Pharmacokinetics and pharmacodynamics of a recombinant fusion protein linking activated coagulation factor VII with human albumin (rVIIa-FP) in patients with congenital FVII deficiency

Clinical, Laboratory, and Molecular Aspects of Factor VII Deficiency

Congenital factor VII (FVII) deficiency, the most frequent among the recessively inherited disorders of blood coagulation, is characterized by a wide range of symptoms, from mild mucosal bleeds to life-threatening intracranial hemorrhage. Complete FVII deficiency may cause perinatal lethality. Clinically relevant thresholds of plasma levels are still uncertain, and modest differences in low FVII levels are associated with large differences in clinical phenotypes. Activated FVII (FVIIa) expresses its physiological protease activity only in a complex with tissue factor (TF), which triggers clotting at a very low concentration. Knowledge of the FVIIa-TF complex helps to interpret the clinical findings associated with low FVII activity as compared with other rare bleeding disorders and permits effective management, including prophylaxis, with recombinant FVIIa, which, however, displays a short half-life. Newly devised substitutive and nonsubstitutive treatments, characterized by extended half-life properties, may further improve the quality of life of patients. Genetic diagnosis has been performed in thousands of patients with FVII deficiency, and among the heterogeneous F7 mutations, mostly missense changes, several recurrent variants show geographical distribution and identity by descent. In the general population, common F7 polymorphisms explain a large proportion of FVII level variance in plasma through FVII-lowering effects. Their combination with pathogenic variants may impact on the frequent detection of FVII coagulant levels lower than normal, as well as on mild bleeding conditions. In the twenties of this century, 70 years after the first report of FVII deficiency, more than 200 studies/reports about FVII/FVII deficiency have been published, with thousands of FVII-deficient patients characterized all over the world.

Successful Laparoscopic Sleeve Gastrectomy in a Patient With Rare Congenital Factor VII Deficiency: A Case Report and Management Strategy

Congenital factor VII (FVII) deficiency is a rare coagulation disorder that increases the risk of bleeding complications during surgery. Although laparoscopic sleeve gastrectomy (LSG) is the most common metabolic bariatric surgery (MBS), it is rarely performed in patients with congenital coagulation disorders such as FVII deficiency, due to the high risk of intraoperative and postoperative bleeding. We report the case of a 57-year-old female with class II obesity (BMI 37.9 kg/m²) and previously undiagnosed congenital FVII deficiency presenting for LSG. The patient's prothrombin time-international normalized ratio (PT-INR) was elevated (2.3; normal range: 0.8-1.2) with a normal activated partial thromboplastin time (aPTT) and no known preexisting liver disease or use of anticoagulant medications. Further hematology workup confirmed isolated low FVII activity (11% of normal). Preoperative management included transfusion of two units of fresh frozen plasma (FFP) to correct the coagulopathy. Intraoperatively, 1000 international units (IU) of prothrombin complex concentrate (PCC) were administered before the end of surgery. The procedure proceeded uneventfully with no bleeding complications. Postoperatively, thromboprophylaxis with low molecular weight heparin (LMWH) was administered for 14 days without any bleeding episodes. This case demonstrates that with careful preoperative evaluation, appropriate correction of coagulopathy, and a multidisciplinary team approach, LSG can be safely performed in patients with congenital FVII deficiency. This report may serve as a reference for managing similar high-risk patients undergoing major surgeries.

Case of concurrent factor VII and factor XI deficiencies manifesting as spontaneous lower extremity compartment syndrome

Factor VII and XI deficiencies are rare bleeding disorders typically associated with mild or provoked bleeding. This case report describes a patient with factor VII and XI deficiencies with an unprovoked episode of lower extremity hematoma causing compartment syndrome requiring multiple surgeries, extensive transfusion of blood products, and ultimately amputation.

Biochemical, molecular and clinical aspects of coagulation factor VII and its role in hemostasis and thrombosis

Activated factor VII (FVIIa), the first protease of clotting, expresses its physiological procoagulant potential only after complexing with tissue factor (TF) exposed to blood. Deep knowledge of the FVIIa-TF complex and F7 gene helps to understand the Janus-faced clinical findings associated to low or elevated FVII activity (FVIIc). Congenital FVII deficiency, the most frequent among the recessively inherited bleeding disorders, is caused by heterogeneous mutations in the F7 gene. Complete FVII deficiency causes perinatal lethality. A wide range of bleeding symptoms, from life-threatening intracranial hemorrhage to mild mucosal bleeding, is observed in patients with apparently modest differences in FVIIc levels. Though clinically relevant FVIIc threshold levels are still uncertain, effective management, including prophylaxis, has been devised, substantially improving the quality of life of patients. The exposure of TF in diseased arteries fostered investigation on the role of FVII in cardiovascular disease. FVIIc levels were found to be predictors of cardiovascular death and to be markedly associated to F7 gene variation. These genotype-phenotype relationships are among the most extensively investigated in humans. Genome-wide analyses extended association to numerous loci that, together with F7, explain >50% of FVII level plasma variance. However, the ability of F7 variation to predict thrombosis was not consistently evidenced in the numerous population studies. Main aims of this review are to highlight i) the biological and clinical information that distinguishes FVII deficiency from the other clotting disorders and ii) the impact exerted by genetically predicted FVII level variation on bleeding as well as on the thrombotic states.