the available evidence and outline our approach to the management of these patients.
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11
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Elevated levels of tissue factor pathway inhibitor in patients with mild to moderate bleeding tendency. Blood Adv 2021; 5:391-398. [PMID: 33496735 DOI: 10.1182/bloodadvances.2020003464] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 12/05/2020] [Indexed: 12/26/2022] Open
Abstract
High levels of tissue factor pathway inhibitor (TFPI), caused by a longer TFPIα half-life after binding to a factor V splice variant and variants in the F5 gene, were recently identified in 2 families with an as-yet-unexplained bleeding tendency. This study aimed to investigate free TFPIα in a well-characterized cohort of 620 patients with mild to moderate bleeding tendencies and its association to genetic alterations in the F5 gene. TFPIα levels were higher in patients with bleeding compared with healthy controls (median [interquartile range], 8.2 [5.5-11.7] vs 7.8 [4.3-11.1]; P = .026). A higher proportion of patients had free TFPIα levels more than or equal to the 95th percentile compared with healthy controls (odds ratio [OR] [95% confidence interval (CI)], 2.82 [0.98-8.13]). This was pronounced in the subgroup of patients in whom no bleeding disorder could be identified (bleeding of unknown cause [BUC; n = 420]; OR [95% CI], 3.03 [1.02-8.98]) and in platelet function defects (PFDs) (n = 121; OR [95% CI], 3.47 [1.09-11.08]). An increase in free TFPIα was associated with a mild delay in thrombin generation (prolonged lag time and time to peak), but not with alterations in routinely used global clotting tests. We could neither identify new or known genetic variations in the F5 gene that are associated with free TFPIα levels, nor an influence of the single-nucleotide variant rs10800453 on free TFPIα levels in our patient cohort. An imbalance of natural coagulation inhibitors such as TFPIα could be an underlying cause or contributor for unexplained bleeding, which is most probably multifactorial in a majority of patients.
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12
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Veen CSB, Huisman EJ, Romano LGR, Schipaanboord CWA, Cnossen MH, de Maat MPM, Leebeek FWG, Kruip MJHA. Outcome of Surgical Interventions and Deliveries in Patients with Bleeding of Unknown Cause: An Observational Study. Thromb Haemost 2021; 121:1409-1416. [PMID: 33853179 DOI: 10.1055/s-0041-1726344] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND The most optimal management for patients with bleeding of unknown cause (BUC) is unknown, as limited data are available. OBJECTIVE Evaluate management and outcome of surgical procedures and deliveries in patients with BUC. MATERIALS AND METHODS All patients ≥12 years of age, referred to a tertiary center for a bleeding tendency, were included. Bleeding phenotype was assessed and hemostatic laboratory work-up was performed. Patients were diagnosed with BUC or an established bleeding disorder (BD). Data on bleeding and treatment during surgical procedures and delivery following diagnosis were collected. RESULTS Of 380 included patients, 228 (60%) were diagnosed with BUC and 152 (40%) with an established BD. In 14/72 (19%) surgical procedures major bleeding occurred and 14/41 (34%) deliveries were complicated by major postpartum hemorrhage (PPH). More specifically, 29/53 (55%) of the BUC patients who underwent surgery received prophylactic treatment to support hemostasis. Despite these precautions, 4/29 (14%) experienced major bleeding. Of BUC patients not treated prophylactically, bleeding occurred in 6/24 (25%). Of pregnant women with BUC, 2/26 (8%) received prophylactic treatment during delivery, one women with and 11 (46%) women without treatment developed major PPH. CONCLUSION Bleeding complications are frequent in BUC patients, irrespective of pre- or perioperative hemostatic treatment. We recommend a low-threshold approach toward administration of hemostatic treatment in BUC patients, especially during delivery.
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Affiliation(s)
- Caroline S B Veen
- Department of Haematology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Elise J Huisman
- Department of Paediatric Haematology, Erasmus University Medical Centre-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Lorenzo G R Romano
- Department of Haematology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | | | - Marjon H Cnossen
- Department of Paediatric Haematology, Erasmus University Medical Centre-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Moniek P M de Maat
- Department of Haematology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Frank W G Leebeek
- Department of Haematology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Marieke J H A Kruip
- Department of Haematology, Erasmus University Medical Centre, Rotterdam, The Netherlands
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13
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Kaufmann J, Adler M, Alberio L, Nagler M. Utility of the Platelet Function Analyzer in Patients with Suspected Platelet Function Disorders: Diagnostic Accuracy Study. TH OPEN 2020; 4:e427-e436. [PMID: 33376942 PMCID: PMC7755505 DOI: 10.1055/s-0040-1721502] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 10/28/2020] [Indexed: 11/30/2022] Open
Abstract
Introduction
The platelet function analyzer (PFA) is widely used as a screening tool for bleeding disorders in various settings. The diagnostic performance regarding platelet function disorders (PFDs), which are among the most common inherited bleeding disorders, is however still elusive. We aimed to assess the diagnostic value of PFA for PFD in clinical practice.
Methods
Comprehensive clinical and laboratory data of all consecutive patients referred to a specialized outpatient between January 2012 and March 2017 with a suspected bleeding disorder were prospectively recorded. The diagnostic work-up was performed according to a prespecified protocol following current guidelines and platelet function was tested using light transmission aggregometry as well as flow cytometry.
Results
Five hundred and fifty-five patients were included (median age 43.7 years; interquartile range [IQR] 29.3, 61.7; 66.9% female). Possible PFD was diagnosed in 64 patients (11.5%) and confirmed PFD in 54 patients (9.7%). In patients with confirmed PFD, median closure times were 107 seconds (ADP or adenosine diphosphate; IQR 89, 130) and 169 seconds (EPI; IQR 121, 211). In patients without bleeding disorders, PFA closure times were 96 seconds (ADP; IQR 83, 109) and 137 seconds (EPI; IQR 116, 158). The sensitivity was 19.5% in case of PFA ADP (95%CI 12.6, 30.0; specificity 86.4%; 95% CI 82.4, 89.8), and 44.3% in case of PFA EPI (95% CI 34.9, 53.9; specificity 75.6%; 95% CI 70.8, 79.9).
Conclusion
The diagnostic performance of PFA for PFD was moderate to poor. Our results do not support the utilization of PFA for screening of PFD in clinical practice.
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Affiliation(s)
- Jonas Kaufmann
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Marcel Adler
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland.,Division of Hematology and Central Hematology Laboratory, CHUV, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Lorenzo Alberio
- Division of Hematology and Central Hematology Laboratory, CHUV, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.,Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Michael Nagler
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland.,University Institute of Clinical Chemistry, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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14
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van der Vorm LN, Huskens D, Florin L, De Kesel P, Roest M, de Laat B, Devreese KM. Active von Willebrand Factor in patients with a bleeding diathesis. THROMBOSIS UPDATE 2020. [DOI: 10.1016/j.tru.2020.100001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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15
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Huskens D, Li L, Florin L, de Kesel P, de Laat B, Roest M, Devreese KMJ. Flow cytometric analysis of platelet function to improve the recognition of thrombocytopathy. Thromb Res 2020; 194:183-189. [PMID: 32788114 DOI: 10.1016/j.thromres.2020.06.037] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 06/02/2020] [Accepted: 06/22/2020] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Light transmission aggregometry (LTA) is the gold standard for diagnosing bleeding disorders. Although LTA is laborious, requires large volumes of blood and is relatively insensitive to small changes in platelet function, there is still no competing alternative approach to replace LTA for the diagnosis of platelet bleeding disorders. MATERIALS AND METHODS This study investigates the correlation between flow cytometry-based whole blood platelet activation test (WB-PACT) and LTA and whether WB-PACT is of additional value for the identification of bleeding disorders. In total, 161 patients with suspected bleeding diathesis were tested. RESULTS A correlation of 0.41 between LTA and WB-PACT was found, and there was agreement between tests in 62% of cases (κ = 0.23). The WB-PACT is of additional value to LTA to detect platelet function disorders (PFD) as 10 patients with elevated bleeding score (BS) were detected with WB-PACT, 4 with LTA and 7 patients were positive with both tests. Interestingly, in contrast to LTA, WB-PACT has an additional option to detect VWF disfunctions. CONCLUSION WB-PACT may have added value for the routine diagnostic work-up in patients who need to have platelet function tested.
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Affiliation(s)
- Dana Huskens
- Synapse Research Institute, Maastricht, the Netherlands; Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, the Netherlands.
| | - Li Li
- Synapse Research Institute, Maastricht, the Netherlands; Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Lisa Florin
- Coagulation Laboratory, Department of Laboratory Medicine, Ghent University Hospital, Ghent, Belgium
| | - Pieter de Kesel
- Coagulation Laboratory, Department of Laboratory Medicine, Ghent University Hospital, Ghent, Belgium
| | - Bas de Laat
- Synapse Research Institute, Maastricht, the Netherlands; Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Mark Roest
- Synapse Research Institute, Maastricht, the Netherlands; Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Katrien M J Devreese
- Coagulation Laboratory, Department of Laboratory Medicine, Ghent University Hospital, Ghent, Belgium; Department of Diagnostic Sciences, Ghent University, Ghent, Belgium
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16
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Thomas W, White D, MacDonald S, Downes K, Obaji S, Desborough M. Diagnostic work up of patients with increased bleeding tendency: Comment. Haemophilia 2020; 26:e209-e210. [PMID: 32311812 DOI: 10.1111/hae.13989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 03/16/2020] [Accepted: 03/17/2020] [Indexed: 06/11/2023]
Affiliation(s)
- Will Thomas
- Department of Haematology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Danielle White
- Department of Haematology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Stephen MacDonald
- Department of Haematology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Kate Downes
- Department of Haematology, University of Cambridge, Cambridge, UK
- East Midlands and East of England Genomic Laboratory Hub, Cambridge University Hospitals NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, UK
| | - Samya Obaji
- Cardiff Haemophilia Centre, University Hospital of Wales, Cardiff, UK
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17
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Srivastava A. Diagnosis of haemophilia and other inherited bleeding disorders ‐ Is a new paradigm needed? Haemophilia 2020; 27 Suppl 3:14-20. [DOI: 10.1111/hae.14042] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 04/29/2020] [Accepted: 04/30/2020] [Indexed: 12/15/2022]
Affiliation(s)
- Alok Srivastava
- Department of Haematology Christian Medical College Vellore India
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18
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Veen CSB, Huisman EJ, Cnossen MH, Kom‐Gortat R, Rijken DC, Leebeek FWG, Maat MPM, Kruip MJHA. Evaluation of thromboelastometry, thrombin generation and plasma clot lysis time in patients with bleeding of unknown cause: A prospective cohort study. Haemophilia 2020; 26:e106-e115. [DOI: 10.1111/hae.13991] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 03/01/2020] [Accepted: 03/18/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Caroline S. B. Veen
- Department of Haematology Erasmus University Medical Center Rotterdam Rotterdam The Netherlands
| | - Elise J. Huisman
- Department of Paediatric Haematology Erasmus University Medical Center - Sophia Children's Hospital Rotterdam The Netherlands
| | - Marjon H. Cnossen
- Department of Paediatric Haematology Erasmus University Medical Center - Sophia Children's Hospital Rotterdam The Netherlands
| | - Regina Kom‐Gortat
- Department of Haematology Erasmus University Medical Center Rotterdam Rotterdam The Netherlands
| | - Dingeman C. Rijken
- Department of Haematology Erasmus University Medical Center Rotterdam Rotterdam The Netherlands
| | - Frank W. G. Leebeek
- Department of Haematology Erasmus University Medical Center Rotterdam Rotterdam The Netherlands
| | - Moniek P. M. Maat
- Department of Haematology Erasmus University Medical Center Rotterdam Rotterdam The Netherlands
| | - Marieke J. H. A. Kruip
- Department of Haematology Erasmus University Medical Center Rotterdam Rotterdam The Netherlands
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19
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Zegers SAM, Smit Y, Saes JL, van Duren C, Schuijt TJ, van Heerde WL, Schols SEM. Diagnostic work up of patients with increased bleeding tendency. Haemophilia 2019; 26:269-277. [PMID: 31886943 PMCID: PMC7155060 DOI: 10.1111/hae.13922] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 11/30/2019] [Accepted: 12/06/2019] [Indexed: 12/13/2022]
Abstract
Introduction The diagnostic trajectory of patients with increased bleeding tendency can be very costly and time‐consuming. In addition, previous studies have shown that half of these patients remain without final diagnosis despite all efforts. Aim This study aimed to improve insight into the current diagnostic process of these patients. Methods A total of 117 adult patients, referred to an academic hospital because of being suspected to have an increased bleeding tendency, were included. Different parameters were compared between patients receiving final diagnosis, patients without final diagnosis but a high Tosetto bleeding assessment tool (BAT) score (classified as bleeding of unknown cause, or BUC) and a control group consisting of patients without final diagnosis and a low BAT score. Results The BAT score was significantly higher in patients in the BUC group as compared to patients reaching final diagnosis (8.1 vs 4.9). Interestingly, the two subcategories most prevalently increased were surgery and post‐partum haemorrhage‐associated bleeding (surgery: 2.1 vs 1.1; post‐partum haemorrhage: 0.7 vs 0.0). Laboratory screening results were more often abnormal in patients reaching final diagnosis compared to patients remaining without diagnosis and a high BAT score (n = 32 (78%) vs n = 14 (46%), 95% CI 1.5‐12), especially concerning the PFA (=27 (66%) vs n = 10 (33%), 95% CI 1.4‐10) and von Willebrand factor activity levels (n = 11 (27%) vs n = 1 (3%), 95% CI 1.3‐91). Conclusion Isolated high bleeding score on surgical or post‐partum bleeding correlates with a lower chance of receiving final diagnosis. Withholding extensive haemostatic testing should be considered. Better screening and confirmative haemostatic assays are still needed.
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Affiliation(s)
- Suzanne A M Zegers
- Department of Haematology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Yolba Smit
- Department of Haematology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Joline L Saes
- Department of Haematology, Radboud University Medical Center, Nijmegen, The Netherlands.,Haemophilia Treatment Center Nijmegen-Eindhoven-Maastricht, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Clint van Duren
- Department of Laboratory Medicine, Laboratory of Haematology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Tim J Schuijt
- Department of Laboratory Medicine, Laboratory of Haematology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Waander L van Heerde
- Department of Haematology, Radboud University Medical Center, Nijmegen, The Netherlands.,Haemophilia Treatment Center Nijmegen-Eindhoven-Maastricht, Radboud University Medical Center, Nijmegen, The Netherlands.,Enzyre BV, Novio Tech Campus, Nijmegen, The Netherlands
| | - Saskia E M Schols
- Department of Haematology, Radboud University Medical Center, Nijmegen, The Netherlands.,Haemophilia Treatment Center Nijmegen-Eindhoven-Maastricht, Radboud University Medical Center, Nijmegen, The Netherlands
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20
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MacDonald S, Wright A, Beuche F, Downes K, Besser M, Symington E, Kelly A, Thomas W. Characterization of a large cohort of patients with unclassified bleeding disorder; clinical features, management of haemostatic challenges and use of global haemostatic assessment with proposed recommendations for diagnosis and treatment. Int J Lab Hematol 2019; 42:116-125. [DOI: 10.1111/ijlh.13124] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 09/27/2019] [Accepted: 10/28/2019] [Indexed: 12/30/2022]
Affiliation(s)
- Stephen MacDonald
- Department of Haematology Cambridge University Hospitals NHS Foundation Trust Cambridge UK
| | - Alfie Wright
- School of Clinical Medicine University of Cambridge Cambridge UK
| | | | - Kate Downes
- Department of Haematology University of Cambridge Cambridge UK
- NIHR BioResource‐Rare Diseases Cambridge University Hospitals NHS Foundation Trust Cambridge UK
- NHS Blood and Transplant Cambridge Biomedical Campus Cambridge UK
| | - Martin Besser
- Department of Haematology Cambridge University Hospitals NHS Foundation Trust Cambridge UK
| | - Emily Symington
- Department of Haematology Cambridge University Hospitals NHS Foundation Trust Cambridge UK
| | - Anne Kelly
- Department of Haematology Cambridge University Hospitals NHS Foundation Trust Cambridge UK
| | - Will Thomas
- Department of Haematology Cambridge University Hospitals NHS Foundation Trust Cambridge UK
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21
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Veen CSB, van der Reijken IS, Jansen AJG, Schipaanboord CWA, Visser W, de Maat MPM, Leebeek FWG, Duvekot JJ, Kruip MJHA. Severe postpartum haemorrhage as first presenting symptom of an inherited bleeding disorder. Haemophilia 2019; 25:1051-1058. [PMID: 31583797 DOI: 10.1111/hae.13846] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 08/11/2019] [Accepted: 08/23/2019] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Postpartum haemorrhage (PPH) is the major cause of maternal death worldwide. Haemostatic abnormalities are independently associated with a significantly increased risk for severe PPH. In this study, the value of haemostatic evaluation in women with severe PPH was explored. AIM To investigate the occurrence of previously unknown inherited bleeding disorders in women with severe PPH. METHODS Women with severe PPH (blood loss of ≥2000 mL) between 2011 and 2017, referred to the haematology outpatient clinic for haemostatic evaluation, were retrospectively included. A bleeding disorder was diagnosed based on (inter)national guidelines, or when having a clear bleeding phenotype, not fulfilling any diagnostic criteria or laboratory abnormalities, this being classified as Bleeding of Unknown Cause (BUC). Logistic regression was used to model the association between diagnosis and obstetrical causes and risk factors for PPH. RESULTS In total, 85 women with PPH were included. In 23% (n = 16), a mild bleeding disorder was diagnosed, including low von Willebrand factor (Low VWF 8/16), platelet function disorders (PFD 5/16), BUC (2/16) and von Willebrand disease type 1 (1/16). No significant associations were found between obstetrical causes or risk factors for PPH and the presence of a bleeding disorder. CONCLUSION In 23% of women with severe PPH, a mild bleeding disorder was diagnosed, independent of obstetrical causes or risk factors for PPH. This implies that severe PPH can be the first clinical symptom of an inherited bleeding disorder. Therefore, to optimize clinical management, haemostatic evaluation after severe PPH is recommended.
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Affiliation(s)
- Caroline S B Veen
- Department of Haematology, Erasmus University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Irene S van der Reijken
- Department of Haematology, Erasmus University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - A J Gerard Jansen
- Department of Haematology, Erasmus University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | | | - Willy Visser
- Department of Obstetrics & Gynaecology, Erasmus University Medical Centre Rotterdam, Rotterdam, The Netherlands.,Department of Vascular Medicine, Erasmus University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Moniek P M de Maat
- Department of Haematology, Erasmus University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Frank W G Leebeek
- Department of Haematology, Erasmus University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Johannes J Duvekot
- Department of Obstetrics & Gynaecology, Erasmus University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Marieke J H A Kruip
- Department of Haematology, Erasmus University Medical Centre Rotterdam, Rotterdam, The Netherlands
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22
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Fundamentals for a Systematic Approach to Mild and Moderate Inherited Bleeding Disorders: An EHA Consensus Report. Hemasphere 2019; 3:e286. [PMID: 31942541 PMCID: PMC6919472 DOI: 10.1097/hs9.0000000000000286] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 07/08/2019] [Accepted: 07/15/2019] [Indexed: 01/05/2023] Open
Abstract
Healthy subjects frequently report minor bleedings that are frequently ‘background noise’ of normality rather than a true disorder. Nevertheless, unexpected or unusual bleeding may be alarming. Thus, the distinction between normal and pathologic bleeding is critical. Understanding the underlying pathologic mechanism in patients with an excessive bleeding is essential for their counseling and treatment. Most of these patients with significant bleeding will result affected by non-severe inherited bleeding disorders (BD), collectively denominated mild or moderate BD for their relatively benign course. Unfortunately, practical recommendations for the management of these disorders are still lacking due to the current state of fragmented knowledge of pathophysiology and lack of a systematic diagnostic approach. To address this gap, an International Working Group (IWG) was established by the European Hematology Association (EHA) to develop consensus-based guidelines on these disorders. The IWG agreed that grouping these disorders by their clinical phenotype under the single category of mild-to-moderate bleeding disorders (MBD) reflects current clinical practice and will facilitate a systematic diagnostic approach. Based on standardized and harmonized definitions a conceptual unified framework is proposed to distinguish normal subjects from affected patients. The IWG proposes a provisional comprehensive patient-centered initial diagnostic approach that will result in classification of MBD into distinct clinical-pathological entities under the overarching principle of clinical utility for the individual patient. While we will present here a general overview of the global management of patients with MBD, this conceptual framework will be adopted and validated in the evidence-based, disease-specific guidelines under development by the IWG.
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23
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Hofer S, Ay C, Rejtö J, Wolberg AS, Haslacher H, Koder S, Pabinger I, Gebhart J. Thrombin-generating potential, plasma clot formation, and clot lysis are impaired in patients with bleeding of unknown cause. J Thromb Haemost 2019; 17:1478-1488. [PMID: 31177606 PMCID: PMC6851858 DOI: 10.1111/jth.14529] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 05/16/2019] [Accepted: 06/03/2019] [Indexed: 01/11/2023]
Abstract
BACKGROUND In a large proportion of patients with a mild to moderate bleeding tendency no diagnosis can be established (bleeding of unknown cause, BUC). OBJECTIVES To investigate possible dysfunctions in thrombin generation and plasma clot formation and lysis in patients with BUC from the Vienna Bleeding Biobank (VIBB). PATIENTS AND METHODS Thrombin generation and plasma clot properties of 382 BUC patients were compared to those of 100 healthy controls and 16 patients with factor VIII (FVIII) activity ≤50%. RESULTS Thrombin generation was significantly impaired in BUC patients compared to healthy controls, exhibiting a prolonged lag time and time to peak and decreased maximum thrombin generation, velocity index, and area under the curve (AUC). The assessment of clot formation and lysis in BUC patients revealed a lower clot formation rate (Vmax), resulting in a longer TTP, increased absorbance (ΔAbs), and a shorter clot lysis time (CLT) than in healthy controls. Comparing patients with FVIII activity ≤ 50% to those with BUC, parameters of thrombin generation and clot formation and lysis were either stronger or comparably impaired. Bleeding severity did not correlate with parameters of thrombin generation, clot formation, or clot lysis. CONCLUSION Patients with BUC have an impaired hemostatic capacity reflected by a lower thrombin-generation potential, a lower clot formation rate, increased clot turbidity, and shorter clot lysis time, which might contribute to their increased bleeding tendency. Assays monitoring these parameters can alert physicians of hemostatic impairment and should be considered in situations where traditional hemostatic lab tests fail to reveal the clinical bleeding tendency.
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Affiliation(s)
- Stefanie Hofer
- Clinical Division of Hematology and HemostaseologyDepartment of Medicine IMedical University of ViennaViennaAustria
| | - Cihan Ay
- Clinical Division of Hematology and HemostaseologyDepartment of Medicine IMedical University of ViennaViennaAustria
| | - Judit Rejtö
- Clinical Division of Hematology and HemostaseologyDepartment of Medicine IMedical University of ViennaViennaAustria
| | - Alisa S. Wolberg
- Department of Pathology and Laboratory MedicineUniversity of North Carolina at Chapel HillChapel HillNorth Carolina
| | - Helmuth Haslacher
- Department of Laboratory MedicineMedical University of ViennaViennaAustria
| | - Silvia Koder
- Clinical Division of Hematology and HemostaseologyDepartment of Medicine IMedical University of ViennaViennaAustria
| | - Ingrid Pabinger
- Clinical Division of Hematology and HemostaseologyDepartment of Medicine IMedical University of ViennaViennaAustria
| | - Johanna Gebhart
- Clinical Division of Hematology and HemostaseologyDepartment of Medicine IMedical University of ViennaViennaAustria
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24
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Hussein HK, Nicolson P, Fordwor K, Lowe GC. Mild bleeding disorders: what every clinician should know. Br J Hosp Med (Lond) 2019; 78:684-710. [PMID: 29240509 DOI: 10.12968/hmed.2017.78.12.684] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Patients with mild bleeding disorders are under-recognized and frequently present to general physicians. The underlying reasons for bleeding are multifactorial. There is little evidence to guide diagnostic and management decision making in patients with mild bleeding disorders. This article outlines different types of mild bleeding disorders, with a particular focus on bleeding associated with low levels of von Willebrand factor and mild platelet defects. It gives practical, evidence-based advice on the investigation and management of patients with a suspected or known mild bleeding disorder, considering the scenarios of an acute bleed, stable outpatient, peri-surgical management and thrombosis. Patients with a mild bleeding disorder have variable bleeding because of the interplay of genetic and environmental factors. The clinical history remains of utmost importance in their general management. Liaison with a specialist centre, multidisciplinary assessment and a careful judgement of the balance of risk in each individual circumstance is required to safely manage these patients.
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Affiliation(s)
- H K Hussein
- Specialty Registrar in Clinical Haematology, Department of Clinical Haematology, Queen Elizabeth Hospital, Birmingham
| | - Plr Nicolson
- Specialty Registrar in Clinical Haematology and BHF Clinical Research Training Fellow, Department of Clinical Haematology, Queen Elizabeth Hospital, Birmingham, and Institute of Cardiovascular Sciences, University of Birmingham, Birmingham B15 2TT
| | - K Fordwor
- Core Medical Trainee, Department of Medicine, Chelsea and Westminster Hospital, London
| | - G C Lowe
- Consultant Haematologist, Department of Clinical Haematology, Queen Elizabeth Hospital, Birmingham
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25
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Adler M, Kaufmann J, Alberio L, Nagler M. Diagnostic utility of the ISTH bleeding assessment tool in patients with suspected platelet function disorders. J Thromb Haemost 2019; 17:1104-1112. [PMID: 31021046 PMCID: PMC6852182 DOI: 10.1111/jth.14454] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 04/11/2019] [Indexed: 01/09/2023]
Abstract
Essentials The utility of bleeding assessment tools regarding platelet function disorders is still elusive. We studied consecutive patients in a prospective cohort study in a tertiary hospital. Substantially higher scorings were observed in patients with platelet function disorders. Bleeding assessment tools might provide a useful screening tool. BACKGROUND Bleeding assessment tools (BATs) have been widely implemented in the evaluation of patients with suspected bleeding disorders. However, diagnostic BAT utility regarding platelet function disorders is still elusive. AIM We aimed to assess the diagnostic value of the International Society on Thrombosis and Haemostasis BAT (ISTH-BAT) for platelet function disorders in clinical practice. METHODS The clinical characteristics and laboratory data of all consecutive patients with a suspected bleeding disorder referred between January 2012 and March 2017 to an outpatient unit of a university hospital were prospectively collected. The diagnostic evaluation was performed according to current recommendations following a prespecified protocol and platelet function was tested using light transmission aggregometry as well as flow cytometry. RESULTS Five hundred and fifty-five patients were assessed; 66.9% were female, median age was 43.7 years (interquartile range [IQR] 29.3, 61.7). Confirmed platelet function disorder was diagnosed in 54 patients (9.7%), possible platelet function disorder in 64 patients (11.5%), and other disorders in 170 patients (30.6%). Median scoring of the ISTH-BAT was 2 in patients without a bleeding disorder (IQR 1, 3), 4 in patients with a possible platelet function disorder (2, 7), and 7 in patients with confirmed platelet function disorder (5, 9). Area under the receiver operating characteristic curve (the area under the curve [AUC]) was 0.75 (95% CI 0.70, 0.80). CONCLUSIONS Presence of a platelet function disorder was associated with substantially higher BAT scorings compared to patients without. Our data suggest that the ISTH-BAT provides a useful screening tool for patients with suspected platelet function disorders.
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Affiliation(s)
- Marcel Adler
- Department of Haematology and Central Haematology Laboratory, InselspitalBern University Hospital and University of BernBernSwitzerland
- Division of Haematology and Central Hematology LaboratoryCHUVLausanne University Hospital and University of LausanneLausanneSwitzerland
| | - Jonas Kaufmann
- Department of Haematology and Central Haematology Laboratory, InselspitalBern University Hospital and University of BernBernSwitzerland
| | - Lorenzo Alberio
- Division of Haematology and Central Hematology LaboratoryCHUVLausanne University Hospital and University of LausanneLausanneSwitzerland
- Faculty of Biology and MedicineUniversity of LausanneLausanneSwitzerland
| | - Michael Nagler
- Department of Haematology and Central Haematology Laboratory, InselspitalBern University Hospital and University of BernBernSwitzerland
- University Institute of Clinical ChemistryUniversity of BernBernSwitzerland
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26
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Thromboelastometry as a diagnostic tool in mild bleeding disorders: A prospective cohort study. Eur J Anaesthesiol 2019; 36:457-465. [PMID: 30950901 DOI: 10.1097/eja.0000000000000985] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Major guidelines emphasise the potential of visco-elastic methods to overcome the limitations of conventional laboratory assays in the peri-operative setting. Their sensitivity regarding mild bleeding disorders (MBDs), the most common bleeding disorders in the general population, is however unknown. OBJECTIVE The aim of this study was to investigate the sensitivity of thromboelastometry for diagnosis of MBD. DESIGN A single-centre prospective cohort study. SETTING Haematology outpatient unit of a tertiary general hospital in Central Switzerland. PATIENTS All consecutive patients referred over a 32-month period with a suspected bleeding disorder were included and thromboelastometry was conducted using a ROTEM delta (EXTEM, INTEM and FIBTEM). Diagnostic work-up was performed according to current guidelines including the ISTH bleeding assessment tool (ISTH BAT). MAIN OUTCOME MEASURES Distribution of clotting time (CT) and maximum clot firmness (MCF) results in relation to the presence of MBD. RESULTS Two hundred and seventeen patients were assessed; the median [IQR] age was 39 years [28 to 57]; 151 patients were women (70%). MBD was diagnosed in 97 patients (45%), no MBD was found in 100 patients (46%) and a systemic disorder recognised in 20 patients (9%). Presence of MBD was not associated with a significant difference in thromboelastometry variables (0.2 s in CT EXTEM, 95% CI -2.3 to 2.7; -0.2 mm in MCF EXTEM, 95% CI -1.8 to 1.5; -0.7 s in CT INTEM, 95% CI -12.6 to 11.2; 0.6 mm in MCF INTEM, 95% CI -1.2 to 1.3; 0.8 mm in MCF FIBTEM, 95% CI -1.6 to 1.4) and most results were within the established reference ranges. CONCLUSION Our data did not support the use of thromboelastometry as a diagnostic tool in patients with MBD.
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27
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Vries MJA, Macrae F, Nelemans PJ, Kuiper GJAJM, Wetzels RJH, Bowman P, Verhezen PWM, Ten Cate H, Ariëns RAS, Henskens YMC. Assessment and determinants of whole blood and plasma fibrinolysis in patients with mild bleeding symptoms. Thromb Res 2018; 174:88-94. [PMID: 30579151 DOI: 10.1016/j.thromres.2018.12.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2018] [Revised: 11/20/2018] [Accepted: 12/03/2018] [Indexed: 01/28/2023]
Abstract
Enhanced clot lysis is associated with bleeding, but assessment of lysis capacity remains difficult. The plasma turbidity lysis and whole blood tissue Plasminogen Activator-Rotational Thromboelastometry (tPA-ROTEM) assays estimate fibrinolysis under more physiological conditions than clinically used assays. We hypothesized that these assays could find signs of enhanced lysis capacity in patients who report bleeding symptoms, but are not diagnosed with bleeding disorders. We also aimed to gain insight in determinants of the results of these lysis assays. Data from 240 patients with and 95 patients without self-reported bleeding symptoms were obtained, who were included in a study that primarily aimed to assess prevalence of haemostatic abnormalities in preoperative patients. ROTEM and turbidity assays were performed with rtPA. Blood counts, fibrinolysis and coagulation factor activities were determined. Data were analysed using multivariable linear regression models. Remarkably, patients reporting bleeding symptoms showed signs of significantly impaired lysis capacity in the tPA-ROTEM, but not in the turbidity lysis assay. In these patients, the tPA-ROTEM results depended on FII, FXII, plasminogen, α2-antiplasmin, PAI-1 and TAFI levels. The turbidity lysis results were significantly influenced by fibrinogen, α2-antiplasmin, PAI-1 and TAFI. In conclusion, the tPA-ROTEM and the turbidity lysis assay could not detect enhanced fibrinolytic capacity in patients with bleeding symptoms. This suggests that these symptoms are not caused by enhanced fibrinolytic activity. As both assays were sensitive to important determinants of fibrinolysis they may be able to detect a fibrinolytic imbalance, but this needs to be validated in patients with known hypo- or hyperfibrinolytic disorders.
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Affiliation(s)
- Minka J A Vries
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, the Netherlands.
| | - Fraser Macrae
- Thrombosis and Tissue Repair Group, Division of Cardiovascular and Diabetes Research, Leeds Institute for Genetics, Health and Therapeutics, Multidisciplinary Cardiovascular Research Centre, University of Leeds, Leeds, UK
| | - Patricia J Nelemans
- Department of Epidemiology and School for Public Health and Primary Care (CAPHRI), Maastricht University Medical Centre (MUMC+), Maastricht, the Netherlands
| | - Gerhardus J A J M Kuiper
- Department of Anaesthesiology, Maastricht University Medical Centre (MUMC+), Maastricht, the Netherlands
| | - Rick J H Wetzels
- Central Diagnostic Laboratory, Maastricht University Medical Centre (MUMC+), Maastricht, the Netherlands
| | - Polly Bowman
- Thrombosis and Tissue Repair Group, Division of Cardiovascular and Diabetes Research, Leeds Institute for Genetics, Health and Therapeutics, Multidisciplinary Cardiovascular Research Centre, University of Leeds, Leeds, UK
| | - Paul W M Verhezen
- Central Diagnostic Laboratory, Maastricht University Medical Centre (MUMC+), Maastricht, the Netherlands
| | - Hugo Ten Cate
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, the Netherlands; Department of Internal Medicine, Maastricht University Medical Centre (MUMC+), Maastricht, the Netherlands
| | - Robert A S Ariëns
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, the Netherlands; Thrombosis and Tissue Repair Group, Division of Cardiovascular and Diabetes Research, Leeds Institute for Genetics, Health and Therapeutics, Multidisciplinary Cardiovascular Research Centre, University of Leeds, Leeds, UK
| | - Yvonne M C Henskens
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, the Netherlands; Central Diagnostic Laboratory, Maastricht University Medical Centre (MUMC+), Maastricht, the Netherlands
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28
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Saes JL, Simons A, de Munnik SA, Nijziel MR, Blijlevens NMA, Jongmans MC, van der Reijden BA, Smit Y, Brons PP, van Heerde WL, Schols SEM. Whole exome sequencing in the diagnostic workup of patients with a bleeding diathesis. Haemophilia 2018; 25:127-135. [PMID: 30431218 DOI: 10.1111/hae.13638] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 10/26/2018] [Accepted: 10/27/2018] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Bleeding assessment tools and laboratory phenotyping often remain inconclusive in patients with a haemorrhagic diathesis. AIM To describe the phenotype and genetic profile of patients with a bleeding tendency. METHODS Whole exome sequencing (WES) was incorporated in the routine diagnostic pathway of patients with thrombocytopenia (n = 17), platelet function disorders (n = 19) and an unexplained bleeding tendency (n = 51). The analysis of a panel of 126 OMIM (Online Mendelian Inheritance in Man) genes involved in thrombosis and haemostasis was conducted, and if negative, further exome-wide analysis was performed if informed consent given. RESULTS Eighteen variants were detected in 15 patients from a total of 87 patients (17%). Causative variants were observed in MYH9 (two cases), SLFN14, P2RY12 and GP9. In addition, one case was considered solved due to combined carriership of F7 and F13A1 variants and one with combined carriership of F2, F8 and VWF, all variants related to secondary haemostasis protein aberrations. Two variants of uncertain significance (VUS) were found in two primary haemostasis genes: GFI1B and VWF. Eight patients were carriers of autosomal recessive disorders. Exome-wide analysis was performed in 54 cases and identified three variants in candidate genes. CONCLUSION Based on our findings, we conclude that performing WES at the end of the diagnostic trajectory can be of additive value to explain the complete bleeding phenotype in patients without a definite diagnosis after conventional laboratory tests. Discovery of combinations of (novel) genes that predispose to bleeding will increase the diagnostic yield in patients with an unexplained bleeding diathesis.
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Affiliation(s)
- Joline L Saes
- Department of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands.,Hemophilia Treatment Center, Nijmegen-Eindhoven-Maastricht, Nijmegen, The Netherlands
| | - Annet Simons
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Sonja A de Munnik
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marten R Nijziel
- Department of Hematology, Catharina Hospital, Eindhoven, The Netherlands
| | - Nicole M A Blijlevens
- Department of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marjolijn C Jongmans
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Medical Genetics, University Medical Center Utrecht, Utrecht, The Netherlands.,Princess Maxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Bert A van der Reijden
- Department of Laboratory Medicine, Laboratory of Haematology, Radboud University Medical Center, Radboud Institute for Molecular Life Sciences, Nijmegen, The Netherlands
| | - Yolba Smit
- Department of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Paul P Brons
- Hemophilia Treatment Center, Nijmegen-Eindhoven-Maastricht, Nijmegen, The Netherlands.,Department of Pediatric Hemato-Oncology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Waander L van Heerde
- Hemophilia Treatment Center, Nijmegen-Eindhoven-Maastricht, Nijmegen, The Netherlands
| | - Saskia E M Schols
- Department of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands.,Hemophilia Treatment Center, Nijmegen-Eindhoven-Maastricht, Nijmegen, The Netherlands
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29
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Vries MJ, van der Meijden PE, Kuiper GJ, Nelemans PJ, Wetzels RJ, van Oerle RG, Lancé MD, ten Cate H, Henskens YM. Preoperative screening for bleeding disorders: A comprehensive laboratory assessment of clinical practice. Res Pract Thromb Haemost 2018; 2:767-777. [PMID: 30349896 PMCID: PMC6178633 DOI: 10.1002/rth2.12114] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 04/22/2018] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Patients with mild bleeding disorders are at risk of perioperative bleeding, but screening for these disorders remains challenging. OBJECTIVES We aimed to assess the prevalence of hemostatic abnormalities in patients with and without reported bleeding symptoms on a preoperative questionnaire, consisting of guideline-proposed questions, and appraised the diagnostic value of several screening modalities for the identification of patients with hemostatic abnormalities. METHODS In this observational study, 240 patients with and 95 patients without bleeding symptoms on the preoperative questionnaire were included. Patients with known bleeding disorders, antithrombotic drugs, thrombocytopenia, and anemia were excluded. Preoperatively, all patients underwent elaborate hemostatic testing. Hemostatic abnormalities were defined as coagulation, vWF, or fibrinolysis factor levels below reference range and platelet function defects. Screening modalities included the ISTH Bleeding Assessment Tool (ISTH-BAT), PT, aPTT, TT, Euglobulin Lysis Time (ELT), and Platelet Function Analyser (PFA). RESULTS In 21 of 240 (8.8%) patients reporting bleeding symptoms, hemostatic abnormalities were found, including 7 reduced coagulation factor levels, 10 platelet function abnormalities, and 4 reduced vWF levels. In comparison, 10 of 95 (10.5%) patients not reporting bleeding symptoms had abnormalities. The ISTH-BAT could not identify patients with abnormalities, while PT, aPTT, TT, ELT, and PFA had high specificity but low sensitivity to detect abnormalities. CONCLUSIONS The prevalence of hemostatic abnormalities in both patients with and without reported bleeding symptoms was 9%-10%. This suggests that the guideline-based questionnaire cannot differentiate between patients with and without abnormalities, while the discriminative power of the screening modalities is also limited.
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Affiliation(s)
- Minka J. Vries
- Laboratory for Clinical Thrombosis and HaemostasisDepartment of BiochemistryCardiovascular Research Institute MaastrichtMaastricht UniversityMaastrichtThe Netherlands
| | - Paola E. van der Meijden
- Laboratory for Clinical Thrombosis and HaemostasisDepartment of BiochemistryCardiovascular Research Institute MaastrichtMaastricht UniversityMaastrichtThe Netherlands
- Thrombosis Expertise CentreMaastricht University Medical CentreMaastrichtThe Netherlands
| | - Gerhardus J. Kuiper
- Department of AnaesthesiologyMaastricht University Medical CentreMaastrichtThe Netherlands
| | - Patricia J. Nelemans
- Department of EpidemiologySchool for Public Health and Primary CareMaastricht University Medical CentreMaastrichtThe Netherlands
| | - Rick J. Wetzels
- Central Diagnostic LaboratoryMaastricht University Medical CentreMaastrichtThe Netherlands
| | - René G. van Oerle
- Laboratory for Clinical Thrombosis and HaemostasisDepartment of BiochemistryCardiovascular Research Institute MaastrichtMaastricht UniversityMaastrichtThe Netherlands
- Central Diagnostic LaboratoryMaastricht University Medical CentreMaastrichtThe Netherlands
| | - Marcus D. Lancé
- Department of AnaesthesiologyMaastricht University Medical CentreMaastrichtThe Netherlands
| | - Hugo ten Cate
- Laboratory for Clinical Thrombosis and HaemostasisDepartment of BiochemistryCardiovascular Research Institute MaastrichtMaastricht UniversityMaastrichtThe Netherlands
- Thrombosis Expertise CentreMaastricht University Medical CentreMaastrichtThe Netherlands
| | - Yvonne M. Henskens
- Laboratory for Clinical Thrombosis and HaemostasisDepartment of BiochemistryCardiovascular Research Institute MaastrichtMaastricht UniversityMaastrichtThe Netherlands
- Central Diagnostic LaboratoryMaastricht University Medical CentreMaastrichtThe Netherlands
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30
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Moenen FCJI, Nelemans PJ, Schols SEM, Schouten HC, Henskens YMC, Beckers EAM. The diagnostic accuracy of bleeding assessment tools for the identification of patients with mild bleeding disorders: A systematic review. Haemophilia 2018; 24:525-535. [DOI: 10.1111/hae.13486] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/11/2018] [Indexed: 11/27/2022]
Affiliation(s)
- F. C. J. I. Moenen
- Department of Haematology, Internal Medicine; Maastricht University Medical Centre+; Maastricht The Netherlands
| | - P. J. Nelemans
- Department of Epidemiology; Maastricht University; Maastricht The Netherlands
| | - S. E. M. Schols
- Department of Haematology, Internal Medicine; Radboud University Medical Centre; Nijmegen The Netherlands
| | - H. C. Schouten
- Department of Haematology, Internal Medicine; Maastricht University Medical Centre+; Maastricht The Netherlands
| | - Y. M. C. Henskens
- Central Diagnostic Laboratory, Unit for Haemostasis and Transfusion; Maastricht University Medical Centre+; Maastricht The Netherlands
| | - E. A. M. Beckers
- Department of Haematology, Internal Medicine; Maastricht University Medical Centre+; Maastricht The Netherlands
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31
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van Asten I, Schutgens REG, Baaij M, Zandstra J, Roest M, Pasterkamp G, Huisman A, Korporaal SJA, Urbanus RT. Validation of flow cytometric analysis of platelet function in patients with a suspected platelet function defect. J Thromb Haemost 2018; 16:689-698. [PMID: 29337406 DOI: 10.1111/jth.13952] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Indexed: 01/19/2023]
Abstract
Essentials The diagnosis of mild platelet function disorders (PFDs) is challenging. Validation of flow cytometric testing in patients with suspected PFDs is required. Flow cytometry has added value to light transmission aggregometry (LTA) in diagnosis of PFDs. There is fair agreement in diagnosing PFDs between LTA and flow cytometry. SUMMARY Background Light transmission aggregometry (LTA) is the most commonly used test for the diagnosis of platelet function disorders (PFDs), but has moderate sensitivity for mild PFDs. Flow cytometry has been recommended for additional diagnostics of PFDs but is not yet standardized as a diagnostic test. We developed a standardized protocol for flow cytometric analysis of platelet function that measures fibrinogen binding and P-selectin expression as platelet activation markers in response to agonist stimulation. Objectives To determine the additional value of flow cytometric platelet function testing to standard LTA screening in a cross-sectional cohort of patients with a suspected PFD. Methods Platelet function was assessed with flow cytometry and LTA in 107 patients suspected of a PFD in whom von Willebrand disease and coagulation factor deficiencies were excluded. Both tests were compared in terms of agreement and discriminative ability for diagnosing patients with PFDs. Results Out of 107 patients, 51 patients had an elevated bleeding score; 62.7% of the patients had abnormal platelet function measured with flow cytometry and 54.2% of the patients were abnormal based on LTA. There was fair agreement between LTA and flow cytometry (κ = 0.32). The discriminative ability of flow cytometric analysis in patients with an elevated bleeding score was good (AUC 0.82, 0.74-0.90), but moderate for LTA (AUC 0.70, 0.60-0.80). Both tests combined had a better discriminative ability (AUC 0.87, 0.80-0.94). Conclusion Flow cytometric analysis of platelet function has added value in diagnostics of PFDs in patients with unexplained bleeding tendency.
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Affiliation(s)
- I van Asten
- Van Creveld Laboratory, University Medical Center Utrecht, Utrecht, the Netherlands
- Van Creveldkliniek, University Medical Center Utrecht, Utrecht, the Netherlands
| | - R E G Schutgens
- Van Creveld Laboratory, University Medical Center Utrecht, Utrecht, the Netherlands
- Van Creveldkliniek, University Medical Center Utrecht, Utrecht, the Netherlands
| | - M Baaij
- Department of Clinical Chemistry and Haematology, Center for Circulatory Health, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- Van Creveld Laboratory, University Medical Center Utrecht, Utrecht, the Netherlands
- Van Creveldkliniek, University Medical Center Utrecht, Utrecht, the Netherlands
| | - J Zandstra
- Department of Clinical Chemistry and Haematology, Center for Circulatory Health, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - M Roest
- Department of Clinical Chemistry and Haematology, Center for Circulatory Health, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - G Pasterkamp
- Department of Clinical Chemistry and Haematology, Center for Circulatory Health, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - A Huisman
- Department of Clinical Chemistry and Haematology, Center for Circulatory Health, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - S J A Korporaal
- Department of Clinical Chemistry and Haematology, Center for Circulatory Health, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - R T Urbanus
- Department of Clinical Chemistry and Haematology, Center for Circulatory Health, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
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32
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Gebhart J, Hofer S, Panzer S, Quehenberger P, Sunder-Plassmann R, Hoermann G, Eigenbauer E, Haslacher H, Kepa S, Kyrle PA, Eichinger S, Knöbl P, Eischer L, Mannhalter C, Ay C, Pabinger I. High proportion of patients with bleeding of unknown cause in persons with a mild-to-moderate bleeding tendency: Results from the Vienna Bleeding Biobank (VIBB). Haemophilia 2018; 24:405-413. [PMID: 29388750 DOI: 10.1111/hae.13422] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/28/2017] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Data on clinical characteristics and the prevalence of underlying coagulopathies in patients with mild-to-moderate bleeding disorders (MBDs) are scarce. AIM We established the Vienna Bleeding Biobank (VIBB) to characterize and thoroughly investigate Austrian patients with MBDs. RESULTS Four hundred eighteen patients (female = 345, 82.5%) were included. A platelet function defect (PFD) was diagnosed in 26 (6.2%) and a possible PFD in 30 (7.2%) patients. Eight patients (1.9%) were diagnosed with von Willebrand disease (VWD) (type 1 n = 6; type 2 n = 2), and 29 patients had low VWF (30-50 IU/dL). Deficiencies in factor VIII, IX, XI or XIII were found in 11 (2.6%), 3 (0.7%), 3 (0.7%) and 1 patient(s), 2 patients had dysfibrinogenaemia, and further 2 had possible PFD and FXI deficiency. Probable causal mutations were detected in 8 of 11 patients with FVIII deficiency, 2 of 3 patients with FIX deficiency and 2 of 8 patients with VWD. Three hundred three patients (72.5%) had normal results in the coagulation assays and were categorized as patients with bleeding of unknown cause (BUC). The bleeding score did not differ between patients with and without established diagnosis. A diagnosis of a bleeding disorder was more frequently made in men than in women (49.3% vs 22.9%). Male sex (OR 3.55, 95% CI: 2.02-6.22; P < .001) and blood group 0 (OR 1.86, 95% CI: 1.17-2.94; P = .008) were independently associated with diagnosis of a bleeding disorder. CONCLUSION The high rate of patients with BUC despite in-depth haemostatic assessment underlines the incompleteness of available routine laboratory tests. Males with MBDs were more likely to be diagnosed with an established bleeding disorder than females.
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Affiliation(s)
- J Gebhart
- Department of Medicine I, Clinical Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna, Austria
| | - S Hofer
- Department of Medicine I, Clinical Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna, Austria
| | - S Panzer
- Department of Blood Group Serology and Transfusion Medicine, Medical University of Vienna, Vienna, Austria
| | - P Quehenberger
- Department of Laboratory Medicine, Division of Medical and Chemical Laboratory Diagnostics, Medical University of Vienna, Vienna, Austria
| | - R Sunder-Plassmann
- Department of Laboratory Medicine, Division of Medical and Chemical Laboratory Diagnostics, Medical University of Vienna, Vienna, Austria
| | - G Hoermann
- Department of Laboratory Medicine, Division of Medical and Chemical Laboratory Diagnostics, Medical University of Vienna, Vienna, Austria
| | - E Eigenbauer
- IT-Systems and Communications, Medical University of Vienna, Vienna, Austria
| | - H Haslacher
- Department of Laboratory Medicine, Division of Medical and Chemical Laboratory Diagnostics, Medical University of Vienna, Vienna, Austria
| | - S Kepa
- Department of Medicine I, Clinical Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna, Austria
| | - P A Kyrle
- Department of Medicine I, Clinical Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna, Austria
| | - S Eichinger
- Department of Medicine I, Clinical Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna, Austria
| | - P Knöbl
- Department of Medicine I, Clinical Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna, Austria
| | - L Eischer
- Department of Medicine I, Clinical Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna, Austria
| | - C Mannhalter
- Department of Laboratory Medicine, Division of Medical and Chemical Laboratory Diagnostics, Medical University of Vienna, Vienna, Austria
| | - C Ay
- Department of Medicine I, Clinical Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna, Austria
| | - I Pabinger
- Department of Medicine I, Clinical Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna, Austria
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33
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Kuiper GJAJM, Christiaans MHL, Mullens MHJM, Ten Cate H, Hamulýak K, Henskens YMC. Routine haemostasis testing before transplanted kidney biopsy: a cohort study. Transpl Int 2017; 31:302-312. [PMID: 29108097 DOI: 10.1111/tri.13090] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Revised: 09/30/2017] [Accepted: 10/30/2017] [Indexed: 01/18/2023]
Abstract
Kidney biopsy can result in bleeding complications. Prebiopsy testing using bleeding time (BT) is controversial. New whole blood haemostasis tests, such as platelet function analyser-100 (PFA-100) and multiple electrode aggregometry (MEA), might perform better. We postulated that PFA-100 would be suitable to replace BT prebiopsy. In 154 patients, transplanted kidney biopsies were performed after measurement of bleeding time, PFA-100, MEA and mean platelet volume (MPV). Bleeding outcome (haemoglobin (Hb) drop, haematuria (±bladder catheterization), ultrasound finding of a bleeding, need for (non)surgical intervention and/or transfusion) after the biopsy was correlated to each test. Male-female ratio was 2:1. 50% had a surveillance biopsy at either three or 12 months. Around 17% (had) used acetylsalicylic acid (ASA) prebiopsy. Of 17 bleeding events, one subject needed a transfusion. Most bleeding events were Hb reductions over 1 mmol/l and all resolved uneventful. BT, PFA-100, MEA and MPV did not predict a bleeding outcome; prior ASA use however could (odds ratio 3.19; 95%-CI 1.06 to 9.61). Diagnostic performance data and Bland-Altman analysis showed that BT could not be substituted by PFA-100. ASA use was the best determinant of bleeding after kidney biopsy. Routine haemostasis testing prebiopsy has no added value.
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Affiliation(s)
- Gerhardus J A J M Kuiper
- Department of Anaesthesiology and Pain Treatment, Maastricht University Medical Center (Maastricht UMC+), Maastricht, the Netherlands.,Laboratory for Clinical Thrombosis and Haemostasis, Department of Internal Medicine, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center (Maastricht UMC+), Maastricht, The Netherlands
| | - Maarten H L Christiaans
- Department of Internal Medicine, Maastricht University Medical Center (Maastricht UMC+), Maastricht, The Netherlands.,Department of Internal Medicine, Subdivision of Nephrology, Maastricht University Medical Center (Maastricht UMC+), Maastricht, The Netherlands
| | - Monique H J M Mullens
- Department of Internal Medicine, Subdivision of Nephrology, Maastricht University Medical Center (Maastricht UMC+), Maastricht, The Netherlands
| | - Hugo Ten Cate
- Laboratory for Clinical Thrombosis and Haemostasis, Department of Internal Medicine, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center (Maastricht UMC+), Maastricht, The Netherlands.,Department of Internal Medicine, Maastricht University Medical Center (Maastricht UMC+), Maastricht, The Netherlands
| | - Karly Hamulýak
- Department of Internal Medicine, Maastricht University Medical Center (Maastricht UMC+), Maastricht, The Netherlands.,Department of Internal Medicine, Subdivision of Haematology, Maastricht University Medical Center (Maastricht UMC+), Maastricht, The Netherlands
| | - Yvonne M C Henskens
- Central Diagnostic Laboratory, Cluster for Haemostasis and Transfusion, Maastricht University Medical Center (Maastricht UMC+), Maastricht, The Netherlands
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Leinøe E, Zetterberg E, Kinalis S, Østrup O, Kampmann P, Norström E, Andersson N, Klintman J, Qvortrup K, Nielsen FC, Rossing M. Application of whole-exome sequencing to direct the specific functional testing and diagnosis of rare inherited bleeding disorders in patients from the Öresund Region, Scandinavia. Br J Haematol 2017; 179:308-322. [PMID: 28748566 PMCID: PMC5655919 DOI: 10.1111/bjh.14863] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Accepted: 06/20/2017] [Indexed: 01/19/2023]
Abstract
Rare inherited bleeding disorders (IBD) are a common cause of bleeding tendency. To ensure a correct diagnosis, specialized laboratory analyses are necessary. This study reports the results of an upfront diagnostic strategy using targeted whole exome sequencing. In total, 156 patients with a significant bleeding assessment tool score participated in the study, of which a third had thrombocytopenia. Eighty‐seven genes specifically associated with genetic predisposition to bleeding were analysed by whole exome sequencing. Variants were classified according to the five‐tier scheme. We identified 353 germline variants. Eight patients (5%) harboured a known pathogenic variant. Of the 345 previously unknown variants, computational analyses predicted 99 to be significant. Further filtration according to the Mendelian inheritance pattern, resulted in 59 variants being predicted to be clinically significant. Moreover, 34% (20/59) were assigned as novel class 4 or 5 variants upon targeted functional testing. A class 4 or 5 variant was identified in 30% of patients with thrombocytopenia (14/47) versus 11% of patients with a normal platelet count (12/109) (P < 0·01). An IBD diagnosis has a major clinical impact. The genetic investigations detailed here extricated our patients from a diagnostic conundrum, thus demonstrating that continuous optimization of the diagnostic work‐up of IBD is of great benefit.
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Affiliation(s)
- Eva Leinøe
- Department of Haematology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Eva Zetterberg
- Department of Haematology, Coagulation Unit, Skaane University Hospital, Lund, Sweden
| | - Savvas Kinalis
- Centre for Genomic Medicine, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Olga Østrup
- Centre for Genomic Medicine, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Peter Kampmann
- Department of Haematology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Eva Norström
- Department of Translational Medicine, Lund University, Skaane University Hospital, Lund, Sweden
| | - Nadine Andersson
- Department of Haematology, Coagulation Unit, Skaane University Hospital, Lund, Sweden
| | - Jenny Klintman
- Department of Haematology, Coagulation Unit, Skaane University Hospital, Lund, Sweden
| | - Klaus Qvortrup
- Department of Biomedical Sciences, Core Facility for Integrated Microscopy (CFIM), University of Copenhagen, Copenhagen, Denmark
| | - Finn Cilius Nielsen
- Centre for Genomic Medicine, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Maria Rossing
- Centre for Genomic Medicine, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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Fager Ferrari M, Leinoe E, Rossing M, Norström E, Strandberg K, Steen Sejersen T, Qvortrup K, Zetterberg E. Germline heterozygous variants in genes associated with familial hemophagocytic lymphohistiocytosis as a cause of increased bleeding. Platelets 2017; 29:56-64. [PMID: 28399723 DOI: 10.1080/09537104.2017.1293808] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Familial hemophagocytic lymphohistiocytosis (FHL) is caused by biallelic variants in genes regulating granule secretion in cytotoxic lymphocytes. In FHL3-5, the affected genes UNC13D, STX11 and STXBP2 have further been shown to regulate the secretion of platelet granules, giving rise to compromised platelet function. Therefore, we aimed to investigate platelet degranulation in patients heterozygous for variants in UNC13D, STX11 and STXBP2. During the work-up of patients referred to the Coagulation Unit, Skåne University Hospital, Malmö, Sweden and the Department of Hematology, Rigshospitalet, Copenhagen, Denmark due to bleeding tendencies, 12 patients harboring heterozygous variants in UNC13D, STX11 or STXBP2 were identified using targeted whole exome sequencing. Transmission electron microscopy (TEM) was used to assess the secretion of platelet dense granules following thrombin stimulation. Platelet degranulation, activation and aggregation were further assessed by flow cytometry (FC) and light transmission aggregometry (LTA) with lumi-aggregometry. In total, eight out of twelve (67%) patients showed impaired degranulation by at least one of the assays (TEM, FC and LTA). In the 12 patients, eight different heterozygous variants were identified. One variant was strongly associated with impaired degranulation, while four of the variants were associated with impaired granule secretion to a slightly lesser extent. One additional variant was found in six out of the twelve patients, and was associated with varying degrees of degranulation impairment. Accordingly, six out of the eight (75%) identified variants were associated with impaired platelet degranulation. Our results suggest that heterozygous variants in UNC13D, STX11 and STXBP2 are sufficient to cause platelet secretion defects resulting in increased bleeding.
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Affiliation(s)
| | - Eva Leinoe
- b Department of Hematology, Rigshospitalet , Copenhagen University Hospital , Copenhagen , Denmark
| | - Maria Rossing
- c Department of Genomic Medicine, Rigshospitalet , Copenhagen University Hospital , Copenhagen , Denmark
| | - Eva Norström
- a Department of Translational Medicine , Lund University , Malmö , Sweden
| | - Karin Strandberg
- d Department of Laboratory Medicine , Lund University , Malmö , Sweden
| | - Tobias Steen Sejersen
- e Department of Biomedical Sciences, Core Facility for Integrated Microscopy (CFIM) , University of Copenhagen , Denmark
| | - Klaus Qvortrup
- e Department of Biomedical Sciences, Core Facility for Integrated Microscopy (CFIM) , University of Copenhagen , Denmark
| | - Eva Zetterberg
- a Department of Translational Medicine , Lund University , Malmö , Sweden
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Gebhart J, Kepa S, Hofer S, Koder S, Kaider A, Wolberg AS, Haslacher H, Quehenberger P, Eigenbauer E, Panzer S, Mannhalter C, Pabinger I. Fibrinolysis in patients with a mild-to-moderate bleeding tendency of unknown cause. Ann Hematol 2016; 96:489-495. [PMID: 28018998 PMCID: PMC5288436 DOI: 10.1007/s00277-016-2893-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Accepted: 11/29/2016] [Indexed: 11/20/2022]
Abstract
In more than 50% of patients with a mild-to-moderate bleeding tendency, no underlying cause can be identified (bleeding of unknown cause, BUC). Data on parameters of fibrinolysis in BUC are scarce in the literature and reveal discrepant results. It was the aim of this study to investigate increased fibrinolysis as a possible mechanism of BUC. We included 270 patients (227 females, median age 44 years, 25–75th percentile 32–58) with BUC and 98 healthy controls (65 females, median age 47 years, 25–75thpercentile 39–55). Tissue plasminogen activator (tPA-) antigen and activity, plasminogen activator inhibitor type-1 (PAI-1), tPA-PAI-1 complexes, thrombin activatable fibrinolysis inhibitor (TAFI), α2-antiplasmin, and D-dimer were determined. While PAI-1 deficiency was equally frequent in patients with BUC and controls (91/270, 34%, and 33/98, 34%, p = 0.996), tPA activity levels were more often above the detection limit in patients than in controls (103/213, 48%, and 23/98, 23%, p < 0.0001). We found lower levels of tPA-PAI-1 complexes (6.86 (3.99–10.00) and 9.11 (7.17–13.12), p < 0.001) and higher activity of TAFI (18.61 (15.80–22.58) and 17.03 (14.02–20.02), p < 0.001) and α2-antiplasmin (102 (94–109) and 98 (90–106], p = 0.003) in patients compared to controls. Detectable tPA activity (OR 3.02, 95%CI 1.75–5.23, p < 0.0001), higher levels of TAFI (OR 2.57, 95%CI 1.48–4.46, p = 0.0008) and α2-antiplasmin (OR 1.03, 95%CI 1.01–1.05, p = 0.011), and lower levels of tPA-PAI-1 complexes (OR 0.90, 95%CI 0.86–0.95, p < 0.0001) were independently associated with BUC in sex-adjusted logistic regression analyses. We conclude that the fibrinolytic system can play an etiological role for bleeding in patients with BUC.
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Affiliation(s)
- Johanna Gebhart
- Department of Medicine I, Clinical Division of Hematology and Hemostaseology, Medical University Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Sylvia Kepa
- Department of Medicine I, Clinical Division of Hematology and Hemostaseology, Medical University Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Stefanie Hofer
- Department of Medicine I, Clinical Division of Hematology and Hemostaseology, Medical University Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Silvia Koder
- Department of Medicine I, Clinical Division of Hematology and Hemostaseology, Medical University Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Alexandra Kaider
- Center for Medical Statistics, Informatics and Intelligent Systems, Medical University Vienna, Vienna, Austria
| | - Alisa S Wolberg
- Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, NC, 27599-7525, USA
| | - Helmuth Haslacher
- Department of Laboratory Medicine, Division of Medical and Chemical Laboratory Diagnostics, Medical University Vienna, Vienna, Austria
| | - Peter Quehenberger
- Department of Laboratory Medicine, Division of Medical and Chemical Laboratory Diagnostics, Medical University Vienna, Vienna, Austria
| | - Ernst Eigenbauer
- IT-Systems and Communications, Medical University Vienna, Vienna, Austria
| | - Simon Panzer
- Department of Blood Group Serology and Transfusion Medicine, Medical University Vienna, Vienna, Austria
| | - Christine Mannhalter
- Department of Laboratory Medicine, Division of Molecular Biology, Medical University Vienna, Vienna, Austria
| | - Ingrid Pabinger
- Department of Medicine I, Clinical Division of Hematology and Hemostaseology, Medical University Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
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Vinholt PJ, Alnor A, Nybo M, Hvas AM. Prediction of bleeding and prophylactic platelet transfusions in cancer patients with thrombocytopenia. Platelets 2016; 27:547-54. [DOI: 10.3109/09537104.2015.1131814] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Pernille J. Vinholt
- Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense C, Denmark
| | - Anne Alnor
- Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense C, Denmark
| | - Mads Nybo
- Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense C, Denmark
| | - Anne-Mette Hvas
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
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Plasma clot properties in patients with a mild-to-moderate bleeding tendency of unknown cause. Ann Hematol 2015; 94:1301-10. [DOI: 10.1007/s00277-015-2399-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Accepted: 01/17/2015] [Indexed: 11/26/2022]
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Dovlatova N. Current status and future prospects for platelet function testing in the diagnosis of inherited bleeding disorders. Br J Haematol 2015; 170:150-61. [PMID: 25920378 DOI: 10.1111/bjh.13405] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Platelets play a crucial role in haemostasis by preventing bleeding at the site of vascular injury. Several defects in platelet morphology and function have been identified and described over the years. Although a range of methodologies is available to assess platelet function, a significant proportion of subjects with bleeding symptoms and normal coagulation parameters still appear to have normal results on platelet function testing. This might suggest that the reason for bleeding is multifactorial and is due to a combination of several minor defects in platelet function and/or other parts of the haemostatic system or might indicate that the currently available platelet function tests do not provide optimal diagnostic power. This review will summarize the established platelet function tests used for diagnosing inherited platelet abnormalities in adults and children, and discuss the newly developed methodologies as well as unmet challenges and potential areas for further improvement in this field.
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Affiliation(s)
- Natalia Dovlatova
- Division of Clinical Neuroscience, Thrombosis and Haemostasis Research Group, Queens Medical Centre, University of Nottingham, Nottingham, UK
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40
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Gresele P. Diagnosis of inherited platelet function disorders: guidance from the SSC of the ISTH. J Thromb Haemost 2015; 13:314-22. [PMID: 25403439 DOI: 10.1111/jth.12792] [Citation(s) in RCA: 177] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Accepted: 11/06/2014] [Indexed: 12/21/2022]
Affiliation(s)
- P Gresele
- Division of Internal and Cardiovascular Medicine, Department of Medicine, University of Perugia, Perugia, Italy
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41
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Díaz R, Dietrich JE, Mahoney D, Yee DL, Srivaths LV. Hemostatic abnormalities in young females with heavy menstrual bleeding. J Pediatr Adolesc Gynecol 2014; 27:324-9. [PMID: 25256871 DOI: 10.1016/j.jpag.2013.12.011] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Revised: 12/13/2013] [Accepted: 12/16/2013] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To study the prevalence of hemostatic abnormalities, including bleeding disorders and risk factors, in young females referred to a multidisciplinary clinic for evaluation of heavy menstrual bleeding (HMB). METHODS Retrospective chart review was undertaken for 131 post-menarchal girls with HMB, 7 to 17 years of age, enrolled in the institutional 'Menorrhagia Data Registry' protocol. The diagnostic approach included: (1) complete blood count, prothrombin time, partial thromboplastin time, fibrinogen, von Willebrand panel (2) platelet aggregometry, specific clotting factor assay, fibrinolytic pathway analysis, and factor XIII level as needed. The prevalence of hemostatic abnormalities and the prognostic significance of clinical variables associated with hemostatic abnormalities in young girls with HMB were evaluated. RESULTS A hemostatic abnormality was identified in 69 (53%) young girls with HMB. Of these, 27 (21%) had an underlying bleeding disorder and 42 (32%) had a risk factor for bleeding, namely low von Willebrand factor activity. A larger number of girls with underlying bleeding disorder had personal history of other bleeding symptoms (48% vs 31%) and bleeding after surgical or dental procedure (25% vs 8%) when compared to females without hemostatic abnormality. Furthermore, girls with risk factor for bleeding (low vWF activity) were more likely to have bleeding after surgical or dental procedure (15% vs 8%) and family history of bleeding (79% vs 60%) than patients without hemostatic abnormality. CONCLUSIONS There is high prevalence of hemostatic abnormalities, including bleeding disorders and risk factors, in young girls with HMB. These findings support comprehensive and systematic hemostatic evaluation in this group of patients.
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Affiliation(s)
- Rosa Díaz
- Texas Children's Hospital, Houston, TX.
| | - Jennifer E Dietrich
- Texas Children's Hospital, Houston, TX; Baylor College of Medicine, Houston, TX
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Mezzano D, Zúñiga P, Pereira J, Quiroga T. Diagnosing type 1 von Willebrand disease: good for patient's health or for doctor's prestige? comment. J Thromb Haemost 2014; 12:2131-4. [PMID: 25213148 DOI: 10.1111/jth.12727] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2014] [Accepted: 09/05/2014] [Indexed: 11/30/2022]
Affiliation(s)
- D Mezzano
- Department of Hematology-Oncology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
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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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Dovlatova N, Lordkipanidzé M, Lowe GC, Dawood B, May J, Heptinstall S, Watson SP, Fox SC. Evaluation of a whole blood remote platelet function test for the diagnosis of mild bleeding disorders. J Thromb Haemost 2014; 12:660-5. [PMID: 24618131 PMCID: PMC4405765 DOI: 10.1111/jth.12555] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2013] [Accepted: 02/23/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND Mild platelet function disorders (PFDs) are complex and difficult to diagnose. The current gold standard test, light transmission aggregometry (LTA), including lumi-aggregometry, is time and labour intensive and blood samples must be processed within a limited time after venepuncture. Furthermore, many subjects with suspected PFDs do not show a platelet abnormality on LTA. OBJECTIVE To assess the diagnostic potential of an easy-to-use remote platelet function test (RPFT) as a diagnostic pre-test for suspected PFDs. METHODS A remote platelet function test was compared with lumi-aggregometry in participants recruited to the Genotyping and Phenotyping of Platelets Study (GAPP, ISRCTN 77951167). For the RPFT, whole blood was stimulated with platelet agonists, stabilized with PAMFix and returned to the central laboratory for analysis of P-selectin and CD63 by flow cytometry. RESULTS For the 61 study participants (42 index cases and 19 relatives) there was a good agreement between lumi-aggregometry and the RPFT, with diagnosis being concordant in 84% of cases (κ = 0.668, P < 0.0001). According to both tests, 29 participants were identified to have a deficiency in platelet function and 22 participants appeared normal. There were four participants where lumi-aggregometry revealed a defect but the RPFT did not, and six participants where the RPFT detected an abnormal platelet response that was not identified by lumi-aggregometry. CONCLUSION This study suggests that the RPFT could be an easy-to-use pre-test to select which participants with bleeding disorders would benefit from extensive platelet phenotyping. Further development and evaluation of the test are warranted in a wider population of patients with excessive bleeding and could provide informative screening tests for PFDs.
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Affiliation(s)
- Natalia Dovlatova
- Cardiovascular Medicine, University of Nottingham, Queens Medical Centre, Nottingham, United Kingdom
- Centre for Cardiovascular Sciences, Birmingham Platelet Group, University of Birmingham, Birmingham, United Kingdom
| | - Marie Lordkipanidzé
- Centre for Cardiovascular Sciences, Birmingham Platelet Group, University of Birmingham, Birmingham, United Kingdom
| | - Gillian C. Lowe
- Centre for Cardiovascular Sciences, Birmingham Platelet Group, University of Birmingham, Birmingham, United Kingdom
| | - Ban Dawood
- Centre for Cardiovascular Sciences, Birmingham Platelet Group, University of Birmingham, Birmingham, United Kingdom
| | - Jane May
- Cardiovascular Medicine, University of Nottingham, Queens Medical Centre, Nottingham, United Kingdom
| | - Stan Heptinstall
- Cardiovascular Medicine, University of Nottingham, Queens Medical Centre, Nottingham, United Kingdom
| | - Steve P. Watson
- Centre for Cardiovascular Sciences, Birmingham Platelet Group, University of Birmingham, Birmingham, United Kingdom
| | - Susan C. Fox
- Cardiovascular Medicine, University of Nottingham, Queens Medical Centre, Nottingham, United Kingdom
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Faranoush M, Abolghasemi H, Toogeh G, Karimi M, Eshghi P, Managhchi M, Hoorfar H, Dehdezi BK, Mehrvar A, Khoeiny B, Kamyar K, Heshmat R, Baghaeipour MR, Mirbehbahani NB, Fayazfar R, Ahmadinejad M, Naderi M. A Comparison Between Recombinant Activated Factor VII (Aryoseven) and Novoseven in Patients With Congenital Factor VII Deficiency. Clin Appl Thromb Hemost 2014; 21:724-8. [DOI: 10.1177/1076029614522545] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
In order to establish the efficacy and biosimilar nature of AryoSeven to NovoSeven in the treatment of congenital factor VII (FVII) deficiency, patients received either agent at 30 μg/kg, intravenously per week for 4 weeks, in a randomized fashion. The primary aim was to compare FVII:coagulation activity (FVII:C), 20 minutes after recombinant activated FVII (rFVIIa) injection, in the 2 groups. A secondary measure was self-reported bleeding. The median interquartile baseline range of the plasma level of activated FVII (FVIIa) activity in the 2 groups was 1.6 (1.1-14.0) IU/dL and 5.0 (1.1-25.5) IU/dL. All patients achieved levels of FVIIa (FVII:C) >30 IU/dL, 20 minutes after the injection of rFVIIa. Bleeding was similar between the 2 groups, with a comparable decrease in severity and frequency compared to the last month prior to treatment. AryoSeven is similar to NovoSeven in increasing postinjection FVIIa activity as well as in clinical safety and efficacy.
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Affiliation(s)
- M. Faranoush
- High Institute of Research, Iranian Blood Transfusion Organization, Iran University of Medical Sciences, Rasool Akram Hospital, Tehran, Iran
| | | | - Gh. Toogeh
- Tehran University of Medical Sciences, Thrombosis and Hemostasis Research Center, Tehran, Iran
| | - M. Karimi
- Shiraz University of Medical Sciences, Shiraz, Iran
| | - P. Eshghi
- Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - M. Managhchi
- Tehran University of Medical Sciences, Thrombosis and Hemostasis Research Center, Tehran, Iran
| | - H. Hoorfar
- Isfahan University of Medical Sciences, Isfahan, Iran
| | | | | | | | - K. Kamyar
- Aryogen Zist Darou Company, Karaj, Iran
| | - R. Heshmat
- Tehran University of Medical Sciences, Thrombosis and Hemostasis Research Center, Tehran, Iran
| | | | | | - R. Fayazfar
- Kerman University of Medical Sciences, Kerman, Iran
| | | | - M. Naderi
- Zahedan University of Medical Sciences, Ahwaz, Iran
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Watson SP, Lowe GC, Lordkipanidzé M, Morgan NV. Genotyping and phenotyping of platelet function disorders. J Thromb Haemost 2013; 11 Suppl 1:351-63. [PMID: 23516995 DOI: 10.1111/jth.12199] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
The majority of patients with platelet function disorders (PFDs) have normal platelet counts and mild day-to-day bleeding symptoms, but are at risk of major hemorrhage at times of trauma, surgery, or childbirth. This group is challenging to investigate, because the assays are often time-intensive and labour-intensive, and interpretation is difficult, especially in patients with mild disorders. In addition, interuser variability in performance of the assays, including the currently accepted gold standard, light transmission aggregometry, makes the results difficult to compare between laboratories. Furthermore, a similar pattern of mucocutaneous bleeding is seen in disorders in other components of the hemostatic pathway, including type 1 von Willebrand disease (VWD). We have undertaken an extensive investigation of patients with clinically diagnosed excessive bleeding, using a genotyping and platelet phenotyping approach based on lumi-aggregometry, and other specialist tests of platelet function, in combination with Sanger and next-generation sequencing (NGS). We found a functional defect in ~ 60% of patients, the majority being associated with feedback pathways of platelet activation. Function-disrupting mutations were identified in known and novel genes, and coinheritance with other genetic disorders of hemostasis, including type 1 VWD, was shown. A significant number of mutations are heterozygous and unlikely to cause extensive bleeding in isolation, consistent with incomplete penetrance of inheritance of bleeding disorders and a multifactorial etiology for excessive bleeding in many patients. Mucocutaneous bleeding is a complex trait, and this has important implications for NGS in the assessment of a PFD.
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Affiliation(s)
- S P Watson
- Centre for Cardiovascular Sciences, Institute of Biomedical Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.
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Abstract
Bleeding symptoms are frequently reported even in otherwise healthy subjects, and differentiating a normal subject from a patient with a mild bleeding disorder (MBD) can be extremely challenging. The concept of bleeding rate, that is, the number of bleeding episodes occurring within a definite time, could be used as the unifying framework reconciling the bleeding risk observed in congenital and acquired coagulopathies into a single picture. For instance, primary prevention trials have shown that the incidence of non-major bleeding symptoms in normal subjects is around five per 100 person-years, and this figure is in accordance with the number of hemorrhagic symptoms reported by normal controls in observational studies on hemorrhagic disorders. The incidence of non-major bleeding in patients with MBDs (e.g. in patients with type 1 VWD carrying the C1130F mutation) is also strikingly similar with that of patients taking antiplatelet drugs, and the incidence in moderately severe bleeding disorders (e.g. type 2 VWD) parallels that of patients taking vitamin K antagonists. The severity of a bleeding disorder may therefore be explained by a bleeding rate model, which also explains several common clinical observations. Appreciation of the bleeding rate of congenital and acquired conditions and of its environmental/genetic modifiers into a single framework will possibly allow the development of better prediction tools in the coming years and represents a major scientific effort to be pursued.
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Affiliation(s)
- A Tosetto
- Department of Cell Therapy and Hematology, Hemophilia and Thrombosis Center, San Bortolo Hospital, Vicenza, Italy.
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48
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Hayward CPM, Moffat KA. Laboratory testing for bleeding disorders: strategic uses of high and low-yield tests. Int J Lab Hematol 2013; 35:322-33. [PMID: 23480172 DOI: 10.1111/ijlh.12077] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2013] [Accepted: 02/04/2013] [Indexed: 11/26/2022]
Abstract
Laboratory testing is essential for diagnosing bleeding disorders. The tests and panels that laboratories currently use for bleeding disorder evaluation are not standardized, although most offer coagulation screening tests in bleeding disorder panels. Some tests for bleeding disorders, including von Willebrand factor multimer assays and tests for rarer disorders, are not widely available. Accordingly, clinicians and laboratories need tailored strategies for evaluating common and rare bleeding disorders. Coagulation screening tests have high specificity, however, false positives and false negatives do occur among subjects evaluated for bleeding disorders and more specific tests (e.g., factor assays) are required to further assess abnormalities. Tests for defects in primary hemostasis have similar high specificity but much greater sensitivity for common bleeding disorders than coagulation screening tests. Nonetheless, extensive testing fails to establish a diagnosis in a significant number of individuals considered to have significant bleeding problems. Rare bleeding disorder investigations are important to diagnose some conditions, particularly those with delayed-onset bleeding, such as factor XIII deficiency, α2 antiplasmin deficiency, plasminogen activator inhibitor-1 deficiency, and Quebec platelet disorder. These issues need careful consideration when assessing patients for congenital and acquired bleeding problems.
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Affiliation(s)
- C P M Hayward
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON,
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