1
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Zhang Y, Zhou X, Guo Y, Gao Y, Niu Z, Wu Y, Wang Y, Zhang J. Small intestinal angiodysplasia and hemorrhage associated with acquired von Willebrand syndrome type 2A secondary to multiple myeloma: Reversal after treatment with IRD regimen (a case report and a brief review of the literature). Thromb Res 2024; 238:37-40. [PMID: 38663044 DOI: 10.1016/j.thromres.2024.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 04/07/2024] [Accepted: 04/11/2024] [Indexed: 05/21/2024]
Affiliation(s)
- Yuxin Zhang
- Department of Hematology, The Second Hospital of Hebei Medical University, Hebei Key Laboratory of Hematology, Shijiazhuang, China
| | - Xuquan Zhou
- Department of Hematology, The Second Hospital of Hebei Medical University, Hebei Key Laboratory of Hematology, Shijiazhuang, China
| | - Yujie Guo
- Department of Hematology, The Second Hospital of Hebei Medical University, Hebei Key Laboratory of Hematology, Shijiazhuang, China
| | - Yongning Gao
- Department of Hemodialysis, The Second Hospital of Hebei Medical University, Shijiazhuang, China.
| | - Zhiyun Niu
- Department of Hematology, The Second Hospital of Hebei Medical University, Hebei Key Laboratory of Hematology, Shijiazhuang, China.
| | - Yi Wu
- Department of Hematology, The Second Hospital of Hebei Medical University, Hebei Key Laboratory of Hematology, Shijiazhuang, China; National Clinical Research Center for Hematologic Diseases, Cyrus Tang Medical Institute, Collaborative Innovation Center of Hematology, State Key Laboratory of Radiation Medicine and Prevention, Soochow University, Suzhou, China.
| | - Yan Wang
- Department of Hematology, The Second Hospital of Hebei Medical University, Hebei Key Laboratory of Hematology, Shijiazhuang, China.
| | - Jingyu Zhang
- Department of Hematology, The Second Hospital of Hebei Medical University, Hebei Key Laboratory of Hematology, Shijiazhuang, China.
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2
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Mennitti C, Miele C, Scarano C, Veneruso I, Gentile A, Mormile R, Saviano F, D’Alicandro G, Mazzaccara C, Frisso G, Capasso F, D’Argenio V, Scudiero O. Integrated Approach to Highlighting the Molecular Bases of a Deep Vein Thrombosis Event in an Elite Basketball Athlete. Int J Mol Sci 2023; 24:12256. [PMID: 37569632 PMCID: PMC10419060 DOI: 10.3390/ijms241512256] [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: 06/30/2023] [Revised: 07/24/2023] [Accepted: 07/29/2023] [Indexed: 08/13/2023] Open
Abstract
Acute or intense exercise can result in metabolic imbalances, muscle injuries, or reveal hidden disorders. Laboratory medicine in sports is playing an increasingly crucial role in monitoring athletes' health conditions. In this study, we designed an integrated approach to explore the causes of a deep venous thrombosis event in an elite basketball player. Since the complete blood count revealed a marked platelet count (838 × 103 µL), and thrombophilia screening tests did not reveal any significant alteration, we evaluated the thrombin generation, which highlights a state of hypercoagulability. First-level haemostasis exams showed only a slight prolongation of the activated Partial Thromboplastin Time (aPTT). Thus, screening tests for von Willebrand Disease showed a reduction in vWF parameters. Therefore, we directed our hypothesis towards a diagnosis of acquired von Willebrand disease secondary to Essential Thrombocythemia (ET). To confirm this hypothesis and highlight the molecular mechanism underlying the observed phenotype, molecular tests were performed to evaluate the presence of the most common mutations associated with ET, revealing a 52-bp deletion in the coding region of CALR exon 9. This case report highlights the importance of an integrated approach to monitoring the athletes' health status to personalise training and treatments, thus avoiding the appearance of diseases and injuries that, if underestimated, can undermine the athlete's life.
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Affiliation(s)
- Cristina Mennitti
- Department of Molecular Medicine and Medical Biotechnology, University of Naples Federico II, 80131 Naples, Italy; (C.M.); (I.V.); (O.S.)
| | - Ciro Miele
- Department of Molecular Medicine and Medical Biotechnology, University of Naples Federico II, 80131 Naples, Italy; (C.M.); (I.V.); (O.S.)
- UOC Laboratory Medicine, Hematology and Laboratory Haemostasis and Special Investigations, AOU Federico II University of Naples, 80131 Naples, Italy
- CEINGE-Biotecnologie Avanzate Franco Salvatore, Via G. Salvatore 486, 80145 Naples, Italy
| | - Carmela Scarano
- Department of Molecular Medicine and Medical Biotechnology, University of Naples Federico II, 80131 Naples, Italy; (C.M.); (I.V.); (O.S.)
- CEINGE-Biotecnologie Avanzate Franco Salvatore, Via G. Salvatore 486, 80145 Naples, Italy
| | - Iolanda Veneruso
- Department of Molecular Medicine and Medical Biotechnology, University of Naples Federico II, 80131 Naples, Italy; (C.M.); (I.V.); (O.S.)
- CEINGE-Biotecnologie Avanzate Franco Salvatore, Via G. Salvatore 486, 80145 Naples, Italy
| | - Alessandro Gentile
- Department of Molecular Medicine and Medical Biotechnology, University of Naples Federico II, 80131 Naples, Italy; (C.M.); (I.V.); (O.S.)
| | - Rosaria Mormile
- Hematology, Department of Translation and Precision Medicine, Sapienza University, Via Benevento 6, 00161 Rome, Italy
| | - Francesca Saviano
- UOC Laboratory Medicine, Hematology and Laboratory Haemostasis and Special Investigations, AOU Federico II University of Naples, 80131 Naples, Italy
| | - Giovanni D’Alicandro
- Department of Neuroscience and Rehabilitation, Center of Sports Medicine and Disability, AORN, Santobono-Pausillipon, 80122 Naples, Italy
| | - Cristina Mazzaccara
- Department of Molecular Medicine and Medical Biotechnology, University of Naples Federico II, 80131 Naples, Italy; (C.M.); (I.V.); (O.S.)
| | - Giulia Frisso
- Department of Molecular Medicine and Medical Biotechnology, University of Naples Federico II, 80131 Naples, Italy; (C.M.); (I.V.); (O.S.)
- CEINGE-Biotecnologie Avanzate Franco Salvatore, Via G. Salvatore 486, 80145 Naples, Italy
| | - Filomena Capasso
- UOC Laboratory Medicine, Hematology and Laboratory Haemostasis and Special Investigations, AOU Federico II University of Naples, 80131 Naples, Italy
| | - Valeria D’Argenio
- CEINGE-Biotecnologie Avanzate Franco Salvatore, Via G. Salvatore 486, 80145 Naples, Italy
- Department of Human Sciences and Quality of Life Promotion, San Raffaele Open University, Via di Val Cannuta 247, 00166 Rome, Italy
| | - Olga Scudiero
- Department of Molecular Medicine and Medical Biotechnology, University of Naples Federico II, 80131 Naples, Italy; (C.M.); (I.V.); (O.S.)
- CEINGE-Biotecnologie Avanzate Franco Salvatore, Via G. Salvatore 486, 80145 Naples, Italy
- Task Force on Microbiome Studies, University of Naples Federico II, 80100 Naples, Italy
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3
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Oganesyan A, Gregory A, Malard F, Ghahramanyan N, Mohty M, Kazandjian D, Mekinian A, Hakobyan Y. Monoclonal gammopathies of clinical significance (MGCS): In pursuit of optimal treatment. Front Immunol 2022; 13:1045002. [PMID: 36505449 PMCID: PMC9728929 DOI: 10.3389/fimmu.2022.1045002] [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] [Received: 09/15/2022] [Accepted: 11/07/2022] [Indexed: 11/24/2022] Open
Abstract
Monoclonal gammopathy of clinical significance (MGCS) represents a new clinical entity referring to a myriad of pathological conditions associated with the monoclonal gammopathy of undetermined significance (MGUS). The establishment of MGCS expands our current understanding of the pathophysiology of a range of diseases, in which the M protein is often found. Aside from the kidney, the three main organ systems most affected by monoclonal gammopathy include the peripheral nervous system, skin, and eye. The optimal management of these MGUS-related conditions is not known yet due to the paucity of clinical data, the rarity of some syndromes, and limited awareness among healthcare professionals. Currently, two main treatment approaches exist. The first one resembles the now-established therapeutic strategy for monoclonal gammopathy of renal significance (MGRS), in which chemotherapy with anti-myeloma agents is used to target clonal lesion that is thought to be the culprit of the complex clinical presentation. The second approach includes various systemic immunomodulatory or immunosuppressive options, including intravenous immunoglobulins, corticosteroids, or biological agents. Although some conditions of the MGCS spectrum can be effectively managed with therapies aiming at the etiology or pathogenesis of the disease, evidence regarding other pathologies is severely limited to individual patient data from case reports or series. Future research should pursue filling the gap in knowledge and finding the optimal treatment for this novel clinical category.
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Affiliation(s)
- Artem Oganesyan
- Department of Hematology and Transfusion Medicine, National Institute of Health, Yerevan, Armenia,Department Of Adult Hematology, Hematology Center after Prof. R. Yeolyan, Yerevan, Armenia,*Correspondence: Artem Oganesyan,
| | - Andrew Gregory
- Wayne State University School of Medicine, Detroit, MI, United States
| | - Florent Malard
- Department of Clinical Hematology and Cellular Therapy, INSERM, Saint-Antoine Research Centre, Assistance Publique-Hôpitaux de Paris, Hôpital Saint Antoine, Paris, France
| | - Nerses Ghahramanyan
- Department Of Adult Hematology, Hematology Center after Prof. R. Yeolyan, Yerevan, Armenia
| | - Mohamad Mohty
- Department of Clinical Hematology and Cellular Therapy, INSERM, Saint-Antoine Research Centre, Assistance Publique-Hôpitaux de Paris, Hôpital Saint Antoine, Paris, France
| | - Dickran Kazandjian
- Myeloma Program, Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL, United States
| | - Arsène Mekinian
- Department of Internal Medicine (DMU i3), Sorbonne University, Assistance Publique-Hôpitaux de Paris, Hôpital Saint Antoine, Paris, France,French-Armenian Clinical Research Center, National Institute of Health, Yerevan, Armenia
| | - Yervand Hakobyan
- Department of Hematology and Transfusion Medicine, National Institute of Health, Yerevan, Armenia,Department Of Adult Hematology, Hematology Center after Prof. R. Yeolyan, Yerevan, Armenia
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4
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Ghariani I, Braham N, Veyradier A, Bekir L. Acquired von Willebrand syndrome: Five cases report and literature review. Thromb Res 2022; 218:145-150. [PMID: 36049419 DOI: 10.1016/j.thromres.2022.08.025] [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: 05/12/2022] [Revised: 07/22/2022] [Accepted: 08/23/2022] [Indexed: 10/15/2022]
Abstract
Acquired von Willebrand syndrome is a rare bleeding disorder with laboratory findings similar to those of inherited von Willebrand disease. Principal factors distinguishing acquired von Willebrand syndrome from the latter condition include lack of prior bleeding disorders, diagnosis at older age, negative family history and association with underlying conditions. METHODS Retrospective, monocentric descriptive case series of acquired von Willebrand syndrome diagnosed between 2010 and 2020. Diagnostic criteria included a recent history of bleeding, a negative family history and a presence of underlying disorders. RESULTS Five men were diagnosed with acquired von Willebrand syndrome. All of them presented with recent mucocutaneous bleeding. The biological phenotype was a type 2 von Willebrand disease in all cases, with decreased VWF:RCo/VWF:Ag and VWF:CB/VWF:Ag ratios (<0.7). Lymphoproliferative, autoimmune and cardiovascular diseases were the main underlying conditions identified. Screening for an anti-von Willebrand factor inhibitor was positive in two patients. Four patients received treatment for the underlying disorder. High-dose intravenous immunoglobulins were the most frequent treatment administrated. Improvement of plasma von Willebrand factor levels was observed in four cases. CONCLUSION Acquired von Willebrand syndrome is a rare but potentially serious disease. The diagnostic should be suspected in adults with unusual mucocutaneous bleeding associated with lymphoproliferative, myeloproliferative, autoimmune and cardiovascular disorders.
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Affiliation(s)
- Ines Ghariani
- Department of Laboratory Hematology, University Hospital of Mongi Slim, La Marsa, Tunisia; University of Pharmacy, Monastir, Tunisia.
| | - Néjia Braham
- University of Pharmacy, Monastir, Tunisia; Department of Laboratory Hematology, University Hospital of Farhat Hached, Tunis, Tunisia
| | - Agnès Veyradier
- Department of Laboratory Hematology, Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Leila Bekir
- Department of Laboratory Hematology, University Hospital of Mongi Slim, La Marsa, Tunisia; University of Pharmacy, Monastir, Tunisia
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Sant'Antonio E, Borsani O, Camerini C, Botta C, Santoro M, Allegra A, Siragusa S. Philadelphia chromosome-negative myeloproliferative neoplasms in younger adults: A critical discussion of unmet medical needs, with a focus on pregnancy. Blood Rev 2021; 52:100903. [PMID: 34742614 DOI: 10.1016/j.blre.2021.100903] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 10/23/2021] [Accepted: 10/27/2021] [Indexed: 11/02/2022]
Abstract
Myeloproliferative neoplasms (MPN) are traditionally regarded as a disease of older adults, though a not negligible fraction of cases occurs at a younger age, including women of childbearing potential. MPN in younger patients, indeed, offer several challenges for the clinical hematologist, that goes from difficulties in reaching a timely and accurate diagnosis to a peculiar thrombotic risk, with a relatively high incidence of thromboses in unusual sites (as the splanchnic veins or the cerebral ones). Moreover, the issue of pregnancy is recently gaining more attention as maternal age is rising and molecular screening are widely implemented, leading to a better recognition of these cases, both before and during pregnancy. In the present work we aim at discussing four clinical topic that we identified as areas of uncertainty or true unmet medical needs in the management of younger patients with MPN, with a particular focus on the topic of pregnancy. For each of these topics, we critically reviewed the available evidence that support treatment decisions, though acknowledging that recommendations in this field are mostly based on expert opinion or derived from guidelines of other clinical conditions that share with MPN a high vascular risk, as antiphospholipid syndrome. Taking into consideration both the lack of evidence-based data and the clinical heterogeneity of MPN, we support an individualized strategy of counseling and management for both young patients and for expectant mother with MPN.
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Affiliation(s)
| | - Oscar Borsani
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Chiara Camerini
- Division of Hematology, Azienda USL Toscana Nord Ovest, Ospedale San Luca, Lucca, Italy
| | - Cirino Botta
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy
| | - Marco Santoro
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy
| | - Alessandro Allegra
- Division of Hematology, Department of Human Pathology in Adulthood and Childhood "Gaetano Barresi", University of Messina, Messina, Italy
| | - Sergio Siragusa
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy
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Abstract
Acquired von Willebrand syndrome can occur in the setting of myeloproliferative neoplasms; plasma cell dyscrasias and other lymphoproliferative disorders; autoimmune conditions; and causes of increased shear forces, such as aortic stenosis or other structural heart disease and mechanical circulatory support. The depletion of von Willebrand factor, especially high-molecular-weight multimers, can lead to mucocutaneous bleeding and the formation of arteriovenous malformations, particularly in the gastrointestinal tract. Management focuses on correction of the underlying cause when possible, but may include intravenous immunoglobulins, von Willebrand factor concentrate, rituximab, or antiangiogenic therapy depending on the clinical context.
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Affiliation(s)
- Arielle L Langer
- Division of Hematology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Nathan T Connell
- Division of Hematology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA.
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7
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Ielasi A, Loffi M, Buono A, De Blasio G, Tespili M. Intracoronary cangrelor administration-assisted primary percutaneous coronary intervention in a patient with essential thrombocythemia and recurrent ST-segment elevation myocardial infarction. J Cardiovasc Med (Hagerstown) 2021; 21:825-828. [PMID: 32740411 DOI: 10.2459/jcm.0000000000001006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Alfonso Ielasi
- Clinical and Interventional Cardiology Unit, Sant'Ambrogio Cardio-Thoracic Center GSD, Milan
| | - Marco Loffi
- Cardiology Unit, Azienda Socio Sanitaria Territoriale (ASST) di Cremona, Cremona
| | - Andrea Buono
- Clinical and Interventional Cardiology Unit, Sant'Ambrogio Cardio-Thoracic Center GSD, Milan
| | | | - Maurizio Tespili
- Clinical and Interventional Cardiology Unit, Sant'Ambrogio Cardio-Thoracic Center GSD, Milan
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Abstract
This article explores how to prevent and manage complications of dentoalveolar surgery. Many complications are avoidable. Surgical skills and knowledge of anatomy play an important role in prevention of complications. Prevention starts with detailed history and physical examination of the patient. Key to perioperative management of patients is risk assessment. Without a proper history and physical examination, the clinician is unable to assess the risk of performing surgery and anesthesia for each patient. Some illnesses and medications increase the risk of complications. The following complications are discussed: alveolar osteitis, displacement, fracture, hemorrhage, infection, nonhealing wound, oroantral communication, swelling, and trismus.
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Affiliation(s)
- Patrick J Louis
- Department of Oral and Maxillofacial Surgery, University of Alabama at Birmingham, 1919 7th Avenue South, SDB 419, Birmingham, AL 35294, USA.
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Awada H, Voso MT, Guglielmelli P, Gurnari C. Essential Thrombocythemia and Acquired von Willebrand Syndrome: The Shadowlands between Thrombosis and Bleeding. Cancers (Basel) 2020; 12:cancers12071746. [PMID: 32629973 PMCID: PMC7407619 DOI: 10.3390/cancers12071746] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 06/28/2020] [Accepted: 06/29/2020] [Indexed: 02/06/2023] Open
Abstract
Over the past decade, new insights have emerged on the pathophysiology of essential thrombocythemia (ET), its clinical management, and associated thrombohemostatic disturbances. Here, we review the latest diagnostic and risk stratification modalities of ET and its therapeutics. Moreover, we discuss the clinical evidence-based benefits, deriving from major clinical trials, of using cytoreductive therapy and antiplatelet agents to lower the risk of fatal vascular events. Also, we focus on the condition of extreme thrombocytosis (>1000 × 109/L) and bleeding risk, the development and pathogenesis of acquired von Willebrand syndrome, and the clinical approach to this paradoxical scenario in ET.
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Affiliation(s)
- Hassan Awada
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH 44106, USA;
- Correspondence: ; Tel.: +1-216-666-0640
| | - Maria Teresa Voso
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, 00133 Rome, Italy;
- Fondazione Santa Lucia, Laboratorio di Neuro-Oncoematologia, 00143 Roma, Italy
| | - Paola Guglielmelli
- CRIMM-Centro Ricerca e Innovazione delle Malattie Mieloproliferative, Department of Experimental and Clinical Medicine, Azienda ospedaliera-Universitaria Careggi, University of Florence, 50139 Florence, Italy;
| | - Carmelo Gurnari
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH 44106, USA;
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, 00133 Rome, Italy;
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Abstract
: The development of neutralizing antibodies is a rare complication of von Willebrand disease treatment. In major surgical procedures for severe forms of the disease, the recognition of ineffective therapy and alternative treatment protocols are lifesaving. We report the case of a 6-year-old girl with type 3 von Willebrand disease in whom inhibitors were sought due to ineffective haemostasis together with lower than expected von Willebrand factor (VWF) recoveries after a surgical procedure. Replacement therapy first with recombinant factor VIIa and then with high doses of recombinant factor VIII in continuous infusion successfully stopped the bleeding. A high level of anti-VWF antibodies was determined by the immunological method. A frameshift mutation associated with premature termination codon (c.2435delC, p.Pro812ArgfsTer31) was determined in our patient. Although the reports on association of this mutation with inhibitor risk are inconsistent, it represents an evidence-based diagnostic and management practice in recognition of high-risk VWF genotype.
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Jennes E, Guggenberger D, Zotz R, Thompson L, Brümmendorf TH, Koschmieder S, Jost E. Perioperative intravenous immunoglobulin treatment in a patient with severe acquired von Willebrand syndrome: case report and review of the literature. Clin Case Rep 2017; 5:664-670. [PMID: 28469872 PMCID: PMC5412814 DOI: 10.1002/ccr3.890] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2016] [Revised: 12/23/2016] [Accepted: 01/04/2017] [Indexed: 02/02/2023] Open
Abstract
Acquired von Willebrand syndrome may be related to plasma cell dyscrasia and can cause severe bleeding complications. Treatment, for example, with intravenous immunoglobulins may be indicated in selected cases. Physicians treating plasma cell dyscrasia have to be aware of bleeding complications in these patients, and clarification is necessary.
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Affiliation(s)
- Eva Jennes
- Department of Hematology, Oncology, Hemostaseology and Stem Cell Transplantation Medical Faculty RWTH Aachen University Aachen Germany
| | | | - Rainer Zotz
- Institute for Laboratory Medicine, Blood Coagulation and Transfusion Medicine (LBT) Düsseldorf Germany
| | - Lora Thompson
- Department of Hematology, Oncology, Hemostaseology and Stem Cell Transplantation Medical Faculty RWTH Aachen University Aachen Germany
| | - Tim H Brümmendorf
- Department of Hematology, Oncology, Hemostaseology and Stem Cell Transplantation Medical Faculty RWTH Aachen University Aachen Germany
| | - Steffen Koschmieder
- Department of Hematology, Oncology, Hemostaseology and Stem Cell Transplantation Medical Faculty RWTH Aachen University Aachen Germany
| | - Edgar Jost
- Department of Hematology, Oncology, Hemostaseology and Stem Cell Transplantation Medical Faculty RWTH Aachen University Aachen Germany
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Swami A, Kaur V. von Willebrand Disease: A Concise Review and Update for the Practicing Physician. Clin Appl Thromb Hemost 2016; 23:900-910. [PMID: 27920237 DOI: 10.1177/1076029616675969] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
von Willebrand disease (vWD) is the most common inherited disorder of hemostasis and comprises a spectrum of heterogeneous subtypes. Significant advances have been made in understanding von Willebrand factor ( vWF) gene mutations, resultant physiologic deficits in the vWF peptide, and their correlation to clinical presentation. Diagnostic tests for this disorder are complex, and interpretation requires a thorough understanding of the underlying pathophysiology by the practicing physician. The objective of this review is to summarize our current understanding of pathophysiology, laboratory investigations, and evolving treatment paradigm of vWD with the availability of recombinant von Willebrand factor.
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Affiliation(s)
| | - Varinder Kaur
- 2 Division of hematology/oncology, Department of Internal Medicine, Vancouver Island Cancer Center, University of British Columbia, British Columbia Cancer Agency, Vancouver, British Columbia, Canada.,3 British Columbia Cancer Agency, Vancouver, British Columbia, Canada
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13
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Ouyang HY, Yu ZJ, Yin J, Zhao XJ, Wang ZY, Zhang W, Ma ZN, Su J, Bai X, Ruan CG. [Acquired von Willebrand syndrome in three patients and literature review]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2016; 37:692-5. [PMID: 27587252 PMCID: PMC7348543 DOI: 10.3760/cma.j.issn.0253-2727.2016.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To deepen the understanding of acquired von Willebrand syndrome (AVWS). METHODS The clinical data of 3 patients were analyzed and related literature were reviewed. RESULTS ① Case 1, a 70- year- old male, diagnosed as Waldenstrom macroglobulinemia and AVWS, was presented with spontaneous epitaxis and bruising. The VWF∶Ag level was 16%. Treatment was initiated with VWF concentrates. Two cycles of chemotherapy with Bortezomib, thalidomide and Dexamethasone were followed. Partial remission was achieved. Half- year' follow- up showed no sign of spontaneous hemorrhage. ② Case 2, a 48- year- old female, diagnosed as monoclonal gammopathy of undetermined significance and AVWS, was presented with repeated epitaxis. The VWF∶Ag level was 7%. Because the bleeding was slight and self-relieved, no specific treatment was addressed. She was followed up for one and a half year. ③ Case 3, a 50- year- old man, diagnosed as monoclonal gammopathy of undetermined significance and AVWS, was referred to our hospital for presentation with significant hematomas. VWF∶ Ag was reduced to 12%. VWF- containing cryoprecipitate, plasma, intravenous immunoglobulin and rituximab were used to control his bleeding symptom. During the follow-up, spontaneous hemorrhage still occurred occasionally. CONCLUSIONS Acquired von Willebrand syndrome presented with heterogeneous symptoms. The level of VWF∶Ag and VWF∶Rco for patients with bleeding disorder should be performed. Abnormal bleeding symptoms in elderly patients without personal or family history of bleeding should prompt consideration of the underlying disorders. Treatment included controlling acute bleeding, curing the underlying diseases and preventing bleeding in high- risk situations. The prognosis of acquired von Willebrand syndrome is mainly related to the underlying diseases.
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Affiliation(s)
| | - Z J Yu
- Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Collaborative Innovation Center of Hematology, Soochow University, Suzhou 215006, China
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14
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D’Onofrio A, Rizzo S, Besola L, Isabella G, Rancitelli V, Randi ML, Campello E, Falasco G, Basso C, Thiene G, Gerosa G. Hyperacute Valve Thrombosis After Transapical Transcatheter Aortic Valve Replacement in a Patient With Polycythemia Vera. JACC Cardiovasc Interv 2016; 9:1746-7. [DOI: 10.1016/j.jcin.2016.05.035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Revised: 05/06/2016] [Accepted: 05/20/2016] [Indexed: 10/21/2022]
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15
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Mital A, Prejzner W, Świątkowska-Stodulska R, Hellmann A. Factors predisposing to acquired von Willebrand syndrome during the course of polycythemia vera - retrospective analysis of 142 consecutive cases. Thromb Res 2015; 136:754-7. [PMID: 26269222 DOI: 10.1016/j.thromres.2015.07.029] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Revised: 07/27/2015] [Accepted: 07/28/2015] [Indexed: 12/20/2022]
Abstract
INTRODUCTION The aim of this study was to verify if PV patients with and without avWS differ in terms of their baseline clinical parameters. MATERIAL AND METHODS The study included 142 consecutive patients with PV. avWS was diagnosed on the basis of abnormally low levels of von Willebrand factor and other routine tests. Patients with and without concomitant avWS were compared in terms of their demographic characteristics, present and past medical histories and laboratory parameters. RESULTS Concomitant avWS was found in 17 PV patients (12.0%). Individuals with avWS have been diagnosed with PV at significantly younger age than those without, and significantly less often were in remission at the time of testing for bleeding disorders. Most of them (58.8%) presented with typical signs of bleeding disorder. Moreover, they showed significantly higher erythrocyte, leukocyte and platelet counts, abnormalities of coagulation profile corresponding to defects of primary hemostasis and abnormal values of all parameters used in the routine diagnosis of avWS. CONCLUSIONS Even every tenth patient with PV may develop avWS. Young age at diagnosis of PV and poor response to previous treatment of this condition are potential risk factors of avWS that should be considered during history taking. Sings of bleeding disorder observed in a person with PV necessitate evaluation for avWS.
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Affiliation(s)
- Andrzej Mital
- Department of Hematology and Transplantology, Medical University of Gdansk, Gdansk, Poland.
| | - Witold Prejzner
- Department of Hematology and Transplantology, Medical University of Gdansk, Gdansk, Poland
| | | | - Andrzej Hellmann
- Department of Hematology and Transplantology, Medical University of Gdansk, Gdansk, Poland
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Lancellotti S, Dragani A, Ranalli P, Petrucci G, Basso M, Tartaglione R, Rocca B, De Cristofaro R. Qualitative and quantitative modifications of von Willebrand factor in patients with essential thrombocythemia and controlled platelet count. J Thromb Haemost 2015; 13:1226-37. [PMID: 25876231 DOI: 10.1111/jth.12967] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Indexed: 12/23/2022]
Abstract
BACKGROUND Essential thrombocythemia (ET) is characterized by increased platelets and prevalent thrombosis. An acquired von Willebrand factor (VWF) disease has been hypothesized and inconsistently associated with extreme thrombocytosis or rare bleeding in ET. Whether VWF is modified in ET patients with controlled platelet count remains unclear. OBJECTIVES We studied different VWF- and platelet-associated parameters in ET patients treated according to current recommendations. PATIENTS/METHODS Sixty-nine ET patients (M = 29; median age, 62 [48-70] years; platelets, 432 [337-620] × 10(3) μL(-1) ), 69 matched controls and 10 subjects with reactive thrombocytosis (RT) were studied. VWF:antigen (Ag), activity (act), electrophoretic patterns, VWF:propeptide, plasma glycocalycin (GC), glycoproteinV (GpV), ADAMTS-13, elastase, C-reactive protein and serum thromboxane (TX)B2 were measured. RESULTS In ET patients, VWF:Ag was increased by 31 ± 13% vs. controls (P < 0.01), without dependence of blood groups, while VWF:act was reduced by 21 ± 12% vs. controls and by 50 ± 24% vs. RT (P < 0.01). The VWF:act/VWF:Ag ratios in ET were reduced by 35 ± 17% vs. controls and RT patients (P < 0.001) and significantly associated with: immature or total platelet counts, GC, GpV and TXB2 . In multivariable analysis, only GC inversely predicted ET patients' VWF:act/VWF:Ag ratios (β = -0.42, P = 0.01). By electrophoresis analyses, high-molecular-weight VWF multimers were variably reduced with atypical cleavage bands in ET only. VWF:propeptide, ADAMTS-13 and elastase levels were normal in ET patients. Platelet-associated ADAM-10 and ADAM-17 hydrolyzed VWFm in vitro, showing patterns similar to those in ET samples. CONCLUSIONS In ET patients with controlled platelet counts, the VWF:act/VWF:Ag ratio is decreased and predicted by GC, a product of platelet activation. ADAM-10 and/or ADAM-17 might be involved. In vivo platelet activation, which characterizes ET, might contribute to disease-specific VWF alterations.
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Affiliation(s)
- S Lancellotti
- Center for Haemorrhagic and Thrombotic Diseases, Department of Medical Sciences, Catholic University School of Medicine, 'A. Gemelli' Hospital, Rome, Italy
| | - A Dragani
- Center for Haemorrhagic, Thrombotic and Rare Hematologic Diseases, Spirito Santo Hospital, Pescara, Italy
| | - P Ranalli
- Center for Haemorrhagic, Thrombotic and Rare Hematologic Diseases, Spirito Santo Hospital, Pescara, Italy
| | - G Petrucci
- Institute of Pharmacology, Catholic University School of Medicine, Rome, Italy
| | - M Basso
- Center for Haemorrhagic and Thrombotic Diseases, Department of Medical Sciences, Catholic University School of Medicine, 'A. Gemelli' Hospital, Rome, Italy
| | - R Tartaglione
- Institute of Haematology, Complesso Integrato Columbus, Catholic University School of Medicine, Rome, Italy
| | - B Rocca
- Institute of Pharmacology, Catholic University School of Medicine, Rome, Italy
| | - R De Cristofaro
- Center for Haemorrhagic and Thrombotic Diseases, Department of Medical Sciences, Catholic University School of Medicine, 'A. Gemelli' Hospital, Rome, Italy
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Franchi F, Biguzzi E, Stufano F, Siboni SM, Baronciani L, Peyvandi F. A two-step approach (Enzyme-linked immunosorbent assay and confirmation assay) to detect antibodies against von Willebrand factor in patients with Acquired von Willebrand Syndrome. Thromb Res 2014; 134:1316-22. [PMID: 25300810 DOI: 10.1016/j.thromres.2014.09.020] [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: 02/05/2014] [Revised: 08/26/2014] [Accepted: 09/20/2014] [Indexed: 11/16/2022]
Abstract
BACKGROUND Acquired von Willebrand Syndrome is a rare bleeding disorder, which arises in individuals with no personal or family history of bleeding, associated with lymphoproliferative and myeloproliferative disorders or other diseases. AIM To develop a two-step approach assay to detect autoantibodies against VWF and to verify their prevalence in AVWS. METHODS AVWS definition: negative personal or family history of bleeding diathesis, VWF below normal range and recent history of bleeding manifestations. Twenty-three consecutive patients affected by AVWS were enrolled. An ELISA assay (first step) using recombinant VWF protein immobilized on plates and sheep/goat polyclonal anti-human IgG or IgM labelled with peroxidase was developed. A group of 40 healthy subjects was tested to calculate the floating cut point value. A confirmation assay (with addition of purified VWF vs buffer) was performed (second step). RESULTS Twenty-one patients (93%) had an associated disease, two patients had idiopathic AVWS. Anti-VWF autoantibodies were detected in 9 patients (39%). Of these, eight (89%) had VWF:RCo levels <10%, but none of them resulted positive using Bethesda assay (neutralizing antibodies). The confirmation test confirmed the positive results obtained with ELISA and resulted negative in those patients with negative results and in the controls. CONCLUSION With the present two-step approach assay nine out of 23 (39%) patients affected with AVWS resulted positive for anti-VWF autoantibodies. This ELISA assay might be used as an additional confirmation tool in the diagnostic procedure in patients affected by AVWS or in the follow-up of congenital and acquired patients exposed to replacement therapy.
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Affiliation(s)
- Franca Franchi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy.
| | - Eugenia Biguzzi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Italy
| | - Francesca Stufano
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Italy
| | - Simona M Siboni
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Italy
| | - Luciano Baronciani
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Italy
| | - Flora Peyvandi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Italy; Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
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18
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Abstract
Bleeding occurs in approximately 10% of patients with cancer: supportive transfusion therapy with Platelets Concentrates (PC), Fresh Frozen Plasma (FFP) and plasma-derived or recombinant concentrates is often required for the cessation and prevention of the bleeding episodes. The most frequent causes of bleeding in cancer is thrombocytopenia followed by liver insufficiency with or without vitamin K deficiency, disseminated intravascular coagulation (DIC) and the inappropriate or excessive use of anticoagulants. Other acquired hemostatic defects such as acquired hemophilia (AHA) and acquired von Willebrand syndrome (AVWS) are rare but they can be life-threatening. Thrombocytopenia in cancer patients may be the consequence of marrow invasion, chemotherapy or platelet auto-antibodies; patients with severe hypoproliferative thrombocytopenia, must be treated with PC and carefully followed to assess refractoriness to PC. The management of the other acquired defects of hemostasis usually requires the use of FFP and specific plasma-derived or recombinant concentrates. PC, FFP and plasma-derived concentrates can induce complications and/or adverse events in cancer patients: these include mainly allergic (ALR) or anaphylactic reactions (ANR), Transfusion-Associated Graft-Versus-Host Disease (TA-GVHD), Trasfusion-transmitted bacteriemia (TTB), Transfusion-Related Acute Lung Injury (TRALI), Acute Hemolytic Transfusion Reactions (AHTR), Febrile Non Hemolytic Transfusion Reactions (FNHTR). Therefore, modifications such as leukocyte-reduction and irradiation of the blood components to be transfused in cancer patients are recommended to reduce the risk of these complications.
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Stuijver DJF, Piantanida E, van Zaane B, Galli L, Romualdi E, Tanda ML, Meijers JCM, Büller HR, Gerdes VEA, Squizzato A. Acquired von Willebrand syndrome in patients with overt hypothyroidism: a prospective cohort study. Haemophilia 2013; 20:326-32. [DOI: 10.1111/hae.12275] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/10/2013] [Indexed: 11/29/2022]
Affiliation(s)
- D. J. F. Stuijver
- Department of Internal Medicine; Slotervaart Hospital; Amsterdam The Netherlands
- Department of Vascular Medicine; Academic Medical Centre; Amsterdam The Netherlands
| | - E. Piantanida
- Endocrinology Unit; Department of Clinical and Experimental Medicine; University of Insubria; Varese Italy
| | - B. van Zaane
- Department of Internal Medicine; Slotervaart Hospital; Amsterdam The Netherlands
- Department of Vascular Medicine; Academic Medical Centre; Amsterdam The Netherlands
| | - L. Galli
- Department of Clinical and Experimental Medicine; Research Center on Thromboembolic Disorders and Antithrombotic Therapies; University of Insubria; Varese Italy
| | - E. Romualdi
- Department of Clinical and Experimental Medicine; Research Center on Thromboembolic Disorders and Antithrombotic Therapies; University of Insubria; Varese Italy
| | - M. L. Tanda
- Endocrinology Unit; Department of Clinical and Experimental Medicine; University of Insubria; Varese Italy
| | - J. C. M. Meijers
- Department of Vascular Medicine; Academic Medical Centre; Amsterdam The Netherlands
- Department of Experimental Vascular Medicine; Academic Medical Centre; Amsterdam The Netherlands
| | - H. R. Büller
- Department of Vascular Medicine; Academic Medical Centre; Amsterdam The Netherlands
| | - V. E. A. Gerdes
- Department of Internal Medicine; Slotervaart Hospital; Amsterdam The Netherlands
- Department of Vascular Medicine; Academic Medical Centre; Amsterdam The Netherlands
| | - A. Squizzato
- Department of Clinical and Experimental Medicine; Research Center on Thromboembolic Disorders and Antithrombotic Therapies; University of Insubria; Varese Italy
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20
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Bharati KP, Prashanth UR. Von Willebrand disease: an overview. Indian J Pharm Sci 2012; 73:7-16. [PMID: 22131616 PMCID: PMC3224412 DOI: 10.4103/0250-474x.89751] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2010] [Revised: 01/10/2011] [Accepted: 01/15/2011] [Indexed: 12/05/2022] Open
Abstract
Most commonly inherited bleeding disorder, first described in Aland Islands by Erik von Willebrand. It occurs as a result of decrease in plasma levels or defect in von Willebrand factor which is a large multimeric glycoprotein. Monomers of this glycoprotein undergo N-glycosylation to form dimers which get arranged to give multimers. Binding with plasma proteins (especially factor VIII) is the main function of von Willebrand factor. The disease is of two forms: Inherited and acquired forms. Inherited forms are of three major types. They are type 1, type 2, and type 3; in which type 2 is sub-divided into 2A, 2B, 2M, 2N. Type 1 is more prevalent than all other types. Mucocutaneous bleeding is mild in type 1 whereas it is mild to moderate in types 2A, 2B, and 2M. Type 2N has similar symptoms of haemophilia. The pathophysiology of each type depends on the qualitative or quantitative defects in von Willebrand factor. The diagnosis is based on von Willebrand factor antigen, von Willebrand factor activity assay, FVIII coagulant activity and some other additional tests. Results should be analyzed within the context of blood group. von Willebrand factor multimer analysis is essential for typing and sub typing the disease. The management of the disease involves replacement therapy, non-replacement therapy and other therapies that include antifibrinolytics and topical agents.
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Affiliation(s)
- K Pavani Bharati
- Department of Pharmacy Practice, JNTUK, Vizianagaram - 535 003, India
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21
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Abstract
The evaluation of a patient presenting with bleeding symptoms is challenging. Bleeding symptoms are frequently reported by a normal population, and overlap significantly with bleeding disorders, such as type 1 Von Willebrand disease. The history is subjective; bleeding assessment tools significantly facilitate an accurate quantification of bleeding severity. The differential diagnosis is broad, ranging from defects in primary hemostasis, coagulation deficiencies, to connective tissue disorders. Finally, despite significant clinical evidence of abnormal bleeding, many patients will have not an identifiable disorder. Clinical management of bleeding disorders is highly individualized and focuses on the particular symptoms experienced by the patient.
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Affiliation(s)
- Natalia Rydz
- Department of Pathology and Molecular Medicine, Queen's University, Room 2025, Etherington Hall, Kingston, ON, Canada K7L 3N6
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22
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Shetty S, Kasatkar P, Ghosh K. Pathophysiology of acquired von Willebrand disease: a concise review. Eur J Haematol 2011; 87:99-106. [PMID: 21535159 DOI: 10.1111/j.1600-0609.2011.01636.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Acquired von Willebrand disease (AVWD) is a rare, underdiagnosed hemorrhagic disorder, which is similar to congenital VWD with regard to the clinical and laboratory parameters; however, it is found in individuals with no positive family history and has no genetic basis. The etiology is varied, the commonest being hematoproliferative disorders and cardiovascular disorders. Other disorders associated with AVWD are autoimmune disorders such as systematic lupus erythematosus, hypothyroidism, and neoplasia, or it may also be drug induced. In quite a few cases, the etiology is unknown. The pathogenic mechanisms are different in different underlying disorders or they may be overlapping among these disorders. Some of the proposed mechanisms include the development of autoantibodies, selective absorption of high molecular weight von Willebrand factor (VWF) multimers, non-selective absorption of VWF, mechanical destruction of VWF under high shear stress, and increased proteolysis. This report presents a concise review of the pathophysiological mechanisms of AVWD in these various underlying conditions.
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Affiliation(s)
- Shrimati Shetty
- National Institute of Immunohaematology (ICMR), KEM Hospital, Parel, Mumbai, India.
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23
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Abstract
von Willebrand disease is a common inherited bleeding disorder characterized by excessive mucocutaneous bleeding. Characteristic bleeding symptoms include epistaxis, easy bruising, oral cavity bleeding, menorrhagia, bleeding after dental extraction, surgery, and/or childbirth, and in severe cases, bleeding into joints and soft tissues. There are three subtypes: types 1 and 3 represent quantitative variants and type 2 is a group of four qualitative variants: (1) type 2A-characterized by defective von Willebrand factor-dependent platelet adhesion because of decreased high-molecular-weight von Willebrand factor multimers, (2) type 2B-caused by pathologically increased von Willebrand factor-platelet interactions, (3) type 2M-caused by decreased von Willebrand factor-platelet interactions not based on the loss of high-molecular-weight multimers, and (4) type 2N-characterized by reduced binding of von Willebrand factor to factor VIII. The diagnosis of von Willebrand disease requires specialized assays of von Willebrand factor and/or molecular genetic testing of von Willebrand factor. Severe bleeding episodes can be prevented or controlled with intravenous infusions of virally inactivated plasma-derived clotting factor concentrates containing both von Willebrand factor and factor VIII. Depending on the von Willebrand disease type, mild bleeding episodes usually respond to intravenous or subcutaneous treatment with desmopressin, a vasopressin analog. Other treatments that can reduce symptoms include fibrinolytic inhibitors and hormones for menorrhagia.
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24
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Pérez-Rodríguez A, Pinto JC, Lourés E, Rodríguez-Trillo A, Cuenca JJ, Batlle J, López-Fernández MF. Acquired von Willebrand syndrome and mitral valve prosthesis leakage. A pilot study. Eur J Haematol 2011; 87:448-56. [PMID: 21668503 DOI: 10.1111/j.1600-0609.2011.01664.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Of patients with severe aortic stenosis, 15-25% present with bleeding episodes possibly attributable to acquired von Willebrand syndrome (AVWS). AVWS associated with mitral valve prosthesis leakage has not been reported. METHODS AND RESULTS Five patients receiving appropriate oral anticoagulation showed mitral valve prosthesis leakage and bleeding episodes; all of them required hospitalization and two blood transfusions, and a von Willebrand factor (VWF) analysis was performed. Two patients with normal functioning metallic prosthesis valves were included as controls. Before surgery, after cessation of acenocumarol, the patients had prolonged activated partial thromboplastin time; four had prolonged closure time (CT) from the platelet function analyzer. Factor VIII procoagulant activity (FVIII:C), VWF ristocetin cofactor activity (VWF:RCo), and VWF collagen binding (VWF:CB) were considerably elevated, while VWF antigen (VWF:Ag) was most elevated. Disproportionate VWF:RCo/VWF:Ag and VWF:CB/VWF:Ag ratios were seen with the loss of large VWF multimers. Following surgery, all parameters were markedly increased and the ratios, CT, and multimeric VWF profile became normal. CONCLUSIONS Acquired VWF qualitative alterations in mitral valve prosthesis leakage may be associated with or contribute to bleeding diathesis. AVWS should be taken into consideration in patients with mitral valve prosthesis leakage with bleeding diathesis not explained by excessive oral anticoagulation.
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Affiliation(s)
- Almudena Pérez-Rodríguez
- Servicio de Hematología y Hemoterapia, INIBIC-Complexo Hospitalario Universitario A Coruña, Carretera del Pasaje s/n, A Coruña, Spain
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25
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Abstract
Abstract
The acquired von Willebrand syndrome (AVWS) is a bleeding disorder that is frequently unrecognized or is misdiagnosed as von Willebrand disease. AVWS is characterized by structural or functional defects of von Willebrand factor (VWF) that are secondary to autoimmune, lymphoproliferative or myeloproliferative, malignant, cardiovascular, or other disorders. VWF abnormalities in these disorders can result from (1) antibody-mediated clearance or functional interference, (2) adsorption to surfaces of transformed cells or platelets, or (3) increased shear stress and subsequent proteolysis. Diagnosis can be challenging as no single test is usually sufficient to prove or exclude AVWS. Furthermore, there are no evidence-based guidelines for management. Treatments of the underlying medical condition, including chemo/radiotherapy, surgery, or immunosuppressants can result in remission of AVWS, but is not always feasible and successful. Because of the heterogeneous mechanisms of AVWS, more than one therapeutic approach is often required to treat acute bleeds and for prophylaxis during invasive procedures; the treatment options include, but are not limited to, desmopressin, VWF-containing concentrates, intravenous immunoglobulin, plasmapheresis or recombinant factor VIIa. Here, we review the management of AVWS with an overview on the currently available evidence and additional considerations for typical treatment situations.
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26
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Leimkühler K, Bach F, Kuhlmann S, Feidicker B, Heim MU, Susemihl C, Schmidt B, Mertzlufft F. [Acquired von Willebrand's disease type 2A following arteriovenous fistula for haemodialysis?]. Hamostaseologie 2011; 31:118-22. [PMID: 21152674 DOI: 10.5482/ha-1129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Acquired von Willebrand's disease (aVWD) is considered to be an underestimated cause of unexplained bleeding. Adsorption of von Willebrand factor (VWF) to tumour cells or hydroxyethyl starch and elimination of VWF by autoantibodies as well as shear stress-induced mechanical alteration of VWF with concomitant cleavage by enzymes may lead to an acquired deficiency of VWF and a bleeding disorder. We report a 39-year-old woman who developed spontaneous bleeding five years after surgical creation of an arteriovenous fistula (AVF) for haemodialysis treatment. AVWD type 2A was diagnosed after successful renal transplantation. One year after surgical closure of the AVF, the aVWD could not be verified again. Thus, the aVWD may have developed because of altered blood flow and shear stress inside the arteriovenous fistula.
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Affiliation(s)
- K Leimkühler
- Klinik für Anästhesiologie, Intensiv-, Notfall-, Transfusionsmedizin und Schmerztherapie, Evangelisches Krankenhaus Bielefeld.
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Snowden JA, Ahmedzai SH, Ashcroft J, D’Sa S, Littlewood T, Low E, Lucraft H, Maclean R, Feyler S, Pratt G, Bird JM. Guidelines for supportive care in multiple myeloma 2011. Br J Haematol 2011; 154:76-103. [DOI: 10.1111/j.1365-2141.2011.08574.x] [Citation(s) in RCA: 151] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Höög CM, Broström O, Lindahl TL, Hillarp A, Lärfars G, Sjöqvist U. Bleeding from gastrointestinal angioectasias is not related to bleeding disorders - a case control study. BMC Gastroenterol 2010; 10:113. [PMID: 20920209 PMCID: PMC2955688 DOI: 10.1186/1471-230x-10-113] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2009] [Accepted: 09/28/2010] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Angioectasias in the gastrointestinal tract can be found in up to 3% of the population. They are typically asymptomatic but may sometimes result in severe bleeding. The reasons for why some patients bleed from their angioectasias are not fully understood but it has been reported that it may be explained by an acquired von Willebrand syndrome (AVWS). This condition has similar laboratory findings to congenital von Willebrand disease with selective loss of large von Willebrand multimers. The aim of this study was to find out if AVWS or any other bleeding disorder was more common in patients with bleeding from angioectasias than in a control group. METHODS We compared bleeding tests and coagulation parameters, including von Willebrand multimers, from a group of 23 patients with anemia caused by bleeding from angioectasias, with the results from a control group lacking angioectasias. RESULTS No significant differences between the two groups were found in coagulation parameters, bleeding time or von Willebrand multimer levels. CONCLUSION These results do not support a need for routine bleeding tests in cases of bleeding from angioectasias and do not show an overall increased risk of AVWS among these patients.
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Affiliation(s)
- Charlotte M Höög
- Department of Medicine, Karolinska Institutet, Stockholm Söder Hospital, Stockholm, Sweden
| | - Olle Broström
- Department of Medicine, Karolinska Institutet, Stockholm Söder Hospital, Stockholm, Sweden
| | - Tomas L Lindahl
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Andreas Hillarp
- Department of Clinical Chemistry, Malmö University Hospital, Malmö, Sweden
| | - Gerd Lärfars
- Department of Medicine, Karolinska Institutet, Stockholm Söder Hospital, Stockholm, Sweden
| | - Urban Sjöqvist
- Department of Medicine, Karolinska Institutet, Stockholm Söder Hospital, Stockholm, Sweden
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29
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Abstract
Patients with solid and hematologic malignancies presenting with major bleeding or thrombotic complications, potentially life-ending events in a cancer patient's clinical course, usually require admission to an intensive care unit (ICU), making their diagnosis and management even more important for the intensivist. Given the significant advances in the diagnosis and treatment of almost all types of cancers in recent years, the intensivist is likely to encounter an ever-increasing number of cancer patients in the ICU setting with these complications. Abnormal hemostasis can occur as a consequence of both the pathology and treatment of cancer. Because cancer can have multiple effects on hemostatic equilibrium, treatment of these complications can be more complex than in the general population. This article reviews the physiology of coagulation and fibrinolysis, with special attention to those aspects that are most frequently altered in the setting of malignancy. The pathophysiology of bleeding and thrombotic complications specific to critically ill cancer patients are then detailed, and the diagnostic and therapeutic strategies are discussed. Special emphasis is placed on new cancer medications that have an effect on hemostasis, and on novel clotting and anticoagulant agents that are available to the intensivist for the management of these patients.
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Affiliation(s)
- Karen S Carlson
- Department of Medicine, New York Presbyterian Hospital of Weill Cornell Medical College, 525 E 68th Street, Payson 3, New York, NY 10065, USA
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30
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Successful imatinib mesylate therapy for acquired von Willebrand syndrome in chronic myelogenous leukemia. Leuk Res 2009; 33:1723-4. [DOI: 10.1016/j.leukres.2009.05.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2009] [Revised: 05/14/2009] [Accepted: 05/16/2009] [Indexed: 11/21/2022]
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Affiliation(s)
- Adam Cuker
- Clinical Pathological Conference Series, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
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Brémaud M, Giraud C, Boinot C, Caranobe C, Macchi L, Gohler C, Guilhot F. [Three cases of IgM monoclonal gammopathy with haemostasis dysfunction]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2009; 28:892-896. [PMID: 19767170 DOI: 10.1016/j.annfar.2009.07.088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/11/2009] [Accepted: 07/30/2009] [Indexed: 05/28/2023]
Abstract
We relate three cases of IgM gammopathy with haemostatic dysfunction in the perioperative period. The acquired von Willebrand syndrome due to IgM gammopathy is rare and sometimes serious. Its different treatments and their efficiency are discussed: desmopressin, intravenous gammaglobulin, chemotherapy and plasmapheresis.
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Affiliation(s)
- M Brémaud
- Service d'anesthésie-réanimation, clinique des Cèdres, Cornebarrieu, France.
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Vanderschueren S, Mylle M, Dierickx D, Delforge M, Verhamme P, Peerlinck K, Meersseman W, Knockaert DC. Monoclonal gammopathy of undetermined significance: significant beyond hematology. Mayo Clin Proc 2009; 84:842-5. [PMID: 19720783 PMCID: PMC2735435 DOI: 10.4065/84.9.842] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
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Vanderschueren S, Mylle M, Dierickx D, Delforge M, Verhamme P, Peerlinck K, Meersseman W, Knockaert DC. Monoclonal gammopathy of undetermined significance: significant beyond hematology. Mayo Clin Proc 2009; 84:842-5. [PMID: 19720783 PMCID: PMC2735435 DOI: 10.1016/s0025-6196(11)60495-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Mayerhofer M, Haushofer A, Kyrle PA, Chott A, Müllner C, Quehenberger P, Worel N, Traby L, Eichinger S. Mechanisms underlying acquired von Willebrand syndrome associated with an IgM paraprotein. Eur J Clin Invest 2009; 39:833-6. [PMID: 19572993 DOI: 10.1111/j.1365-2362.2009.02177.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Acquired von Willebrand (vW) syndrome is a rare bleeding disorder which is frequently associated with immunological, malignant or cardiovascular disorders. The underlying pathomechanisms, particularly in patients with IgM monoclonal gammopathies, often remain unknown. We report a patient with indolent small B-cell lymphoma (immunocytoma) and plasmacytic differentiation with an IgM kappa paraprotein who was admitted with retroperitoneal haematoma. Medical history and coagulation testing were consistent with acquired vW syndrome. vW immunohistochemistry showed normal cytoplasmic labelling of endothelial cells and megakaryocytes, whereas the lymphomatous infiltrate was negative. Acquired vW syndrome due to adsorption of vW factor on malignant cells was thus excluded. In the multimeric analysis, all multimers were present similar to that in type 1 vW syndrome, but the triplet structures were blurred. The bands on serum immunofixation electrophoresis were also atypically broadened, which suggested complex formation between the IgM and vW factor. Immunoprecipitation studies showed that the 176-kDa proteolytic fragment of vW factor co-precipitated with the IgM paraprotein in the patient but not in the controls, suggesting a specific interaction between vW factor and the paraprotein in the patient. The patient required surgery and was successfully managed by chemotherapy consisting of rituximab and fludarabin as well as plasma exchange.
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Affiliation(s)
- M Mayerhofer
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Vienna, Vienna, Austria
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36
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Berntorp E, Archey W, Auerswald G, Federici AB, Franchini M, Knaub S, Kreuz W, Lethagen S, Mannucci PM, Pollmann H, Scharrer I, Hoots K. A systematic overview of the first pasteurised VWF/FVIII medicinal product, Haemate P/ Humate -P: history and clinical performance. Eur J Haematol 2008:3-35. [PMID: 18380871 DOI: 10.1111/j.1600-0609.2008.01049.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Patients with von Willebrand disease (VWD) and haemophilia A (HA) lack, to varying degrees, the von Willebrand factor (VWF) and coagulation factor VIII (FVIII) that are critical for normal haemostasis. These conditions in turn make patients prone to uncontrolled bleeding. Historically, patients with severe forms of VWD or HA were crippled before adulthood and their life expectancy was significantly reduced. Over the past decades, specific coagulation factor replacement therapies including Haemate P, have been developed to help patients achieve and maintain normal haemostasis. Haemate P is a human, plasma-derived VWF/FVIII medicinal product, which was first licensed in Germany in 1981 for the treatment of HA-associated bleeding. It has since then come to be accepted as the gold standard for both the treatment and prophylaxis of bleeding in VWD, especially in cases where desmopressin [1-deamino-8-D-arginine vasopressin (DDAVP)] has been ineffective. Haemate P was the first effectively virus-inactivated (pasteurisation: 60 degrees C for 10 h in aqueous solution) FVIII product, whereby the risk of potentially threatening infective complications of plasma-derived products was reduced. Haemate P was also shown to have a VWF multimer profile remarkably close to that of normal plasma. This bibliographic review presents previously unpublished clinical data of Haemate P, based upon internal clinical study reports of the proprietor, CSL Behring, in addition to data already presented in other publications. The data demonstrate a predictable and well-characterised pharmacokinetic profile, and a proven record of short- and long-term safety, while effectively correcting the haemostatic defects in VWD and HA. Recently available data have also shown Haemate P to be of haemostatic value in exceptional clinical circumstances including surgical interventions. By virtue of its plasma-derived combination of VWF and FVIII, in addition to its high VWF:FVIII content ratio (2.4:1), Haemate P is also associated with successful immune tolerance induction in those patients developing inhibitor antibodies. Although the theoretical risk of thromboembolic complications does exist while receiving Haemate P, as it does with any FVIII replacement therapy, the incidence of such complications has remained notably low. Given the robust data that have accumulated for the use of Haemate P, dosing recommendations are also described in this review; the recommendations are tailored to patient-specific contexts including baseline VWF and FVIII levels in plasma and the type of surgical intervention being undertaken. A wide variety of studies have also provided data on paediatric and geriatric populations, all of which have suggested that Haemate P can be safely and effectively used in a wide variety of clinical circumstances.
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Affiliation(s)
- Erik Berntorp
- Centre for Thrombosis and Haemostasis, Malmö University Hospital, Malmö, Sweden
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COLLINS P, BUDDE U, RAND JH, FEDERICI AB, KESSLER CM. Epidemiology and general guidelines of the management of acquired haemophilia and von Willebrand syndrome. Haemophilia 2008; 14 Suppl 3:49-55. [DOI: 10.1111/j.1365-2516.2008.01745.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Federici AB. The use of desmopressin in von Willebrand disease: the experience of the first 30 years (1977-2007). Haemophilia 2008; 14 Suppl 1:5-14. [PMID: 18173689 DOI: 10.1111/j.1365-2516.2007.01610.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The aim of the treatment for von Willebrand disease (VWD) is to correct the dual defect of haemostasis, i.e. the abnormal platelet adhesion as a result of reduced and/or dysfunctional von Willebrand factor (VWF) and the abnormal coagulation expressed by low levels of factor VIII (FVIII). Correction of both deficiencies can be achieved by administering the synthetic peptide desmopressin (DDAVP) or, in cases unresponsive to this agent, the plasma concentrates containing VWF and FVIII (VWF/FVIII). DDAVP is the treatment of choice for type 1 VWD because it can induce release of normal VWF from cellular compartments, but the drug can be clinically useful also in other VWD types, including acquired von Willebrand syndrome (AVWS). A test dose of DDAVP at the time of diagnosis is recommended to establish the individual patterns of biological response and to predict clinical efficacy during bleeding and surgery. DDAVP is not effective in VWD type 3 and in severe forms of VWD 1 and 2. It can induce transient thrombocytopenia in patients with VWD type 2B. The results of several retrospective studies on the use of DDAVP in VWD management have been reported by many authors in different countries for the last 30 years. However, despite the widespread use of DDAVP in the treatment of VWD, there are only a few prospective clinical trials in a large number of cases on DDAVP efficacy and safety aimed at determining benefits and limits of this therapeutic approach. An investigator-driven observational prospective study on clinical efficacy of DDAVP in 200 patients with VWD types 1 and 2 has been recently organized: the effectiveness and safety of DDAVP will be evaluated prospectively for 24 months during bleeding episodes and minor or major surgeries in the VWD patients who were exposed to an infusion trial at enrollment.
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Affiliation(s)
- A B Federici
- Angelo Bianchi Bonomi Haemophilia and Thrombosis Centre, Department of Medicine and Medical Specialities, IRCCS Maggiore Policlinico Hospital, University of Milan, Milan, Italy.
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Federici AB. Acquired von Willebrand syndrome: is it an extremely rare disorder or do we see only the tip of the iceberg? J Thromb Haemost 2008; 6:565-8. [PMID: 18221357 DOI: 10.1111/j.1538-7836.2008.02917.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- A B Federici
- Angelo Bianchi Bonomi Haemophilia and Thrombosis Centre, Department of Internal Medicine and Medical Specialties, IRCCS Foundation Maggiore Policlinico Hospital, Mangiagalli, Regina Elena and University of Milan, Milan, Italy.
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Tiede A, Priesack J, Werwitzke S, Bohlmann K, Oortwijn B, Lenting P, Eisert R, Ganser A, Budde U. Diagnostic workup of patients with acquired von Willebrand syndrome: a retrospective single-centre cohort study. J Thromb Haemost 2008; 6:569-76. [PMID: 18208537 DOI: 10.1111/j.1538-7836.2008.02909.x] [Citation(s) in RCA: 104] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Diagnosis of acquired von Willebrand syndrome (AVWS) remains challenging. Diagnostic algorithms suggest the use of factor VIII (FVIII:C), von Willebrand factor antigen (VWF:Ag), ristocetin cofactor (VWF:RCo), and collagen-binding capacity (VWF:CB), but the sensitivity of these and other laboratory tests for the diagnosis of AVWS is unknown. OBJECTIVES To analyze the capacity of laboratory tests, including point-of-care testing (POCT), for the identification of patients with AVWS. PATIENTS/METHODS Thirty-five consecutive patients were enrolled with AVWS diagnosed because of a history of recent onset of bleeding, a negative family history of von Willebrand disease, and abnormal plasma VWF multimers. RESULTS According to our inclusion criteria, all patients had bleeding symptoms, and the VWF high molecular weight multimers were either decreased or absent. Regarding POCT, PFA-100 was inconclusive, due to anemia or thrombocytopenia, in 29%; the sensitivity was 80% in the remaining patients. The sensitivity of VWF:Ag (23%), VWF:RCo/Ag ratio < 0.7 (26%), VWF:CB/Ag ratio < 0.7 (46%), anti-VWF antibodies (15%) and VWF propeptide/Ag ratio (22%) was too low to rule out the disease. A combination of VWF:Ag < 50 IU dL(-1), VWF:RCo/Ag ratio < 0.7 and VWF:CB/Ag ratio < 0.8 yielded a sensitivity of 86%. Patients diagnosed only because of abnormal VWF multimers showed similar clinical characteristics as other patients. CONCLUSIONS Early diagnosis of AVWS is difficult, due to lack of sensitivity of the tests used. A substantial number of patients present with normal or increased test results, emphasizing the importance of multimer analysis in all patients with suspected AVWS.
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Affiliation(s)
- A Tiede
- Department of Haematology, Haemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany.
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Immunohematologic disorders. Clin Immunol 2008. [DOI: 10.1016/b978-0-323-04404-2.10062-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Clapson P, Bordier E, Grasser L, Merat S, Diraison Y, Brinquin L. [Perioperative management of a patient with an acquired von Willebrand syndrome]. ACTA ACUST UNITED AC 2007; 27:86-9. [PMID: 18155390 DOI: 10.1016/j.annfar.2007.11.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2007] [Accepted: 11/07/2007] [Indexed: 11/25/2022]
Abstract
We report the case of a man suffering from a monoclonal gammapathy with an acquired von Willebrand disease in a perioperative context. This pathology is rare, but is important to diagnose because of the possible haemorrhagic complications encountered. We describe the main therapeutic options available today to prevent bleeding during major surgery.
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Affiliation(s)
- P Clapson
- Département d'anesthésie et de réanimation, hôpital d'Instruction-des-Armées-Percy, 101, avenue H.-Barbusse, 92141 Clamart, France.
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Coleman R, Favaloro EJ, Soltani S, Keng TB. Acquired von Willebrand disease: potential contribution of the VWF:CB to the identification of functionally inhibiting auto-antibodies to von Willebrand factor. J Thromb Haemost 2006; 4:2085-8. [PMID: 16961622 DOI: 10.1111/j.1538-7836.2006.02072.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Abstract
AbstractThe differential diagnosis of a long APTT with a normal prothrombin time can be due to either a clotting factor deficiency or the presence of an inhibitor, which can be distinguished by using a plasma-mixing study. The various clotting factor deficiency states are reviewed. Clinical bleeding following cardiac bypass surgery due to acquired factor V and thrombin antibodies is also reviewed.
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Affiliation(s)
- Lawrence L K Leung
- VA Palo Alto HCS, Medical Service, B2-125, 3801 Miranda Ave., Palo Alto, CA 94304, USA.
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