Congenital coagulopathies

Hemophilia A
Hemophilias

single-factor deficiencies marked by anatomic soft tissue bleeding.

Second to VWD in prevalence among congenital bleeding disorders
1 in 10,000 individuals
85% = deficient in Factor VIII
14% = deficient in Factor IX
1% = deficient in Factor XI or Factor II, V, VII, X, or XII
Congenital deficiencies of Factor VIII classic hemophilia or hemophilia A

Factor VIII deficiency

2 chain, 285,000D protein translated from the X chromosomes

Thrombin cleaves plasma Factor VIII -> B domain (large polypeptide) that
dissociates from the molecule
Calcium dependent heterodimer that detaches from VWF to bind
phospholipid and Factor IXa -> VIIIa/IXa complex (tenase)
Tenase cleaves and activates Factor X 10times faster than free IXa
Factor VIII deficiency significantly slows production of thrombin and leads to
hemorrhage

Hemophilia Genetics

Factor VIII genes 186 kb of the X chromosomes

o Site of various deletion, stop codons, and nonsense and missense
mutation
Most of mutation results in quantitative disorders
Rare cases = low activity despite normal antigen concentration
o Due to qualitative or structural factor VIII abnormalities = cross
reacting material positive disorders
Male = anatomic bleeding
Females = carriers
Female carrier + unaffected male:
o 25% chance of a carrier daughter
o 25% chance of a normal son
o 25% chance of a normal daughter
o 25% chance of a hemophilic son
Affected male + non carrier female
o All sons are normal
o All daughters are obligate carriers
30% of newly diagnosed cases= spontaneous germline mutations; no family
history of disease
Rarely = symptoms can be seen in females

Could be due to true homozygosity or double heterozygosity; Daughter

of a female carrier and a hemophilic father
o Spontaneous germline mutation in otherwise normal allele of a
heterozygous female
o Disproportional inactivation of the X chromosome with normal gene
extreme lyonization
VWD of Normandy subtype = present as mild hemophilia A in females and
males
o

Clinical manifestations of HEMOPHILIA A

Anatomic bleeds with deep muscle and joint hemorrhages

o Acute joint bleeds ( hemarthroses ) = painful and causes temporary
immobilization
o Chronic joint bleeds = inflammation, permanent loss of mobility
o Bleeding into muscles = nerve compression injury; initially temporary
then lasting disability
Hematomas
Wound oozing after trauma or surgery
Bleeding into CNS, peritoneum, GIT and kidneys
Cranial bleeds:
o Severe, debilitating durable neurologic symptoms
Loss of memory
Paralysis
Seizures
Coma
Diagnosis of hemophilia:
o Laboratory testing after birth of an infant with a mother who has family
history of hemophilia
o No family history:
Abnormal bleeding in the neonatal period easy bruising,
bleeding from the umbilical stump, postcircumcision bleeding,
hematuria, intracranial bleeding
Severe hemophilia
o Diagnosed in the first year of life
Mild hemophilia
o After triggering event; late childhood, adolescence, adulthood
Laboratory diagnosis of coagulopathies in newborn or older infants in
complicated:
o Difficult to obtain 2 ml of unhemolyzed blood
o Low levels of coagulation factors ( II, VII, IX, X )
factor VIII levels similar to that of adults
o can have a correct diagnosis of hemophilia by using factor VIII activity
assay

factor VIII activity level <1% = severe; associated with spontaneous or

exaggerated bleeding in the neonatal bleeding
factor VIII activity level 1% to 5% = moderate; usually diagnosed in early
childhood
factor VIII activity level 5% to 20% = mild; hemorrhage follow significant
trauma; risk factor in surgery or dental extractions; may go for long periods
without symptoms

HEMOPHILIA A COMPLICATIONS

Debilitating and progressive musculoskeletal lesions and deformities

Neurologic deficiencies
Effects of chronic diseases: limited productivity, low self-esteem, poverty,
drug dependency, depression
Chronic hepatitis
AIDS

Laboratory diagnosis of hemophilia A

Clear history of the hemorrhagic symptoms of the patient

PT, PTT, thrombin time, factor assays
PT, thrombin time = normal
PTT is prolonged if reagent is sensitive to factor VIII deficiencies at or less
than 30% plasma level
Contact factors ( XII, kininogen, prekallikrein ) have no relationship to
bleeding

Results of clot based screening assays in congenital single factor deficiencies

DEFICIENT
FACTOR
Fibrinogen

PT

PTT

TCT

REFLEX TEST

Prolonged

Prolonged

Prolonged

Prothrombin

Prolonged

Prolonged

Normal

Prolonged

Prolonged

Normal

VII
VIII

Prolonged
Normal

Normal
Prolonged

Normal
Normal

IX

Normal

Prolonged

Normal

Fibrinogen
assay
Prothrombin,
V, VII, and X
assays
Prothrombin,
V, VII, and X
assays
VII assays
VIII, IX, XI
assays
VIII, IX, XI

Prolonged

Prolonged

Normal

XI

Normal

Prolonged

Normal

XIII

Normal

Normal

Normal

assays
Prothrombin,
V, VII, and X
assays
VIII, IX, XI
assays
Factor XIII
quantitative
assay

Hemophilia A carrier detection

Ratio of factor VIII activity to VWF:Ag value (VIII:VWF)

o Detects 90% of female carriers
o Effective because VWF production is unaffected by factor VIII
deficiency
o Normalizes some of the physiologic variables that affects factor VIII
activity and VWF:Ag assays (estrogen levels, inflammation, stress,
exercise)

Hemophilia A treatment

Goal:
o
o
o

Recombinant factor VIII

o Prophylactic dosage to keep factor VIII activity at hemostatic levels

Desmopressin acetate
o Alone or in combination with antifibrinolytic
o Raises factor VIII activity

Intravenous factor VIII concentrates

o From mammalian cells using recombinant DNA technology or from
human plasma using factor VIII specific monoclonal antibodies and
column separation
o Contains factor VIII, VWF, fibrinogen, and noncoagulant proteins

raise the patients factor VIII activity to hemostatic levels

Experiences or suspects a bleeding episode
Anticipates a hemostatic challenge
Twice-a-day infusions are required since factor VIII has a half life of 8
12 hours

Plasma derived factor VIII concentrates may transmit nonlipid viruses such
as parvovirus B19 and hepatitis A
Recombinant products may use human albumin risk of Creutzfeldt-jakob
disease
Factor VIII concentrate dosage based on:
o Definition of unit of factor VIII activity = amount present in 1mL of
normal plasma and is synonymous with 100% activity
Also calculate the desired increase after factor VIII concentrate infusion by
subtracting the patients preinfusion factor activity from the target activity
level
o Desired increase multiplied by the patients plasma volume to compute
the dosage
Patients plasma volume = estimated from blood volume and hematocrit
o Blood volume = 65mL/kg body weight
o Plasma volume = plasmacrit (100% - hematocrit%)
Plasma volume:
o Weight (kg) x 65mL/kg x (1 hematocrit)
Factor VIII concentrate dose:
o Plasma volume x (target factor VIII level initial factor VIII level)
Formula also used in the treatment of VWD
Overdosing = no thrombotic risk
Laboratory monitoring and close clinical observation prevent or halt
bleeding and its complications
Repeating dosing is done on 8 12 hours schedule
2nd administration of factor VIII is half the concentration of the first dose

Hemophilia A and Factor VIII inhibitors

Alloantibody inhibitors of factor VIII will arise in response to treatment

o 30% in severe hemophilia
o 3% in moderate hemophilia
Presence is suspected if bleeding persist or plasma factor VIII activity fails to
reach the target level
Most inhibitors are immunoglobulin G4, non-complement-fixing, warmreacting antibodies

Detection of antibodies:

Factor VIII assay

o Factor VIII activity exceeds 30% - no inhibitors present
o If below 30% = proceed to mixing studies
Mixing studies

o
o
o

Test plasma from bleeding patient has prolonged PTT -> mix 1:1 NP,
incubate 1-2 hours at 37 C -> measure PTT
No inhibitor = incubated mixture should produce normal to near
normal PTT
Inhibitor present = factor VIII from the normal plasma is partially
neutralized, PTT remains prolonged or uncorrected
Presumptive evidence of inhibitor

Bethesda assay

If mixing studies and clinical picture suggest presence of factor VIII inhibitor
Quantitates the inhibitor
NP with 100% activity is mixed t increasing dilutions in a series of tubes with
the full strength patients plasma
Factor VIII assay is performed on each mixture
Results of the various dilutions are compared and expresses the titer as
Bethesda units
One Bethesda unit = reciprocal of the dilution that caused neutralization of
50% of factor VIII from the NP
Same assay is used to measure factor VIII inhibitors in acquired hemophilia
Patients with inhibitors may be high or low responders
o Low responders = titers of 5 bethesda units or less; titers does not
increase significantly after factor VIII administration
o High responders = inhibitor titers that exceeds 5 bethesda units;
titers increase after theraphy

Treatment of Hemophilia A in patients with inhibitors

Individualized treatment plan

Low responders:
o Large doses of factor VIII concentrates
High responders:
o Factor VIII concentrates is of no use
o Use autoplex T o FEIBA generates thrombin in the presence of factor
VIII inhibitors
FEIBA dosage should not exceed 200 units/kg per day
distributed in 2-4 injections since it may trigger DIC
NovoSeven bypasses the physiologic factor VIII requirement promoted
thrombin formation through the tissue factor pathway

Hemophilia B ( Factor IX Deficiency )

Also called Christmas disease

14% of hemophilia cases in USA
Caused by deficiency of factor IX vitamin K dependent serine proteases

Factor IX substrate for both Factors XIa andVIIa

Factor IXa complexes with factor VIIIA to cleave and activate Factor X
Factor IX deficiency reduces thrombin production and cause soft tissue
bleeding
Also sex-linked
PTT typically prolonged
PT normal
Factor IX assay performed if clinical symptoms suggests hemophilia B even
if PTT is within reference range
o PTT reagent may be insensitive to mild factor IX deficiency

Treatment

Recombinant or column-purified plasma- derived factor IX concentrates

o Dosage calculated the same way as for Factor VIII concentrate
o Calculated initial dose is doubled to compensate for Factor IX
distribution into the extravascular space
o Repeat doses are given every 24 hours
o Second and subsequent doses half the initial dose if the target level
is achieved
Inhibitors to factor IX 3% of hemophilia B
o May be detected by Bethesda assay
o Treated as in patients with factor VIII inhibitors using Autoplex T, FEIBA,
or NovoSeven

Hemophilia C (Rosenthal syndrome, Factor XI Deficiency)

Autosomal dominant hemophilia

Mild to moderate bleeding symptoms
Half of cases in Ashkenazi jews
Frequency and severity of bleeding do not correlate with factor IX levels
Treated with frequent transfusion of FP during times of hemostatic challenge
PTT is prolonged, PT is normal

Other Congenital single-Factor deficiencies

Rare, autosomal recessive mutations, often associated with consanguity

PT, PTT may be used to distinguish these disorders
Immunoassays - distinguish among the more prevalent quantitative and less
prevalent qualitative abnormalities

Dysproteinemias - Qualitative disorders

o
o
o
o
o

Ratio of factor activity to antigen is less than 0.7

Bleeding symptoms may be more severe than the quantitative
deficiencies
Risk of inhibitor formation is lower
Clot based measurement of factors II and X may be supplemented by
chromogenic substrate assays
Fibrinogen I measured using Clauss assay
Modification of thrombin time
May be measured by turbidimetry or immunoassay

Rare Congenital Single-Factor Deficiencies

DEFICIENCY
Afibrinogenemia
Hyperfibrinogene
mia
Dysfibrinogenem
ia
Prothrombin
deficiency
Factor V
deficiency
Factor VII
deficiency
Factor X
deficiency
Factor XI
deficiency
Factor XIII
deficiency

FACTOR LEVELS
No measurable
fibrinogen
Fibrinogen activity
assay <100mg/dL
Fibrinogen activity
assay <100mg/dL
Factor II <30%
Factor V <30%
Factor VII <30%
Factor X <30%
Factor XI <50%
Factor XIII <1%

SYMPTOMS
Severe anatomic
bleeding
Moderate systemic
bleeding
Mild systemic
bleeding
Mild systemic
bleeding
Mild systemic
bleeding
Moderate to severe
anatomic bleeding
Severe anatomic
bleeding
Anatomic bleeding
Moderate to severe
anatomic bleeding,
poor wound
bleeding

THERAPHY
CRYO to raise
>100mg/dl
CRYO to raise
>100mg/dl
CRYO to raise
>100mg/dl
PCC or plasma to
raise to 75%
Plasma to raise to
75%
Activated factor
VII, plasma
PCC or plasma to
raise to 75%
Plasma to raise to
75%
Plasma or CRYO
every 3 weeks

Factor V Deficiency

Platelet function may be diminished since 20% of circulating factor V is

transported by platelets
Prolonged bleeding time, normal platelet aggregation
PT and PTT are prolonged
Platelet concentrate effective therapy due to concentration of factor V in
platelet alpha granules

Combined factor V and VIII deficiency due to genetic defect in chromosomes

18 affecting transport of both factors by a common protein in the golgi
apparatus

Factor VII Deficiency

Moderate to severe anatomic bleeding

Bleeding does not reflect the activity of the factor
Half-life = approximately 6 hours
NovoSeven at 30 mcg/mL and PCC (Autoplex) may provide target level of
10% to 30%
PT but not PTT is prolonged

Factor X Deficiency

Moderate to severe anatomic bleeding

Treated with FP or PCC to produce therapeutic levels of 10% to 40%
Half-life = 24 to 40 hours
Acquired factor X deficiency:
o Amyloidosis
o Antifungal drug therapy
o Paraproteinemia
o Bleeding is severe and life-threatening
PT and PTT are prolonged
Russell viper venom time test
o Activates coagulation system at the level of factor X
o Clotting time prolonged in deficiencies of factor V and X, prothrombin,
and fibrinogen
o Useful in distinguishing factor VII deficiency which does not affect the
result from deficiencies in the common pathway

Factor XIII

Tetramer of paired alpha and beta monomers

Intracellular form = homodimer ( two alpha chains )
Stored in platelets, monocytes, placenta, prostate and uterus
Alpha chains contains active enzyme site
Beta chain is binding and stabilizing portion
3 forms of deficiencies related to the affected chain
Normal PT, PTT and thrombin time
Form weak clots that dissolves within 2 hours when suspended in 5M urea
solution traditional factor XIII screening assay
Factor XIII activity measured by chromogenic substrate assay Behring
Behrichrome FXIII assay

TYPE OF

INCIDENCE

FACTOR XIII

BETA-

ALPHA

DEFICIENCY
TYPE I
TYPE II
TYPE III

Rare
Frequent
Rare low

ACTIVITY
Absent
Absent
Low

PROTEIN
Absent
Normal
Absent

Fibrinolytic Regulatory Protein Deficiencies

Alpha2- antiplasmin, plasminogen activator inhibitor-1

Moderate to severe bleeding
Rare, diagnosed using chromogenic substrate assay

PROTEIN
Absent
Low
Low