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Kelly C, Thomas W, Baker RI, O'Donnell JS, Sanchez-Luceros A, Lavin M. Examining variability in the diagnosis and management of people with bleeding disorders of unknown cause: communication from the ISTH SSC Subcommittee on von Willebrand Factor. J Thromb Haemost 2024; 22:2900-2909. [PMID: 38866246 DOI: 10.1016/j.jtha.2024.05.027] [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: 02/12/2024] [Revised: 05/14/2024] [Accepted: 05/15/2024] [Indexed: 06/14/2024]
Abstract
BACKGROUND Bleeding disorder of unknown cause (BDUC) is characterized by a bleeding phenotype in the setting of normal hemostatic testing. No standardized diagnostic criteria or treatment algorithms exist for people with BDUC. To address the unmet need, the International Society on Thrombosis and Haemostasis von Willebrand Factor Scientific Subcommittee performed a real-world survey aimed at addressing knowledge gaps, developing consensus pathways, and ultimately improving care. OBJECTIVES We sought to determine current international clinical practices in the investigation, registration, and treatment of people with BDUC internationally. METHODS An online structured survey was conducted of healthcare providers who managed patients with bleeding disorders using the ISTH RedCap tool. RESULTS Two hundred sixteen respondents from 39 countries were included in the final analysis. The clinical assessment of those with a possible bleeding disorder varied, with only 55% excluding hypermobility but high levels (80%) of bleeding assessment tool usage. In hemostatic testing, only the prothrombin time and activated partial thromboplastin time tests gained universal support. Tranexamic acid was favored for prophylaxis for minor (71%)/major (59%) surgeries and pregnancy (58%), but advice on the treatment if bleeding occurred was heterogeneous. The management of heavy menstrual bleeding in women despite combined oral contraceptive pill use also proved challenging, with healthcare providers selecting multiple alternative strategies. CONCLUSION Significant variation exists in the recognition, registration, and management of people with BDUC worldwide. This survey emphasizes the need for consensus pathways to diagnose and treat BDUC to standardize and improve care for patients internationally.
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Affiliation(s)
- Claire Kelly
- National Coagulation Centre, St. James's Hospital, Dublin, Ireland; Irish Centre for Vascular Biology, School of Pharmacy and Biomedical Sciences, RCSI, Dublin, Ireland
| | - Will Thomas
- Haematology Department, Cambridge University Hospitals National Health Service Foundation Trust, Cambridge, United Kingdom
| | - Ross I Baker
- Western Australia Centre for Thrombosis and Haemostasis, Perth Blood Institute, Murdoch University, Perth, Australia; Hollywood Hospital Haemophilia Treatment Centre, Perth, Australia; Irish-Australian Blood Collaborative Network, Perth, Australia
| | - James S O'Donnell
- National Coagulation Centre, St. James's Hospital, Dublin, Ireland; Irish Centre for Vascular Biology, School of Pharmacy and Biomedical Sciences, RCSI, Dublin, Ireland; Irish-Australian Blood Collaborative Network, Perth, Australia
| | - Analia Sanchez-Luceros
- Department of Haemostasis and Thrombosis, Haematological Research Institute, National Academy of Medicine, Buenos Aires, Argentina; Laboratory of Haemostasis and Thrombosis, Instituto de Medicina ExperimentalConsejo Nacional de Investigaciones Cientificas y Tecnicas-National Academy of Medicine, Buenos Aires, Argentina
| | - Michelle Lavin
- National Coagulation Centre, St. James's Hospital, Dublin, Ireland; Irish Centre for Vascular Biology, School of Pharmacy and Biomedical Sciences, RCSI, Dublin, Ireland.
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MUW researcher of the month. Wien Klin Wochenschr 2024; 136:523-524. [PMID: 39259334 DOI: 10.1007/s00508-024-02438-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/13/2024]
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Mehic D, Gebhart J, Pabinger I. Bleeding Disorder of Unknown Cause: A Diagnosis of Exclusion. Hamostaseologie 2024; 44:287-297. [PMID: 38412996 DOI: 10.1055/a-2263-5706] [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] [Indexed: 02/29/2024] Open
Abstract
Patients with an unexplained mild to moderate bleeding tendency are diagnosed with bleeding disorder of unknown cause (BDUC), a classification reached after ruling out other mild to moderate bleeding disorders (MBD) including von Willebrand disease (VWD), platelet function defects (PFDs), coagulation factor deficiencies (CFDs), and non-hemostatic causes for bleeding. This review outlines our diagnostic approach to BDUC, a diagnosis of exclusion, drawing on current guidelines and insights from the Vienna Bleeding Biobank (VIBB). According to guidelines, we diagnose VWD based on VWF antigen and/or activity levels ≤50 IU/dL, with repeated VWF testing if VWF levels are <80 IU/dL. This has been introduced in our clinical routine after our findings of diagnostically relevant fluctuations of VWF levels in a high proportion of MBD patients. PFDs are identified through repeated abnormalities in light transmission aggregometry (LTA), flow cytometric mepacrine fluorescence, and glycoprotein expression analysis. Nevertheless, we experience diagnostic challenges with regard to reproducibility and unspecific alterations of LTA. For factor (F) VIII and FIX deficiency, a cutoff of 50% is utilized to ensure detection of mild hemophilia A or B. We apply established cutoffs for other rare CFD being aware that these do not clearly reflect the causal role of the bleeding tendency. Investigations into very rare bleeding disorders due to hyperfibrinolysis or increase in natural anticoagulants are limited to cases with a notable family history or distinct bleeding phenotypes considering cost-effectiveness. While the pathogenesis of BDUC remains unknown, further explorations of this intriguing area may reveal new mechanisms and therapeutic targets.
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Affiliation(s)
- Dino Mehic
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Johanna Gebhart
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Ingrid Pabinger
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
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Baker RI, Choi P, Curry N, Gebhart J, Gomez K, Henskens Y, Heubel-Moenen F, James P, Kadir RA, Kouides P, Lavin M, Lordkipanidze M, Lowe G, Mumford A, Mutch N, Nagler M, Othman M, Pabinger I, Sidonio R, Thomas W, O'Donnell JS. Standardization of definition and management for bleeding disorder of unknown cause: communication from the SSC of the ISTH. J Thromb Haemost 2024; 22:2059-2070. [PMID: 38518896 DOI: 10.1016/j.jtha.2024.03.005] [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] [Revised: 02/08/2024] [Accepted: 03/08/2024] [Indexed: 03/24/2024]
Abstract
In many patients referred with significant bleeding phenotype, laboratory testing fails to define any hemostatic abnormalities. Clinical practice with respect to diagnosis and management of this patient cohort poses significant clinical challenges. We recommend that bleeding history in these patients should be objectively assessed using the International Society on Thrombosis and Haemostasis (ISTH) bleeding assessment tool. Patients with increased bleeding assessment tool scores should progress to hemostasis laboratory testing. To diagnose bleeding disorder of unknown cause (BDUC), normal complete blood count, prothrombin time, activated partial thromboplastin time, thrombin time, von Willebrand factor antigen, von Willebrand factor function, coagulation factors VIII, IX, and XI, and platelet light transmission aggregometry should be the minimum laboratory assessment. In some laboratories, additional specialized hemostasis testing may be performed to identify other rare causes of bleeding. We recommend that patients with a significant bleeding phenotype but normal laboratory investigations should be registered with a diagnosis of BDUC in preference to other terminology. Global hemostatic tests and markers of fibrinolysis demonstrate variable abnormalities, and their clinical significance remains uncertain. Targeted genomic sequencing examining candidate hemostatic genes has a low diagnostic yield. Underlying BDUC should be considered in patients with heavy menstrual bleeding since delays in diagnosis often extend to many years and negatively impact quality of life. Treatment options for BDUC patients include tranexamic acid, desmopressin, and platelet transfusions.
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Affiliation(s)
- Ross I Baker
- Western Australia Centre for Thrombosis and Haemostasis, Murdoch University, Perth, Australia; Clinical Research Unit, Perth Blood Institute, Perth, Australia; Hollywood Hospital Haemophilia Centre, Haematology Academic Unit, Perth, Australia; Irish-Australian Blood Collaborative Network, Dublin, Ireland and Perth, Australia.
| | - Philip Choi
- Haematology Department, The Canberra Hospital, Canberra, Australia; Division of Genome Sciences and Cancer, John Curtin School of Medical Research, Australian National University, Canberra, Australia
| | - Nicola Curry
- Department of Clinical Haematology, Haemophilia & Thrombosis Centre, Oxford University Hospitals National Health Service Foundation Trust, Oxford, United Kingdom; Radcliffe Department of Medicine, Oxford University, Oxford, United Kingdom
| | - Johanna Gebhart
- Department of Medicine, Division of Hematology and Hemostaseology, Medical University Vienna, Vienna, Austria
| | - Keith Gomez
- Katharine Dormandy Haemophilia Centre and Thrombosis Unit, Royal Free London National Health Service Foundation Trust, London, United Kingdom
| | - Yvonne Henskens
- Central Diagnostic Laboratory, Maastricht University Medical Centre, Maastricht, The Netherlands; Department of Biochemistry, Institute for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
| | - Floor Heubel-Moenen
- Department of Hematology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Paula James
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Rezan Abdul Kadir
- Department of Obstetrics and Gynaecology, Katharine Dormandy Haemophilia and Thrombosis Centre, The Royal Free National Health Service Hospital, London, United Kingdom; Institute for Women's Health, University College, London, United Kingdom
| | - Peter Kouides
- Mary M. Gooley Hemophilia Center, Rochester, New York, USA
| | - Michelle Lavin
- Irish-Australian Blood Collaborative Network, Dublin, Ireland and Perth, Australia; National Coagulation Centre, St. James's Hospital, Dublin, Ireland; Irish Centre for Vascular Biology, School of Pharmacy & Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Marie Lordkipanidze
- Research Center, Montreal Heart Institute, Montreal, Quebec, Canada; Faculty of Pharmacy, Université de Montréal, Montreal, Quebec, Canada
| | - Gillian Lowe
- West Midlands Adult Comprehensive Care Haemophilia Centre, University Hospitals Birmingham National Health Service Foundation Trust, Birmingham, United Kingdom
| | - Andrew Mumford
- School of Cellular and Molecular Medicine, University of Bristol, Bristol, United Kingdom
| | - Nicola Mutch
- Aberdeen Cardiovascular and Diabetes Centre, Institute of Medical Sciences, School of Medicine, United Kingdom; Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, United Kingdom
| | - Michael Nagler
- Department of Clinical Chemistry, Inselspital, Bern University Hospital, Bern, Switzerland; Department of Clinical Chemistry, Inselspital University Hospital Bern, Bern, Switzerland
| | - Maha Othman
- Department of Biomedical and Molecular Sciences, School of Medicine, Queen's University, Kingston, Ontario, Canada; School of Baccalaureate Nursing, St Lawrence College, Kingston, Ontario, Canada; Clinical Pathology Department, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Ingrid Pabinger
- Department of Medicine, Division of Hematology and Hemostaseology, Medical University Vienna, Vienna, Austria
| | - Robert Sidonio
- Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Will Thomas
- Department of Haematology, Cambridge University Hospitals National Health Service Foundation Trust, Cambridge, United Kingdom
| | - James S O'Donnell
- Irish-Australian Blood Collaborative Network, Dublin, Ireland and Perth, Australia; National Coagulation Centre, St. James's Hospital, Dublin, Ireland; Irish Centre for Vascular Biology, School of Pharmacy & Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
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Casini A, Gebhart J. How to investigate mild to moderate bleeding disorders and bleeding disorder of unknown cause. Int J Lab Hematol 2024; 46 Suppl 1:27-33. [PMID: 38454298 DOI: 10.1111/ijlh.14266] [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: 01/16/2024] [Accepted: 02/28/2024] [Indexed: 03/09/2024]
Abstract
A bleeding tendency is one of the most common complaints observed by hematologists. It is challenging to differentiate a clinically insignificant bleeding from a bleeding phenotype that requires hemostatic evaluation and medical intervention. A thorough review of personal and familial history, objective assessment of bleeding severity using a bleeding assessment tool, and a focused physical examination are critical to correctly identifying suspected patients with mild to moderate bleeding disorders (MBDs). A basic laboratory work-up should be performed in all patients referred for a bleeding tendency. If a hemostatic abnormality is found such as evidence of von Willebrand disease, a platelet function disorder, or a coagulation factor deficiency, more extensive testing should be performed to further characterize the bleeding disorder. Conversely, if all results are normal the patient is considered to have bleeding disorder of unknown cause (BDUC). For patients with BDUC, further evaluation may include non-routine testing to look for rare bleeding disorders not detected by routine hemostasis tests, such as thrombomodulin-associated coagulopathy, tissue factor pathway inhibitor-related bleeding disorder, hyperfibrinolytic-bleeding disorders or impaired tissue factor production. In this review, we summarize the stepwise diagnostic procedure in MBDs and provide some insights into the biological features of BDUC.
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Affiliation(s)
- Alessandro Casini
- Division of Angiology and Hemostasis, University Hospitals of Geneva, Geneva, Switzerland
| | - Johanna Gebhart
- Department of Medicine I, Division of Hematology and Hemostaseology, Medical University Vienna, Austria
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Mehic D, Schramm T, Forstner-Bergauer B, Haslacher H, Ay C, Pabinger I, Gebhart J. Activated protein C and free protein S in patients with mild to moderate bleeding disorders. Thromb Res 2024; 235:98-106. [PMID: 38324941 DOI: 10.1016/j.thromres.2024.01.018] [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: 10/04/2023] [Revised: 11/29/2023] [Accepted: 01/22/2024] [Indexed: 02/09/2024]
Abstract
BACKGROUND Underlying mechanisms for bleeding and impaired thrombin generation (TG) and plasma clot formation (PCF) in patients with mild to moderate bleeding disorders (MBDs) are still to be elucidated, especially in bleeding disorder of unknown cause (BDUC). The role of the natural anticoagulants activated protein C (APC) and free protein S (PS) has not yet been investigated in this patient population. AIMS To analyze antigen levels of APC and PS in patients with MBDs and BDUC and investigate associations to clinical bleeding phenotype and severity as well as and hemostatic capacity. METHODS Antigen levels of APC and free PS were measured in 262 patients from the Vienna Bleeding Biobank (VIBB), a single-center cohort study, by ELISA and compared to 61 healthy controls (HC). RESULTS Antigen levels of APC were higher in MBD patients than in HC when adjusted for age, sex and BMI (median (IQR) 33.1 (20.6-52.6) and 28.6 (16.4-47.2) ng/mL). This was most pronounced in patients with BDUC (35.3 (21.7-54.3) ng/mL). No differences in PS antigen levels between patients and HC were seen overall, or according to specific diagnoses. Further, no association between APC or PS and bleeding severity or global tests of hemostasis or TG were identified, while paradoxically APC weakly correlated with shorter lag time and time to peak of PCF in BDUC. CONCLUSION Our data demonstrate increased antigen levels of APC in BDUC, which might contribute to the bleeding tendency in some patients and could be a future therapeutic target in BDUC.
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Affiliation(s)
- Dino Mehic
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Theresa Schramm
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Birgit Forstner-Bergauer
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Helmuth Haslacher
- Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Cihan Ay
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Ingrid Pabinger
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Johanna Gebhart
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria.
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Berkowitz C, Kirkland K, Ma A, Key NS. Bleeding disorder of unknown cause & unclassified bleeding disorders at US hemophilia treatment centers. Res Pract Thromb Haemost 2024; 8:102296. [PMID: 38292351 PMCID: PMC10824970 DOI: 10.1016/j.rpth.2023.102296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Revised: 11/01/2023] [Accepted: 11/20/2023] [Indexed: 02/01/2024] Open
Affiliation(s)
- Callie Berkowitz
- Division of Hematology and Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Kristi Kirkland
- Division of Hematology and Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Alice Ma
- Division of Hematology and Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Nigel S. Key
- Division of Hematology and Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Mehic D, Kraemmer D, Tolios A, Bücheler J, Quehenberger P, Haslacher H, Ay C, Pabinger I, Gebhart J. The necessity of repeat testing for von Willebrand disease in adult patients with mild to moderate bleeding disorders. J Thromb Haemost 2024; 22:101-111. [PMID: 37741511 DOI: 10.1016/j.jtha.2023.09.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 08/23/2023] [Accepted: 09/13/2023] [Indexed: 09/25/2023]
Abstract
BACKGROUND In patients with mild-to-moderate bleeding disorders (MBD), von Willebrand disease (VWD) is diagnosed at von Willebrand factor (VWF) levels ≤50 IU/dL. Although VWF levels are unstable, repeated testing for VWD diagnosis is not necessarily advised in recent guidelines. OBJECTIVES To analyze the relevance of repeated VWF testing to diagnose VWD in patients with MBD. METHODS Data of 277 patients with MBD from the Vienna Bleeding Biobank with at least 2 separate assessments of VWF antigen (VWF:Ag) and activity (VWF:Act) were analyzed. RESULTS In repeated VWF measurements, 36 patients (13.0%) had "changing" VWF levels (≤/>50 IU/dL), 27 (9.7%) had persistent levels ≤50 IU/dL ("pathologic"), and 214 (77.3%) had levels >50 IU/dL ("normal"). Of the 36 changing patients, 22 (61%) were diagnosed with VWD at baseline, whereas the others only met VWD diagnostic criteria at repeated measurements. Using logistic regression, we estimated a probability of change of 26.4% (95% CI, 12.5-47.4) at baseline VWF levels of 30 IU/dL, 50.8% (95% CI, 35.6-65.8) at 50 IU/dL, 18.8% (95% CI, 12.3-27.6) at 60 IU/dL, and 1.2% (95% CI, 0.3-4.9) at 80 IU/dL. Baseline VWF was a strong predictor for changing status (Χ2 = 49.9; P < .001), while age, sex, Vicenza score, and blood type O had limited added value (Χ2 = 5.1; P = .278). Baseline VWF:Ag or VWF:Act cutoffs of 80 IU/dL had negative predictive values of 98.1% and 99.1% for changing status, respectively. CONCLUSION Our data emphasize an overlap between patients with VWD and MBD with bleeding disorder of unknown cause and underline the need for repeated VWF testing, especially in patients with VWF levels <80 IU/dL.
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Affiliation(s)
- Dino Mehic
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria; Institute of Vascular Biology and Thrombosis Research, Centre of Physiology and Pharmacology, Medical University of Vienna, Vienna, Austria. https://twitter.com/dino_mehic
| | - Daniel Kraemmer
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Alexander Tolios
- Department of Transfusion Medicine and Cell Therapy, Medical University of Vienna, Vienna, Austria
| | - Julia Bücheler
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Peter Quehenberger
- Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Helmuth Haslacher
- Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Cihan Ay
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria. https://twitter.com/Cihan_Ay_MD
| | - Ingrid Pabinger
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria. https://twitter.com/IngridPabinger
| | - Johanna Gebhart
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria.
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Mehic D, Pabinger I, Gebhart J. Investigating patients for bleeding disorders when most of the "usual" ones have been ruled out. Res Pract Thromb Haemost 2023; 7:102242. [PMID: 38193045 PMCID: PMC10772891 DOI: 10.1016/j.rpth.2023.102242] [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: 08/30/2023] [Revised: 10/06/2023] [Accepted: 10/12/2023] [Indexed: 01/10/2024] Open
Abstract
A State of the Art lecture titled "Investigating Patients for Bleeding Disorders When Most of the Usual Ones Have Been Ruled Out" was presented at the International Society on Thrombosis and Haemostasis Congress in 2023. Mild to moderate bleeding disorders (MBDs) in patients in whom no diagnosis of an established disorder, such as platelet function defect, von Willebrand disease, or a coagulation factor deficiency, can be identified are classified as bleeding disorders of unknown cause (BDUCs). Prospective data from the Vienna Bleeding Biobank and other studies have revealed a high proportion of BDUCs of up to 70% among patients with MBD who have a similar bleeding phenotype as other MBDs. As BDUC is a diagnosis of exclusion, the accuracy of the diagnostic workup is essential. For example, repeated testing for von Willebrand disease should be considered if von Willebrand factor values are <80 IU/dL. Current evidence does not support the clinical use of global assays such as thromboelastography, platelet function analyzer, or thrombin generation potential. Rare and novel bleeding disorders due to genetic variants in fibrinolytic factors or natural anticoagulants are rare and should only be analyzed in patients with specific phenotypes and a clear family history. In BDUC, blood group O was identified as a risk factor for increased bleeding severity and bleeding risk after hemostatic challenges. Future studies should improve the phenotypical characterization and ideally identify novel risk factors in BDUC, as a multifactorial pathogenesis is suspected. Finally, we summarize relevant new data on this topic presented during the 2023 International Society on Thrombosis and Haemostasis Congress.
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Affiliation(s)
- Dino Mehic
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Ingrid Pabinger
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Johanna Gebhart
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
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Mehic D, Schwarz S, Shulym I, Ay C, Pabinger I, Gebhart J. Health-related quality of life is impaired in bleeding disorders of unknown cause: results from the Vienna Bleeding Biobank. Res Pract Thromb Haemost 2023; 7:102176. [PMID: 37720482 PMCID: PMC10502434 DOI: 10.1016/j.rpth.2023.102176] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 07/14/2023] [Accepted: 07/17/2023] [Indexed: 09/19/2023] Open
Abstract
Background Bleeding disorder of unknown cause (BDUC) is a diagnosis of exclusion after extensive investigation of coagulation and platelet function and is commonly seen among patients with mild-to-moderate bleeding disorders. Despite increasing awareness among treating physicians, little is known about the health-related quality of life (HrQoL) in BDUC. Objectives To investigate HrQoL in patients with BDUC in comparison to the general population and patients diagnosed with other established bleeding disorders. Methods Patients with mild-to-moderate bleeding disorders from the Vienna Bleeding Biobank, a prospective cohort study, were contacted via mail and phone to complete the 36-Item Health Survey Questionnaire form. Results In total, 333/657 (50.7%) patients completed the 36-Item Health Survey Questionnaire. Patients with BDUC (n = 207, 62%) had significantly impaired HrQoL both in physical (47.8 vs 49.2) and mental health parameters (42.9 vs 51.0) compared to the general population (n = 2914, 56% females), which remained after adjustment for sex and age in multivariable linear regression. The impairment in HrQoL, compared to patients with von Willebrand disease, platelet function defects, or mild clotting factor deficiencies, did not prevail after adjustment for age and sex. In patients with BDUC, age and the presence of at least 1 comorbidity were associated with impaired physical health but not sex or bleeding severity. Of all analyzed bleeding symptoms, only joint bleeding was associated with impaired physical health and gastrointestinal bleeding with mental health in BDUC. Conclusion The impairments in HrQoL in patients with BDUC emphasize the burden of BDUC on mental and physical well-being, encouraging early recognition and better counseling of patients with BDUC.
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Affiliation(s)
- Dino Mehic
- Department of Medicine I, Clinical Division of Haematology and Haemostaseology, Medical University of Vienna, Vienna, Austria
- Centre of Physiology and Pharmacology, Institute of Vascular Biology and Thrombosis Research, Medical University of Vienna, Vienna, Austria
| | - Stephan Schwarz
- Department of Medicine I, Clinical Division of Haematology and Haemostaseology, Medical University of Vienna, Vienna, Austria
| | - Ihor Shulym
- IT-Systems and Communications, Medical University of Vienna, Vienna, Austria
| | - Cihan Ay
- Department of Medicine I, Clinical Division of Haematology and Haemostaseology, Medical University of Vienna, Vienna, Austria
| | - Ingrid Pabinger
- Department of Medicine I, Clinical Division of Haematology and Haemostaseology, Medical University of Vienna, Vienna, Austria
| | - Johanna Gebhart
- Department of Medicine I, Clinical Division of Haematology and Haemostaseology, Medical University of Vienna, Vienna, Austria
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Thomas W. The natural history of bleeding disorder of unknown cause. J Thromb Haemost 2023; 21:1747-1749. [PMID: 37330263 DOI: 10.1016/j.jtha.2023.03.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 03/22/2023] [Indexed: 06/19/2023]
Affiliation(s)
- Will Thomas
- Haemophilia and Thrombophilia Centre, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom.
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