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Pai N, Dhaimade P, Chaudhari VL, Shanmukaiah C, Gujar H, Raj JP. Matched cohort study evaluating the hemostatic efficacy of fibrin sealant versus conventional approaches following dental surgery in patients with hemophilia. Int J Oral Maxillofac Surg 2024:S0901-5027(24)00240-6. [PMID: 39068048 DOI: 10.1016/j.ijom.2024.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Revised: 07/13/2024] [Accepted: 07/16/2024] [Indexed: 07/30/2024]
Abstract
Patients with hemophilia frequently require supplementary interventions, either invasive (suturing, gel foam, or cauterization) or non-invasive (fibrin sealant/glue), to attain hemostasis post dental procedures. This study aimed to compare the efficacy of fibrin sealant against traditional methods for achieving hemostasis post dental surgery. The medical records of patients with factor VIII or IX deficiency, or von Willebrand disease, who underwent dental procedures in the Department of Dentistry, Seth GSMC and KEM Hospital, were evaluated for inclusion in this retrospective matched cohort study. Cohort-1 included those treated with a fibrin sealant (Tisseel Lyo) with/without traditional hemostatic measures post-procedure, while cohort-2 (controls) included those in whom no fibrin sealant was used. A total of 128 patients, 64 in each group, were evaluated. There was no statistically significant difference in demographics, disease-related variables, dental complaints, or preoperative treatment given between the groups. However, there was a significant reduction (P < 0.001) in the requirement for secondary procedures for hemostasis (suturing, gel foam application, and/or cauterization) and postoperative requirement for factor replacement (P = 0.003) in the fibrin glue group as compared to the controls. In this study, fibrin sealant demonstrated superior efficacy in mitigating the necessity for active hemostasis control.
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Affiliation(s)
- N Pai
- Department of Dentistry, Seth GSMC and KEM Hospital, Mumbai, India.
| | - P Dhaimade
- Graduate Periodontics, University of Oklahoma School of Dentistry, Oklahoma City, OK, USA.
| | - V L Chaudhari
- Department of Clinical Pharmacology, Seth GSMC and KEM Hospital, Mumbai, India.
| | - C Shanmukaiah
- Department of Hematology, Seth GSMC and KEM Hospital, Mumbai, India.
| | - H Gujar
- Department of Dentistry, Seth GSMC and KEM Hospital, Mumbai, India.
| | - J P Raj
- Division of Clinical Pharmacology, Department of Pharmacology, Kasturba Medical College, Manipal, Manipal Academy of Higher Education (MAHE), Manipal, Karnataka, India.
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Vasava R, Shastri M, Rathod VM, Laha G, Vaishnovi V, Patel NJ, Deshagoni R, Singh P, Joshi N, Raval DM. A Study of Clinical Profile and Treatment in Adult Hemophilia Patients with Special Reference to the Inhibitor Levels. Cureus 2024; 16:e54663. [PMID: 38524060 PMCID: PMC10960162 DOI: 10.7759/cureus.54663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2024] [Indexed: 03/26/2024] Open
Abstract
Introduction Hemophilia is an uncommon, X-linked recessive bleeding condition characterized by a lack of either factor VIII or factor IX. It is more prevalent in men. Due to the substantial impact inhibitor development has on patient prognosis, the primary treatment for hemophilia is the transfusion of recombinant factors. The aim of our study is to investigate 40 adult patients with hemophilia in terms of their clinical profile, clinically relevant risk factors for inhibitor development, therapy-related aspects such as treatment duration, factor requirements, transfusion frequency, presence of inhibitors, and complications. Methods This cross-sectional observational study involving 40 patients of hemophilia over 12 years of age was conducted at a tertiary care hospital in Gujarat. Data on sociodemographic characteristics, presenting complaints, bleeding episodes, hemophilia type, and medical history were gathered over a one-year span. Patients were stratified into mild, moderate, and severe groups based on their respective levels of factor activity. Various parameters, including the frequency of factor therapy, percentage of factor concentrate, inhibitor presence, and disease and therapy-related complications, were analyzed. The distribution of patients across these parameters was calculated and illustrated using pie charts. Results Nineteen out of 40 patients were from 20 to 40 years of age. The majority of cases (n=24), however, had been diagnosed before the patients reached the age of 10. All patients were male, and half of the patients (n=20) suffered from mild disease. The most common site of bleeding was the knee joint, and 33 cases had one to 10 bleeding episodes per year. Thirty-two out of 40 patients needed less than 40 factor vial transfusions, whereas eight needed more than 40 factor vial transfusions. Two cases of severe disease were positive for inhibitors of factor VIII, whereas one patient was found to have a hepatitis B virus (HBV) infection. Conclusions Hemophilia, a rare bleeding disorder, has primarily been studied in pediatric populations. This study, however, shifts the focus toward adult individuals. Our cohort consisted exclusively of male patients, with the predominant group diagnosed with hemophilia A and falling within the age range of 20 to 40 years. Most patients had been diagnosed before 10 years of age. The primary complication observed was joint bleeding, with the knee joint being the most commonly affected site. Approximately two-thirds of cases had a history of minor trauma necessitating factor replacement, yet only 5% exhibited the presence of inhibitors.
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Affiliation(s)
- Renuka Vasava
- General Medicine, Sir Sayajirao General Hospital, Medical College Baroda, Vadodara, IND
| | - Minal Shastri
- General Medicine, Sir Sayajirao General Hospital, Medical College Baroda, Vadodara, IND
| | - Vaishnavi M Rathod
- General Medicine, Parul Institute of Medical Sciences and Research, Vadodara, IND
| | - Gayatri Laha
- General Medicine, Sir Sayajirao General Hospital, Medical College Baroda, Vadodara, IND
| | - Vaishnovi Vaishnovi
- General Medicine, Sir Sayajirao General Hospital, Medical College Baroda, Vadodara, IND
| | | | - Rajani Deshagoni
- Internal Medicine, Rajiv Gandhi Institute of Medical Sciences, Adilabad, IND
| | - Prerna Singh
- Infectious Disease Department, Mayo Clinic, Jacksonville, USA
| | - Nandan Joshi
- Internal Medicine, Surat Municipal Institute of Medical Education and Research, Surat, IND
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Ray D, Kumar N, Hans C, Kler A, Jain R, Bansal D, Trehan A, Jain A, Malhotra P, Ahluwalia J. Inhibitor; An Uncommon But Vexing Challenge In North Indian Patients With Hemophilia A. Indian J Hematol Blood Transfus 2022; 38:703-709. [PMID: 36258733 PMCID: PMC9569402 DOI: 10.1007/s12288-022-01539-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 04/09/2022] [Indexed: 10/18/2022] Open
Abstract
Factor VIII replacement is the mainstay of treatment in hemophilia A but may lead to the development of inhibitors. While a vexing clinical problem, some observations suggest that the presence of inhibitors may not necessarily portend a higher bleeding risk. Our aim was to assess the prevalence and clinicopathological correlates of inhibitors in a well characterized cohort of Indian patients with HA patients. We retrospectively reviewed the clinical details and laboratory findings of consecutive hemophilia A patients attending a north-Indian tertiary-care center from 2010 to 2020. Among 592 patients with HA, inhibitors were detected in 35 patients (5.9%). Prevalence of inhibitors in moderate and severe hemophilia was 4.2% and 6.7%, respectively. Most patients with inhibitors had history of transfusion with factor VIII alone (54.3%) or a combination of factor VIII concentrate and other blood-products (42.9%). Intracranial bleed was significantly more frequent in patients with inhibitors compared to those without inhibitors (20% vs. 4.1%; p-0.001). Time dependent and immediately acting inhibitors were seen in 60% and 40% patients, respectively. High-titre (> 5 BU) and low-titre inhibitors (< 5 BU) were detected in 28 (80%) and 7 (20%) patients, respectively. Prevalence of inhibitors in our cohort was 5.9% and most had high-titre, time dependent inhibitors. These patients may have a higher risk of intracranial bleeding.
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Affiliation(s)
- Debadrita Ray
- Department of Hematology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Narender Kumar
- Department of Hematology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Chander Hans
- Department of Hematology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Anita Kler
- Department of Hematology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Richa Jain
- Department of Pediatric Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Deepak Bansal
- Department of Pediatric Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Amita Trehan
- Department of Pediatric Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Arihant Jain
- Department of Clinical Hematology & Medical Oncology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Pankaj Malhotra
- Department of Clinical Hematology & Medical Oncology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Jasmina Ahluwalia
- Department of Hematology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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4
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Ashfaq J, Ahmed R, Tariq F, Abedin QU, Abid M, Borhany M. Frequency of Intron 22 Inversion in Severe Hemophilia A Patients. Cureus 2022; 14:e28247. [PMID: 36158401 PMCID: PMC9490293 DOI: 10.7759/cureus.28247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/19/2022] [Indexed: 11/05/2022] Open
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Ashfaq J, Tariq F, Ahmed R, Thakur W, Abid M, Borhany M. Frequency of Specific and Non-specific Inhibitors in Haemophilia A Patients. Cureus 2022; 14:e26008. [PMID: 35855246 PMCID: PMC9286306 DOI: 10.7759/cureus.26008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/16/2022] [Indexed: 11/24/2022] Open
Abstract
Objective: To determine the frequency of specific and non-specific inhibitors in haemophilia A patients. Study design: This is a cross-sectional study. Patients and methods: A total of 150 male haemophilia A patients were included in this cross-sectional study at the National Institute of Blood Diseases and Bone Marrow Transplant (NIBD), Karachi, Pakistan, from September 2019 to January 2022. Results: Among 150 patients included in this study, 23 (15.3%) had an inhibitor and 127 (84.6%) did not. All patients had specific inhibitors against Factor VIII (FVIII). Non-specific inhibitors were not identified in our population. Among the patients in the inhibitor group, there were 13 (56.5%) in the severe (<1%) category. There were 10 (43.5%) patients in the moderate (1-5%) category. There were no patients in the mild category. The median inhibitor level was 15.4 Bethesda unit (BU). Conclusion: The development of inhibitors has not been identified as a major problem in our population. However, it is noteworthy that only 15.3% of patients with haemophilia A developed inhibitors in this data set. They were essentially treated with plasma and its products.
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Rathaur VK, Vigneshwar NKV, Imran A, Pathania M, Agrawal S, Chacham S, Verma PK, Bhat NK. Rare but not Abdicated: Status of Haemophilia in foothills of Himalaya, Uttarakhand: A cross-sectional study. J Family Med Prim Care 2021; 10:1437-1442. [PMID: 34041191 PMCID: PMC8140229 DOI: 10.4103/jfmpc.jfmpc_1613_20] [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: 08/13/2020] [Revised: 10/06/2020] [Accepted: 10/28/2020] [Indexed: 11/04/2022] Open
Abstract
Background Haemophilia is one of the bleeding disorders, which is inherited, in an xlinked recessive pattern. The diagnosis is by estimation of factor levels of 8 and 9. Timebound treatment for people living with Haemophilia (PWH) is factor replacement during bleeding manifestation. The prevalence of Haemophilia was mostly underestimated, and it is more so in hilly terrains like the state of Uttarakhand. Materials and Method This is a crosssectional study by compiling the data of PWH visiting the tertiary care centre for Haemophilia in Uttarakhand. We collected data from the patients with bleeding disorder reporting to the Haemophilia centre from July 2017 to December 2018. In this manuscript, we try to describe the pattern of Haemophilia and the degree of severity and incidence of inhibitors among the sample population of PWH who represent the population of Uttarakhand. The magnitude of problems faced by PWH from this hilly terrain to assess basic treatment in case of emergency is also being depicted. Result We reported Haemophilia A contributing about 80% of the PWH in our centre. Average distance a PWH has to travel to obtain treatment was about 131.5 km (SD ± 83.7 km). Incidence of inhibitors was about 5%. Conclusion We infer from our study that Hemophilia A is more common than Hemophilia B. Through this manuscript we hope to spread awareness of the Haemophilia care that is ongoing, the role of prophylaxis therapy and the future role of primary care physicians that may change the care of PWH in future.
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Affiliation(s)
- Vyas K Rathaur
- Professor and Head of the Department, Department of Pediatrics, Veer Chandra Singh Garhwali Govt. Institute of Medical Science & Research, N. K. V. Vigneshwar, Dehradun, Uttarakhand, India
| | - N K V Vigneshwar
- Junior Resident, Department of Pediatrics, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Ayesha Imran
- Assistant Professor, Department of Pediatrics, Government Doon Medical College, Dehradun, Uttarakhand, India
| | - Monika Pathania
- Associate Professor, Department of Internal Medicine, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Sonam Agrawal
- Assistant Professor, Department of Pediatrics, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Swathi Chacham
- Additional Professor, Department of Pediatrics, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Prashant K Verma
- Associate Professor, Department of Pediatrics, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Nowneet K Bhat
- Professor and Head of the Department, Department of Pediatrics, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
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Mahmoud Abu Arra C, Samarah F, Sudqi Abu Hasan N. Factor VIII Intron 22 Inversion in Severe Hemophilia A Patients in Palestine. SCIENTIFICA 2020; 2020:3428648. [PMID: 33062376 PMCID: PMC7533029 DOI: 10.1155/2020/3428648] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 08/15/2020] [Accepted: 09/15/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Hemophilia A is an X-linked recessive bleeding disorder caused by mutations in FVIII gene with an incidence of 1 in 5,000 to 10,000 live born males. The Inv22 mutation is a major cause of the disease worldwide, accounting for up to 40%-50% of severe FVIII mutations. The aim of the present study was to screen Inv22 of the FVIII gene in Palestinian patients with severe HA and reveal its role as a predisposing factor for the development of inhibitors. MATERIALS AND METHODS A cohort of 77 HA individuals including 5 carrier females from 52 unrelated families registered at governmental hemophilia centers in the West Bank area of Palestine was investigated. The demographic data and the clinical history were retrieved from medical files. Molecular analysis of Inv22 mutation in severe HA (30 cases) from Palestine was performed using the subcycling polymerase reaction (S-PCR). FVIII coagulant activities were carried out on an aPTT-based 1-stage clotting assay. FVIII inhibitors were quantified using the Nijmegen modification of the Bethesda assay. RESULT Overall, 41.7% (30/72) of the studied cases were classified as having severe HA, 22.2% (16/72) had moderate HA, and 36.1% (26/72) had mild HA. Five randomly selected carrier mothers were screened for the Inv22 mutation to confirm its transmission to their sons. The Inv22 mutation was detected in 11 severe HA patients (36.6%). Among the severe HA patients with positive Inv22, 45.5% (5/11) had developed inhibitors. The current study showed that there was no association (p=0.53) between inhibitor development and the Inv22 mutation. CONCLUSION Findings on Inv22 are in agreement with worldwide reports, being a major genetic mutation in severe HA. The S-PCR is a simple, rapid, and cost-effective method for the diagnosis of Inv22 in severe HA patients. Although the Inv22 mutation was associated with 36.6% of severe HA phenotype cases, it was not a major predisposing factor for inhibitor formation.
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Affiliation(s)
| | - Fekri Samarah
- Department of Medical Laboratory Sciences, Arab American University (AAUP), Jenin, State of Palestine
| | - Nael Sudqi Abu Hasan
- Department of Biology and Biotechnology, An-Najah National University, Nablus, State of Palestine
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8
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Sherief LM, Gaber OA, Youssef HM, Sherbiny HS, Mokhtar WA, Ali AAA, Kamal NM, Abdel Maksoud YH. Factor VIII inhibitor development in Egyptian hemophilia patients: does intron 22 inversion mutation play a role? Ital J Pediatr 2020; 46:129. [PMID: 32928254 PMCID: PMC7488666 DOI: 10.1186/s13052-020-00878-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 07/29/2020] [Indexed: 11/30/2022] Open
Abstract
Background Hemophilia A (HA) is an X-linked recessive bleeding disorder characterized by qualitative and quantitative deficiency of factor VIII (FVIII). The development of inhibitor antibodies against FVIII is the most challenging complication of treatment. Mutations in the FVIII gene is one of the genetic factors that leads to development of FVIII inhibitors especially intron 22 inversion (Inv22). Objectives This study was carried out to assess the frequency of Inv22 of FVIII gene in Egyptian patients with hemophilia A and its role as a risk factor for developing inhibitors. Patients and methods Seventy-two patients with severe HA and 48 patients with moderate HA were enrolled in the current study. All patients were treated on demand with either plasma-derived factor VIII or recombinant factor VIII concentrates. Genotyping of FVIII Inv22 was performed by LD-PCR while the presence and magnitude of inhibitor activity in blood was determined by the Bethesda assay. Results Around 23% of all hemophilia cases had positive Inv22. Intron 22 inversion mutation was detected in 6 and 33% of patients with moderate and severe HA respectively. Twenty-one cases (18%) of all hemophilic patients developed inhibitors. Thirty-7% of patients with Inv22 had inhibitor in their blood, almost all, but one, had severe HA. The risk of an inhibitor development during replacement therapy was four folds higher among Inv22 positive cases as compared with mutation negative peers (OR 4.3, 95% CI 1.6–11.9, P = 0.003). Conclusions The prevalence of Inv22 of F VIII in Egyptian hemophiliacs is nearly like that of other population. This mutation was more frequently detected among severe hemophilic patients as compared with moderately affected peers. The presence of Inv22 mutation significantly predispose to FVIII inhibitor development.
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Affiliation(s)
- Laila M Sherief
- Pediatric Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Osama A Gaber
- Biochemistry Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Hala Mosaad Youssef
- Biochemistry Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Hanan S Sherbiny
- Pediatric Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt.,Pediatric Department, Collage of Medicine, University of Bisha (UB), Bisha, Kingdom of Saudi Arabia
| | - Wesam A Mokhtar
- Pediatric Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Asmaa A A Ali
- Biochemistry Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Naglaa M Kamal
- Pediatric Department, Faculty of Medicine, Cairo University, Cairo, Egypt.
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9
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Anti-factor VIII inhibitors against A2 and C2 domains in hemophilia A patients from India. Blood Cells Mol Dis 2018; 75:11-12. [PMID: 30502565 DOI: 10.1016/j.bcmd.2018.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Revised: 11/13/2018] [Accepted: 11/13/2018] [Indexed: 11/21/2022]
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10
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Prevalence of factor VIII inhibitors among Afghan patients with hemophilia A: a first report. Blood Coagul Fibrinolysis 2018; 29:697-700. [PMID: 30439768 DOI: 10.1097/mbc.0000000000000780] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
: Prevalence of inhibitors in Afghan hemophilia patients has not been reported previously. Our aim was to determine the prevalence of factor VIII inhibitors among hemophilia A patients from the Kabul province of Afghanistan to identify and characterize the pattern of inhibitor formation. Clinical information and blood samples were collected from three hemophilia centers in Kabul, Afghanistan. Plasma samples were obtained from 62 patients with severe (80.5%) and 15 patients with moderate hemophilia A (19.5%) in this cross-sectional study design. All the patients were receiving on-demand treatment. The Nijmegen modification of the Bethesda assay was used to detect inhibitors. Multiplex PCR, inverse-PCR, Multiplex ligation-dependent probe amplification and direct sequencing were performed for genotyping. Inhibitor activity was detected in one out of 15 (6.7%) patients with moderate hemophilia and in six out of 62 (9.7%) with severe disease. Apart from the intron 22 inversion, five different mutations including one missense, two large and two small deletions were detected. This is the first report showing that the prevalence of inhibitors in Afghan hemophilia A patients is much lower than in other populations.
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Arshad S, Singh A, Awasthi NP, Kumari S, Husain N. Clinicopathological parameters influencing inhibitor development in patients with hemophilia A receiving on-demand therapy. Ther Adv Hematol 2018; 9:213-226. [PMID: 30181842 PMCID: PMC6116755 DOI: 10.1177/2040620718785363] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Accepted: 05/27/2018] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Development of inhibitors to transfused factor VIII in patients with hemophilia A continues to be a challenge for professionals involved in hemophilia care. The majority of patients in India receive 'on-demand' rather than prophylactic therapy. The present study was done to assess the prevalence of factor VIII inhibitors in patients with hemophilia A (PWHA) receiving 'on-demand' therapy in a North Indian population and to study the clinicopathological parameters influencing the development of inhibitors. METHODS The study group comprised of 300 PWHA. Detailed clinical parameters, treatment history, bleeding profile including family history were recorded. Diagnosis of hemophilia A was confirmed by relevant coagulation tests. Inhibitors were screened using mixing based studies followed by quantification by Bethesda assay and Nijmegen modified Bethesda assay. Samples were collected from five cities in North India where a free supply of factor VIII was available and effectively used in three of these cities. RESULTS In the 300 PWHA, disease phenotype was severe in 219 (73%), moderate in 62 (20.67%) and mild in 19 (6.34%), based on the factor VIII bioassay. Inhibitor prevalence was 9.6% (n = 29) and seen only in the severe phenotype. Inhibitor titers ranged from 0.8 to 108.8 BU/ml. A total of 12 PWHA had low and 17 had high titers. Correlation of various clinicopathological parameters in inhibitor-positive versus negative PWHA showed significant correlation with age at onset of disease, severity of disease, age at first exposure to treatment, annual factor intake (IU/kg/year), intense treatment episodes and bleeding manifestations like central nervous system bleed and hematuria. The total study sample had blood group B in 33.34% PWHA, followed by O (27.34%), A (24.34%) and AB (15%), however, in inhibitor-positive samples, significant inhibitor formation was associated with the ABO subtype A (19/29, 65.51%). CONCLUSIONS Factor VIII inhibitor prevalence in PWHA receiving 'on-demand' therapy was 9.6%. Clinicopathological correlates of inhibitor development in such PWHA have been analyzed in this novel study.
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Affiliation(s)
- Sanya Arshad
- Dr. Ram Manohar Lohia Institute of Medical
Sciences, Lucknow, Uttar Pradesh, India
| | - Anshima Singh
- Dr. Ram Manohar Lohia Institute of Medical
Sciences, Lucknow, Uttar Pradesh, India
| | - Namrata Punit Awasthi
- Department of Pathology, Dr. Ram Manohar Lohia
Institute of Medical Sciences, Vibhuti Khand, Gomti Nagar, Lucknow 226010,
India
| | - Swati Kumari
- Dr. Ram Manohar Lohia Institute of Medical
Sciences, Lucknow, Uttar Pradesh, India
| | - Nuzhat Husain
- Dr. Ram Manohar Lohia Institute of Medical
Sciences, Lucknow, Uttar Pradesh, India
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12
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Pinto P, Ghosh K, Shetty S. F8 gene mutation profile in Indian hemophilia A patients: Identification of 23 novel mutations and factor VIII inhibitor risk association. Mutat Res 2016; 786:27-33. [PMID: 26897466 DOI: 10.1016/j.mrfmmm.2016.02.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Revised: 01/20/2016] [Accepted: 02/07/2016] [Indexed: 10/22/2022]
Abstract
'FVIII inhibitors', especially in severe hemophilia A (HA) patients, is a serious adverse effect that complicates their clinical management. Many genetic and non-genetic risk factors have been proposed for FVIII inhibitor development, diverse in different population groups. This is the first study in Indian hemophiliacs that analyzes inhibitor risk in relation to the complete F8 mutation profile, in a case-control study that included 145 Indian severe HA patients, i.e. 69 inhibitor positive (with 18 inhibitor concordant/discordant family members), and 58 inhibitor negative patients, after informed consent. While 53.54% (68/127) index cases were positive for intron 22 or intron 1 inversions, 55 causative F8 mutations were detected in the 59 inversion negative patients, of which 23 were novel mutations (in 24 patients) and 32 were reported earlier (in 35 patients). A higher incidence of mutations, in the C1 and C2 domains in inhibitor positive patients, and in the A1 domain in inhibitor negative patients was observed, though not significantly different. The study suggests that large F8 rearrangements (significantly higher in the inhibitor positive patients) pose the highest risk, while missense mutations (significantly higher in the inhibitor negative patients) pose the lowest risk of inhibitor development in Indian hemophilia A patients.
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Affiliation(s)
- Patricia Pinto
- National Institute of Immunohaematology (ICMR), 13th Floor, New Multistoreyed Building, KEM Hospital Campus, Parel, Mumbai 400 012, India
| | - Kanjaksha Ghosh
- National Institute of Immunohaematology (ICMR), 13th Floor, New Multistoreyed Building, KEM Hospital Campus, Parel, Mumbai 400 012, India
| | - Shrimati Shetty
- National Institute of Immunohaematology (ICMR), 13th Floor, New Multistoreyed Building, KEM Hospital Campus, Parel, Mumbai 400 012, India.
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13
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Pinto P, Shetty S, Lacroix-Desmazes S, Bayry J, Kaveri S, Ghosh K. Antibody profile in Indian severe haemophilia A patients with and without FVIII inhibitors. Immunol Lett 2015; 169:93-7. [PMID: 26433059 DOI: 10.1016/j.imlet.2015.09.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Accepted: 09/27/2015] [Indexed: 11/17/2022]
Abstract
Diagnosis and management of haemophilia patients with inhibitors is often tricky due to the heterogeneous nature of the antibodies with regard to their kinetics, as well as the co-existence of other interfering antibodies. Plasma samples from severe haemophilia A patients from India with and without FVIII inhibitors were analysed for the presence of possible co-existing antibodies such as lupus anticoagulants (LA), anti-cardiolipin antibodies (ACLA), anti-β2-glycoprotein-I (anti-β2-GP-I) antibodies, viral transfusion transmitted disease (HIV, HBsAg, HCV) related antibodies, anti-cyclic citrullinated peptides (anti-CCP), and anti-nuclear antibodies. A high incidence of LA and anti-HCV antibodies was detected in Indian haemophilia A patients similar to earlier reports. More importantly, a relatively high incidence of autoantibodies to nuclear antigens (18.62%) and anti-CCP antibodies (1.38%) associated with autoimmune disorders was also seen in these congenital haemophilia A patients with and without inhibitors. Knowledge on the antibody profile in these haemophilia patients especially in those with FVIII inhibitors along with correlation with the clinical manifestations and other risk factors for inhibitor development could possibly shed more light on the complex immune response in these patients.
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Affiliation(s)
- Patricia Pinto
- National Institute of Immunohaematology (ICMR), 13th Floor, New Multistoreyed Building, KEM Hospital Campus, Parel, Mumbai 400012, India
| | - Shrimati Shetty
- National Institute of Immunohaematology (ICMR), 13th Floor, New Multistoreyed Building, KEM Hospital Campus, Parel, Mumbai 400012, India
| | - Sebastien Lacroix-Desmazes
- INSERM, UMRS 1138, Centre de Recherche des Cordeliers, Paris, France; Université Pierre et Marie Curie-Paris 6, UMRS 1138, Paris, France; Université Paris Descartes, UMRS 1138, Paris, France; Laboratoire International Associé INSERM (France) - ICMR, India
| | - Jagadeesh Bayry
- INSERM, UMRS 1138, Centre de Recherche des Cordeliers, Paris, France; Université Pierre et Marie Curie-Paris 6, UMRS 1138, Paris, France; Université Paris Descartes, UMRS 1138, Paris, France; Laboratoire International Associé INSERM (France) - ICMR, India
| | - Srini Kaveri
- INSERM, UMRS 1138, Centre de Recherche des Cordeliers, Paris, France; Université Pierre et Marie Curie-Paris 6, UMRS 1138, Paris, France; Université Paris Descartes, UMRS 1138, Paris, France; Laboratoire International Associé INSERM (France) - ICMR, India
| | - Kanjaksha Ghosh
- National Institute of Immunohaematology (ICMR), 13th Floor, New Multistoreyed Building, KEM Hospital Campus, Parel, Mumbai 400012, India.
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Ghosh K, Ghosh K. Management of Haemophilia in Developing Countries: Challenges and Options. Indian J Hematol Blood Transfus 2015; 32:347-55. [PMID: 27429529 DOI: 10.1007/s12288-015-0562-x] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Accepted: 06/04/2015] [Indexed: 12/13/2022] Open
Abstract
There are significant challenges in managing haemophilia patients in developing countries. These challenges are (i) Lack of proper health care infrastructure and human resources suitable for haemophilia care (ii) Competing health care priorities of the government. (iii) Lack of penetrance of medical insurance in the population. (iv) Lesser visibility of the haemophilia patients in health care system (v) Low awareness across the medical profession, population and the policy makers about the condition (vi) Non availability of factor concentrates (vii) Inadequate utilization of knowledge for reducing factor concentrate use. (viii) Inadequate pain relief (ix) Challenges due to inhibitor developing (x) Viral hepatitis & (xi) Lack of research publications relevant to the country are some of the challenges faced by PWH for their management in developing country. The solutions are not easy but development of a strong patient organization with linkages with World Federation of Haemophilia is an important initial step. Following that internal and international twinning, use of internal sources, strong advocacy programme targeting government, doctors, opinion makers will solve many of the challenges in the time to come.
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Affiliation(s)
- Kanjaksha Ghosh
- National Institute of Immunohaematology, 13 Th Fl KEM Hospital, Parel Mumbai, 400012 India ; Haemophilia Federation of India, New Delhi, India
| | - Kinjalka Ghosh
- National Institute of Immunohaematology, 13 Th Fl KEM Hospital, Parel Mumbai, 400012 India ; Department of Biochemistry, Seth GS Medical College and KEM Hospital, Parel Mumbai, 400012 India
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Singh N, Mishra P, Tyagi S, Pati HP, Mahapatra M, Seth T, Saxena R. Clinicohematologic Profile of Patients With Factor VIII Inhibitors: A Case Series. Clin Appl Thromb Hemost 2014; 21:246-50. [PMID: 25172870 DOI: 10.1177/1076029614548720] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Factor VIII (FVIII) inhibitors present major clinical challenge as a complication of hemophilia A in patients on treatment with FVIII concentrates and as acquired autoantibodies in patients without hemophilia A. We aimed to study the prevalence of FVIII inhibitors in Indian settings, risk factors involved in early development of inhibitors in patients with hemophilia, differences in their clinical behavior, and approach to treatment, in comparison to patients with acquired hemophilia. The overall prevalence of FVIII inhibitors in patients with severe hemophilia A was found to be 22.3%. Two cases of acquired hemophilia were reported. Due to heterogeneity of our study population, cases have been discussed individually. We observed that the early development of FVIII inhibitors in patients with hemophilia A is dependent upon an interplay of several risk factors that need to be studied in a multivariable analysis to bring out significant correlation with response to treatment. Also, they differ from patients without hemophilia A entirely in terms of presentation and management.
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Affiliation(s)
- Neha Singh
- Department of Hematology, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Pravas Mishra
- Department of Hematology, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Seema Tyagi
- Department of Hematology, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - H P Pati
- Department of Hematology, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - M Mahapatra
- Department of Hematology, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Tulika Seth
- Department of Hematology, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Renu Saxena
- Department of Hematology, All India Institute of Medical Sciences, New Delhi, Delhi, India
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Analysis of F8 inversions as risk factors for FVIII inhibitor development in Indian severe haemophilia A patients. Blood Cells Mol Dis 2014; 53:161-3. [PMID: 24824129 DOI: 10.1016/j.bcmd.2014.04.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2014] [Revised: 04/19/2014] [Accepted: 04/20/2014] [Indexed: 11/21/2022]
Abstract
FVIII inhibitor development in haemophilia A (HA) patients, especially those with severe manifestations is a serious adverse effect in patients with haemophilia A, and the clinical management of these patients is very difficult as most don't respond to conventional treatment. Many genetic and non-genetic risk factors have been proposed however, these are diverse in different population groups, highlighting the importance of determining specific risk factors for each population. F8 mutations and especially inversions, which are the most common causative mutation in severe HA, have been significantly associated with inhibitor development earlier, however there is no conclusive data so far with regard to Indian haemophiliacs. This study provides novel evidence that intron 22 inversions in the F8 gene are indeed significantly associated with FVIII inhibitor development in Indian haemophiliacs. Further studies with other risk factors would enable better insights into the immune response towards FVIII in these patients, and possibly help to characterize patients at a higher risk for inhibitor development.
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Pinto P, Parasannanavar D, Ghosh K, Shetty S. The association of HLA-DRB1 and HLA-DQB1 alleles with the development of factor VIII inhibitors in severe haemophilia A patients in India. ACTA ACUST UNITED AC 2014; 84:235-7. [DOI: 10.1111/tan.12364] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2013] [Revised: 03/04/2014] [Accepted: 03/31/2014] [Indexed: 11/26/2022]
Affiliation(s)
- P. Pinto
- Department of Haemostasis & Thrombosis; National Institute of Immunohaematology (ICMR); Mumbai India
| | - D. Parasannanavar
- Department of Haemostasis & Thrombosis; National Institute of Immunohaematology (ICMR); Mumbai India
| | - K. Ghosh
- Department of Haemostasis & Thrombosis; National Institute of Immunohaematology (ICMR); Mumbai India
| | - S. Shetty
- Department of Haemostasis & Thrombosis; National Institute of Immunohaematology (ICMR); Mumbai India
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18
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Pinto P, Shelar T, Nawadkar V, Mirgal D, Mukaddam A, Nair P, Kasatkar P, Gaikwad T, Ali S, Jadli A, Patil R, Parihar A, Shanbhag S, Kulkarni B, Ghosh K, Shetty S. The Epidemiology of FVIII Inhibitors in Indian Haemophilia A Patients. Indian J Hematol Blood Transfus 2014; 30:356-63. [PMID: 25435742 DOI: 10.1007/s12288-014-0342-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2013] [Accepted: 01/15/2014] [Indexed: 11/24/2022] Open
Abstract
A serious complication of replacement therapy in patients with bleeding disorders is the development of 'inhibitors', particularly FVIII inhibitors in haemophilia A patients. This leads to an increase in the management cost, morbidity and mortality, especially post-operatively. The mechanism of FVIII inhibitor development is quite complex and it is difficult to predict inhibitor development, but a prompt and accurate diagnosis is critical as early therapy can save lives. The aim of this study was to screen patients with bleeding disorders in India for inhibitors, and to analyse and compare the prevalence of inhibitors in different regions in India. Patient details were recorded and blood samples were collected in sodium citrate vacutainers from 1,505 patients with bleeding disorders, in different cities in India. Coagulation and inhibitor screening assays were performed, followed by the Bethesda assay in inhibitor positive samples to quantify the FVIII inhibitor titre. Out of the 1,505 samples analysed, 1,285 were Haemophilia A patients, out of which 78 (6.07 %) were positive for 'FVIII Inhibitors'. The highest incidence of FVIII Inhibitors was seen in South India (13.04 %). The highest incidence of 20.99 % was observed in Chennai, followed by Hyderabad (13.33 %), Jammu (9.90 %) and Guwahati (8.51 %), respectively, with respect to the samples analysed. The other regions showed an inhibitor incidence <8 %. The incidence of inhibitors in haemophilia A patients is different in different regions of India; this may be due to the intensity of treatment, type of product or the genetic characteristics of these patients.
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Affiliation(s)
- Patricia Pinto
- Department of Haemostasis & Thrombosis, National Institute of Immunohaematology, Indian Council of Medical Research, 13th Floor, New Multistoreyed Building, KEM Hospital Campus, Parel, Mumbai, 400 012 India
| | - Tejashree Shelar
- Department of Haemostasis & Thrombosis, National Institute of Immunohaematology, Indian Council of Medical Research, 13th Floor, New Multistoreyed Building, KEM Hospital Campus, Parel, Mumbai, 400 012 India
| | - Vidhya Nawadkar
- Department of Haemostasis & Thrombosis, National Institute of Immunohaematology, Indian Council of Medical Research, 13th Floor, New Multistoreyed Building, KEM Hospital Campus, Parel, Mumbai, 400 012 India
| | - Darshana Mirgal
- Department of Haemostasis & Thrombosis, National Institute of Immunohaematology, Indian Council of Medical Research, 13th Floor, New Multistoreyed Building, KEM Hospital Campus, Parel, Mumbai, 400 012 India
| | - Alfiya Mukaddam
- Department of Haemostasis & Thrombosis, National Institute of Immunohaematology, Indian Council of Medical Research, 13th Floor, New Multistoreyed Building, KEM Hospital Campus, Parel, Mumbai, 400 012 India
| | - Preethi Nair
- Department of Haemostasis & Thrombosis, National Institute of Immunohaematology, Indian Council of Medical Research, 13th Floor, New Multistoreyed Building, KEM Hospital Campus, Parel, Mumbai, 400 012 India
| | - Priyanka Kasatkar
- Department of Haemostasis & Thrombosis, National Institute of Immunohaematology, Indian Council of Medical Research, 13th Floor, New Multistoreyed Building, KEM Hospital Campus, Parel, Mumbai, 400 012 India
| | - Tejasvita Gaikwad
- Department of Haemostasis & Thrombosis, National Institute of Immunohaematology, Indian Council of Medical Research, 13th Floor, New Multistoreyed Building, KEM Hospital Campus, Parel, Mumbai, 400 012 India
| | - Shahnaz Ali
- Department of Haemostasis & Thrombosis, National Institute of Immunohaematology, Indian Council of Medical Research, 13th Floor, New Multistoreyed Building, KEM Hospital Campus, Parel, Mumbai, 400 012 India
| | - Anshul Jadli
- Department of Haemostasis & Thrombosis, National Institute of Immunohaematology, Indian Council of Medical Research, 13th Floor, New Multistoreyed Building, KEM Hospital Campus, Parel, Mumbai, 400 012 India
| | - Rucha Patil
- Department of Haemostasis & Thrombosis, National Institute of Immunohaematology, Indian Council of Medical Research, 13th Floor, New Multistoreyed Building, KEM Hospital Campus, Parel, Mumbai, 400 012 India
| | - Anita Parihar
- Department of Haemostasis & Thrombosis, National Institute of Immunohaematology, Indian Council of Medical Research, 13th Floor, New Multistoreyed Building, KEM Hospital Campus, Parel, Mumbai, 400 012 India
| | - Sharda Shanbhag
- Department of Haemostasis & Thrombosis, National Institute of Immunohaematology, Indian Council of Medical Research, 13th Floor, New Multistoreyed Building, KEM Hospital Campus, Parel, Mumbai, 400 012 India
| | - Bipin Kulkarni
- Department of Haemostasis & Thrombosis, National Institute of Immunohaematology, Indian Council of Medical Research, 13th Floor, New Multistoreyed Building, KEM Hospital Campus, Parel, Mumbai, 400 012 India
| | - Kanjaksha Ghosh
- Department of Haemostasis & Thrombosis, National Institute of Immunohaematology, Indian Council of Medical Research, 13th Floor, New Multistoreyed Building, KEM Hospital Campus, Parel, Mumbai, 400 012 India
| | - Shrimati Shetty
- Department of Haemostasis & Thrombosis, National Institute of Immunohaematology, Indian Council of Medical Research, 13th Floor, New Multistoreyed Building, KEM Hospital Campus, Parel, Mumbai, 400 012 India
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19
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Pinto P, Ghosh K, Shetty S. A specific and sensitive activated partial thromboplastin time (APTT)-based factor VIII inhibitor screening assay. Clin Chem Lab Med 2013; 52:e39-41. [PMID: 24088610 DOI: 10.1515/cclm-2013-0595] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2013] [Accepted: 09/05/2013] [Indexed: 11/15/2022]
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Dubey A, Verma A, Elhence P, Agarwal P. Evaluation of transfusion-related complications along with estimation of inhibitors in patients with hemophilia: A pilot study from a single center. Asian J Transfus Sci 2013; 7:8-10. [PMID: 23559756 PMCID: PMC3613672 DOI: 10.4103/0973-6247.106714] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background: Apart from inhibitor development in patients with hemophilia (PWH) the old problems of blood borne viral infections and red cell alloimmunization still persist in PWH from developing countries. This study was planned to detect the presence of inhibitors in our PWH and to determine the presence of transfusion transmitted infections (TTI) markers and clinically significant red cell alloantibodies in these patients. Materials and Methods: One hundred fourteen PWH were screened for various laboratory tests. Screening for inhibitors was done by mixing study. Blood grouping, TTI testing and red cell alloantibody detection were done as per the departmental standard operating procedures. Results: Out of 114 patients evaluated 98(86%) had hemophilia A and remaining 16(14%) had hemophilia B. Five (5.1%) patients of hemophilia A were positive on inhibitor screening. On Bethesda assay, one patient was high responder (14.4 BU/ml) and rest 4 were low responders (<5 BU/ml). Overall, 19 PWH were positive for TTI markers and two had clinically significant red cell alloantibody (anti-E and anti-Jkb). Conclusion: This is probably first comprehensive study from our state on laboratory testing in PWH. The specialty of Transfusion Medicine can be a core part of hemophilia care. The overall prevalence of inhibitors in our hemophilia A patients was 5.1%, which is less as compared to majority of published studies.
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Affiliation(s)
- Anju Dubey
- Department of Transfusion Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
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21
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Pinto P, Ghosh K, Shetty S. Factor VIII haplotypes in severe hemophilia A patients in India. Ann Hematol 2012; 92:999-1000. [PMID: 23262994 DOI: 10.1007/s00277-012-1658-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2012] [Accepted: 12/14/2012] [Indexed: 10/27/2022]
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Pinto P, Ghosh K, Shetty S. Immune regulatory gene polymorphisms as predisposing risk factors for the development of factor VIII inhibitors in Indian severe haemophilia A patients. Haemophilia 2012; 18:794-7. [PMID: 22630053 DOI: 10.1111/j.1365-2516.2012.02845.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/03/2012] [Indexed: 11/28/2022]
Abstract
Development of inhibitors to factor VIII, a serious complication of replacement therapy in haemophilia A patients, leads to increased bleeding, morbidity and mortality. There is no data on the risk factors for inhibitor development in Indian patients with severe haemophilia A. Our aim was to study the role of immune regulatory gene polymorphisms in the development of inhibitors. Fourteen immune regulatory gene polymorphisms (IL1β, IL4, IL10, TNFA and CTLA4) were analysed in 120 patients with severe haemophilia A, i.e. 50 inhibitor positive patients, and 70 inhibitor negative control patients, by PCR-RFLP, DNA sequencing and allele-specific PCRs. The IL10 promoter 'GCC' haplotypes overall (P: 0.002, OR: 3.452, 95% CI: 1.607-7.416), and 'GCC/ATA' (P: 0.011, OR: 3.492, 95% CI: 1.402-8.696) haplotype, associated with high and intermediate IL10 production, respectively, were significantly higher in inhibitor positive patients, whereas the 'non-GCC' haplotypes overall (P: 0.002,OR: 0.290, 95% CI 0.135-0.622) and 'ATA/ATA' haplotype (P: 0.025, OR: 0.278, 95% CI: 0.096-0.802), associated with low IL10 synthesis, were significantly higher among inhibitor negative patients. The TNFA rs1799724 C/T heterozygote prevalence was significantly higher in the inhibitor positive group (P: 0.021, OR: 3.190, 95% CI: 1.273-7.990), whereas the other polymorphisms showed no statistically significant association with the presence of inhibitors. Different immune regulatory gene polymorphisms play a significant role as possible risk factors for the development of inhibitors in severe haemophilia A patients.
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Affiliation(s)
- P Pinto
- National Institute of Immunohaematology, ICMR, KEM Hospital Campus, Parel, Mumbai, India
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23
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Eckhardt CL, van der Bom JG, van der Naald M, Peters M, Kamphuisen PW, Fijnvandraat K. Surgery and inhibitor development in hemophilia A: a systematic review. J Thromb Haemost 2011; 9:1948-58. [PMID: 21838755 DOI: 10.1111/j.1538-7836.2011.04467.x] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Although the association between intensive treatment and the formation of inhibiting antibodies towards factor VIII (FVIII) in hemophilia A has been demonstrated, the contributing effect of surgery is presently unclear. The release of immunological danger signals resulting from tissue damage during surgery in the presence of a high FVIII antigen load may elicit the formation of FVIII antibodies. The aim of this systematic review was to investigate the role of surgery in the inhibitor risk associated with intensive treatment as compared with treatment for bleeding and prophylactic administration of FVIII. METHODS A comprehensive literature search was performed that identified four cohort studies and three case control studies, comprising 342 inhibitor patients among a total of 957 hemophilia A patients. RESULTS Intensive treatment increased the inhibitor risk, most pronounced with intensive treatment of ≥ 5 exposure days (EDs) compared with < 3 EDs (OR, 4.1; 95% confidence interval, 2.6-6.5). Pooled odds ratio for inhibitor development in severe hemophilia patients that received intensive treatment for surgery at first exposure was 4.1 (95% confidence interval, 2.0-8.4) compared with treatment for bleeding or prophylaxis. Information on continuous infusion, previously treated patients and non-severe hemophilia A was insufficient for valid meta-analyses. CONCLUSIONS Intensive FVIII treatment for surgery at first exposure leads to a higher inhibitor risk in hemophilia A patients compared with intensive treatment for bleeding.
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Affiliation(s)
- C L Eckhardt
- Department of Pediatric Hematology, Emma Children's Hospital, Academic Medical Center, Amsterdam, the Netherlands
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Phadke S. Hemophilia care in India: a review and experience from a tertiary care centre in uttar pradesh. Indian J Hematol Blood Transfus 2011; 27:121-6. [PMID: 22942560 DOI: 10.1007/s12288-011-0084-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2010] [Accepted: 05/27/2011] [Indexed: 10/18/2022] Open
Abstract
Approximately 14,000 people with hemophilia are registered at the Hemophilia Federation of India; however, hemophilia remains under-diagnosed and many cases are not registered. In June 2009, the Government of Uttar Pradesh made anti-hemophilic factors available at a few centers, including the Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow. Consequently, the level of hemophilia care has improved considerably in recent times. Amongst the many challenges facing people with hemophilia, the development of inhibitors, which neutralize clotting factors provided by replacement therapy, is the most feared one. Healthcare professionals who treat people with hemophilia should not only be knowledgeable about the condition and committed to bettering the management of hemophilia, but also take responsibility for the judicious allocation of resources for various aspects of managing hemophilia. This manuscript aims to raise awareness regarding the detection and management of inhibitors in hemophilia based on the experience of a tertiary care hemophilia treatment centre in Uttar Pradesh, India.
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Affiliation(s)
- Shubha Phadke
- Department of Medical Genetics, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014 India
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Eshghi P, Mahdavi-Mazdeh M, Karimi M, Aghighi M. Haemophilia in the developing countries: the Iranian experience. Arch Med Sci 2010; 6:83-9. [PMID: 22371725 PMCID: PMC3278948 DOI: 10.5114/aoms.2010.13512] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2008] [Revised: 10/22/2008] [Accepted: 11/06/2008] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Management of haemophilia and inherited bleeding disorders is a major challenge especially in developing countries, because of a shortage or absence of products, the cost and the infrastructural health problems. Development of local expertise which results in an improved outlook and reduction in mortality and morbidity in these countries can be helpful for advocators in other developing countries. However, very little information on demography and organizational models for haemophilia care in developing countries are available in the literature. Our aim is a comprehensive report of haemophilia status and its management in Iran. MATERIAL AND METHODS THE MANAGEMENT CENTER OF TRANSPLANTATION AND SPECIAL DISEASES (MCTSD) OF THE MINISTRY OF HEALTH OF IRAN DECIDED TO CARRY OUT A COMPLETE REVIEW AND COMPILATION OF ALL OF THE PUBLISHED OR AVAILABLE DATA ABOUT PATIENTS WITH HAEMOPHILIA (PWH) IN IRAN: their health status, their management planning, organizations, treatment products, facilities and care problems during 2007. RESULTS 6496 patients with congenital bleeding disorders were registered. Most of them had haemophilia A and B and von Willebrand disease (vWD). However, rare bleeding disorders are seen more than expected. Inhibitor development is 14-28%. There are different data about virological status of PWH. Factor products and facilities are fairly available with more than 1.5 units per capita of inhabitant factor consumption. CONCLUSIONS A national formulary based on facilities of the country should be considered and followed by collaboration among the Ministry Of Health, universities and non-governmental organizations.
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Affiliation(s)
- Peyman Eshghi
- Paediatric Haematology and Oncology, Shahid Beheshti University of Medical Sciences; Iranian Blood Transfusion Organization, Tehran, Iran
| | - Mitra Mahdavi-Mazdeh
- Management Center of Transplantation and Special Diseases (MCTSD-MOH), Tehran University of Medical Sciences, Tehran, Iran
| | - Mehran Karimi
- Pediatric Hematology and Oncology, Hematology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mohammad Aghighi
- Management Center of Transplantation and Special Diseases (MOH), Tehran, Iran
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Zhubi B, Mekaj Y, Baruti Z, Bunjaku I, Belegu M. Transfusion-transmitted infections in haemophilia patients. Bosn J Basic Med Sci 2010; 9:271-7. [PMID: 20001991 DOI: 10.17305/bjbms.2009.2777] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
One of the largest therapeutic problem during the continuous treatment of the patients with Hemophilia A and B, are viral infections as Hepatitis B and C, and HIV, and the other infective diseases, which can be transmitted by the transfusion of blood products. The aim of this study is to analyze the complications of the hemophiliacs in Kosovo which have been treated with fresh frozen plasma, cryoprecipitate and concentrated products of FVIII and FIX. We have tested 75 patients with hemophilia A or B and there were used enzyme immunoassay test-Elisa method for the following: anti-HCV, HBsAg, HIV and TPHA.The serological data showed that HCV infection was positive in 29 cases or 38,7%, whereas infection with HBV and HIV were present in a smaller percentage of the patients (2,7% HBV and 1,4% for HIV). HCV infection was present only in 9,5% of the cases of the age group under 18 years. Infected hemophiliacs with one or two infective agents were found in 34,7%, respectively 4%. Infection with T. pallidum was present at none of the examined patients with hemophilia. HCV infection was higher in severe forms of hemophilia B (44,4%), compared with severe form of hemophilia A (30%).Based on our results, despite the infrequent application of FVIII and FIX concentrates, and other anti hemophilic preparations used in treating hemophilia patients, the number of infected hemophiliacs with blood-transmittable infectious agents was substantially high, especially with hepatitis C virus.
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Affiliation(s)
- Bukurije Zhubi
- National Blood Transfusion Centre of Kosovo Prishtina (NBTCK). Mother Theresa str., 10000 Prishtina, Kosovo
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27
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Ghosh K, Shetty S. Immune response to FVIII in hemophilia A: an overview of risk factors. Clin Rev Allergy Immunol 2009; 37:58-66. [PMID: 19148784 DOI: 10.1007/s12016-009-8118-1] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Development of inhibitors is perhaps the most serious complication of factor VIII (FVIII) replacement therapy, which can practically preclude efficient clinical management of patients with hemophilia A. Much effort therefore has been focused both in improving our understanding of the reasons for the formation of FVIII antibodies and to find alternative methods of treatment. Several patient-related factors have been related to the risk of inhibitor development such as ethnicity, FVIII gene mutation type, family history of inhibitors, HLA haplotype, polymorphisms in the promoter regions of IL 10 gene, single nucleotide polymorphisms of tumor necrosis factor alpha gene, and so on. In addition to the genetic determinants, there are several nongenetic factors which mainly include treatment characteristics like the type and purity of coagulation factor concentrates used for treatment, age at the time of initial treatment, initial doses of concentrate, mode of infusion, surgery, frequency of dosing prior to inhibitor development, and intensity of treatment or regular prophylaxis. Inflammatory processes in early childhood are under discussion as being an environmental factor that may modify the immune response to a foreign antigen. The genetic risks cannot be changed, while environmental factors may increase or decrease the inhibitor risk in an individual patient. In addition, there are other causes of inhibitor development against FVIII like stress, age, malignancy, infection, pregnancy, antibiotics, etc. Development of inhibitors in such cases happens in individuals who are not hemophilic and have normal plasma FVIII levels. Acquired inhibitors to FVIII in nonhemophiliacs (autoantibodies) pose a further challenge to treatment, as this is often associated with significant morbidity and mortality. Prognosis in case of autoantibodies is related to the underlying disease process and is associated with high mortality. Improved understanding of these complex interactions may lead to the development of preventive measures to minimize FVIII inhibitor formation. The modifiable risk factors for inhibitor formation may provide the key to predict and perhaps prevent the formation of inhibitors in hemophilia patients.
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Affiliation(s)
- Kanjaksha Ghosh
- National Institute of Immunohaematology, 13th Fl, KEM Hospital, Parel, Mumbai 400012, India.
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28
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Leiria LB, Roisenberg I, Salzano FM, Bandinelli E. Introns 1 and 22 inversions and factor VIII inhibitors in patients with severe haemophilia A in southern Brazil. Haemophilia 2008; 15:309-13. [PMID: 18759747 DOI: 10.1111/j.1365-2516.2008.01868.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
A total of 107 unrelated severe haemophilia A patients living in the southern Brazilian state of Rio Grande do Sul were studied in relation to the prevalence of inversions present in introns 22 and 1 and a subsample of them (95) tested for the presence of Factor VIII inhibitors. These data were then incorporated with those from 15 other countries and 3871 patients. The frequencies of these two inversions show a remarkable homogeneity in series collected in different continents, from people with diverse ethnic extraction. The prevalence of inhibitors among patients with inversion 22, on the other hand, varies widely (5-51%; seven countries, 1482 patients), the value observed by us being the highest. The importance of obtaining data from patients throughout the world to clarify the aetiology of this important complicating factor in the therapeutics of the disease is emphasized.
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Affiliation(s)
- L B Leiria
- Departamento de Genética, Instituto de Biociências, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
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DJAMBAS KHAYAT C, SALEM N, CHOUERY E, CORBANI S, MOIX I, NICOLAS E, MORRIS M, DE MOERLOOSE P, MGARBAN A. Molecular analysis ofF8in Lebanese haemophilia A patients: novel mutations and phenotypegenotype correlation. Haemophilia 2008; 14:709-16. [DOI: 10.1111/j.1365-2516.2008.01760.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Mishra KL, Kumar A, Gupta A. An experience of single centre at C S M Medical University, Lucknow, for the prevalence of hemophilia in Uttar Pradesh. Indian J Hematol Blood Transfus 2008; 24:49-53. [PMID: 23100943 DOI: 10.1007/s12288-008-0028-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2008] [Accepted: 07/05/2008] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To evaluate the incidence of hereditary bleeding disorders, registered at our centre from all over Uttar Pradesh over an extended period of 10 years. MATERIAL AND METHODS A complete coagulation profile of 240 cases conducted, followed by clinical history of the patient. The frequency and type of bleeding, age of onset, treatment taken, consanguinity and the blood transfusion if any, are little information collected from the patient. RESULTS The complete scenario of bleeders indicated maximum number (92%) of hemophilia 'A' from northern UP as compared from other zones (76.5% ± 3). Contrarily, hemophilia 'B' registered maximum from eastern zone (26%) and minimum from the northern zone (8%). The age diversity at diagnosis ranged between 1-32 years. The reasons for difference are all speculative. Definite cause needs extensive research. CONCLUSIONS The study showed that elderly patients with hemophilia had significantly more impairments in physical functioning and depression than younger ones.
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Affiliation(s)
- Kusum Lata Mishra
- Department of Pathology, C S M Medical University, Lucknow (UP)-, 226 003 India
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Bigger BW, Siapati EK, Mistry A, Waddington SN, Nivsarkar MS, Jacobs L, Perrett R, Holder MV, Ridler C, Kemball-Cook G, Ali RR, Forbes SJ, Coutelle C, Wright N, Alison M, Thrasher AJ, Bonnet D, Themis M. Permanent partial phenotypic correction and tolerance in a mouse model of hemophilia B by stem cell gene delivery of human factor IX. Gene Ther 2005; 13:117-26. [PMID: 16163377 DOI: 10.1038/sj.gt.3302638] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Immune responses against an introduced transgenic protein are a potential risk in many gene replacement strategies to treat genetic disease. We have developed a gene delivery approach for hemophilia B based on lentiviral expression of human factor IX in purified hematopoietic stem cells. In both normal C57Bl/6J and hemophilic 129/Sv recipient mice, we observed the production of therapeutic levels of human factor IX, persisting for at least a year with tolerance to human factor IX antigen. Secondary and tertiary recipients also demonstrate long-term production of therapeutic levels of human factor IX and tolerance, even at very low levels of donor chimerism. Furthermore, in hemophilic mice, partial functional correction of treated mice and phenotypic rescue is achieved. These data show the potential of a stem cell approach to gene delivery to tolerize recipients to a secreted foreign transgenic protein and, with appropriate modification, may be of use in developing treatments for other genetic disorders.
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Affiliation(s)
- B W Bigger
- Gene Therapy Research Group, Faculty of Medicine, Imperial College London, South Kensington, UK.
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Abstract
Eighty per cent of people with haemophilia live in developing countries, where technical expertise and health care facilities may be less than optimal. Haemophilia is a relatively rare disease and high-cost, technology-intensive therapy is not a high priority for the governments of developing countries. The rapid spread of transfusion-related viral infections in many developing countries presents further problems for haemophiliacs. However, it is possible to manage haemophiliacs patients with limited resources. Strategies for conserving factor concentrates, include education of doctors and patients, prenatal diagnosis, increasing the use of anti-fibrinolytic agents, physiotherapy, the use of fibrin glue, and simple orthotics and prosthetic measures. These approaches are helpful in the majority of these patients. Meanwhile, with the help of the World Federation of Haemophilia (WFH), all developing countries are gradually improving management skills for this relatively rare but disabling disease. The present review broadly describes the management of various aspects of severe haemophilia in developing countries.
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Affiliation(s)
- K Ghosh
- Institute of Immunohaematology, KEM Hospital, Parel, Mumbai, India.
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Ghosh K, Shetty S, Jijina F, Mohanty D. Role of epsilon amino caproic acid in the management of haemophilic patients with inhibitors. Haemophilia 2004; 10:58-62. [PMID: 14962221 DOI: 10.1046/j.1351-8216.2003.00839.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
We managed bleeding crisis in 10 consecutive severe haemophilic patients with inhibitors (eight had an inhibitor level of >5 BU mL(-1)) mainly with the antifibrinolytic agent, i.e. epsilon amino caproic acid (EACA). EACA was used by local, oral or intravenous routes either in combination or separately. Five patients developed inhibitors postoperatively and among the remaining five, four had recurrent haemarthrosis or soft tissue bleeds and one patient presented with severe gastrointestinal bleeding without demonstrable lesion. In all the patients, addition of EACA to their management protocol resulted in stoppage and/or reduced frequency of bleeding. In six of 10 patients, the results were excellent; of these six patients, five developed inhibitors postoperatively. Although a reduction in the frequency of bleeding was observed in patients with haemarthrosis and soft tissue bleed, it was not spectacular and the patients required additional therapy. Hence the results could be described as poor. No patient needed to stop the medicine because of the side-effect of EACA. Symptoms like mild nausea and vertigo were seen as the side-effects of this medicine when high intravenous dosage was administered. EACA thus appears to be an excellent adjuvant therapy for haemophilic patients with inhibitors. Besides its well-recognized antifibrinolytic activity, EACA may have additional mechanisms of action in haemophilic patients with inhibitors. More extensive use of this cheap and safe product is warranted in haemophilic patients with inhibitors. If larger studies confirm this observation, then using antifibrinolytics will allow substantial reduction of FEIBA or activated prothrombin complex (APCC) usage in such patients without necessarily increasing the thrombotic complications or reduction of the clinical efficacy, when compared with higher dosage of FEIBA or APCC alone. This will lead to substantial financial savings in countries where up to 35% of severe haemophilia A patients develop inhibitors.
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Affiliation(s)
- K Ghosh
- Comprehensive Hemophilia Care Centre, Hemostasis Unit, Institute of Immunohaematology, KEM Hospital, Parel, Mumbai, India.
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Abstract
This paper emphasizes the importance of distinguishing between the prevalence, incidence and cumulative incidence of inhibitors in haemophilia A. Incidence and cumulative incidence data will include patients with transient inhibitors or whose inhibitors have been eliminated by treatment. As these will not be included in prevalence data, prevalence studies will tend to give rise to lower figures than incidence studies. As a result, the most accurate estimates of the true risk of inhibitor development comes from prospective studies of newly diagnosed haemophiliacs who are tested regularly for the presence of inhibitors. This paper reports a systematic review of the best available evidence relating to the epidemiology of inhibitors in haemophilia A. Cohort studies, registry data reporting incidence or prevalence of inhibitors in patients with haemophilia A, and prospective studies of factor VIII (FVIII) in the treatment of previously untreated patients which reported the development of inhibitors as an outcome, were included in the review. The overall prevalence of inhibitors in unselected haemophiliac populations was found to be 5-7%. The cumulative risk of inhibitor development varied (0-39%). Incidence and prevalence were substantially higher in patients with severe haemophilia. Studies of patients using a single plasma-derived FVIII (pdFVIII) preparation reported lower inhibitor incidence than those using multiple pdFVIII preparations or single recombinant FVIII preparations. Incidence data should be used to estimate the likely demand for treatments aimed at eliminating inhibitors, whereas the best estimates of the overall burden to the National Health Service (NHS) of treating bleeding episodes in patients with continuing inhibitors will come from prevalence studies.
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Affiliation(s)
- J Wight
- ScHARR, University of Sheffield, Sheffield, S1 4DA, UK.
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Ghosh K, Madkaikar M, Jijina F, Gandhi S, Shetty S, Mohanty D. Open heart surgery with mitral valve replacement--ordeal of an undiagnosed haemophilia patient. CLINICAL AND LABORATORY HAEMATOLOGY 2003; 25:131-3. [PMID: 12641618 DOI: 10.1046/j.1365-2257.2003.00498.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- K Ghosh
- Comprehensive haemophilia care centre, Institute of Immunohaematology, 13th flr, K. E. M. Hospital, Parel, Mumbai 400012, India
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Abstract
Chronic synovitis affects about 10% of patients with severe haemophilia in India. This disease has some features in common with ankylosing spondylitis, which has been linked to HLA B27. We therefore aimed to test whether there is an association between HLA B27 and chronic synovitis. We studied 473 patients with severe haemophilia (33 of whom had chronic synovitis), and 1175 healthy controls using a standard serological technique and the reverse line strip assay. 64% (21 of 33) of patients with haemophilia and chronic synovitis were positive for HLA B27, compared with 5% (23 of 440) of those with severe haemophilia, but not chronic synovitis (odds ratio 31.6 [95% CI 9.28-39.38], p<0.0001), and 9% (100 of 1175) of healthy controls (18.81 [9.6-27.7], p<0.0001). We conclude that there is a strong association between HLA B27 and chronic synovitis in Indian patients with severe haemophilia and screening in this population could allow treatment and prevention of the complication.
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Affiliation(s)
- Kanjaksha Ghosh
- Institute of Immunohaematology, Floor 13, New Building, KEM Hospital Campus, Parel, 400 012, Mumbai, India
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Ghosh K, Jijina F, Shetty S, Madkaikar M, Mohanty D. First-time development of FVIII inhibitor in haemophilia patients during the postoperative period. Haemophilia 2002; 8:776-80. [PMID: 12410646 DOI: 10.1046/j.1365-2516.2002.00687.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Development of inhibitor to FVIII in haemophilia patients is well-known and is not uncommon. However, their development for the first time during the postoperative period has hardly been reported. In a developing country such as India, where resources are limited, development of such an eventuality may prove disastrous. However, as many of our patients are sparingly treated, therefore, even if they test negative for the inhibitor preoperatively, they may get the requisite FVIII antigenic stimulation during the preoperative and immediate postoperative period, leading to the development of inhibitors during this critical time of wound healing. We describe here six patients who developed such an inhibitor, from a group of 35 patients with haemophilia A who underwent various surgical procedures (19%). We stress that such an eventuality may not remain rare in developing countries as more patients of severe haemophilia undergo surgery and are therefore challenged for the first time in their life with large amounts of FVIII concentrate during their preoperative period.
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Affiliation(s)
- K Ghosh
- Institute of Immunohaematology (ICMR), KEM Hospital, Parel, Mumbai, India
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