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Franchini M, Focosi D. Clinical, Laboratory, and Molecular Aspects of Factor V Deficiency. Semin Thromb Hemost 2024. [PMID: 39191405 DOI: 10.1055/s-0044-1789021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2024]
Abstract
Factor V (FV) is a glycoprotein that plays a pivotal role in hemostasis, being involved in coagulant and anticoagulant pathways. Congenital FV deficiency is a rare bleeding disorder with an incidence of 1 per million live births, considering the most severe homozygous form. FV deficiency is diagnosed using routine coagulation tests and FV activity assays. Several mutations, including missense, nonsense, and frameshift, have been detected in the F5 gene. Clinical symptoms are variable, ranging from mild ecchymoses and mucosal bleeding to life-threatening intracranial hemorrhage. The mainstay of treatment includes fresh-frozen plasma, preferentially virus-inactivated. In this narrative review, we provide an update of the main laboratory, molecular, clinical, and therapeutic features of inherited FV deficiency.
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Affiliation(s)
- Massimo Franchini
- Department of Hematology and Transfusion Medicine, Carlo Poma Hospital, Mantua, Italy
| | - Daniele Focosi
- North-Western Tuscany Blood Bank, Pisa University Hospital, Pisa, Italy
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De Pablo-Moreno JA, Miguel-Batuecas A, Rodríguez-Merchán EC, Liras A. Treatment of congenital coagulopathies, from biologic to biotechnological drugs: The relevance of gene editing (CRISPR/Cas). Thromb Res 2023; 231:99-111. [PMID: 37839151 DOI: 10.1016/j.thromres.2023.10.001] [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: 07/17/2023] [Revised: 09/09/2023] [Accepted: 10/02/2023] [Indexed: 10/17/2023]
Abstract
Congenital coagulopathies have, throughout the history of medicine, been a focus of scientific study and of great interest as they constitute an alteration of one of the most important and conserved pathways of evolution. The first therapeutic strategies developed to address them were aimed at restoring the blood components lost during hemorrhage by administering whole blood or plasma. Later on, the use of cryoprecipitates was a significant breakthrough as it made it possible to decrease the volumes of blood infused. In the 1970' and 80', clotting factor concentrates became the treatment and, from the 1990's to the present day, recombinant factors -with increasingly longer half-lives- have taken over as the treatment of choice for certain coagulopathies in a seamless yet momentous transition from biological to biotechnological drugs. The beginning of this century, however, saw the emergence of new advanced (gene and cell) treatments, which are currently transforming the therapeutic landscape. The possibility to use cells and viruses as well as specific or bispecific antibodies as medicines is likely to spark a revolution in the world of pharmacology where therapies will be individualized and have long-term effects. Specifically, attention is nowadays focused on the development of gene editing strategies, chiefly those based on CRISPR/Cas technology. Rare coagulopathies such as hemophilia A and B, or even ultra-rare ones such as factor V deficiency, could be among those deriving the greatest benefit from these new developments.
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Affiliation(s)
- Juan A De Pablo-Moreno
- Department of Genetic, Physiology and Microbiology, Biology School, Complutense University of Madrid, Spain
| | - Andrea Miguel-Batuecas
- Department of Genetic, Physiology and Microbiology, Biology School, Complutense University of Madrid, Spain
| | - E Carlos Rodríguez-Merchán
- Osteoarticular Surgery Research, Hospital La Paz Institute for Health Research-IdiPAZ (La Paz University Hospital-Autonomous University of Madrid), Spain
| | - Antonio Liras
- Department of Genetic, Physiology and Microbiology, Biology School, Complutense University of Madrid, Spain.
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Yang J, Mao H, Sun L. Congenital coagulation factor V deficiency with intracranial hemorrhage. J Clin Lab Anal 2022; 36:e24705. [PMID: 36125894 DOI: 10.1002/jcla.24705] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 08/27/2022] [Accepted: 09/06/2022] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Congenital coagulation factor V (FV) deficiency is a very rare hemorrhagic disease with an incidence of approximately one in a million. The common clinical manifestations of FV deficiency include ecchymosis and mucosal bleeding. Life-threatening intracranial bleeding is rare. It has been reported in several cases. However, the molecular basis has been established in only a few cases. METHODS We reported a 2-month-old girl with congenital FV deficiency and intracranial hemorrhage. Coagulation screening combined with clinical manifestations was performed to diagnose congenital FV deficiency. Genetic testing was performed to identify the pathogenic genes. A literature review was included to emphasize the clinical manifestation, diagnosis, and treatment for congenital FV deficiency with intracranial bleeding. RESULTS The coagulation tests revealed a significantly prolonged prothrombin time (PT) of 51 s and an activated partial thromboplastin time (APTT) of 73.7 s. The patient had a plasma FV activity of 0.9%. Genetic testing showed compound heterozygous mutations of the patient's FV gene. A literature review showed that patients with homozygous or compound heterozygous variants of the FV gene were often associated with a severe bleeding phenotype. CONCLUSION Our study provides a direction for the rapid and accurate diagnosis and treatment for FV deficiency to avoid life-threatening bleeding. Infants with spontaneous cranial hematoma and intracranial hemorrhage should be investigated for underlying hemostatic defects. Congenital coagulation factor deficiency should be considered. Once congenital FV deficiency is diagnosed, fresh frozen plasma (FFP) should be given on a regular basis. Liver transplantation may be performed in severe cases.
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Affiliation(s)
- Jingjing Yang
- Department of Clinical Laboratory, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Hongli Mao
- Department of Clinical Laboratory, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Li Sun
- Department of Clinical Laboratory, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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Factor V deficiency with a unique genetic mutation presenting as post-circumcision bleeding in a neonate, A-case-report. Ann Med Surg (Lond) 2022; 78:103723. [PMID: 35600191 PMCID: PMC9121243 DOI: 10.1016/j.amsu.2022.103723] [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: 03/28/2022] [Revised: 04/28/2022] [Accepted: 05/01/2022] [Indexed: 11/22/2022] Open
Abstract
Introduction and importance Factor V deficiency is a rare bleeding disorder with varying presentations from minor mucosal bleeding to a life-threatening postoperative bleed. Currently, treatment is mainly supportive with Fresh Frozen Plasma. Case presentation A previously healthy 14-day-old male presented with an uncontrollable bleeding following a circumcision. Physical examination was normal. Investigations showed hemoglobin 15.5 g/dl, platelets 409000, Prothrombin Time 57 seconds, Partial-Thromboplastin-Time 120 seconds. Mixing study corrected the coagulation profile, and the factor assay showed factor V activity of 11%. Genetic testing showed a pathogenic frameshift mutation in the F5 gene p.(P927Lfs*7) causing premature termination after 7 codons thus the diagnosis of Factor V deficiency was made. Clinical discussion In this case, factor V deficiency presented as post-circumcision bleeding. For diagnosis, increased PT and PTT with normal thrombin time increases the index of suspicion for a bleeding disorder. Further testing with coagulation factors assays is required to make the final diagnosis. Factor V deficient patients undergoing surgery should be adequately prepared, and factor V activity level should be maintained at least at 25% of the normal activity level. The patient level prior to the circumcision was unknown, which led to the life threatening bleed. Conclusions One of the early presentations of factor V deficiency is a post-circumcision bleeding. Adequate preparation with laboratory tests before circumcision is therefore recommended, especially for high-risk individuals. More than 100 genetic mutations were detected; frameshift mutation involving F5 gene p.(P927Lfs*7) was seen in our case.
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Thau A, Saffren B, Zakrzewski H, Anderst JD, Carpenter SL, Levin A. Retinal hemorrhage and bleeding disorders in children: A review. CHILD ABUSE & NEGLECT 2021; 112:104901. [PMID: 33401159 DOI: 10.1016/j.chiabu.2020.104901] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 11/27/2020] [Accepted: 12/16/2020] [Indexed: 06/12/2023]
Abstract
BACKGROUND Retinal hemorrhages (RH) are a common manifestation of abusive head trauma (AHT) resulting from acceleration-deceleration injury with or without blunt impact. Evaluation of a child with RH requires careful consideration of these differential diagnoses. The extent to which coagulopathy alone can cause RH would be useful to understand as coagulopathy may accompany AHT. OBJECTIVE In this systematic review, we sought to identify whether coagulopathies have been reported with RH similar to those of AHT. METHODS We performed a literature search for ocular manifestations of bleeding disorders in children less than 18 years old. We included clotting factor deficiencies, vitamin K deficiency, platelet function abnormalities, thrombocytopenia, disseminated intravascular coagulation (DIC), and trauma induced coagulopathy (TIC). We included only pediatric reports of intraocular bleeding or documented eye examinations that indicated no hemorrhages. We then re-examined cases for ocular and systemic findings that could potentially mimic abuse. RESULTS Our initial search yielded 816 results. Sixty-one articles met our inclusion criteria. Of these, there were 32 children within the AHT age range (less than 5 years old) who had RH and concomitant coagulopathy. Only 5 cases might potentially be confused for abuse. Of these, no classic characteristics of RH from abuse such as retinoschisis or retinal folds were found. Systemic features were inconsistent with AHT. CONCLUSIONS The presence of coagulopathy alone does not rule out the possibility that the child has been abused. Coagulopathy alone has not been reported as an etiology of RH that are consistent with AHT, especially when other findings are present.
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Affiliation(s)
- Avrey Thau
- Thomas Jefferson University, Philadelphia, PA, USA
| | - Brooke Saffren
- Philadelphia College of Osteopathic Medicine, Philadelphia, PA, USA
| | - Helena Zakrzewski
- Department of Experimental Surgery, McGill University, Montreal, QC, Canada
| | - James D Anderst
- Division of Child Adversity and Resilience, Children's Mercy Hospital, Kansas City, MO, USA
| | - Shannon L Carpenter
- Department of Hematology, Oncology, and Bone Marrow Transplantation, Children's Mercy Hospital, Kansas City, MO, USA
| | - Alex Levin
- Flaum Eye Institute and Golisano Children's Hospital, University of Rochester, New York, USA.
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Lee D, Nayak S, Martin SW, Heatherington AC, Vicini P, Hua F. A quantitative systems pharmacology model of blood coagulation network describes in vivo biomarker changes in non-bleeding subjects. J Thromb Haemost 2016; 14:2430-2445. [PMID: 27666750 DOI: 10.1111/jth.13515] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Accepted: 09/01/2016] [Indexed: 01/03/2023]
Abstract
Essentials Baseline coagulation activity can be detected in non-bleeding state by in vivo biomarker levels. A detailed mathematical model of coagulation was developed to describe the non-bleeding state. Optimized model described in vivo biomarkers with recombinant activated factor VII treatment. Sensitivity analysis predicted prothrombin fragment 1 + 2 and D-dimer are regulated differently. SUMMARY Background Prothrombin fragment 1 + 2 (F1 + 2 ), thrombin-antithrombin III complex (TAT) and D-dimer can be detected in plasma from non-bleeding hemostatically normal subjects or hemophilic patients. They are often used as safety or pharmacodynamic biomarkers for hemostatis-modulating therapies in the clinic, and provide insights into in vivo coagulation activity. Objectives To develop a quantitative systems pharmacology (QSP) model of the blood coagulation network to describe in vivo biomarkers, including F1 + 2 , TAT, and D-dimer, under non-bleeding conditions. Methods The QSP model included intrinsic and extrinsic coagulation pathways, platelet activation state-dependent kinetics, and a two-compartment pharmacokinetics model for recombinant activated factor VII (rFVIIa). Literature data on F1 + 2 and D-dimer at baseline and changes with rFVIIa treatment were used for parameter optimization. Multiparametric sensitivity analysis (MPSA) was used to understand key proteins that regulate F1 + 2 , TAT and D-dimer levels. Results The model was able to describe tissue factor (TF)-dependent baseline levels of F1 + 2 , TAT and D-dimer in a non-bleeding state, and their increases in hemostatically normal subjects and hemophilic patients treated with different doses of rFVIIa. The amount of TF required is predicted to be very low in a non-bleeding state. The model also predicts that these biomarker levels will be similar in hemostatically normal subjects and hemophilic patients. MPSA revealed that F1 + 2 and TAT levels are highly correlated, and that D-dimer is more sensitive to the perturbation of coagulation protein concentrations. Conclusions A QSP model for non-bleeding baseline coagulation activity was established with data from clinically relevant in vivo biomarkers at baseline and changes in response to rFVIIa treatment. This model will provide future mechanistic insights into this system.
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Affiliation(s)
- D Lee
- PharmaTherapeutics Clinical Research, Pfizer Inc., Cambridge, MA, USA
| | - S Nayak
- Pharmacometrics, Global Innovative Pharma Business, Pfizer Inc., Cambridge, MA, USA
| | - S W Martin
- Pharmacometrics, Global Innovative Pharma Business, Pfizer Inc., Cambridge, MA, USA
| | - A C Heatherington
- PharmaTherapeutics Clinical Research, Pfizer Inc., Cambridge, MA, USA
| | - P Vicini
- Pharmacokinetics, Dynamics and Metabolism - New Biological Entities, Pfizer Inc., San Diego, CA, USA
| | - F Hua
- PharmaTherapeutics Clinical Research, Pfizer Inc., Cambridge, MA, USA
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Udayakumaran S. Cavum vergae bleed in a term neonate with severe factor V deficiency. J Pediatr 2014; 164:944. [PMID: 24388321 DOI: 10.1016/j.jpeds.2013.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2013] [Accepted: 11/04/2013] [Indexed: 11/28/2022]
Affiliation(s)
- Suhas Udayakumaran
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Amrita Institute of Medical Sciences and Research Center, Kochi, India
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Abstract
Congenital factor V deficiency (also known as labile factor or proaccelerin) is a rather uncommon [1:1000,000] inherited coagulopathy (autosomal recessive inheritance). Affected patients become symptomatic in early childhood with spontaneous or post-traumatic bleeding complications. The authors report an infant who presented with a much feared complication of the same probably as a neonatal presentation.
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Shakhnovich V, Daniel J, Wicklund B, Kearns G, Neville K. Use of pharmacokinetic modelling to individualize FFP dosing in factor V deficiency. Haemophilia 2012; 19:251-5. [PMID: 23173558 DOI: 10.1111/hae.12045] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/28/2012] [Indexed: 11/30/2022]
Abstract
Therapy with fresh frozen plasma (FFP) confers serious risks, such as contraction of blood-borne viruses, allergic reaction, volume overload and development of alloantibodies. The aim of this study was to apply principles of pharmacokinetic (PK) modelling to individual factor content of FFP to optimize individualized dosing, while minimizing potential risks of therapy. We used PK modelling to successfully target individual factor replacement in an 8-month-old patient receiving FFP for treatment of a severe congenital factor V (FV) deficiency. The model fit for the FV activity vs. time data was excellent (r = 0.98) and the model accurately predicted FV activity during the intraoperative and postoperative period. Accurate PK modelling of individual factor activity in FFP has the potential to provide better targeted therapy, enabling clinicians to more precisely dose patients requiring coagulation products, while avoiding wasteful and expensive product overtreatment, minimizing potentially life-threatening complications due to undertreatment and limiting harmful product-associated risks.
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Affiliation(s)
- V Shakhnovich
- Children's Mercy Hospital and Clinics, Kansas City, MO 64108, USA.
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Frotscher B, Toussaint-Hacquard M, Fouyssac F, Devignes J, Lecompte T, Briquel ME. Severe factor V deficiency in two brothers with different clinical presentations. Haemophilia 2012; 18:e383-5. [DOI: 10.1111/j.1365-2516.2012.02902.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/23/2012] [Indexed: 11/29/2022]
Affiliation(s)
| | | | - F. Fouyssac
- Department of Paediatrics; University Hospital Nancy; France
| | - J. Devignes
- Department of Laboratory Haematology; University Hospital Nancy; France
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Ozkaya H, Akcan AB, Aydemir G, Akcan M, Kul M. Factor v deficiency associated with congenital cardiac disorder and intracranial hemorrage. Indian J Hematol Blood Transfus 2012; 29:99-101. [PMID: 24426348 DOI: 10.1007/s12288-012-0149-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2011] [Accepted: 02/20/2012] [Indexed: 11/26/2022] Open
Abstract
Factor V deficiency is an inherited disorder, in which the clotting factor V is low. The disorder is very rare, occurring in only one in one million people. It is inherited as an autosomal recessive disorder. The results of coagulation studies include a prolonged prothrombin time and partial thromboplastin time associated with reduced plasma factor V content. Patients with factor V deficiency have a hemophiliac like hemorrhagic disorder. Epistaxis, bruising, and menorrhagia are some of the common features. If treatment is needed, fresh frozen plasma is typically given. In this report we present a 12 year old girl who was admitted to our clinic with recurrent nosebleeds and intracranial hemorrage after head trauma. After examination, factor V deficiency was diagnosed. She also had congenital cardiac disorder (VSD), probably a co-incidental finding.
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Affiliation(s)
- Halit Ozkaya
- Department of Pediatrics, GATA Haydarpaşa Teaching Hospital, Uskudar, 34668 Istanbul, Turkey
| | - A Barıs Akcan
- Department of Pediatrics, GATA Haydarpaşa Teaching Hospital, Uskudar, 34668 Istanbul, Turkey
| | - Gökhan Aydemir
- Department of Pediatrics, GATA Haydarpaşa Teaching Hospital, Uskudar, 34668 Istanbul, Turkey
| | - Mediha Akcan
- Department of Pediatrics, Division of Pediatric Hemotology and Oncology, Akdeniz University, Antalya, Turkey
| | - Mustafa Kul
- Department of Pediatrics, GATA Haydarpaşa Teaching Hospital, Uskudar, 34668 Istanbul, Turkey
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