Deseases afecting blood coagulation factors

Hemophilia A
HEMOPHILIA, CLASSIC; HEMA COAGULATION FACTOR VIIIC, PROCOAGULANT COMPONENT, INCLUDED; F8C, INCLUDED COAGULATION FACTOR VIII, INCLUDED; F8, INCLUDED

Gene Map Locus: Xq28

Genetic
Hemophilia A is a hereditary blood disorder, primarily affecting males, characterized by a deficiency of the blood clotting protein known as Factor VIII that results in abnormal bleeding. Babylonian Jews first described hemophilia more than 1700 years ago;

Genetic
Hemophilia A is an X-linked, recessive, bleeding disorder caused by a deficiency in the activity of coagulation factor VIII. Despite the heterogeneity in factor VIII mutations, carrier detection and prenatal diagnosis can be done by direct detection of selected mutations (especially the inversions), as well as indirectly by linkage analysis.

Queen Victoria

The disease first drew widespread public attention when Queen Victoria transmitted it to several European royal families.

PHENOTYPE
Affected individuals develop a variable phenotype of hemorrhage into joints and muscles, easy bruising, and prolonged bleeding from wounds. A partial deficiency in heterozygous carriers was demonstrated by Rapaport et al. (1960). Hemophilia A and B are clinically similar and can only be distinguished by assays of factor VIII and IX activity.

von Willebrand disease

In contrast von Willebrand disease more often presents with : mucocutaneous ... or gastrointestinal hemorrhage .... or menorrhagia.

Tests used in its diagnosis include bleeding time, platelet aggregation, and factor VIII asay von Willebrand factor assay

CLINICAL FEATURES
The severity and frequency of bleeding in hemophilia A is inversely related to the amount of residual factor VIII (<1%, severe; 2-5%, moderate; and 5-30%, mild). The proportion of cases that are severe, moderate, and mild are about 50, 10, and 40%, respectively, see Antonarakis et al. (1995). The joints (ankles, knees, hips, and elbows) are frequently affected causing swelling, pain, decreased function, and degenerative arthritis. Similarly, muscle hemorrhage can cause necrosis, contractures, and neuropathy by entrapment.

CLINICAL FEATURES
Hematuria occurs occasionally and is usually painless. Intracranial hemorrhage, while uncommon, can occur after even mild head trauma and lead to severe complications. Bleeding from tongue or lip lacerations is often persistent.

Rosendaal et al. (1990) presented evidence supporting their earlier findings that mortality due to ischemic heart disease is lower in hemophilia patients than in the general male population.

Antihemophilic globulin
Hemophilia A is the result of a hereditary defect in antihemophilic globulin (factor VIII). It is a complex of a large inert carrier protein and a noncovalently bound small fragment which contains the procoagulant active site. it is synthesized primarily in the liver. Cooper and Wagner (1974) presented evidence that the carrier molecule is normally present in the plasma of hemophilia A patients and Fay et al. (1982) isolated a highly purified human factor VIII that consisted of a single high molecular weight polypeptide chain having the highest specific activity.

Antihemophilic globulin
Cooper and Wagner (1974) presented evidence that the carrier molecule is normally present in the plasma of hemophilia A patients and Fay et al. (1982) isolated a highly purified human factor VIII that consisted of a single high molecular weight polypeptide chain having the highest specific activity.

2 components of The factor VIII complex

The factor VIII complex, with a molecular weight in excess of 1 million, has 2 components: (1)factor VIII (molecular weight of 293,000 ) called factor VIII C, when measured by procoagulant activity and factor VIII Ag, when measured immunologically (2) factor VIII R (the von Willebrand factor or vWF) has a molecular weight of 220,000. Polymerization leads to the high molecular weight of the factor VIII complex (Levin, 1979).

The vWF
The vWF which affects bleeding time and ristocetin aggregation of platelets is encoded by a gene on chromosome 12. Alexander and Goldstein (1953) first noted low levels of factor VIII in cases of von Willebrand disease. Thus, an autosomal locus can also cause low factor VIII levels. This overlap in phenotype between hemophilia A and von Willebrand disease is seen in families such as that of Graham et al. (1953) and Bond et al. (1962) in which the carrier females showed depression of factor VIII levels, not as low as in hemizygous affected males and sometimes clinical hemophilia.

Human factor VIII C2 domain

Pratt et al. (1999) reported the crystal structure of the human factor VIII C2 domain at a resolution of 1.5 angstroms.

The structure reveals a beta-sandwich core, from which 2 beta-turns and a loop display a group of solvent-exposed hydrophobic residues.
Behind the hydrophobic surface lies a ring of positively charged residues. This motif suggests a mechanism for membrane binding involving both hydrophobic and electrostatic interactions. The structure explains, in part, mutations in the C2 region of factor VIII that lead to bleeding disorders in hemophilia A.

Pathophysiology
Mutation of the HEMA gene on the X chromosome causes Hemophilia A. Normally, females have two X chromosomes, whereas males have one X and one Y chromosome. Since males have only a single copy of any gene located on the X chromosome, they cannot offset damage to that gene with an additional copy as can females. Consequently, X-linked disorders such as Hemophilia A are far more common in males.

Pathophysiology
The HEMA gene codes for Factor VIII, which is synthesized mainly in the liver, and is one of many factors involved in blood coagulation

Its loss alone is enough to cause Hemophilia A even if all the other coagulation factors are still present.

GENOTYPE
In a review, Antonarakis et al. (1995) collected the findings of more than 1,000 hemophilia subjects examined for factor VIII gene mutations. These include point mutations, inversions, deletions, and unidentified mutations which constitute 46%, 42%, 8%, 4%, and 91%, 0%, 0%, and 9%, respectively, of those with severe versus mild to moderate disease, respectively, in selected studies.

GENOTYPE
The 266 point mutations described as of April, 1994 comprised missense (53%), CpG-to-TpG (16%), small deletions (12%), nonsense (9%), small inversions and splicing (3% each), and missense polymorphisms and silent mutations in exons (2% each).

GENOTYPE
In addition to these point mutations 100 different larger deletions and 9 insertion mutations had been reported. Inversion mutations resulting from recombinations between DNA sequences in the A gene in intron 22 of the factor VIII gene and 1 of 2 other A genes upstream to factor VIII have been shown to cause a large portion of cases.

GENOTYPE
Data on more than 2,000 samples suggested that the common inversion mutations are found in 42% of all severe hemophilia A subjects. Whereas 98% of the mothers of those with inversions were carriers of the inversion, only about 1 de novo inversion was found in maternal cells for every 25 mothers of sporadic cases; see Antonarakis et al. (1995).

When the maternal grandparental origin of inversions was examined the ratio of de novo occurrences in male:female germ cells was 69:1.

GENOTYPE
Brinke et al. (1996) reported the presence of a novel inversion in 2 hemophilic monozygotic twins. These patients showed an inversion that affects the first intron of the factor 8 gene, displacing the most telomeric exon (exon 1) of factor 8 further towards the telomere and close to the C6.1A gene (DXS551E). Brinke et al. (1996) noted that this novel inversion creates 2 hybrid transcription units. One of these is formed by the promoter and first exon of factor 8 and widely expressed sequences that map telomeric to the C6.1A sequence. The other hybrid transcription unit contains the CpG island and all of the known sequence of C6.1A and the 3-prime section of most of the factor 8 gene.

Regarding those with inhibitors, a variety of factor VIII gene mutations have been found.

GENOTYPE
Of the 30 cases reviewed, 87 and 13% had different nonsense and missense mutations, respectively; see Antonarakis et al. (1995). Finally, factor VIII gene inversions do not seem to be a major predisposing factor for the development of inhibitors. Of severe hemophilia A cases 16% of those without and 20% of those with inversions develop inhibitors; see Antonarakis et al. (1995).

GENOTYPE
Schwaab et al. (1995) found that the probability of developing factor VIII inhibitors is greater in patients with large deletions in the factor VIII gene. Factor VIII inhibitors neutralize factor VIII procoagulant activity by sterically preventing the interaction of factor VIII with von Willebrand factor, phospholipids, activated factor IX, thrombin, and activated factor X.

Another mechanism for inactivation of factor VIII is the proteolysis of factor VIII by anti-factor VIII antibodies.

GENOTYPE
Lacroix-Desmazes et al. (2002) found significant proteolytic activity in IgG from 13 of 24 inhibitor-positive patients.

No hydrolytic activity was detected in control antibodies of IgG from patients without inhibitors.
The relationship between hydrolytic activity of IgG and factor VIII-neutralizing activity was not consistent. Antibodies from some patients caused hydrolysis of factor VIII at low rates, but the plasma had strong inhibitory activity; in other cases, the IgG caused hydrolysis of factor VIII at high rates, but the plasma had weak inhibitory activity; in yet other samples, there were high rates of both hydrolysis and inhibitory activity.

INHERITANCE
Hemophilia A is an X-linked recessive disorder whose locus (factor VIII) has been mapped to Xq28. Using improved methods of carrier detection, Biggs and Rizza (1976) studied 41 mothers of sporadic cases of hemophilia A and found that 39 were in fact carriers. Vidaud et al. (1989) presented evidence that a case of apparent transmission of hemophilia from father to son was due to uniparental disomy. Gamete complementation, involving fertilization of a nullisomic oocyte by a disomic sperm carrying both an X and a Y, was thought to have occurred.

Inheritance
The other 2 were cases of hemophilia A. First, the maternal and paternal X chromosomes were distinguished by RFLPs.

Second, patterns of methylation of selected genes on the Xchromosome were determined using methylationsensitive restriction endonucleases.

Therapy
Replacement by intravenous infusion of factor VIII restores normal hemostasis during the time period that the infused factor remains in physiologic concentrations in the circulation. Replacement of factor VIII is done using a variety of preparations derived from human plasma or recombinant techniques. While replacement therapy is effective in most cases, 10 to 15% of treated individuals develop neutralizing antibodies that decrease its effectiveness.

CLINICAL MANAGEMENT
The mainstay of routine treatment for hemophilia A is infusion of factor VIII done using amounts that are required to restore the factor VIII activity to therapeutic levels. Since the half-life of factor VIII is 8-12 hours twice daily infusions may be required in some circumstances. Desmopressin (dDAVP), a synthetic analog of the neurohypophyseal nonapeptide arginine vasopressin, has been approved for treatment of mild hemophilia A and von Willebrand disease. Following dDAVP in some cases concentrations of factor VIII and von Willebrand factor are transiently increased to levels that allow minor surgery.

Patients with antibodies to factor VIII

Combined cyclophosphamide, intravenous IgG, factor VIII therapy to induce immune tolerance to factor VIII infusions in patients with antibodies to factor VIII liver transplant from a normal donor Conceptually, retroviral vectors can permanently insert the FVIII gene into DNA of the whole cell and, therefore, appear to be the most suitable vehicles for gene therapy.