Transcript Rare Coaglation Disorders - Southern Haemophilia Network

Rare Coagulation
Disorders
Dr Sam Ackroyd
Consultant Haematologist and Haemophilia Director Bradford
Introduction
 Factor V deficiency
 Factor VII deficiency
 Factor XIII deficiency
 Units for talk IU/ml ie 1.00 is normal = 100% or 100 iu/dl
General Points

Prevalence in the population is low

consanguineous marriage is common

Diagnosis & monitoring require specialist investigations

Laboratory and clinical phenotype not always predictable

Some good registry data now available e.g. EN-RBD, American, Iranian

No RCT mostly retrospective data or observational studies and
evidence moderate or low (level b or c). Mostly recommendations level
2 (weak).
BLEEDING DISORDER
INCIDENCE
Afibrinogenaemia
(homozygous state)
1 in 1 000 000
Prothrombin deficiency
(homozygous state)
1 in 2 000 000
Factor V deficiency
(homozygous state)
1 in 1 000 000
Factor V + VIII deficiency
1 in 1000000
Factor VII deficiency
(homozygous state)
1 in 300 000 to 1 in 500 000
Factor X deficiency
(homozygous state)
1 in 1 000 000
Factor XI deficiency
(homozygous state)
1 in 1 000 000
Factor XIII
1 in 1000 000
Factor V Deficiency
FACTOR V
 Synthesised by liver and megakaryocytes
 FV and FVIII have very similar protein structure
 Platelets contain 20% total circulating FV in a-granules
 Activated by thrombin
 FVa acts as a cofactor for FXa in conversion of prothrombin to thrombin
 Poor correlation between genotype and phenotype
Factor V deficiency–clinical phenotype
 Autosomal recessive disorder
 Homozygotes – FV levels <0.01 to 0.20 iu/ml
 Heterozygous carriers FV levels 0.20 to 0.60 iu /ml and are mostly
asymptomatic
 In general most severe bleeding in patients with levels <0.10 iu/ml but
some reports including ICH in levels >0.10 iu/ml
 Poor association between lab levels and clinical phenotype
 Usually presents in childhood with easy bruising , epistaxis and oral
bleeding
 Haemarthrosis and haematomas less frequent than in haemophilia and
are often trauma related
 GI bleeding and haematuria occur rarely
 Postop and postpartum bleeding have been reported
ICH in FV deficiency
 Mostly reported in neonates
 6- 8% in registry data
 Mostly levels <0.10 iu/ml
 Normal Neonatal FV levels 0.36 – 1.08 iu/ml
 May require retesting at 6 months of age to clarify baseline level
FV deficiency-diagnosis
 Prolonged PT and APTT but normal TT
 Functional FV assay
 FV antigen ELISA
 Consider excluding FV inhibitor ( usually follow use of topical bovine
thrombin in surgery) by mixing studies
 Measure FVIII to exclude combined FV and FVIII deficiency
 Exclude liver disease as a cause
FV deficiency-management

For less severe mucosal bleeding – tranexamic acid my be sufficient

FFP only option currently. SD-FFP (Octaplas) contains 0.7 – 0.9 iu/ml

Dose FFP 15-25 ml/kg then 10 ml/kg every 12-24 hours

Half life 16-36h

Monitor levels and aim for trough > 0.20 iu/ml

A few severely affected individuals <0.05 iu/ml presenting early in life have been treated
with prophylactic FFP infusions 20ml/kg at least 2x week

rVIIa is a possible alternative

In severe bleeding not responding to FFP due to inhibitors or acquired FV deficiency,
consider platelet transfusion. ( Platelet FV may be more resistant to inhibitors)

Patients with inhibitors following FFP – other options are FEIBA or rFVIIa

IV IG may be effective in eradicating inhibitor
Case AM
 Presented 2 years old
 Fell and cut top lip
 Minor cut <1 cm but profuse bleeding that would not stop
 Taken to A&E who injected with adrenaline and gave tranexamic acid but
not improvement so admitted for investigation of bleeding disorder
 Parents mentioned 6 month history of spontaneous bruising that took long
time to heal. Also she was not walking and had delayed talking.
 History of recurrent epistaxis and had some umbilical stump bleeding
 Previous history of possible antenatal haemorrhage
 No FHx of bleeding disorder – parents 1st Cousins
 FBC and Clotting screen sent
Results
 Appeared well
 Multiple large bruises on pressure points
 Bleeding top lip
 Hb 119
 Platelets 300
 PT 59 seconds
 APTT 205 seconds
 Given 10mg Vitamin K and clotting factors sent
 FII 1.02
 FV <0.01
 FVII 1.10
 FX
0.99
 FVIII 1.30
 FIX
0.87
 FXI
1.01
 FXII 1.08
 Mixing studies – no inhibitor
 Given Octaplas FFP 15 ml/kg – had immediate cessation of bleeding
 Genetics sent: Homozygous Mutation C.2862 delT Exon 13 FV gene
Progress
 She was confirmed as having developmental delay and spastic diplegia
 Antenatal scans reviewed and MRI scan head arranged
 Confirmed diagnosis of antenatal ICH related to severe FV deficiency
 Over next 24 months has had 20 admissions requiring treatment with
Octaplas – usually minor trauma following falls, biting tongue / lip
 Required a frame to walk with but was making improvement in
development with help from CDC
 She has 3 siblings none with severe FV deficiency but 2 have significant
inherited medical illnesses
Factor VII Deficiency
Factor VII
 Vitamin K – dependent glycoprotein
 99% inactive and 1% active binds to TF at sites of vessel injury activating
FX and FIX to form low levels of thrombin
 Levels low at birth
 Levels influenced by environmental factors - dietary fat intake, age,
obesity, diabetes, sex hormones
 Common variation FVII promoter intron 7 and Exon 8 cause
considerable variation in baseline FVII
Factor VII deficiency
 poor correlation between absolute FVII levels and risk of bleeding
 Severe deficiency – level <0.01 iu/ml associated with more severe
bleeding
 Above 0.30 iu/ml is probably haemostatic
Patients with severe FVII deficiency
and bleeding phenotype
 Bleeding starts early in life
 The most frequent bleeds in 1st 6 months are intracranial and GI bleeds
 Haemarthrosis can occur when infant starts to crawl or walk
Functional FVII assays
 One stage PT-based assay
 Have been discrepancies in levels depending on source of
thromboplastin
 Do not store samples on ice before assay – may induce cold activation of
FVII and cause an overestimate of the level
Differential diagnosis
 Acquired deficiency is much commoner as a cause of prolonged PT
- severe liver disease
- drugs eg warfarin
- vitamin K deficiency – haemorrhagic disease
of the newborn
- prolonged use of antibiotics
- bile duct obstruction
- malabsorption
 Often worth trial of Vitamin K replacement while await investigations
Management
 Consider patient previous Hx of bleeding as Tranexamic acid may be
sufficient
 rVIIa (Novoseven) Dose 15 – 30 micrograms/kg – may only need this “on
stand-by”
 Short half-life- needs to be given every 4 - 6 hours
 Remember can get inhibitors in severe FVII deficiency !!!
 4 reported world wide
 more likely if FVII < 0.01 Ag assay
 Occur early (after 10 doses ie similar to FVIII inhibitors)
 Treatment V difficult
Factor VII in Bradford
patients
30
25
20
patients
15
10
5
0
FVII < 1
FVII 1-5
FVII 5-30 FVII 30-40
Do they bleed?
 These patients generally don’t cause much trouble
 Last 2 years novoseven used:
 once to cover delivery in patient with FVII level 0.13 iu/ml
 Once to cover circumcision FVII 0.10 iu/ml (was planning to have on “stand by” but
surgeon less keen)
 Tranexamic acid to cover dental work or minor bleeding
 3 patients with severe deficiency – no significant bleeding problems ever
 Many diagnosed after routine clotting screen
 Large variation in FVII levels within some families
 - family A varies 0.03 0 0.25 iu/ml
 -family B varies 0.01 – 0.16 iu/ml
Case AA
 69 year old lady admitted with mild left sided weakness and slurred speech
 CT Head confirms right cerebral infarct stroke
 Commenced on aspirin
 Routine clotting screen sent
 Previous history of 3 children with no PPH
 Dental extractions with minor prolonged bleeding
 No history of epistaxis, menorrhagia, bruising
 Known diabetic, obesity and elevated cholesterol
Results
 Hb 123
 Platelets 350
 PT 120 seconds
 APTT 35 seconds
 TT 14 seconds
 Fibrinogen 3.5
 FII
1.03
 FV
1.10
 FVII 0.01
 FIX 1.02
 FX
1.10
Diagnosis
 Severe FVII deficiency
 ELISA FVII antigen 0.83 iu/ml
 Genetics confirm homozygous mutation a.c1109G.T substitution exon 9
 Qualitative type II defect
Factor XIII Deficiency
First description of Factor XIII deficiency
Duckert et al 1960
Case report of a boy with a severe bleeding syndrome
Normal conventional clotting tests
Clots rapidly soluble in 5M Urea
Clots became insoluble with addition of small amount
of normal plasma
“whole” Blood transfusion normalised clot solubility and
corrected the bleeding tendency
Factor XIII structure
Hetero-tetramer consisting of 2 A subunits & 2 B subunits held together by noncovalent bonds
Homodimer A subunits - megakaryocytes , platelets, monocytes,
macrophages, placenta and uterus
Factor XIII synthesis
 Synthesis of FXIII B subunits - liver
 Synthesis of FXIII A subunits - bone marrow
macrophages)
( megakaryocytes,
 In plasma FXIII circulates bound to fibrinogen
 Fibrinogen has an important regulatory role in the FXIII activation process
 In blood , FXIII in platelets comprises 50% total FXIII activity
FACTOR XIII ACTIVATION
 1st Stage – Thrombin cleaves off activation peptide ( AP-FXIII ) from A
subunits
 2nd stage- In presence of Ca and fibrin, B subunits dissociate from A
subunits
Other important cross-linking actions of
the F XIII A subunit
 Cross-linking of α 2 anti plasmin to the α chains of fibrin – reducing
fibrinolysis
 Cross-linking other protein substrates in plasma and subendothelium:
Fibrin - Fibronectin
Fibrin - Von Willebrand factor
Fibronectin - Collagen
Fibrin – Fibronectin - Collagen
Factor V
Thrombospondin
Factor XIII deficiency
 Inherited autosomal recessive condition
 Acquired
Congenital FXIII deficiency
 Autosomal recessive
 Rare : In UK – 1 case per 2 million
 High frequency of consanguinity
 Therefore much commoner in areas with high incidence of
consanguinity : In Bradford and Airedale – 10 cases
 Most due to defect in FXIII A gene
 69 mutations reported for FXIII A – vast majority are missense or
nonsense mutations with poor correlation with disease phenotype
 Only 4 known mutations for FXIII B – much milder phenotype
F XIII deficiency – clinical features
 Bleeding – umbilical stump, ICH
 Delayed wound healing
 Recurrent spontaneous abortions
CONGENITAL FACTOR XIII DEFICIENCY
SYMPTOMS IN > 25% OF 100 CASES (BOARD, LOSOWSKY,
MILOSZEWSKI)

UMBILICAL HAEMORRHAGE
80

BRUISING

SUBCUTANEOUS HAEMATOMAS

ORAL BLEEDING

INTRACRANIAL BLEEDING

BLEEDING INTO MUSCLES

HAEMARTHROSIS
60
55
30
30
27
24
Mutations in B subunit
 Much less common – only 5 families
 Plasma half-life A subunit shorter ( 3 days)
 Reduced levels both A & B subunits
 Bleeding phenotype is only mild ( probably because of A subunits in
platelets & monocytes)
Diagnosis
 Normal PT, APTT, TT
 Need to do specific functional assay – based on ammonia release or
amine incorporation
 Functional assays have limit of detection of around 0.05 iu/ml
 Immunoassays ELISA FXIII-A and FXIII-B
 Clot Solubility test (qualitative test) – only detect severe FXIII deficiency
<0.01 – 0.05 (depending on reagents used)
Measuring FXIII
UKNEQUAS results clot solubility test
Sample
level
Report
normal
Report
low FXIII
Normal
108
98
2
FXIII def 6
3
95
FXIII
trough
70
25
8
Berichrom Ammonia Release assay
 Chromogenic assay
 Based on NH3 release (measuring effect on NADH)
 Functional quantification
 Must use plasma blank as other enzymes present release ammonia
 UKNEQUAS – show variable results for same sample
 Case reports severe FXIII deficiency misdiagnosed with levels 0.15 iu/ml
What we do in Bradford
Suspected
bleeding disorder
Normal PT/APTT
Berichrom
FXIII assay
FXIII <0.15 iu/ml
Probably
Severe
deficiency
Repeat test
CST
ELISA FXIII-A
Genetic studies
FXIII 0.15-0.50 iu/ml
FXIII 0.50 –
1.50 iu/ml
Normal
?acquired
deficiency or
carrier
Management - prophylaxis
 Commence FXIII concentrate prophylaxis – as high CNS bleed rate
 Plasma derived Fibrogammin P FXIII (CSL)
 Half life 7 days
 20 – 40 iu/kg every 28 days
 Aim trough 0.10 – 0.20 iu/ml
 rFXIII-A (Novothirteen) –
 35 iu/kg every 28 days
 Very expansive consider in newly diagnosed
 Outcome – reduce ABR to near 0 in all patients
Bleeding
 Give top up dose 10-40 iu/kg FXIII to ensure levels >0.60 iu/ml
 Dose will depend on when recent prophylaxis
 May have to increase dose interval to every 14 days
 May need to repeat dose earlier if ongoing bleeding
 Add in tranexamic acid
 Consider Platelet transfusions
Obstetrics
 Rate of spontaneous miscarriage >90% without prophylaxis
 Reduced FXIII in pregnancy
 Increase treatment to every 14-21 days
 Aim to keep trough >0.20 iu/ml
 Give further dose at time of labour to top up
 Successful pregnancy reported with prophylaxis
Bradford Factor XIII cases
Sam Ackroyd
Haemophilia Director
Factor XIII deficiency in Bradford
 10 patients (5 children)
 Some are siblings or cousins
 All on Factor XIII prophylaxis
Case HH (family II)
 24 year old male
 Umbilical cord bleeding 6 days
 Bleeding post circumcision
 3 months old spontaneous ICH – presented very sick with raised ICP needed
shunt and left hemi – now fully resolved
 Clot solubility test positive
 Commenced prophylaxis
 No further spontaneous bleeds
 Late teens body builder / cage fighter
 Admissions with traumatic injuries – including knife injury and knee injury
Case TA family III

28 year old male

Umbilical cord bleeding 10 days given FFP

3 years excessive bruising and oral bleeding

1er phase only to ADP, increased lag phase AA (all other tests normal including nucleotides and
FACS)

Diagnosed with “platelet disorder”

Significant bleeding episodes treated with platelet Tx

Large haemarthrosis x2

ICH aged 13 years (full recovery)

Referred 2nd opinion

Functional FXIII amine incorp. <0.05 iu/ml

Commenced prophylaxis

No further bleeding episodes
Summary clinical presentaion
note: case 9 commenced prophylaxis aged 1 day
UC
blee
d
ICH
joints
cuts
1
2
3
4
5
6
7
8
x
x
x
x
x
x
x
X
x
x
bro
the
r
x
x
x
x
epist
axis
hae
mat
oma
s
x
x
X
x
x
9
10
x
x
Initials
Berichrom
(No PB)
ZG
0.11 iu/ml
HG
EY
Berichrom
(PB)
FXIII-A Ag
ELISA
CST
Amine
incorp.
Genetics
I
0.07 iu/ml
0.12 iu/ml
SH
HH
Family
I
0.11 iu/ml
<0.01 iu/ml
0.11 iu/ml
<0.01 iu/ml
<0.01 iu/ml
Homozygous C.[1405C>T] non-sense
premature truncation (new mutation)
I
+ve U
Homozygous AGC-AGG codon 295 Exon7
FXIII-A
II
+ve U
Homozygous AGC-AGG codon 295 Exon7
FXIII-A
II
MA
+ve
U/T
<0.05 iu/ml
Homozygous AGC-AGG codon 295 Exon7
FXIII-A
III
TA
+ve
U/T
<0.05 iu/ml
Homozygous AGC-AGG codon 295 Exon7
FXIII-A
III
US
+ve
U/T
0.08 iu/ml
Homozygous AGC-AGG codon 295 Exon7
FXIII-A
III
JH
0.08 iu/ml
1.00 iu/ml
HA
0.13 – 0.32
iu/ml
0.34 iu/ml
0.41 iu/ml
<0.05 iu/ml
IV
Homozygous GAA-AAA codon 102 Exon 3
FXIII-A
V
Summary
 FV – main question who to give prophylaxis
 FVII – most patients have mild phenotype what ever the level
 FXIII – easy to treat – hard to diagnose
Any Questions??
Additional slides
Combined FV and FVIII deficiency
 Caused by defect in intracellular trafficking of certain proteins including
FV and FVIII
 Not a defect in the FV or FVIII gene
 Defective LMAN1 or MCFD2 results in disturbance of passage of FV and
FVIII through the cell and impaired release into circulation
Clinical phenotype
 Usually Mild bleeding symptoms – easy bruising, epistaxis
 Levels usually high enough to prevent more severe spontaneous bleeding
 Bleeding is common after surgery, dental extraction and trauma
 Menorrhagia and PPH are common in affected women
Diagnosis
 Prolonged PT and APTT
 APTT-based FV and FVIII activity assays and antigen assays - levels
between 0.05 – 0.20 iu /ml (not usually <0.05)
 Confirm on genetic testing
Management
 SD-FFP to correct FV >0.20 iu/ml
 rVIII or DDAVP to correct FVIII levels
 Pregnancy – FV levels don’t change. FVIII levels rise.
Acquired Factor XIII deficiency
 Commoner in middle-aged or elderly patients
 Bleeding can be severe or mild
 Due either to inhibitors(usually autoantibodies) or underlying conditions
Acquired FXIII deficiency due to
inhibitors
 DRUGS – isoniazid ,penicillin , phenytoin , ciprofloxacin
 SLE
 HSP
 In inherited FXIII deficiency, inhibitors to injected FXIII occur rarely
Acquired FXIII deficiency due to
underlying conditions
 Significance of mild FXIII deficiency in these patients is unknown as usually
level is >0.30 iu/ml
 LIVER DISEASES – impaired synthesis
acute and chronic
hepatitis
acute liver failure
 INFLAMMATORY GI DISEASE – proteolytic degradation at site of
inflamation
Ulcerative colitis, Crohns, Henoch Schonlein
 SYSTEMIC HAEMATOLOGICAL DISEASE
- Increased turnover and
consumption
Acute & chronic leukaemia
Myeloproliferative & myelodysplastic syndromes
 DIC & SEPSIS
 MAJOR SURGERY
Fibronectin
 Large component of the proteins in fibrin clot
 Through fibronectin, clot can be linked to fibroblasts & collagen
 Increases fibre size, density and strength of clot
 Important in attachment of clot to vessel wall
 Impact on tissue repair
 Modulates synthesis of collagen by fibroblasts
Other important cross-linking actions of
the
F
XIII
A
subunit
Cross-linking proteins within vascular matrix,
platelets, endothelial cells and monocytes – this may
play an equally important role in haemostasis
Substrates for intracellular FXIII include myosin,
actin, vinculin and filamin
- suggests a major role
for FXIII in cytoskeletal remodelling in platelet
adhesion, aggregation and contraction
Other functions of FXIII A
 Promotes wound healing by providing a scaffolding for fibroblast migration
and proliferation
 Fibrin-fibronectin cross-linking is necessary to support the formation of the
cytotrophoblastic shell at the site of placental implantation – an important
role in maintaining pregnancy
 Probably has a role in phagocytosis
Factor XIII B subunit
 No known catalytic activity
 Stabilisation and transport of A subunit in plasma
 May have a role in decreasing the degradation and inactivation of A
subunit by proteases
 Important role in localization of FXIII to the growing fibrin polymer
 Acts as a brake on FXIII activation