1
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O'Donnell JS, Baker RI, Atiq F. Low von Willebrand factor-unraveling an enigma wrapped in a conundrum. J Thromb Haemost 2024:S1538-7836(24)00501-4. [PMID: 39265913 DOI: 10.1016/j.jtha.2024.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2024] [Revised: 08/28/2024] [Accepted: 08/30/2024] [Indexed: 09/14/2024]
Abstract
The 2021 ASH ISTH NHF WFH guidelines recommendation that patients with von Willebrand factor (VWF) levels of 30 to 50 IU/dL and an increased bleeding phenotype be categorized as type 1 von Willebrand disease (VWD) rather than Low VWF has proved controversial. However, in support of that decision, recent data have demonstrated that individuals with partial quantitative VWF deficiency exhibit an age-dependent evolving phenotype and confirmed that Low VWF represents a subgroup within heterogeneous type 1 VWD. Nonetheless, type 1 VWD heterogeneity continues to pose significant diagnostic challenges. In this Forum article, we address outstanding issues critical to preventing the inappropriate overdiagnosis of type 1 VWD while maximizing access to healthcare and minimizing diagnostic delays. In addition, we propose an algorithm for type 1 VWD diagnosis. This algorithm pays special attention to individuals with plasma VWF levels in the 30 to 50 IU/dL range who have no or minimal bleeding history and have not yet been exposed to significant hemostatic challenges.
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Affiliation(s)
- James S O'Donnell
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland; National Coagulation Centre, St James's Hospital, Dublin, Ireland; Irish-Australian Blood Collaborative (IABC) Network.
| | - Ross I Baker
- Irish-Australian Blood Collaborative (IABC) Network; Western Australia Centre for Thrombosis and Haemostasis, Perth Blood Institute, Murdoch University, Perth, Western Australia, Australia
| | - Ferdows Atiq
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
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2
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Sidonio RF, Lu A, Hale S, Caicedo J, Bullano M, Xing S. Early diagnosis of persons with von Willebrand disease using a machine learning algorithm and real-world data. Expert Rev Hematol 2024; 17:261-268. [PMID: 38779711 DOI: 10.1080/17474086.2024.2354925] [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: 12/22/2023] [Accepted: 05/07/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND Von Willebrand disease (VWD) is underdiagnosed, often delaying treatment. VWD claims coding is limited and includes no severity qualifiers; improved identification methods for VWD are needed. The aim of this study is to identify and characterize undiagnosed symptomatic persons with VWD in the US from medical insurance claims using predictive machine learning (ML) models. RESEARCH DESIGN AND METHODS Diagnosed and potentially undiagnosed VWD cohorts were defined using Komodo longitudinal US claims data (January 2015-March 2020). ML models were built using key characteristics predictive of VWD diagnosis from the diagnosed cohort. Two ML models predicted VWD diagnosis with the highest accuracy in females (random forest; 84%) and males (gradient boosting machine; 85%). Undiagnosed persons suspected to have VWD were identified using an 80% cutoff probability; profiles of key characteristics were constructed. RESULTS The trained ML models were applied to the undiagnosed cohort (28,463 females; 20,439 males) with suspected VWD. Fifty-two percent of undiagnosed females had heavy menstrual bleeding, a key pre-diagnosis symptom. Undiagnosed males tended to have more frequent medical procedures, hospitalizations, and emergency room visits compared with undiagnosed females. CONCLUSIONS ML algorithms successfully identified potentially undiagnosed symptomatic people with VWD, although many may remain undiagnosed and undertreated. External validation of the algorithms is recommended.
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Affiliation(s)
- Robert F Sidonio
- Aflac Cancer and Blood Disorders Center, Egleston Hospital, Emory University School of Medicine, Atlanta, GA, USA
| | - Anan Lu
- Life Sciences Practice, Charles River Associates, Boston, MA, USA
| | - Sarah Hale
- US Medical, Takeda Pharmaceuticals USA Inc, Lexington, MA, USA
| | - Jorge Caicedo
- US Medical, Takeda Pharmaceuticals USA Inc, Lexington, MA, USA
| | - Mike Bullano
- US Medical, Takeda Pharmaceuticals USA Inc, Lexington, MA, USA
| | - Shan Xing
- US Medical, Takeda Pharmaceuticals USA Inc, Lexington, MA, USA
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3
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Atiq F, Blok R, van Kwawegen CB, Doherty D, Lavin M, van der Bom JG, O'Connell NM, de Meris J, Ryan K, Schols SEM, Byrne M, Heubel-Moenen FCJI, van Galen KPM, Preston RJS, Cnossen MH, Fijnvandraat K, Baker RI, Meijer K, James P, Di Paola J, Eikenboom J, Leebeek FWG, O'Donnell JS. Type 1 VWD classification revisited: novel insights from combined analysis of the LoVIC and WiN studies. Blood 2024; 143:1414-1424. [PMID: 38142407 PMCID: PMC11033584 DOI: 10.1182/blood.2023022457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 11/07/2023] [Accepted: 11/29/2023] [Indexed: 12/26/2023] Open
Abstract
ABSTRACT There is significant ongoing debate regarding type 1 von Willebrand disease (VWD) defintion. Previous guidelines recommended patients with von Willebrand factor (VWF) levels <30 IU/dL be diagnosed type 1 VWD, whereas patients with significant bleeding and VWF levels from 30 to 50 IU/dL be diagnosed with low VWF. To elucidate the relationship between type 1 VWD and low VWF in the context of age-induced increases in VWF levels, we combined data sets from 2 national cohort studies: 162 patients with low VWF from the Low VWF in Ireland Cohort (LoVIC) and 403 patients with type 1 VWD from the Willebrand in The Netherlands (WiN) studies. In 47% of type 1 VWD participants, VWF levels remained <30 IU/dL despite increasing age. Conversely, VWF levels increased to the low VWF range (30-50 IU/dL) in 30% and normalized (>50 IU/dL) in 23% of type 1 VWD cases. Crucially, absolute VWF antigen (VWF:Ag) levels and increase of VWF:Ag per year overlapped between low VWF and normalized type 1 VWD participants. Moreover, multiple regression analysis demonstrated that VWF:Ag levels in low VWF and normalized type 1 VWD patients would not have been different had they been diagnosed at the same age (β = 0.00; 95% confidence interval, -0.03 to 0.04). Consistently, no difference was found in the prevalence of VWF sequence variants; factor VIII activity/VWF:Ag or VWF propeptide/VWF:Ag ratios; or desmopressin responses between low VWF and normalized type 1 VWD patients. In conclusion, our findings demonstrate that low VWF does not constitute a discrete clinical or pathological entity. Rather, it is part of an age-dependent type 1 VWD evolving phenotype. Collectively, these data have important implications for future VWD classification criteria.
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Affiliation(s)
- Ferdows Atiq
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
- Department of Haematology, Erasmus University Medical Center-Erasmus MC, Rotterdam, The Netherlands
| | - Robin Blok
- Department of Haematology, Erasmus University Medical Center-Erasmus MC, Rotterdam, The Netherlands
| | - Calvin B. van Kwawegen
- Department of Haematology, Erasmus University Medical Center-Erasmus MC, Rotterdam, The Netherlands
| | - Dearbhla Doherty
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
- National Coagulation Centre, St James’s Hospital, Dublin, Ireland
| | - Michelle Lavin
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
- National Coagulation Centre, St James’s Hospital, Dublin, Ireland
| | - Johanna G. van der Bom
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Joke de Meris
- Netherlands Hemophilia Society, Leiden, The Netherlands
| | - Kevin Ryan
- National Coagulation Centre, St James’s Hospital, Dublin, Ireland
| | - Saskia E. M. Schols
- Department of Hematology, Radboud University Medical Center, Nijmegen and Hemophilia Treatment Center, Nijmegen-Eindhoven-Maastricht, The Netherlands
| | - Mary Byrne
- National Coagulation Centre, St James’s Hospital, Dublin, Ireland
| | | | - Karin P. M. van Galen
- Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Roger J. S. Preston
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Marjon H. Cnossen
- Department of Pediatric Hematology and Oncology, Erasmus MC, University Medical Center–Sophia Children's Hospital Rotterdam, Rotterdam, The Netherlands
| | - Karin Fijnvandraat
- Department of Pediatric Hematology, Emma Children's Hospital, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
| | - Ross I. Baker
- Western Australia Centre for Thrombosis and Haemostasis, Perth Blood Institute, Murdoch University, Perth, WA, Australia
- Irish-Australian Blood Collaborative Network, Dublin, Ireland
| | - Karina Meijer
- Department of Hematology, University Medical Center Groningen, Groningen, The Netherlands
| | - Paula James
- Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Jorge Di Paola
- Department of Pediatrics, School of Medicine, Washington University in St. Louis, St. Louis, MO
| | - Jeroen Eikenboom
- Department of Internal Medicine, Division of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Frank W. G. Leebeek
- Department of Haematology, Erasmus University Medical Center-Erasmus MC, Rotterdam, The Netherlands
| | - James S. O'Donnell
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
- National Coagulation Centre, St James’s Hospital, Dublin, Ireland
- Irish-Australian Blood Collaborative Network, Dublin, Ireland
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4
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Mollica MY, Beussman KM, Kandasamy A, Rodríguez LM, Morales FR, Chen J, Manohar K, Del Álamo JC, López JA, Thomas WE, Sniadecki NJ. Distinct platelet F-actin patterns and traction forces on von Willebrand factor versus fibrinogen. Biophys J 2023; 122:3738-3748. [PMID: 37434354 PMCID: PMC10541491 DOI: 10.1016/j.bpj.2023.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 04/27/2023] [Accepted: 07/07/2023] [Indexed: 07/13/2023] Open
Abstract
Upon vascular injury, platelets form a hemostatic plug by binding to the subendothelium and to each other. Platelet-to-matrix binding is initially mediated by von Willebrand factor (VWF) and platelet-to-platelet binding is mediated mainly by fibrinogen and VWF. After binding, the actin cytoskeleton of a platelet drives its contraction, generating traction forces that are important to the cessation of bleeding. Our understanding of the relationship between adhesive environment, F-actin morphology, and traction forces is limited. Here, we examined F-actin morphology of platelets attached to surfaces coated with fibrinogen and VWF. We identified distinct F-actin patterns induced by these protein coatings and found that these patterns were identifiable into three classifications via machine learning: solid, nodular, and hollow. We observed that traction forces for platelets were significantly higher on VWF than on fibrinogen coatings and these forces varied by F-actin pattern. In addition, we analyzed the F-actin orientation in platelets and noted that their filaments were more circumferential when on fibrinogen coatings and having a hollow F-actin pattern, while they were more radial on VWF and having a solid F-actin pattern. Finally, we noted that subcellular localization of traction forces corresponded to protein coating and F-actin pattern: VWF-bound, solid platelets had higher forces at their central region while fibrinogen-bound, hollow platelets had higher forces at their periphery. These distinct F-actin patterns on fibrinogen and VWF and their differences in F-actin orientation, force magnitude, and force localization could have implications in hemostasis, thrombus architecture, and venous versus arterial thrombosis.
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Affiliation(s)
- Molly Y Mollica
- Department of Bioengineering, University of Washington, Seattle, Washington; Division of Hematology, School of Medicine, University of Washington, Seattle, Washington; Bloodworks Research Institute, Seattle, Washington; Department of Mechanical Engineering, University of Maryland, Baltimore County, Baltimore, Maryland.
| | - Kevin M Beussman
- Department of Mechanical Engineering, University of Washington, Seattle, Washington; Institute for Stem Cell and Regenerative Medicine, University of Washington, Seattle, Washington
| | - Adithan Kandasamy
- Department of Mechanical Engineering, University of Washington, Seattle, Washington; Center for Cardiovascular Biology, University of Washington, Seattle, Washington
| | | | | | - Junmei Chen
- Bloodworks Research Institute, Seattle, Washington
| | - Krithika Manohar
- Department of Mechanical Engineering, University of Washington, Seattle, Washington
| | - Juan C Del Álamo
- Department of Mechanical Engineering, University of Washington, Seattle, Washington; Center for Cardiovascular Biology, University of Washington, Seattle, Washington
| | - José A López
- Division of Hematology, School of Medicine, University of Washington, Seattle, Washington; Bloodworks Research Institute, Seattle, Washington
| | - Wendy E Thomas
- Department of Bioengineering, University of Washington, Seattle, Washington
| | - Nathan J Sniadecki
- Department of Bioengineering, University of Washington, Seattle, Washington; Department of Mechanical Engineering, University of Washington, Seattle, Washington; Institute for Stem Cell and Regenerative Medicine, University of Washington, Seattle, Washington; Center for Cardiovascular Biology, University of Washington, Seattle, Washington; Resuscitation Engineering Science Unit, University of Washington, Seattle, Washington; Molecular Engineering and Science Institute, University of Washington, Seattle, Washington; Department of Lab Medicine and Pathology, University of Washington, Seattle, Washington.
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5
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Corrales-Medina FF, Federici AB, Srivastava A, Dougall A, Millar CM, Roberts JC, Jaffray J, Berntorp E. A need to increase von Willebrand disease awareness: vwdtest.com - A global initiative to help address this gap. Blood Rev 2023; 58:101018. [PMID: 36210240 DOI: 10.1016/j.blre.2022.101018] [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: 07/22/2022] [Revised: 09/14/2022] [Accepted: 09/27/2022] [Indexed: 11/02/2022]
Abstract
Von Willebrand disease (VWD) is an inherited bleeding disorder caused by quantitative or qualitative deficiencies in von Willebrand factor (VWF). People with VWD may experience excessive, recurrent or prolonged bleeding, particularly during menstruation, childbirth, surgery or following trauma. However, many VWD patients are undiagnosed, and therefore inadequately treated. Reasons for the underdiagnosis of VWD include its relatively mild symptoms, complex diagnosis, lack of awareness among non-specialist healthcare providers and the general population, and a lack of prioritisation of disorders disproportionately affecting females. The vwdtest.com platform was launched as part of a global initiative to raise awareness and improve diagnosis of VWD. Besides providing VWD-specific educational resources, the website includes an online bleeding self-assessment tool and offers diagnostic support for individuals, and their providers, who have a score suggestive of a bleeding disorder. vwdtest.com helps to address these unmet needs, especially in regions with limited access to educational and diagnostic resources.
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Affiliation(s)
- Fernando F Corrales-Medina
- Division of Pediatric Hematology-Oncology, Department of Pediatrics, University of Miami-Miller School of Medicine, Miami, FL, USA; University of Miami-Hemophilia Treatment Center, Miami, FL, USA.
| | - Augusto B Federici
- University of Milan, School of Medicine, Department of Oncology and Haematology Oncology, Milan, Italy; Division of Haematology and Transfusion Medicine of Luigi Sacco University Hospital, Milan, Italy
| | - Alok Srivastava
- Christian Medical College, Department of Haematology, Vellore, India
| | - Alison Dougall
- School of Dental Science, Trinity College Dublin, Ireland; Dublin Dental University Hospital, Dublin, Ireland
| | - Carolyn M Millar
- Imperial College London, Department of Immunology and Inflammation, Centre for Haematology, London, UK
| | - Jonathan C Roberts
- Bleeding & Clotting Disorders Institute, Peoria, IL, USA; University of Illinois College of Medicine at Peoria, Department of Pediatrics and Medicine, Peoria, IL, USA
| | - Julie Jaffray
- Children's Hospital Los Angeles, University of Southern California, Keck School of Medicine, Los Angeles, CA, USA
| | - Erik Berntorp
- Clinical Coagulation Research, Department of Translational Medicine, Lund University, Malmö, Sweden
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6
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O'Donnell JS, Baker RI. Low von Willebrand Disease: A Bleeding Disorder of Unknown Cause? Hamostaseologie 2023; 43:44-51. [PMID: 36807819 DOI: 10.1055/a-1980-8198] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023] Open
Abstract
von Willebrand disease (VWD) represents the most common inherited bleeding disorder. The majority of VWD cases are characterized by partial quantitative reductions in plasma von Willebrand factor (VWF) levels. Management of patients with mild to moderate VWF reductions in the range of 30 to 50 IU/dL poses a common clinical challenge. Some of these low VWF patients present with significant bleeding problems. In particular, heavy menstrual bleeding and postpartum hemorrhage can cause significant morbidity. Conversely, however, many individuals with mild plasma VWF:Ag reductions do not have any bleeding sequelae. In contrast to type 1 VWD, most patients with low VWF do not have detectable pathogenic VWF sequence variants, and bleeding phenotype correlates poorly with residual VWF levels. These observations suggest that low VWF is a complex disorder caused by variants in other genes beyond VWF. With respect to low VWF pathobiology, recent studies have shown that reduced VWF biosynthesis within endothelial cells likely plays a key role. However, pathological enhanced VWF clearance from plasma has also been described in approximately 20% of low VWF cases. For low VWF patients who require hemostatic treatment prior to elective procedures, tranexamic acid and desmopressin have both been shown to be efficacious. In this article, we review the current state of the art regarding low VWF. In addition, we consider how low VWF represents an entity that appears to fall between type 1 VWD on the one hand and bleeding disorders of unknown cause on the other.
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Affiliation(s)
- James S O'Donnell
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin 2, Ireland.,National Coagulation Centre, St James's Hospital, Dublin, Ireland.,Irish-Australian Blood Collaborative (IABC) Network, Dublin, Ireland
| | - Ross I Baker
- Irish-Australian Blood Collaborative (IABC) Network, Dublin, Ireland.,Western Australia Centre for Thrombosis and Haemostasis, Perth Blood Institute, Murdoch University, Perth, Australia.,Hollywood Haemophilia Treatment Centre, Hollywood Hospital, Perth, Australia
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7
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Eladly F, Miesbach W. Von Willebrand Disease—Specific Aspects in Women. Hamostaseologie 2022; 42:330-336. [DOI: 10.1055/a-1891-9976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
AbstractVon Willebrand disease (VWD) is the most common inherited bleeding disorder, which results from a deficiency or dysfunction of von Willebrand factor (VWF). The major symptoms of patients affected by VWD include mucocutaneous and gastrointestinal bleeding, easy bruising, and prolonged provoked bleeding due to injury or surgery. Although women and men are equally likely to be affected by VWD, women continue to be disproportionately affected by the bleeding challenges. Women with VWD suffer from sex-specific symptoms, such as menorrhagia, and are at higher risk of reproductive problems and recurrent miscarriage. Furthermore, pregnant women with VWD are more likely at higher risk of suffering from primary and secondary peripartal hemorrhage and anemia and the need for transfusions. Despite being affected by gynecologic and obstetrical bleeding, women face multiple barriers in obtaining an accurate diagnosis. This constitutes a problem that needs to be addressed, and early appropriate medical care should be ensured. There are several effective treatment options for women with VWD that can significantly improve their quality of life, including desmopressin, VWF concentrates, hormonal therapy, and antifibrinolytic therapy. During pregnancy, the monitoring of VWF activity levels is essential. The peripartal management depends on the type of VWD and on the measured levels of VWF levels and activity prior to delivery.
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Affiliation(s)
- Fagr Eladly
- Department of Medicine, Medical Clinic 2, Institute of Transfusion Medicine, University Hospital, Goethe University, Frankfurt, Germany
| | - Wolfgang Miesbach
- Department of Medicine, Medical Clinic 2, Institute of Transfusion Medicine, University Hospital, Goethe University, Frankfurt, Germany
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8
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Harris NS, Pelletier JP, Marin MJ, Winter WE. Von Willebrand factor and disease: a review for laboratory professionals. Crit Rev Clin Lab Sci 2021; 59:241-256. [DOI: 10.1080/10408363.2021.2014781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Neil S. Harris
- Department of Pathology, Immunology & Laboratory Medicine, University of Florida, Gainesville, FL, USA
| | - J. Peter Pelletier
- Department of Pathology, Immunology & Laboratory Medicine, University of Florida, Gainesville, FL, USA
| | - Maximo J. Marin
- Department of Pathology, Immunology & Laboratory Medicine, University of Florida, Gainesville, FL, USA
| | - William E. Winter
- Department of Pathology, Immunology & Laboratory Medicine, University of Florida, Gainesville, FL, USA
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9
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Srivaths L, Kouides PA. Low von Willebrand Factor in Children and Adolescents: A Review. JAMA Pediatr 2021; 175:1060-1067. [PMID: 34338716 DOI: 10.1001/jamapediatrics.2021.2186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Recent studies have documented increased bleeding symptoms and related complications in patients with low von Willebrand factor (VWF), highlighting the clinical significance of this entity. Because children and adolescents with VWF deficiencies often present to primary care physicians with bleeding symptoms, physicians need to be aware of this condition for early detection. OBSERVATIONS Studies have found that children and adolescents with low VWF (VWF levels of 30-50 IU/dL) can present with clinically significant bleeding, including mucosal, menstrual, postsurgical, and posttraumatic bleeding, leading to complications such as anemia, iron deficiency, transfusion, hospitalization, and poor quality of life. Detecting and promptly managing low VWF in children and adolescents with bleeding are essential because failure to do so can lead to significant morbidity in adulthood, especially among female patients, including continued heavy menstrual bleeding; postpartum hemorrhage; related gynecologic complications, such as hemorrhagic ovarian cysts; and surgical interventions for heavy menstrual bleeding, including hysterectomy. This narrative review summarizes the observations of several studies that have shed light on the pathophysiologic mechanisms of low VWF and bleeding in these patients and the available diagnostic modalities and treatment options. CONCLUSIONS AND RELEVANCE Studies in children and adolescents have provided important insights into the clinical phenotype, complications, pathophysiologic mechanisms, evaluation, and management of low VWF, now recognized as an important clinicopathologic entity, as presented in this review. As gatekeepers, primary care physicians play an important role in guiding patients with this recently recognized clinicopathologic entity toward appropriate specialty care and providing continued comanagement to prevent future complications as the patients enter adulthood.
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Affiliation(s)
- Lakshmi Srivaths
- Gulf States Hemophilia & Thrombophilia Center, Department of Pediatrics, McGovern School of Medicine, The University of Texas Health Science Center at Houston, Houston
| | - Peter A Kouides
- Mary M. Gooley Hemophilia Center, University of Rochester School of Medicine, Rochester, New York
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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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Colonne CK, Reardon B, Curnow J, Favaloro EJ. Why is Misdiagnosis of von Willebrand Disease Still Prevalent and How Can We Overcome It? A Focus on Clinical Considerations and Recommendations. J Blood Med 2021; 12:755-768. [PMID: 34429677 PMCID: PMC8380198 DOI: 10.2147/jbm.s266791] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 07/31/2021] [Indexed: 12/19/2022] Open
Abstract
Despite von Willebrand disease (VWD) being the most common inherited bleeding disorder, its accurate diagnosis is frequently shrouded by diagnostic pitfalls. VWD is frequently under-diagnosed, over-diagnosed and misdiagnosed, leading to significant avoidable patient morbidity and health care system burden. At the heart of this dilemma lies the heterogeneity and complexity of von Willebrand factor (VWF) and associated defects, and the necessity of coalescing clinical and laboratory features to obtain an accurate diagnosis. Common pitfalls include poor clinical and scientific understanding and familiarity with VWD, incomplete clinical history and lack of routine use of standardised bleeding assessment tools (BAT), difficulty in accessing a comprehensive repertoire of laboratory tests, significant pre-analytical, analytical and post-analytical issues, and lack of expertise in laboratory testing and interpretation. Errors, resulting in under-diagnosis, over-diagnosis, and misdiagnosis of VWD, are presented and discussed. Strategies to minimise errors include better education of clinicians and laboratory staff on VWD, routine use of validated BAT, utilising a comprehensive gamut of laboratory investigations according to a standardised algorithm, and repeating testing to minimise pre-analytical errors. Recommendations on appropriate patient selection for VWD testing, how VWD should be investigated in the laboratory, and how to ensure test results are accurately interpreted in the correct clinical context are detailed.
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Affiliation(s)
- Chanukya K Colonne
- Department of Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead Hospital, Sydney, NSW, Australia
| | - Benjamin Reardon
- Department of Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead Hospital, Sydney, NSW, Australia
| | - Jennifer Curnow
- Department of Clinical Haematology, Westmead Hospital, Sydney, NSW, Australia.,Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia.,Sydney Centres for Thrombosis and Haemostasis, Sydney, NSW, Australia
| | - Emmanuel J Favaloro
- Department of Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead Hospital, Sydney, NSW, Australia.,Sydney Centres for Thrombosis and Haemostasis, Sydney, NSW, Australia.,School of Biomedical Sciences, Charles Sturt University, Wagga Wagga, NSW, Australia
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12
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Cheves TA, DeMarinis S, Sweeney JD. Laboratory Methods in the Assessment of Hereditary Hemostatic Disorders. Hematol Oncol Clin North Am 2021; 35:1051-1068. [PMID: 34391602 DOI: 10.1016/j.hoc.2021.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
In patients presenting with a suspect hereditary bleeding disorder a detailed bleeding history is first obtained. Testing proceeds in a tiered manner with platelet count, platelet morphology, platelet histogram, PFA-100, fibrinogen, prothrombin time, and activated partial thromboplastin time. More detailed testing includes von Willebrand factor, individual clotting factor assays, and platelet function testing. Next, testing for a dysfibrinogenemia, FXIII, or a fibrinolytic defect is considered. Hemostatic abnormality is not demonstrated in a fraction of patients. An approach to management in these patients, such as desmopressin or antifibrinolytic therapy, may be required and empiric use of blood component therapy is discouraged.
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Affiliation(s)
- Tracey A Cheves
- Coagulation and Transfusion Medicine, Rhode Island Hospital and Warren Alpert School of Medicine at Brown University, 593 Eddy Street, Providence, RI 02903, USA
| | - Sandra DeMarinis
- Coagulation and Transfusion Medicine, Rhode Island Hospital and Warren Alpert School of Medicine at Brown University, 593 Eddy Street, Providence, RI 02903, USA
| | - Joseph D Sweeney
- Coagulation and Transfusion Medicine, Rhode Island Hospital and Warren Alpert School of Medicine at Brown University, 593 Eddy Street, Providence, RI 02903, USA.
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13
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Kanamaru Y, Uchiyama T, Kaname T, Yanagi K, Ohara O, Kunishima S, Ishiguro A. ETV6-related thrombocytopenia associated with a transient decrease in von Willebrand factor. Int J Hematol 2021; 114:297-300. [PMID: 33768492 DOI: 10.1007/s12185-021-03136-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 03/15/2021] [Accepted: 03/17/2021] [Indexed: 11/24/2022]
Abstract
ETV6-related thrombocytopenia is an autosomal dominant thrombocytopenia, characterized by a bleeding tendency and predisposition to hematological malignancies. The similarity in symptoms makes differentiating immune and congenital thrombocytopenia challenging. We report a 5-year-old girl who presented with chronic thrombocytopenia associated with repetitive and long-lasting epistaxis, leading to blood transfusion for severe anemia. Blood tests showed thrombocytopenia (52 × 103/µL) with normal-sized platelets and transiently low von Willebrand factor (VWF) levels (VWF:RCo 13%, VWF:Ag 50%); therefore, von Willebrand disease type 2 was initially suspected. Repetition of the blood tests revealed normal levels of VWF. Exome and Sanger sequencing identified a germline ETV6 heterozygous variant, c.641C > T:p.(P214L). No additional pathogenic variants were found, including VWF, in the gene panel testing of the 53 known target causative genes for thrombocytopenia. High-throughput exome sequencing for chronic thrombocytopenia can be utilized to differentially diagnose ETV6-related thrombocytopenia from chronic/intractable immune thrombocytopenia and to effectively monitor malignancy.
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Affiliation(s)
- Yuri Kanamaru
- Center for Postgraduate Education and Training, National Center for Child Health and Development (NCCHD), Tokyo, Japan
| | - Toru Uchiyama
- Department of Human Genetics, Research Institute, NCCHD, Tokyo, Japan
| | - Tadashi Kaname
- Department of Genome Medicine, Research Institute, NCCHD, Tokyo, Japan
| | - Kumiko Yanagi
- Department of Genome Medicine, Research Institute, NCCHD, Tokyo, Japan
| | - Osamu Ohara
- Department of Applied Genomics, Kazusa DNA Research Institute, Chiba, Japan
| | - Shinji Kunishima
- Department of Medical Technology, School of Health Sciences, Gifu University of Medical Science, Gifu, Japan
| | - Akira Ishiguro
- Center for Postgraduate Education and Training, National Center for Child Health and Development (NCCHD), Tokyo, Japan.
- Division of Hematology, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, 157-8535, Japan.
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14
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Low VWF: insights into pathogenesis, diagnosis, and clinical management. Blood Adv 2021; 4:3191-3199. [PMID: 32663299 DOI: 10.1182/bloodadvances.2020002038] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 05/29/2020] [Indexed: 01/17/2023] Open
Abstract
von Willebrand disease (VWD) constitutes the most common inherited human bleeding disorder. Partial quantitative von Willebrand factor (VWF) deficiency is responsible for the majority of VWD cases. International guidelines recommend that patients with mild to moderate reductions in plasma VWF antigen (VWF:Ag) levels (typically in the range of 30-50 IU/dL) should be diagnosed with low VWF. Over the past decade, a series of large cohort studies have provided significant insights into the biological mechanisms involved in type 1 VWD (plasma VWF:Ag levels <30 IU/dL). In striking contrast, however, the pathogenesis underpinning low VWF has remained poorly understood. Consequently, low VWF patients continue to present significant clinical challenges with respect to genetic counseling, diagnosis, and management. For example, there is limited information regarding the relationship between plasma VWF:Ag levels and bleeding phenotype in subjects with low VWF. In addition, it is not clear whether patients with low VWF need treatment. For those patients with low VWF in whom treatment is deemed necessary, the optimal choice of therapy remains unknown. However, a number of recent studies have provided important novel insights into these clinical conundrums and the molecular mechanisms responsible for the reduced levels observed in low VWF patients. These emerging clinical and scientific findings are considered in this review, with particular focus on pathogenesis, diagnosis, and clinical management of low VWF.
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15
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von Willebrand disease: what does the future hold? Blood 2021; 137:2299-2306. [PMID: 33662989 DOI: 10.1182/blood.2020008501] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 02/09/2021] [Indexed: 12/12/2022] Open
Abstract
von Willebrand disease (VWD) is characterized by its heterogeneous clinical manifestation, which complicates its diagnosis and management. The clinical management of VWD has remained essentially unchanged over the last 30 years or so, using von Willebrand factor (VWF) concentrates, desmopressin, and anti-fibrinolytic agents as main tools to control bleeding. This is in contrast to hemophilia A, for which a continuous innovative path has led to novel treatment modalities. Despite current VWD management being considered effective, quality-of-life studies consistently reveal a higher than anticipated burden of VWD on patients, which is particularly true for women. Apparently, despite our perceived notion of current therapeutic efficiency, there is space for innovation with the goal of reaching superior efficacy. Developing innovative treatments for VWD is complex, especially given the heterogeneity of the disease and the multifunctional nature of VWF. In this perspective article, we describe several potential strategies that could provide the basis for future VWD treatments. These include genetic approaches, such as gene therapy using dual-vector adenoassociated virus and transcriptional silencing of mutant alleles. Furthermore, protein-based approaches to increase factor FVIII levels in VWD-type 3 or 2N patients are discussed. Finally, antibody-based options to interfere with VWF degradation (for congenital VWD-type 2A or acquired von Willebrand syndrome-type 2A) or increase endogenous VWF levels (for VWD-type 1) are presented. By highlighting these potential strategies, we hope to initiate an innovative path, which ultimately would allow us to better serve VWD patients and their specific needs.
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16
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Castaman G, Linari S. Obstacles to Early Diagnosis and Treatment of Inherited von Willebrand Disease: Current Perspectives. J Blood Med 2021; 12:165-175. [PMID: 33790680 PMCID: PMC7997550 DOI: 10.2147/jbm.s232758] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 01/15/2021] [Indexed: 01/02/2023] Open
Abstract
Von Willebrand disease (VWD), the most common inherited bleeding disorder, is highly heterogeneous, and its early diagnosis may be difficult, especially for mild cases and in qualitative von Willebrand factor (VWF) defects. Appropriate VWD diagnosis requires the combination of personal and/or family history of bleeding and abnormal VWF laboratory testing. The use of bleeding assessment tools has been helpful in standardizing bleeding history collection and quantification of bleeding symptoms to select patients who may benefit of further hemostatic testing. Type 1 and 3 VWD which represent quantitative VWD variants are relatively easy to diagnose. The diagnosis of type 2 VWD requires multiple assessments to evaluate the effects induced by the responsible abnormality on the heterogeneous functions of VWF. Sensitive and reproducible tests are needed to evaluate different VWF activities, starting from measuring VWF-platelet interaction. In the recent years, several increasingly sensitive, rapid and automated assays have been developed, but they are not widely available so far. Genetic testing for VWD diagnosis is not a common practice because VWF gene is very large and highly polymorphic and therefore it is used only in specific cases. It is evident that the early and correct VWD diagnosis allows optimal management of bleeding and situations at risk. Tranexamic acid, desmopressin, replacement therapy with plasma-derived concentrates with a variable content of VWF and FVIII, or the new recombinant VWF are the different therapeutic options available. Careful VWD classification guides treatment because desmopressin is widely used in type 1 while replacement therapy is the cornerstone of treatment for type 2 and 3 variants.
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Affiliation(s)
- Giancarlo Castaman
- Center for Bleeding Disorders and Coagulation, Department of Oncology, Careggi University Hospital, Florence, Italy
| | - Silvia Linari
- Center for Bleeding Disorders and Coagulation, Department of Oncology, Careggi University Hospital, Florence, Italy
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17
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Doherty D, Lavin M, O'Sullivan JM, Ryan K, O'Connell NM, Dougall A, Byrne M, Rafferty M, Doyle MM, Di Paola J, James PD, O'Donnell JS. Management of elective procedures in low von Willebrand factor patients in the LoVIC study. J Thromb Haemost 2021; 19:701-710. [PMID: 33346399 DOI: 10.1111/jth.15220] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 12/02/2020] [Accepted: 12/14/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Most individuals with mild to moderate reductions in plasma von Willebrand factor (VWF) levels do not demonstrate increased bleeding. However, some patients with plasma VWF levels of 30-50 IU/dl do have a significant bleeding phenotype. Management of these "low VWF" patients, who may have significant bleeding scores >10, around times of elective procedures continues to pose a common clinical challenge because of a lack of evidence. OBJECTIVE To investigate the safety and efficacy of different periprocedural management options for adult patients with low VWF. METHODS Treatment and outcomes were retrospectively reviewed for 160 invasive procedures performed in 60 patients with well characterized low VWF enrolled in the previously described Low Von Willebrand factor Ireland Cohort study. RESULTS We demonstrate that 1-desamino-8-D-arginine vasopressin is efficacious in preventing bleeding for both minor or major elective procedures in adult low VWF patients, even in those with significant bleeding histories. In addition, tranexamic acid alone is effective for low VWF patients undergoing nondental minor procedures. Importantly, age-related increases in plasma VWF:antigen levels above 50 IU/dl were not necessarily associated with complete correction of bleeding phenotype. Procedure-related bleeding complications were increased in low VWF patients who did not receive any hemostatic cover before their procedure. CONCLUSION Elective procedures in adult patients with low VWF should be managed in liaison with a comprehensive care tertiary referral center so that personalized treatment plans may be implemented before all minor or major elective procedures.
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Affiliation(s)
- Dearbhla Doherty
- National Coagulation Centre, St James's Hospital, Dublin, Ireland
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin 2, Ireland
| | - Michelle Lavin
- National Coagulation Centre, St James's Hospital, Dublin, Ireland
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin 2, Ireland
| | - Jamie M O'Sullivan
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin 2, Ireland
| | - Kevin Ryan
- National Coagulation Centre, St James's Hospital, Dublin, Ireland
| | | | - Alison Dougall
- National Coagulation Centre, St James's Hospital, Dublin, Ireland
- Trinity College Dublin, Dublin, Ireland
| | - Mary Byrne
- National Coagulation Centre, St James's Hospital, Dublin, Ireland
| | - Marie Rafferty
- National Coagulation Centre, St James's Hospital, Dublin, Ireland
| | - Mairead M Doyle
- National Coagulation Centre, St James's Hospital, Dublin, Ireland
| | - Jorge Di Paola
- Department of Pediatrics, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Paula D James
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - James S O'Donnell
- National Coagulation Centre, St James's Hospital, Dublin, Ireland
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin 2, Ireland
- National Children's Research Centre, Our Lady's Children's Hospital Crumlin, Dublin, Ireland
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18
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Atiq F, Wuijster E, de Maat MP, Kruip MJ, Cnossen MH, Leebeek FW. Criteria for low von Willebrand factor diagnosis and risk score to predict future bleeding. J Thromb Haemost 2021; 19:719-731. [PMID: 33370487 PMCID: PMC7986755 DOI: 10.1111/jth.15227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 12/01/2020] [Accepted: 12/18/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Important diagnostic and clinical aspects of moderately reduced von Willebrand factor (VWF) levels are still unknown. There is no clear evidence which cutoff value (0.50 vs 0.60 IU/ml) should be used to diagnose "low VWF." Also, the incidence of bleeding after the diagnosis has been made, and risk factors for bleeding are unknown yet. OBJECTIVES To investigate the incidence of postsurgical bleeding, postpartum hemorrhage (PPH), and traumatic and spontaneous bleeding after low VWF diagnosis, and to develop a risk score to predict future bleeding. METHODS We performed a cohort study in patients with historically lowest VWF levels of 0.31 to 0.60 IU/ml. Clinical data of patients were retrospectively collected. RESULTS We included 439 patients with low VWF. During a follow-up of 6.3 ± 3.7 years, 259 surgical procedures, 81 deliveries, and 109 spontaneous and traumatic bleeding episodes were reported. The incidence of postsurgical bleeding was 2.7%, whereas 10% of deliveries was complicated by PPH. Overall, 65 patients (14.8%) had bleeding requiring treatment, which was not different between patients with historically lowest VWF levels of 0.31-0.50 and 0.51-0.60 IU/ml (p = .154). Age <18 years, abnormal bleeding score at diagnosis, and being referred for bleeding symptoms at the time of diagnosis were independent risk factors for bleeding during follow-up, and therefore included in the risk score. CONCLUSIONS The cutoff value of low VWF diagnosis should be set at 0.60 IU/ml. Furthermore, a risk score is developed to identify individuals with a high risk for bleeding after low VWF diagnosis.
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Affiliation(s)
- Ferdows Atiq
- Department of HematologyErasmus MCUniversity Medical Center RotterdamRotterdamThe Netherlands
| | - Esmee Wuijster
- Department of HematologyErasmus MCUniversity Medical Center RotterdamRotterdamThe Netherlands
| | - Moniek P.M. de Maat
- Department of HematologyErasmus MCUniversity Medical Center RotterdamRotterdamThe Netherlands
| | - Marieke J.H.A. Kruip
- Department of HematologyErasmus MCUniversity Medical Center RotterdamRotterdamThe Netherlands
| | - Marjon H. Cnossen
- Department of Pediatric HematologyErasmus MC‐Sophia Children’s HospitalUniversity Medical Center RotterdamRotterdamThe Netherlands
| | - Frank W.G. Leebeek
- Department of HematologyErasmus MCUniversity Medical Center RotterdamRotterdamThe Netherlands
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19
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O'Donnell JS. Toward Personalized Treatment for Patients with Low von Willebrand Factor and Quantitative von Willebrand Disease. Semin Thromb Hemost 2021; 47:192-200. [PMID: 33636750 DOI: 10.1055/s-0041-1722864] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The biological mechanisms involved in the pathogenesis of type 2 and type 3 von Willebrand disease (VWD) have been studied extensively. In contrast, although accounting for the majority of VWD cases, the pathobiology underlying partial quantitative VWD has remained somewhat elusive. However, important insights have been attained following several recent cohort studies that have investigated mechanisms in patients with type 1 VWD and low von Willebrand factor (VWF), respectively. These studies have demonstrated that reduced plasma VWF levels may result from either (1) decreased VWF biosynthesis and/or secretion in endothelial cells and (2) pathological increased VWF clearance. In addition, it has become clear that some patients with only mild to moderate reductions in plasma VWF levels in the 30 to 50 IU/dL range may have significant bleeding phenotypes. Importantly in these low VWF patients, bleeding risk fails to correlate with plasma VWF levels and inheritance is typically independent of the VWF gene. Although plasma VWF levels may increase to > 50 IU/dL with progressive aging or pregnancy in these subjects, emerging data suggest that this apparent normalization in VWF levels does not necessarily equate to a complete correction in bleeding phenotype in patients with partial quantitative VWD. In this review, these recent advances in our understanding of quantitative VWD pathogenesis are discussed. Furthermore, the translational implications of these emerging findings are considered, particularly with respect to designing personalized treatment plans for VWD patients undergoing elective procedures.
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Affiliation(s)
- James S O'Donnell
- Irish Centre for Vascular Biology, School of Pharmacy & Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland.,National Coagulation Centre, St. James's Hospital, Dublin, Ireland.,National Children's Research Centre, Our Lady's Children's Hospital at Crumlin, Dublin, Ireland
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20
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Karampini E, O'Donnell JS. Correcting dominant-negative von Willebrand disease. J Thromb Haemost 2021; 19:55-57. [PMID: 33405380 DOI: 10.1111/jth.15123] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 09/29/2020] [Accepted: 10/02/2020] [Indexed: 01/22/2023]
Affiliation(s)
- Ellie Karampini
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - James S O'Donnell
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
- National Coagulation Centre, St James's Hospital, Dublin, Ireland
- National Children's Research Centre, Our Lady's Children's Hospital, Dublin, Ireland
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21
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Biguzzi E, Siboni SM, le Cessie S, Baronciani L, Rosendaal FR, van Hylckama Vlieg A, Peyvandi F. Increasing levels of von Willebrand factor and factor VIII with age in patients affected by von Willebrand disease. J Thromb Haemost 2021; 19:96-106. [PMID: 32998182 DOI: 10.1111/jth.15116] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 09/01/2020] [Accepted: 09/17/2020] [Indexed: 12/01/2022]
Abstract
Essentials VWF and FVIII increase with age in patients affected by VWD. VWF and FVIII increase in type 1 and in low levels of VWF patients. VWF and FVIII do not increase in type 1 Vicenza. FVIII increases in type 2 VWD patients. ABSTRACT: Background Increasing levels of von Willebrand factor (VWF) and factor VIII (FVIII:C) was associated with age in type 1 von Willebrand disease (VWD). Objectives To evaluate VWF and FVIII:C increase with age in a large group of patients with VWD and low levels of VWF, in whom levels were repeatedly measured. Methods Clinical charts from all patients evaluated at the A. Bianchi Bonomi Center between 1970 and 2018 were reviewed and data on VWF and FVIII:C collected. Patients affected by type 3, severe type 1 and 2N VWD were excluded. The repeated measurements were evaluated by linear mixed-effects models. A linear association between age and VWF/FVIII:C was shown after the age of 40 years in the linear mixed models and analyzed by calculating the regression slope coefficient (β). Results A total of 617 patients were included in the study (314 type 2, 112 type 1, 181 low VWF levels), with a median age at first measurement of 28 years (interquartile range 14/42) and a mean follow-up of 16 years (standard deviation 11). VWF and FVIII:C increased with age in the whole group. The increase became linear after the age of 40 years (3.68 and 7.44 IU/dL per decade for VWF:activity and FVIII:C). In type 2, FVIII:C increased with age, whereas an increase of both VWF:activity and FVIII:C were shown in patients with type 1 VWD and low levels of VWF. Conclusions A differential increase of VWF and FVIII:C with age was shown among in different ages and types of VWD.
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Affiliation(s)
- Eugenia Biguzzi
- A. Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Simona Maria Siboni
- A. Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Saskia le Cessie
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Biomedical Datasciences, Section of Medical Statistics, Leiden University Medical Center, Leiden, The Netherlands
| | - Luciano Baronciani
- A. Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Frits R Rosendaal
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Flora Peyvandi
- A. Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
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22
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Castaman G. How I treat von Willebrand disease. Thromb Res 2020; 196:618-625. [DOI: 10.1016/j.thromres.2020.07.051] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 07/27/2020] [Accepted: 07/29/2020] [Indexed: 01/17/2023]
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23
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de Jager NCB, Heijdra JM, Kieboom Q, Kruip MJHA, Leebeek FWG, Cnossen MH, Mathôt RAA. Population Pharmacokinetic Modeling of von Willebrand Factor Activity in von Willebrand Disease Patients after Desmopressin Administration. Thromb Haemost 2020; 120:1407-1416. [PMID: 32746466 DOI: 10.1055/s-0040-1714349] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Most von Willebrand disease (VWD) patients can be treated with desmopressin during bleeding or surgery. Large interpatient variability is observed in von Willebrand factor (VWF) activity levels after desmopressin administration. The aim of this study was to develop a pharmacokinetic (PK) model to describe, quantify, and explain this variability. METHODS Patients with either VWD or low VWF, receiving an intravenous desmopressin test dose of 0.3 µg kg-1, were included. A PK model was derived on the basis of the individual time profiles of VWF activity. Since no VWF was administered, the VWF dose was arbitrarily set to unity. Interpatient variability in bioavailability (F), volume of distribution (V), and clearance (Cl) was estimated. RESULTS The PK model was developed using 951 VWF activity level measurements from 207 patients diagnosed with a VWD type. Median age was 28 years (range: 5-76), median predose VWF activity was 0.37 IU/mL (range: 0.06-1.13), and median VWF activity response at peak level was 0.64 IU/mL (range: 0.04-4.04). The observed PK profiles were best described using a one-compartment model with allometric scaling. While F increased with age, Cl was dependent on VWD type and sex. Inclusion resulted in a drop in interpatient variability in F and Cl of 81.7 to 60.5% and 92.8 to 76.5%, respectively. CONCLUSION A PK model was developed, describing VWF activity versus time profile after desmopressin administration in patients with VWD or low VWF. Interpatient variability in response was quantified and partially explained. This model is a starting point toward more accurate prediction of desmopressin dosing effects in VWD.
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Affiliation(s)
- Nico C B de Jager
- Hospital Pharmacy-Clinical Pharmacology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jessica M Heijdra
- Department of Paediatric Haematology, Erasmus University Medical Centre - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Quincy Kieboom
- Department of Paediatric Haematology, Erasmus University Medical Centre - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Marieke J H A Kruip
- Department of Haematology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Frank W G Leebeek
- 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
| | - Ron A A Mathôt
- Hospital Pharmacy-Clinical Pharmacology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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24
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Srivaths L, Minard CG, O'Brien SH, Wheeler AP, Mullins E, Sharma M, Sidonio R, Jain S, Zia A, Ragni MV, Kulkarni R, Dietrich JE, Kouides PA. The spectrum and severity of bleeding in adolescents with low von Willebrand factor-associated heavy menstrual bleeding. Blood Adv 2020; 4:3209-3216. [PMID: 32663297 PMCID: PMC7362347 DOI: 10.1182/bloodadvances.2020002081] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 05/29/2020] [Indexed: 01/31/2023] Open
Abstract
Low von Willebrand factor (VWF) in adults is associated with significant bleeding, most notably heavy menstrual bleeding (HMB) and postpartum hemorrhage, although this has not been characterized in adolescents. The objectives of this analysis of a multicenter single arm observational cohort study in adolescents with low VWF-associated HMB were to describe the bleeding phenotype, HMB severity, and related complications. Eligibility criteria included postmenarchal females <21 years of age with HMB (Pictorial Blood Assessment Chart [PBAC] score >100) and low VWF (2 values of VWF activity ≥30 and ≤50 IU/dL). Patients diagnosed with other bleeding disorders were ineligible. Clinical phenotype data, including PBAC and Bleeding Assessment Tool (BAT) scores, laboratory data, and HMB management/outcome details, were extracted. Patient demographics and clinical characteristics were summarized as medians with minimum/maximum values or frequencies with percentages. Groups were compared using a Wilcoxon rank-sum test or Fisher's exact test. A total of 113 patients met inclusion criteria, and 2 were excluded. Ninety four percent had a significant bleeding phenotype (BAT score >2), with predominantly mucocutaneous bleeding (32%-44%), postprocedural/surgical bleeding (15%), and severe HMB (BAT HMB domain score ≥2; 90%). Bleeding complications included iron deficiency (60%), anemia (21%), transfusion (12%), and hospitalization (10%). Desmopressin challenge response in subjects tested was good and sustained. Several (48%) required combined therapy for HMB (hormonal/hemostatic), and one third did not show improvement despite therapy. Our results suggest that adolescent females with low VWF have a significant bleeding phenotype and resultant complications warranting a focus on prompt diagnosis, appropriate therapy, and prevention of complications.
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Affiliation(s)
- Lakshmi Srivaths
- Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Charles G Minard
- Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Sarah H O'Brien
- Division of Pediatric Hematology/Oncology, Nationwide Children's Hospital, Columbus, OH
| | - Allison P Wheeler
- Department of Pediatrics, Vanderbilt University Medical Center, Vanderbilt, TN
| | - Eric Mullins
- Division of Hematology, University of Cincinnati College of Medicine and Cincinnati Children's Hospital, Cincinnati, OH
| | - Mukta Sharma
- Department of Pediatrics, Children's Mercy Hospital, Kansas City, MO
| | - Robert Sidonio
- Aflac Cancer and Blood Disorders Center, Emory University, Atlanta, GA
| | - Shilpa Jain
- Department of Pediatrics, University of Buffalo, Buffalo, NY
| | - Ayesha Zia
- Department of Pediatrics, The University of Texas, Southwestern, Dallas, TX
| | - Margaret V Ragni
- Division of Hematology/Oncology, University of Pittsburgh, Pittsburgh, PA
| | - Roshni Kulkarni
- Department of Pediatrics and Human Development, Michigan State University, East Lansing, MI
| | - Jennifer E Dietrich
- Department of Pediatrics, Baylor College of Medicine, Houston, TX
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX; and
| | - Peter A Kouides
- Department of Medicine, University of Rochester, Rochester, NY
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25
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Miesbach W. Perioperative management for patients with von Willebrand disease: Defining the optimal approach. Eur J Haematol 2020; 105:365-377. [DOI: 10.1111/ejh.13462] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 05/28/2020] [Accepted: 05/29/2020] [Indexed: 01/19/2023]
Affiliation(s)
- Wolfgang Miesbach
- Haemophilia Centre Medical Clinic II Institute of Transfusion Medicine Goethe University Hospital Frankfurt am Main Germany
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26
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Laffan M, Sathar J, Johnsen JM. von Willebrand disease: Diagnosis and treatment, treatment of women, and genomic approach to diagnosis. Haemophilia 2020; 27 Suppl 3:66-74. [PMID: 32578345 DOI: 10.1111/hae.14050] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 05/03/2020] [Accepted: 05/11/2020] [Indexed: 01/08/2023]
Abstract
von Willebrand disease (VWD) is the most common inherited bleeding disorder. VWD is caused by deficiencies in von Willebrand factor (VWF), a critical adhesive haemostatic protein. This review provides an overview of VWD diagnosis and treatment, special considerations in treating women with VWD, and current genomic approaches to VWD. For diagnosis and treatment in VWD, an accurate diagnosis is critical to providing effective treatments, determining appropriate laboratory monitoring and for counselling the patient and family. Diagnosis of VWD begins with the clinical assessment for the bleeding phenotype, which is usually characterized by mucocutaneous and provoked bleeding. The diagnosis of VWD is then made by laboratory investigation. Multiple assays are used to assess VWF levels and functions. The mainstays of VWD treatment are tailored by VWD type and symptoms, and can include antifibrinolytic treatment, desmopressin and VWF replacement treatment. Women with VWD are also at risk for excessive uterine bleeding, such as with menses and childbirth. In addition to standard VWD treatments, heavy menstrual bleeding can be treated with hormones. Interdisciplinary management of childbirth and prophylaxis in the postpartum period are needed to reduce the risk of postpartum haemorrhage. Genomic approaches to VWD can inform VWD diagnosis, treatment, test assay selection, reproductive planning and family counselling. Most VWD patients have an identifiable VWF gene DNA variant. Next-generation sequencing is rapidly being adopted to provide more comprehensive VWF sequence information for patients with known or suspected VWD.
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Affiliation(s)
- Michael Laffan
- Centre for Haematology, Imperial College London, London, UK
| | - Jameela Sathar
- Department of Haematology, Ampang Hospital, Ampang, Selangor, Malaysia.,Clinical Trial Unit, Clinical Research Centre, Ministry of Health, Ampang, Selangor, Malaysia
| | - Jill M Johnsen
- Research Institute, Bloodworks Northwest, Seattle, WA, USA.,Washington Center for Bleeding Disorders, Seattle, WA, USA.,Department of Medicine, University of Washington, Seattle, WA, USA
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27
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Fogarty H, Doherty D, O'Donnell JS. New developments in von Willebrand disease. Br J Haematol 2020; 191:329-339. [PMID: 32394456 DOI: 10.1111/bjh.16681] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 03/30/2020] [Accepted: 04/01/2020] [Indexed: 12/19/2022]
Abstract
Von Willebrand disease (VWD) constitutes the most common inherited human bleeding disorder. It is associated with a mucocutaneous bleeding phenotype that can significantly impact upon quality of life. Despite its prevalence and associated morbidity, the diagnosis and subclassification of VWD continue to pose significant clinical challenges. This is in part attributable to the fact that plasma von Willebrand factor (VWF) levels vary over a wide range in the normal population, together with the multiple different physiological functions played by VWF in vivo. Over recent years, substantial progress has been achieved in elucidating the biological roles of VWF. Significant advances have also been made into defining the pathophysiological mechanisms underpinning both quantitative and qualitative VWD. In particular, several new laboratory assays have been developed that enable more precise assessment of specific aspects of VWF activity. In the present review, we discuss these recent developments in the field of VWD diagnosis, and consider how these advances can impact upon clinical diagnostic algorithms for use in routine clinical practice. In addition, we review some important recent advances pertaining to the various treatment options available for managing patients with VWD.
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Affiliation(s)
- Helen Fogarty
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland.,National Coagulation Centre, St James's Hospital, Dublin, Ireland
| | - Dearbhla Doherty
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - James S O'Donnell
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland.,National Coagulation Centre, St James's Hospital, Dublin, Ireland.,National Children's Research Centre, Our Lady's Children's Hospital Crumlin, Dublin, Ireland
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28
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Lin TC, Cai ZY. The effects of whole body vibration training combined with blood flow restriction on von Willebrand factor response. ISOKINET EXERC SCI 2020. [DOI: 10.3233/ies-192147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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29
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Itzhar-Baikian N, Boisseau P, Joly B, Veyradier A. Updated overview on von Willebrand disease: focus on the interest of genotyping. Expert Rev Hematol 2019; 12:1023-1036. [PMID: 31536379 DOI: 10.1080/17474086.2019.1670638] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Introduction: Von Willebrand disease (VWD) is the most common inherited bleeding disorder, characterized by a quantitative or qualitative defect of von Willebrand factor (VWF), a multimeric glycoprotein crucial for primary hemostasis and coagulation. VWD pathophysiology is heterogeneous as it includes several types and subtypes which therapeutic management is different. The mainstays of VWD treatment are desmopressin and replacement therapy based on both plasma-derived concentrates and a recently developed recombinant VWF. VWD definitive diagnosis is achieved by a battery of phenotypic biologic assays and genotyping is currently performed mostly for research.Areas covered: This narrative review will firstly present a general overview on VWD epidemiology, pathophysiology, classification, clinics, phenotypic biologic diagnosis, and treatment. Secondly, a focus on VWD genotyping will be presented with specific emphasis on the evolution of its technical aspects, its applications for research dedicated to a better understanding of VWD pathophysiology and epidemiology and its interest in both a faster diagnosis and an optimal treatment of VWD.Expert opinion: Based on analysis of the literature, it can be concluded that the fast evolution of genetic techniques together with the development of innovating treatments may significantly change diagnostic flow charts for VWD and their use for specific and personalized treatment.
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Affiliation(s)
- Nathalie Itzhar-Baikian
- Service d'Hématologie biologique Hôpital Lariboisière and EA-3518 Institut de Recherche Saint Louis, Assistance Publique-Hôpitaux de Paris, Université Paris Diderot, Paris, France
| | - Pierre Boisseau
- Service de Génétique médicale, Hôpital Hôtel-Dieu, CHU de Nantes, Nantes, France
| | - Bérangère Joly
- Service d'Hématologie biologique Hôpital Lariboisière and EA-3518 Institut de Recherche Saint Louis, Assistance Publique-Hôpitaux de Paris, Université Paris Diderot, Paris, France
| | - Agnès Veyradier
- Service d'Hématologie biologique Hôpital Lariboisière and EA-3518 Institut de Recherche Saint Louis, Assistance Publique-Hôpitaux de Paris, Université Paris Diderot, Paris, France
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30
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Moonla C, Akkawat B, Kittikalayawong Y, Sukperm A, Meesanun M, Uaprasert N, Sosothikul D, Rojnuckarin P. Bleeding Symptoms and von Willebrand Factor Levels: 30-Year Experience in a Tertiary Care Center. Clin Appl Thromb Hemost 2019; 25:1076029619866916. [PMID: 31359769 PMCID: PMC6829631 DOI: 10.1177/1076029619866916] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Correlations between bleeding symptoms and von Willebrand factor (VWF) levels may help to
predict hemorrhagic severity in the Westerners with von Willebrand disease (VWD), but data
in Asians are lacking. In this study, Thai patients with VWF levels <50 IU/dL without
any secondary causes were enrolled from 1988 to 2018 to determine the relationship between
VWF levels and hemorrhagic manifestations. According to the current concept, we
reclassified VWD and low VWF by VWF levels ≤30 and 30 to 50 IU/dL, respectively. Type 2
VWD was diagnosed if VWF activity to antigen ratio was ≤0.6. Bleeding severity was
determined by the condensed MCMDM-1VWD bleeding score (BS). Among 83 patients, VWF
activities showed negative correlations with BS (P = .001), which were
higher in type 2 (median: 7, interquartile range [IQR]: 5-11) compared with type 1 VWD
(median: 3, IQR: 2-4) and low VWF (median: 4, IQR: 2-8). Bleeding symptoms were
indistinguishable between type 1 VWD and low VWF using the 30 IU/dL cutoff point. However,
VWF ristocetin cofactor activity or gain-of-function mutant glycoprotein Ib binding
activity <36.5 IU/dL and VWF collagen binding activity <34.5 IU/dL could predict
increased bleeding risk (BS ≥3) by 92.3% specificity and 70.0% sensitivity
(P < .0001).
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Affiliation(s)
- Chatphatai Moonla
- 1 Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand.,2 Research Collaborations in Hematologic Malignancies and Hematopoietic Stem Cell Transplantation, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Benjaporn Akkawat
- 1 Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand.,2 Research Collaborations in Hematologic Malignancies and Hematopoietic Stem Cell Transplantation, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Yaowaree Kittikalayawong
- 3 Department of Pediatrics, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Autcharaporn Sukperm
- 1 Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand.,2 Research Collaborations in Hematologic Malignancies and Hematopoietic Stem Cell Transplantation, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Mukmanee Meesanun
- 1 Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand.,2 Research Collaborations in Hematologic Malignancies and Hematopoietic Stem Cell Transplantation, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Noppacharn Uaprasert
- 1 Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand.,2 Research Collaborations in Hematologic Malignancies and Hematopoietic Stem Cell Transplantation, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Darintr Sosothikul
- 3 Department of Pediatrics, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Ponlapat Rojnuckarin
- 1 Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand.,2 Research Collaborations in Hematologic Malignancies and Hematopoietic Stem Cell Transplantation, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
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31
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Boyd SC, O'Connor AD, Horan MA, Dicker P, Manning C, Lynch C, Regan C, Ryan K, Tan T, Byrne BM. Analgesia, anaesthesia and obstetric outcome in women with inherited bleeding disorders. Eur J Obstet Gynecol Reprod Biol 2019; 239:60-63. [PMID: 31185377 DOI: 10.1016/j.ejogrb.2019.05.043] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 05/28/2019] [Accepted: 05/30/2019] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Vertebral canal haematoma (VCH) complicates 1 in 168,000 obstetric epidurals (Ruppen et al., 2006). This risk is increased in women with inherited bleeding disorders (IBD). The impact of a contraindication to regional anaesthesia on pain management and obstetric outcome in these women is unknown. The purpose of this study was to determine anaesthetic use and obstetric outcomes in a cohort of women with IBD. STUDY DESIGN 97 women with IBD that delivered 130 babies at the CWIUH from Jan 2011 to Dec 2016 were identified from a maternal medicine database. Multidisciplinary planning of peripartum care was communicated to labour ward staff using a simple checklist. The primary bleeding disorders were: Von Willebrands disease (VWD) Type 1 27 (27.8%); VWD Type 2A 3 (3.8%); Low VWF 3 (3.8%); Bleeding disorder of unknown aetiology (BDUA) 19 (19.6%); deficiency of Factors VII, VIII, IX, X, and XI 13 (13.4%); Carriers of Factor VIII, IX, X, XIII deficiency 17 (17.5%); 5 had combined deficiencies (5.2%) and there was one platelet function defect. 9 had a family history of a bleeding disorder (9.3%). Haemostatic support, analgesia, mode of delivery and maternal and fetal outcomes were compared between pregnancies where regional anaesthesia was permitted and those that were not using the Chi-squared test. RESULTS When pregnancies where regional anaesthesia was not recommended (49) were compared with pregnancies where regional anaesthesia was considered safe (81), the women were more likely to see an anaesthetist before labour 46 (94%) vs 46 (61%): p < 0.001; to require prophylactic haemostatic support for delivery 30 (61%) vs 1 (1%): p < 0.001; to use a remifentanil infusion 15 (31%) vs 0: p < 0.001, and have general anaesthesia for Caesarean Section (CS) 10 (20%) vs 1(1%): p < 0.001. Vaginal birth 35 (71%) vs 53(65%): p = 0.4 and CS rates 14 (29%) vs 26 (32%) p = 0.28 were similar. Postpartum haemorrhage (PPH) was more common 11 (24%) vs 9(12%) vs p = 0.07 but not statistically so. There were no cases of neonatal bleeding or VCH. CONCLUSION Contraindication to neuraxial blockade in labouring women with IBD does not influence mode of delivery. This information is reassuring to these women who may be anxious about delivery without regional anaesthesia.
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Affiliation(s)
- Sean C Boyd
- University College Dublin, Coombe Women and Infants University Hospital, Dublin 8, Ireland.
| | - Anna D O'Connor
- Maternal Medicine, Coombe Women and Infants University Hospital, Dublin 8, Ireland
| | - Maebh A Horan
- Maternal Medicine, Coombe Women and Infants University Hospital, Dublin 8, Ireland
| | - Pat Dicker
- Department of Epidemiology Royal College of Surgeons, Ireland
| | - Catherine Manning
- Maternal Medicine, Coombe Women and Infants University Hospital, Dublin 8, Ireland
| | - C Lynch
- Maternal Medicine, Coombe Women and Infants University Hospital, Dublin 8, Ireland
| | - C Regan
- Maternal Medicine, Coombe Women and Infants University Hospital, Dublin 8, Ireland
| | - K Ryan
- Maternal Medicine, Coombe Women and Infants University Hospital, Dublin 8, Ireland
| | - T Tan
- Perioperative Medicine Service, Coombe Women and Infants University Hospital, Dublin 8, Ireland
| | - B M Byrne
- Maternal Medicine, Coombe Women and Infants University Hospital, Dublin 8, Ireland
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