1
|
Seidizadeh O, Baronciani L, Lillicrap D, Peyvandi F. Application of genetic testing for the diagnosis of von Willebrand disease. J Thromb Haemost 2024:S1538-7836(24)00288-5. [PMID: 38762018 DOI: 10.1016/j.jtha.2024.05.006] [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: 01/12/2024] [Revised: 04/13/2024] [Accepted: 05/08/2024] [Indexed: 05/20/2024]
Abstract
von Willebrand disease (VWD) is the most frequent inherited bleeding disorder, with an estimated symptomatic prevalence of 1 per 1000 in the general population. VWD is characterized by defects in the quantity, quality, or multimeric structure of von Willebrand factor (VWF), a glycoprotein being hemostatically essential in circulation. VWD is classified into 3 principal types: low VWF/type 1 with partial quantitative deficiency of VWF, type 3 with virtual absence of VWF, and type 2 with functional abnormalities of VWF, being classified as 2A, 2B, 2M, and 2N. A new VWD type has been officially recognized by the ISTH SSC on von Willebrand factor which has also been discussed by the joint ASH/ISTH/NHF/WFH 2021 guidelines (ie, type 1C), indicating patients with quantitative deficiency due to an enhanced VWF clearance. With the advent of next-generation sequencing technologies, the process of genetic diagnosis has substantially changed and improved accuracy. Therefore, nowadays, patients with type 3 and severe type 1 VWD can benefit from genetic testing as much as type 2 VWD. Specifically, genetic testing can be used to confirm or differentiate a VWD diagnosis, as well as to provide genetic counseling. The focus of this manuscript is to discuss the current knowledge on VWD molecular pathophysiology and the application of genetic testing for VWD diagnosis.
Collapse
Affiliation(s)
- Omid Seidizadeh
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy. https://twitter.com/OmidSeidi
| | - Luciano Baronciani
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - David Lillicrap
- Department of Pathology and Molecular Medicine, Queen's University, Kingston, Ontario, Canada. https://twitter.com/DavidLillicrap
| | - Flora Peyvandi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy.
| |
Collapse
|
2
|
Roberts JC, Christopherson PA, Tarantino MD, Gonzales SE, Morateck PA, Perry CL, Flood VH, Abshire TC, Montgomery RR. Von Willebrand Factor (VWF) multiplex activity assay differentiation of type 1 von Willebrand Disease (VWD) and variant VWD. Haemophilia 2024; 30:161-168. [PMID: 38013388 PMCID: PMC10842138 DOI: 10.1111/hae.14901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 10/10/2023] [Accepted: 11/12/2023] [Indexed: 11/29/2023]
Abstract
INTRODUCTION VWD diagnosis is challenging requiring multiple VWF activity tests using many individual assays. We have developed an ELISA-based VWF Multiplex Activity Assay (VWF-MAA) to address this concern; however, the ability of the VWF-MAA to discriminate between type 1 VWD, variant VWD, and normal subjects has not been evaluated. AIM To evaluate the VWF-MAA and its ability to differentiate between type 1 VWD, variant VWD and normal subjects in individuals undergoing an initial laboratory evaluation for bleeding. METHODS A total of 177 plasma samples from the Zimmerman Program: Comparative Effectiveness in the Diagnosis of VWD were evaluated from 11 centres across the US and Canada. The VWF-MAA was compared to Versiti Blood Research Institute (VBRI) and Local Center (LC) assigned VWD diagnosis. RESULTS Overall, 129/177 (72.9%) were correctly assigned as normal (non-VWD), type 1, or variant VWD compared to the VBRI assigned diagnosis. VWF-MAA assigned non-VWD accurately in 29/57 (50.9%) samples, and type 1 VWD accurately in 93/110 (84.6%) samples. Considering LC diagnosis where there was agreement with VWF-MAA and not VBRI diagnosis, type 1 VWD was accurate in 105/110 (95.5%) samples. Bland-Altman analysis demonstrated good correlation between laboratory methods. VWD, types 2A, 2B, 1C VWD were also assigned by the VWF-MAA. CONCLUSIONS We demonstrate that the VWF-MAA has utility in differentiating type 1 VWD, variant VWD and normal subjects in individuals undergoing an initial laboratory evaluation for bleeding.
Collapse
Affiliation(s)
- Jonathan C Roberts
- Bleeding & Clotting Disorders Institute (BCDI), Peoria, Illinois, USA
- Departments of Pediatrics and Medicine, University of Illinois College of Medicine at Peoria, Peoria, Illinois, USA
| | | | - Michael D Tarantino
- Bleeding & Clotting Disorders Institute (BCDI), Peoria, Illinois, USA
- Departments of Pediatrics and Medicine, University of Illinois College of Medicine at Peoria, Peoria, Illinois, USA
| | - Sarah E Gonzales
- Bleeding & Clotting Disorders Institute (BCDI), Peoria, Illinois, USA
| | - Patti A Morateck
- Versiti Blood Research Institute (VBRI), Milwaukee, Wisconsin, USA
| | - Crystal L Perry
- Versiti Blood Research Institute (VBRI), Milwaukee, Wisconsin, USA
| | - Veronica H Flood
- Versiti Blood Research Institute (VBRI), Milwaukee, Wisconsin, USA
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Thomas C Abshire
- Versiti Blood Research Institute (VBRI), Milwaukee, Wisconsin, USA
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Robert R Montgomery
- Versiti Blood Research Institute (VBRI), Milwaukee, Wisconsin, USA
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| |
Collapse
|
3
|
Doevelaar AAN, Bachmann M, Hölzer B, Seibert FS, Rohn BJ, Zgoura P, Witzke O, Dittmer U, Brenner T, Paniskaki K, Yilmaz S, Dittmer R, Schneppenheim S, Wilhelm J, Stervbo U, Babel N, Budde U, Westhoff TH. Generation of potentially inhibitory autoantibodies to ADAMTS13 in coronavirus disease 2019. Sci Rep 2023; 13:10501. [PMID: 37380654 PMCID: PMC10307883 DOI: 10.1038/s41598-023-37405-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 06/21/2023] [Indexed: 06/30/2023] Open
Abstract
It has recently been shown that von Willebrand factor (VWF) multimers contribute to immunothrombosis in Coronavirus disease 2019 (COVID-19). Since COVID-19 is associated with an increased risk of autoreactivity, the present study investigates, whether the generation of autoantibodies to ADAMTS13 contributes to this finding. In this observational prospective controlled multicenter study blood samples and clinical data of patients hospitalized for COVID-19 were collected from April to November 2020. The study included 156 individuals with 90 patients having confirmed COVID-19 of mild to critical severity. 30 healthy individuals and 36 critically ill ICU patients without COVID-19 served as controls. ADAMTS13 antibodies occurred in 31 (34.4%) COVID-19 patients. Antibodies occurred more often in critically ill COVID-19 patients (55.9%) than non-COVID-19 ICU patients and healthy controls (5.6% and 6.7%; p < 0.001), respectively. Generation of ADAMTS13 antibodies in COVID-19 was associated with lower ADAMTS13 activity (56.5%, interquartile range (IQR) 21.25 vs. 71.5%, IQR 24.25, p = 0.0041), increased disease severity (severe or critical in 90% vs. 62.3%, p = 0.019), and a trend to higher mortality (35.5% vs. 18.6%, p = 0.077). Median time to antibody development was 11 days after first positive SARS-CoV-2-PCR specimen. Gel analysis of VWF multimers resembled the constellation in patients with TTP. The present study demonstrates for the first time, that generation of ADAMTS13 antibodies is frequent in COVID-19, associated with lower ADAMTS13 activity and increased risk of an adverse disease course. These findings provide a rationale to include ADAMTS13 antibodies in the diagnostic workup of SARS-CoV-2 infections.
Collapse
Affiliation(s)
- Adrian A N Doevelaar
- Medical Department 1, University Hospital Marien Hospital Herne, Ruhr-University Bochum, Hölkeskampring 40, 44625, Herne, Germany
| | - Martin Bachmann
- Department of Intensive Care and Ventilatory Medicine, Asklepios Klinikum Hamburg Harburg, Hamburg, Germany
| | - Bodo Hölzer
- Medical Department 1, University Hospital Marien Hospital Herne, Ruhr-University Bochum, Hölkeskampring 40, 44625, Herne, Germany
| | - Felix S Seibert
- Medical Department 1, University Hospital Marien Hospital Herne, Ruhr-University Bochum, Hölkeskampring 40, 44625, Herne, Germany
| | - Benjamin J Rohn
- Medical Department 1, University Hospital Marien Hospital Herne, Ruhr-University Bochum, Hölkeskampring 40, 44625, Herne, Germany
| | - Panagiota Zgoura
- Medical Department 1, University Hospital Marien Hospital Herne, Ruhr-University Bochum, Hölkeskampring 40, 44625, Herne, Germany
| | - Oliver Witzke
- Department of Infectiology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Ulf Dittmer
- Institute for Virology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Thorsten Brenner
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Krystallenia Paniskaki
- Department of Infectiology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- Center for Translational Medicine, University Hospital Marien Hospital Herne, Ruhr-University Bochum, Herne, Germany
| | - Serap Yilmaz
- Department of Intensive Care and Ventilatory Medicine, Asklepios Klinikum Hamburg Harburg, Hamburg, Germany
| | - Rita Dittmer
- Department of Hemostaseology, MEDILYS Laborgesellschaft mbH, Hamburg, Germany
| | - Sonja Schneppenheim
- Department of Hemostaseology, MEDILYS Laborgesellschaft mbH, Hamburg, Germany
| | - Jochen Wilhelm
- Department of Hemostaseology, MEDILYS Laborgesellschaft mbH, Hamburg, Germany
| | - Ulrik Stervbo
- Center for Translational Medicine, University Hospital Marien Hospital Herne, Ruhr-University Bochum, Herne, Germany
| | - Nina Babel
- Center for Translational Medicine, University Hospital Marien Hospital Herne, Ruhr-University Bochum, Herne, Germany
| | - Ulrich Budde
- Department of Hemostaseology, MEDILYS Laborgesellschaft mbH, Hamburg, Germany
| | - Timm H Westhoff
- Medical Department 1, University Hospital Marien Hospital Herne, Ruhr-University Bochum, Hölkeskampring 40, 44625, Herne, Germany.
| |
Collapse
|
4
|
Perioperative diagnosis and impact of acquired von Willebrand syndrome in infants with congenital heart disease. Blood 2023; 141:102-110. [PMID: 36054926 DOI: 10.1182/blood.2022015699] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 07/06/2022] [Accepted: 08/11/2022] [Indexed: 01/28/2023] Open
Abstract
Acquired von Willebrand syndrome (aVWS) has been reported in patients with congenital heart diseases associated with shear stress caused by significant blood flow gradients. Its etiology and impact on intraoperative bleeding during pediatric cardiac surgery have not been systematically studied. This single-center, prospective, observational study investigated appropriate diagnostic tools of aVWS compared with multimer analysis as diagnostic criterion standard and aimed to clarify the role of aVWS in intraoperative hemorrhage. A total of 65 newborns and infants aged 0 to 12 months scheduled for cardiac surgery at our tertiary referral center from March 2018 to July 2019 were included in the analysis. The glycoprotein Ib M assay (GPIbM)/von Willebrand factor antigen (VWF:Ag) ratio provided the best predictability of aVWS (area under the receiver operating characteristic curve [AUC], 0.81 [95% CI, 0.75-0.86]), followed by VWF collagen binding assay/VWF:Ag ratio (AUC, 0.70 [0.63-0.77]) and peak systolic echocardiographic gradients (AUC, 0.69 [0.62-0.76]). A cutoff value of 0.83 was proposed for the GPIbM/VWF:Ag ratio. Intraoperative high-molecular-weight multimer ratios were inversely correlated with cardiopulmonary bypass (CPB) time (r = -0.57) and aortic cross-clamp time (r = -0.54). Patients with intraoperative aVWS received significantly more fresh frozen plasma (P = .016) and fibrinogen concentrate (P = .011) than those without. The amounts of other administered blood components and chest closure times did not differ significantly. CPB appears to trigger aVWS in pediatric cardiac surgery. The GPIbM/VWF:Ag ratio is a reliable test that can be included in routine intraoperative laboratory workup. Our data provide the basis for further studies in larger patient cohorts to achieve definitive clarification of the effects of aVWS and its potential treatment on intraoperative bleeding.
Collapse
|
5
|
Gritsch H, Schrenk G, Weinhappl N, Mellgård B, Ewenstein B, Turecek PL. Structure and Function of Recombinant versus Plasma-Derived von Willebrand Factor and Impact on Multimer Pharmacokinetics in von Willebrand Disease. J Blood Med 2022; 13:649-662. [PMID: 36405429 PMCID: PMC9673800 DOI: 10.2147/jbm.s377126] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 11/03/2022] [Indexed: 11/07/2023] Open
Abstract
BACKGROUND Recombinant von Willebrand factor (rVWF, vonicog alfa) is a purified VWF concentrate produced from Chinese hamster ovary cells. rVWF is not exposed to the VWF-cleaving protease ADAMTS13 and so is not subject to proteolytic degradation of large (L) and ultra-large (UL) VWF multimers by that enzyme. PURPOSE To compare the structure and function of rVWF with the human plasma-derived VWF [pdVWF] concentrates Haemate P®/Humate-P®, Voncento®, Wilate®/Eqwilate®, and Wilfactin®/Willfact®; to investigate the relationship between VWF multimeric pattern and VWF:ristocetin cofactor (VWF:RCo) activity through population pharmacokinetic (PK) modeling in patients with severe von Willebrand disease (VWD) treated with rVWF. METHODS Analyses included VWF:RCo activity, VWF:collagen-binding activity, VWF:platelet glycoprotein Ib receptor binding, factor VIII (FVIII) binding capacity, and VWF-mediated platelet adhesion under flow conditions. VWF multimeric structure was determined by agarose gel electrophoresis. Population PK models describing the activity-time profile of small, medium, and L/UL multimers following intravenous administration of rVWF in patients with severe VWD were developed. RESULTS Findings demonstrate that rVWF contains a non-degraded VWF multimer pattern including the UL multimers not present in pdVWF concentrates. rVWF displayed higher specific platelet-binding activity, and faster mediation of platelet adhesion to collagen under shear stress versus pdVWF concentrates. rVWF also demonstrated higher FVIII binding capacity than Haemate P®, Voncento® and Wilate®. Modeling provided evidence that VWF:RCo activity in patients with severe VWD treated with rVWF is associated with L/UL VWF multimers in the circulation. CONCLUSIONS Findings suggest that the L and UL multimers preserved in rVWF contribute to high biological activity and might be important for providing hemostatic efficacy.
Collapse
Affiliation(s)
- Herbert Gritsch
- Pharmaceutical Sciences, Baxalta Innovations GmbH, a Takeda Company, Vienna, Austria
| | - Gerald Schrenk
- Pharmaceutical Sciences, Baxalta Innovations GmbH, a Takeda Company, Vienna, Austria
| | - Nina Weinhappl
- Pharmaceutical Sciences, Baxalta Innovations GmbH, a Takeda Company, Vienna, Austria
| | - Björn Mellgård
- Rare Genetics and Hematology, Research & Development, Takeda Development Center Americas, Inc, Cambridge, MA, USA
| | - Bruce Ewenstein
- Rare Genetics and Hematology, Research & Development, Takeda Development Center Americas, Inc, Cambridge, MA, USA
| | - Peter L Turecek
- Department of Pharmaceutical Sciences, Division of Pharmacology, University of Vienna, Vienna, Austria
- Plasma Derived Therapies, Research & Development, Baxalta Innovations GmbH, a Takeda Company, Vienna, Austria
| |
Collapse
|
6
|
Sandoval‐Pérez A, Mejía‐Restrepo V, Aponte‐Santamaría C. Thermodynamic stabilization of von Willebrand factor
A1
domain induces protein loss of function. Proteins 2022; 90:2058-2066. [DOI: 10.1002/prot.26397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 06/24/2022] [Accepted: 06/30/2022] [Indexed: 11/10/2022]
Affiliation(s)
- Angélica Sandoval‐Pérez
- Max Planck Tandem Group in Computational Biophysics Universidad de Los Andes Bogotá Colombia
| | | | | |
Collapse
|
7
|
Importance of Genotyping in von Willebrand Disease to Elucidate Pathogenic Mechanisms and Variability in Phenotype. Hemasphere 2022; 6:e718. [PMID: 35747851 PMCID: PMC9208869 DOI: 10.1097/hs9.0000000000000718] [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] [Received: 11/19/2021] [Accepted: 03/24/2022] [Indexed: 11/26/2022] Open
Abstract
Genotyping is not routinely performed at diagnosis of von Willebrand disease (VWD). Therefore, the association between genetic variants and pathogenic mechanism or the clinical and laboratory phenotype is unknown in most patients, especially in type 1 VWD. To investigate whether genotyping adds to a better understanding of the pathogenic mechanisms and variability in phenotype, we analyzed the VWF gene in 390 well-defined VWD patients, included in the WiN study. A VWF gene variant was found in 155 patients (61.5%) with type 1, 122 patients (98.4%) with type 2, and 14 patients (100%) with type 3 VWD. Forty-eight variants were novel. For each VWF gene variant, the pathogenic mechanisms associated with reduced VWF levels was investigated using the FVIII:C/VWF:Ag and VWFpp/VWF:Ag ratios. In type 1 VWD, reduced synthesis or secretion of VWF was most frequently found in patients with nonsense variants, frameshift variants, and deletions, whereas rapid clearance of VWF was mainly found in patients with missense variants. Furthermore, type 1 VWD patients with and without a VWF gene variant were clearly distinct in their clinical features such as age of diagnosis, laboratory phenotype, and bleeding phenotype. In type 2 VWD, 81% of variants were associated with an increased clearance of VWF. To conclude, we identified the pathogenic mechanisms associated with various VWF gene variants in type 1, 2, and 3 VWD patients. Additionally, major differences in the phenotype of type 1 VWD patients with and without a variant were observed, which may be of importance for clinical management.
Collapse
|
8
|
Icheva V, Budde U, Magunia H, Jaschonek K, Hinterleitner C, Neunhoeffer F, Schlensak C, Hofbeck M, Wiegand G. Acquired von Willebrand syndrome is common in infants with systemic-to-pulmonary shunts: Retrospective case-series. Front Pediatr 2022; 10:1040128. [PMID: 36568413 PMCID: PMC9768211 DOI: 10.3389/fped.2022.1040128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 11/21/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Although acquired von Willebrand syndrome (aVWS) has been described in congenital heart disease before, anatomical features leading to aVWS with characteristic reduction or loss of high molecular weight von Willebrand multimers (HMWM) are not well known. This study assesses the prevalence and effects of aVWS in infants with systemic-to-pulmonary shunts (SPS). METHODS This retrospective single-center study analyzes diagnostic data of infants with complex congenital heart defects requiring palliation with SPS. During the study period between 12/15-01/17 fifteen consecutive patients were eligible for analysis. Results of von Willebrand factor antigen (VWF:Ag), collagen binding activity (VWF:CB) and von Willebrand factor multimer analysis were included. RESULTS In all 15 patients with SPS an aVWS could be found. Blood samples were collected between 5 and 257 days after shunt implantation (median 64 days). None of the patients demonstrated increased bleeding in everyday life. However, 6 out of 15 patients (40%) showed postoperative bleeding complications after SPS implantation. Following shunt excision multimeric pattern normalized in 8 of 10 (80%) patients studied. CONCLUSIONS This study shows that in patients undergoing SPS implantation aVWS might emerge. Pathogenesis can be explained by shear stress resulting from turbulent flow within the shunt. Knowledge of aVWS existence is important for the consideration of replacement therapy with von Willebrand factor containing products and antifibrinolytic treatment in bleeding situations. Implementation of methods for rapid aVWS detection is required to achieve differentiated hemostatic therapy and reduce the risk of complications caused by empiric replacement therapy.
Collapse
Affiliation(s)
- Vanya Icheva
- Department of Pediatric Cardiology and Intensive Care Medicine, University Children's Hospital Tübingen, Tübingen, Germany
| | | | - Harry Magunia
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Tübingen, Tübingen, Germany
| | - Karl Jaschonek
- Department of Hematology, Oncology, Clinical Immunology and Rheumatology (Internal Medicine II), University Hospital Tübingen, Tübingen, Germany
| | - Clemens Hinterleitner
- Department of Medical Oncology and Pneumology (Internal Medicine VIII), University Hospital Tübingen, Tübingen, Germany
| | - Felix Neunhoeffer
- Department of Pediatric Cardiology and Intensive Care Medicine, University Children's Hospital Tübingen, Tübingen, Germany
| | - Christian Schlensak
- Department of Thoracic and Cardiovascular Surgery, University Hospital Tübingen, Tübingen, Germany
| | - Michael Hofbeck
- Department of Pediatric Cardiology and Intensive Care Medicine, University Children's Hospital Tübingen, Tübingen, Germany
| | - Gesa Wiegand
- Department of Pediatric Cardiology and Intensive Care Medicine, University Children's Hospital Tübingen, Tübingen, Germany
| |
Collapse
|
9
|
Häußler KS, Keese M, Weber CF, Geisen C, Miesbach W. Prospective Evaluation of the Pre-, Intra-, and Postoperative Kinetics of ADAMTS-13, von Willebrand Factor, and Interleukin-6 in Vascular Surgery. Clin Appl Thromb Hemost 2021; 26:1076029620930273. [PMID: 33023308 PMCID: PMC7545751 DOI: 10.1177/1076029620930273] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Postoperative thrombotic thrombocytopenic purpura (TTP) shows clinical presentation similar to classical TTP, whereas exact pathophysiological contexts remain unexplained. In this study, we investigated intraoperative and postoperative changes in ADAMTS-13 (a disintegrin and metalloprotease with thrombospondin type 1 motifs, member 13), von Willebrand factor (VWF), large VWF multimers, and interleukin-6 (IL-6) in vascular surgery patients. The objective was to compare the impact of endovascular, peripheral, and aortic surgery on target parameters which are supposed to play a role in surgery-associated TTP. A total of 93 vascular surgery patients were included and divided into 4 groups according to the specific type of intervention they underwent. Blood samples were taken preoperatively, intraoperatively, and postoperatively on days 2 and 4. The ADAMTS-13 activity decreased significantly in 3 of the 4 groups during surgery (from median 81% to 49%, P < .001, in the group undergoing aortoiliacal interventions), whereas the percentage of large VWF multimers increased in all groups of patients. von Willebrand factor antigen increased significantly in all groups on postoperative day 2 and IL-6 increased significantly in the intraoperative and early postoperative period. There was no significant correlation between the intraoperative decrease in ADAMTS-13 and the increase in VWF or IL-6. No patient in this study showed clinical picture of TTP; the precise cause and clinical significance of moderately reduced ADAMTS-13 activity in the perioperative setting have not yet been definitely determined.
Collapse
Affiliation(s)
- Katja Susanne Häußler
- University Hospital Frankfurt, Medical Clinic II, Institute of Transfusion Medicine and Immunohematology, Hemophilia Center, Frankfurt, Germany
| | - Michael Keese
- Department for Vascular Surgery, University Hospital Mannheim, Mannheim, Germany
| | - Christian Friedrich Weber
- Department for Anesthesiology, Intensive Care Medicine and Emergency Medicine, Asklepios Klinik Wandsbek, Hamburg, Germany
| | - Christof Geisen
- German Red Cross Blood Center Frankfurt am Main, Institute of Transfusion Medicine and Immunohematology, Frankfurt, Germany
| | - Wolfgang Miesbach
- University Hospital Frankfurt, Medical Clinic II, Institute of Transfusion Medicine and Immunohematology, Hemophilia Center, Frankfurt, Germany
| |
Collapse
|
10
|
Characterization of large in-frame von Willebrand factor deletions highlights differing pathogenic mechanisms. Blood Adv 2021; 4:2979-2990. [PMID: 32609846 DOI: 10.1182/bloodadvances.2018027813] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 05/02/2020] [Indexed: 11/20/2022] Open
Abstract
Copy number variation (CNV) is known to cause all von Willebrand disease (VWD) types, although the associated pathogenic mechanisms involved have not been extensively studied. Notably, in-frame CNV provides a unique opportunity to investigate how specific von Willebrand factor (VWF) domains influence the processing and packaging of the protein. Using multiplex ligation-dependent probe amplification, this study determined the extent to which CNV contributed to VWD in the Molecular and Clinical Markers for the Diagnosis and Management of Type 1 von Willebrand Disease cohort, highlighting in-frame deletions of exons 3, 4-5, 32-34, and 33-34. Heterozygous in vitro recombinant VWF expression demonstrated that, although deletion of exons 3, 32-34, and 33-34 all resulted in significant reductions in total VWF (P < .0001, P < .001, and P < .01, respectively), only deletion of exons 3 and 32-34 had a significant impact on VWF secretion (P < .0001). High-resolution microscopy of heterozygous and homozygous deletions confirmed these observations, indicating that deletion of exons 3 and 32-34 severely impaired pseudo-Weibel-Palade body (WPB) formation, whereas deletion of exons 33-34 did not, with this variant still exhibiting pseudo-WPB formation similar to wild-type VWF. In-frame deletions in VWD, therefore, contribute to pathogenesis via moderate or severe defects in VWF biosynthesis and secretion.
Collapse
|
11
|
Doevelaar AAN, Bachmann M, Hölzer B, Seibert FS, Rohn BJ, Bauer F, Witzke O, Dittmer U, Bachmann M, Yilmaz S, Dittmer R, Schneppenheim S, Babel N, Budde U, Westhoff TH. von Willebrand Factor Multimer Formation Contributes to Immunothrombosis in Coronavirus Disease 2019. Crit Care Med 2021; 49:e512-e520. [PMID: 33591004 DOI: 10.1097/ccm.0000000000004918] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Prevention and therapy of immunothrombosis remain crucial challenges in the management of coronavirus disease 2019, since the underlying mechanisms are incompletely understood. We hypothesized that endothelial damage may lead to substantially increased concentrations of von Willebrand factor with subsequent relative deficiency of a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13 (ADAMTS13). DESIGN Prospective controlled cross-over trial. SETTING Blood samples of patients with confirmed coronavirus disease 2019 and healthy controls were obtained in three German hospitals and analyzed in a German hemostaseologic laboratory. PATIENTS Seventy-five patients with confirmed coronavirus disease 2019 of mild to critical severity and 30 healthy controls. MEASUREMENTS AND MAIN RESULTS von Willebrand factor antigen, ADAMTS13, and von Willebrand factor multimer formation were analyzed. von Willebrand factor antigen was 4.1 times higher in COVID-19 patients compared with healthy controls (p < 0.0001), whereas ADAMTS13 activities were not significantly different (p = 0.18). The ADAMTS13/von Willebrand factor antigen ratio was significantly lower in COVID-19 than in the control group (24.4 ± 20.5 vs 82.0 ± 30.7; p < 0.0001). Fourteen patients (18.7%) undercut a critical ratio of 10 as described in thrombotic thrombocytopenic purpura. Gel analysis of multimers resembled a thrombotic thrombocytopenic purpura pattern with loss of the largest multimers in 75% and a smeary triplet pattern in 39% of the patients. The ADAMTS13/von Willebrand factor antigen ratio decreased continuously from mild to critical disease (analysis of variance p = 0.026). Furthermore, it differed significantly between surviving patients and those who died from COVID-19 (p = 0.001) yielding an area under the curve of 0.232 in receiver operating characteristic curve curve analysis. CONCLUSION COVID-19 is associated with a substantial increase in von Willebrand factor levels, which can exceed the ADAMTS13 processing capacity resulting in the formation of large von Willebrand factor multimers indistinguishable from thrombotic thrombocytopenic purpura. The ADAMTS13/von Willebrand factor antigen ratio is an independent predictor of severity of disease and mortality. These findings provide a rationale to consider plasma exchange as a therapeutic option in COVID-19 and to include von Willebrand factor and ADAMTS13 in the diagnostic workup.
Collapse
Affiliation(s)
- Adrian A N Doevelaar
- Medical Department I, University Hospital Marien Hospital Herne, Ruhr-University Bochum, Herne, Germany
| | - Martin Bachmann
- Department of Intensive Care and Ventilatory Medicine, Asklepios Klinikum Hamburg Harburg, Hamburg, Germany
| | - Bodo Hölzer
- Medical Department I, University Hospital Marien Hospital Herne, Ruhr-University Bochum, Herne, Germany
| | - Felix S Seibert
- Medical Department I, University Hospital Marien Hospital Herne, Ruhr-University Bochum, Herne, Germany
| | - Benjamin J Rohn
- Medical Department I, University Hospital Marien Hospital Herne, Ruhr-University Bochum, Herne, Germany
| | - Frederic Bauer
- Medical Department I, University Hospital Marien Hospital Herne, Ruhr-University Bochum, Herne, Germany
| | - Oliver Witzke
- Department of Infectiology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Ulf Dittmer
- Department of Virology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Michael Bachmann
- Department of Microbiology and Molecular Genetics, Michigan State University, East Lansing, MI
| | - Serap Yilmaz
- Department of Intensive Care and Ventilatory Medicine, Asklepios Klinikum Hamburg Harburg, Hamburg, Germany
| | - Rita Dittmer
- Department of Hemostaseology, MEDILYS Laborgesellschaft mbH, Hamburg, Germany
| | - Sonja Schneppenheim
- Department of Hemostaseology, MEDILYS Laborgesellschaft mbH, Hamburg, Germany
| | - Nina Babel
- Medical Department I, University Hospital Marien Hospital Herne, Ruhr-University Bochum, Herne, Germany
| | - Ulrich Budde
- Department of Hemostaseology, MEDILYS Laborgesellschaft mbH, Hamburg, Germany
| | - Timm H Westhoff
- Medical Department I, University Hospital Marien Hospital Herne, Ruhr-University Bochum, Herne, Germany
| |
Collapse
|
12
|
Alwan F, Vendramin C, Budde U, Liesner R, Taylor A, Thomas M, Lämmle B, Scully M. Assessing thrombogenesis and treatment response in congenital thrombotic thrombocytopenic purpura. EJHAEM 2021; 2:188-195. [PMID: 35845267 PMCID: PMC9175835 DOI: 10.1002/jha2.178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 02/16/2021] [Accepted: 02/17/2021] [Indexed: 11/29/2022]
Abstract
Despite clinical remission and normal platelet counts, congenital TTP (cTTP) is associated with non‐overt symptoms. Prophylactic ADAMTS13 replacement therapy such as plasma infusion (PI) prevents acute episodes and improves symptomatology. There is no current method to investigate disease severity or monitor the impact of treatment. We utilize a dynamic high shear flow assay to further understand disease pathophysiology and determine the impact of cTTP on symptomatology and therapy, despite normal platelet counts. Whole blood, under high shear, was run over collagen‐coated channels, causing platelet adhesion to von Willebrand factor (VWF) multimers. The resulting surface coverage by platelet‐VWF thrombus was assessed. The normal range was 6–39% in 50 controls. Twenty‐two cTTP patients with normal platelet counts were evaluated. Median pre‐treatment surface coverage was 89%, and PI reduced coverage to a median of 44% (p = 0.0005). Patients taking antiplatelets had further reduced coverage when combined with PI and improved non‐overt symptoms such as headache, lethargy, and abdominal pain in 100% of patients compared to 74% with PI alone (p = 0.046). We use a dynamic assay to report increased in vitro platelet adhesion and aggregation and additionally demonstrate significantly decreased thrombi following PI, with levels in the normal range levels achieved in patients taking additional antiplatelet therapy.
Collapse
Affiliation(s)
- Ferras Alwan
- Department of Haematology University College London Hospital London UK
- Haemostasis Research Unit University College London London UK
| | - Chiara Vendramin
- Department of Haematology University College London Hospital London UK
- Haemostasis Research Unit University College London London UK
| | - Ulrich Budde
- Medilys Laboratory Coagulation Asklepios Hospital Altona Hamburg Germany
| | - Ri Liesner
- Haemophilia Comprehensive Care Centre Great Ormond Street Hospital for Children NHS Trust London UK
- NIHR Great Ormond Street Hospital Biomedical Research Centre London UK
| | - Alice Taylor
- Haemophilia Comprehensive Care Centre Great Ormond Street Hospital for Children NHS Trust London UK
| | - Mari Thomas
- Department of Haematology University College London Hospital London UK
- Department of Haematology University College London Hospital Cardiometabolic Programme‐NIHR UCLH/UCL BRC London UK
| | - Bernhard Lämmle
- Department of Hematology and Central Hematology Laboratory Inselspital Bern University Hospital University of Bern Bern Switzerland
- Center for Thrombosis and Hemostasis University Medical Center Mainz Mainz Germany
| | - Marie Scully
- Department of Haematology University College London Hospital London UK
- Department of Haematology University College London Hospital Cardiometabolic Programme‐NIHR UCLH/UCL BRC London UK
| |
Collapse
|
13
|
Von Willebrand Factor Multimer Densitometric Analysis: Validation of the Clinical Accuracy and Clinical Implications in Von Willebrand Disease. Hemasphere 2021; 5:e542. [PMID: 33623884 PMCID: PMC7892298 DOI: 10.1097/hs9.0000000000000542] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 12/16/2020] [Indexed: 11/25/2022] Open
Abstract
Von Willebrand factor (VWF) multimer analysis is important in the classification of von Willebrand disease (VWD). Current visual VWF multimer analysis is time consuming and inaccurate in detecting subtle changes in multimer patterns. Although VWF multimer densitometric analysis may be useful, the accuracy needs further investigation before it can be widely applied. In this study we aimed to validate VWF multimer densitometric analysis in a large cohort of VWD patients and to identify patient characteristics associated with densitometric outcomes. Patients were included from the Willebrand in the Netherlands (WiN) study, in which a bleeding score (BS) was obtained, and blood was drawn. For multimer analysis, citrated blood was separated on an agarose gel and visualized by Western blotting. IMAGEJ was used to generate densitometric images and medium-large VWF multimer index was calculated. We included 560 VWD patients: 328 type 1, 211 type 2, and 21 type 3 patients. Medium-large VWF multimer index performed excellent in distinguishing visually classified normal VWF multimers from reduced high-molecular-weight (HMW) multimers (area under the curve [AUC]: 0.96 [0.94-0.98], P < 0.001), normal multimers from absence of HMW multimers (AUC 1.00 [1.00-1.00], P < 0.001), and type 2A and 2B from type 2M and 2N (AUC: 0.96 [0.94-0.99], P < 0.001). Additionally, higher medium-large VWF multimer index was associated with lower BS in type 1 VWD: β = -7.6 (-13.0 to -2.1), P = 0.007, adjusted for confounders. Densitometric analysis of VWF multimers had an excellent accuracy compared with visual multimer analysis and may contribute to a better understanding of the clinical features such as the bleeding phenotype of VWD patients.
Collapse
|
14
|
DiGiandomenico S, Christopherson PA, Haberichter SL, Abshire TC, Montgomery RR, Flood VH. Laboratory variability in the diagnosis of type 2 VWD variants. J Thromb Haemost 2021; 19:131-138. [PMID: 33049112 PMCID: PMC7790985 DOI: 10.1111/jth.15129] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 09/27/2020] [Accepted: 09/29/2020] [Indexed: 12/20/2022]
Abstract
Essentials Patients with von Willebrand disease were enrolled in our study. Type 2 VWD diagnoses were based on original test results. Repeat evaluation resulted in many patients receiving a different type 2 diagnosis. Some genetic variants were particularly likely to move type 2 subcategories. ABSTRACT: Introduction Type 2 von Willebrand disease (VWD) refers to patients with a qualitative defect in von Willebrand factor. Accurate diagnosis of type 2 VWD subtypes can be challenging. Aim of the study To compare the historical diagnosis of type 2 VWD with current laboratory testing. Methods Subjects were enrolled in the Zimmerman Program either because of a preexisting diagnosis of VWD (retrospective cohort) or from evaluation for bleeding symptoms or suspected VWD (prospective cohort). Original diagnosis was assigned by the local center and central diagnosis was based on central laboratory testing. Results Two hundred and seventeen index cases in the retrospective cohort and 35 subjects in the prospective cohort carried a local diagnosis of type 2 VWD (29% and 6% of enrolled index cases, respectively). In the retrospective cohort, the diagnosis was confirmed in 66% of cases with a preexisting diagnosis of 2A, 77% 2B, 54% 2M, and 72% 2N. In the prospective cohort, 31% were confirmed 2A, 60% 2B, 23% 2M, and 100% 2N. Several genetic variants were repeatedly implicated in subjects with changed diagnosis: p.M1304R, p.R1315C, p.R1374C, and p.R1374H. Conclusions Both the prospective and retrospective cohorts demonstrated consistent variation in subjects whose diagnosis changed between 2A, 2B, and 2M. The importance of accurately diagnosing type 2 VWD may be most significant in the 2B subtype given potential concerns with the use of desmopressin in type 2B VWD. Some genetic variants appear in multiple types of VWD, making specific diagnoses challenging.
Collapse
Affiliation(s)
- Stefanie DiGiandomenico
- Department of Pediatrics, Division of Hematology/Oncology, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI 53226
| | | | - Sandra L. Haberichter
- Department of Pediatrics, Division of Hematology/Oncology, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI 53226
- Versiti Blood Research Institute, 8727 Watertown Plank Rd, Milwaukee, WI 53226
| | - Thomas C. Abshire
- Department of Pediatrics, Division of Hematology/Oncology, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI 53226
- Versiti Blood Research Institute, 8727 Watertown Plank Rd, Milwaukee, WI 53226
| | - Robert R. Montgomery
- Department of Pediatrics, Division of Hematology/Oncology, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI 53226
- Versiti Blood Research Institute, 8727 Watertown Plank Rd, Milwaukee, WI 53226
| | - Veronica H. Flood
- Department of Pediatrics, Division of Hematology/Oncology, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI 53226
- Versiti Blood Research Institute, 8727 Watertown Plank Rd, Milwaukee, WI 53226
- Children’s Research Institute, Children’s Hospital of Wisconsin, Milwaukee, WI 53226
| | | |
Collapse
|
15
|
Hennessy-Strahs S, Bermudez CA, Acker MA, Bartoli CR. Toward a Standard Practice to Quantify von Willebrand Factor Degradation During Left Ventricular Assist Device Support. Ann Thorac Surg 2020; 112:1257-1264. [PMID: 33227272 DOI: 10.1016/j.athoracsur.2020.09.039] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 08/24/2020] [Accepted: 09/20/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Continuous-flow left ventricular assist devices (LVADs) cause degradation of von Willebrand factor (VWF) multimers and bleeding. Multiple techniques exist to characterize VWF deficiency. However, a standard methodology has not been established in LVAD patients. Toward this goal, we evaluated 4 methods to quantify VWF multimers. METHODS We collected paired blood samples from patients (n = 48) before and after 1 week of LVAD support. After 652 ± 59 days of support, patients were classified as bleeders (≥1 bleeding episode) or nonbleeders. VWF multimers were resolved with electrophoresis and immunoblotting, the gold-standard to evaluate VWF multimers. We evaluated 4 quantification methods. RESULTS Each method demonstrated significant VWF degradation during LVAD support vs a paired, pre-LVAD sample (method 1, VWF length: 48 of 48 patients, -10% ± 1%, P < .0001; method 2, VWF density: 40 of 48, -34% (interquartile range, -46% to -8%), P < .0001; method 3, pre-LVAD to LVAD ratio: 46 of 48, 17 ± 5: 10 ± 1, P < .0001; method 4, LVAD/pre-LVAD index: 46 of 48, 57% (interquartile range, 50% to 73%), P < .0001). Bleeding occurred in 27 of 48 patients. Method 1 demonstrated significantly fewer VWF multimers in bleeders compared with nonbleeders (-11% ± 1% vs -8% ± 1%; P = .01). Other methods did not demonstrate this potentially important clinical relationship. CONCLUSIONS A standardized methodology is needed to quantify VWF multimer degradation with mechanical circulatory support devices. Novel method 1 successfully quantified the patient-specific change in VWF multimer length during LVAD support and demonstrated a difference in VWF multimers between bleeders and nonbleeders. Adoption of consensus methodology will assist to standardize patient-specific bleeding risk, inform anticoagulation and antiplatelet therapy, and evaluate LVAD hemocompatibility.
Collapse
Affiliation(s)
- Samson Hennessy-Strahs
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christian A Bermudez
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael A Acker
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Carlo R Bartoli
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
| |
Collapse
|
16
|
Bortot M, Sharifi A, Ashworth K, Walker F, Cox A, Ruegg K, Clendenen N, Neeves KB, Bark D, Di Paola J. Pathologic Shear and Elongation Rates Do Not Cause Cleavage of Von Willebrand Factor by ADAMTS13 in a Purified System. Cell Mol Bioeng 2020; 13:379-390. [PMID: 32952737 PMCID: PMC7479076 DOI: 10.1007/s12195-020-00631-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Accepted: 06/18/2020] [Indexed: 01/13/2023] Open
Abstract
INTRODUCTION Pathological flows in patients with severe aortic stenosis are associated with acquired von Willebrand syndrome. This syndrome is characterized by excessive cleavage of von Willebrand factor by its main protease, A Disintegrin and Metalloproteinase with a Thrombospondin Type 1 Motif, Member 13 (ADAMTS13) leading to decreased VWF function and mucocutaneous bleeding. Aortic valve replacement and correction of the flow behavior to physiological levels reverses the syndrome, supporting the association between pathological flow and acquired von Willebrand syndrome. We investigated the effects of shear and elongational rates on von Willebrand factor cleavage in the presence of ADAMTS13. METHODS We identified acquired von Willebrand syndrome in five patients with severe aortic stenosis. Doppler echography values from these patients were used to develop three computational fluid dynamic (CFD) aortic valve models (normal, mild and severe stenosis). Shear, elongational rates and exposure times identified in the CFD simulations were used as parameters for the design of microfluidic devices to test the effects of pathologic shear and elongational rates on the structure and function of von Willebrand factor. RESULTS The shear rates (0-10,000s-1), elongational rates (0-1000 s-1) and exposure times (1-180 ms) tested in our microfluidic designs mimicked the flow features identified in patients with aortic stenosis. The shear and elongational rates tested in vitro did not lead to excessive cleavage or decreased function of von Willebrand factor in the presence of the protease. CONCLUSIONS High shear and elongational rates in the presence of ADAMTS13 are not sufficient for excessive cleavage of von Willebrand Factor.
Collapse
Affiliation(s)
- Maria Bortot
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO 80045 USA
- Department of Bioengineering, University of Colorado Anschutz Medical Campus, Aurora, CO 80045 USA
| | - Alireza Sharifi
- Department of Mechanical Engineering, Colorado State University, Fort Collins, CO 80523 USA
| | - Katrina Ashworth
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO 80045 USA
| | - Faye Walker
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO 80045 USA
| | - Allaura Cox
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO 80045 USA
| | - Katherine Ruegg
- Hemophilia Center, University of Colorado Anschutz Medical Campus, Aurora, CO 80045 USA
| | - Nathan Clendenen
- Department of Anesthesiology, University of Colorado Anschutz Medical Campus, Aurora, CO 80045 USA
| | - Keith B. Neeves
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO 80045 USA
- Department of Bioengineering, University of Colorado Anschutz Medical Campus, Aurora, CO 80045 USA
| | - David Bark
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO 80045 USA
- Department of Mechanical Engineering, Colorado State University, Fort Collins, CO 80523 USA
- School of Biomedical Engineering, Colorado State University, Fort Collins, CO 80523 USA
| | - Jorge Di Paola
- Department of Pediatrics, Washington University in St. Louis, 660 S. Euclid Avenue, Campus Box 8208, 5th floor MPRB, St. Louis, MO 63110 USA
| |
Collapse
|
17
|
Favaloro EJ, Oliver S, Mohammed S, Vong R. Comparative assessment of von Willebrand factor multimers vs activity for von Willebrand disease using modern contemporary methodologies. Haemophilia 2020; 26:503-512. [PMID: 32159272 DOI: 10.1111/hae.13957] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 02/02/2020] [Accepted: 02/24/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Diagnosis of von Willebrand disease (VWD) is challenging due to heterogeneity of VWD and test limitations. Many von Willebrand factor (VWF) assays are utilized, including antigen (Ag), activity and multimer analysis. Activity assays include ristocetin cofactor using platelets (VWF:RCo) or other particles incorporating recombinant glycoprotein I ('VWF:GPIbR'), or other GPI binding assays using gain-of-function mutations ('VWF:GPIbM'), or collagen binding (VWF:CB). AIM To comparatively evaluate modern contemporary VWF activity assays vs VWF multimer analysis using modern contemporary methods. MATERIALS AND METHODS Several VWF activity assays (VWF:RCo, VWF:GPIbR, VWF:GPIbM, VWF:CB) assessed (typically as a ratio against VWF:Ag) against a new semi-automated procedure for different types of VWD (1, 3, 2A, 2B, 2M), plus control material (n = 580). The evaluation also focussed on relative loss of high and very high molecular weight multimers (HMWM and VHMWM) by densitometric scanning. RESULTS All evaluated VWF activity/Ag ratios showed high correlation to the presence/absence of HMWM and VHMWM, although VWF:CB/Ag and VWF:GPIbR/Ag ratios using an automated chemiluminescence method yielded highest correlation coefficients (r = .909 and .874, respectively, for HMWM). Use of the investigative procedure (VHMWM) identified fewer false positives for 'loss' in type 1 VWD. CONCLUSIONS This comparative investigation identified that new automated chemiluminescence VWF activity assays best identified relative loss or presence of HMWM and VHMWM according to activity to Ag ratios and an alternative investigative method for identifying VHMWM in multimer testing for a new commercial multimer method may lead to fewer false identifications of HMW loss in type 1 VWD.
Collapse
Affiliation(s)
- Emmanuel J Favaloro
- Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead Hospital, Westmead, NSW, Australia.,Sydney Centres for Thrombosis and Haemostasis, Westmead Hospital, Westmead, NSW, Australia
| | - Susan Oliver
- Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead Hospital, Westmead, NSW, Australia
| | - Soma Mohammed
- Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead Hospital, Westmead, NSW, Australia
| | - Ronny Vong
- Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead Hospital, Westmead, NSW, Australia
| |
Collapse
|
18
|
Stahl K, Schmidt JJ, Seeliger B, Schmidt BMW, Welte T, Haller H, Hoeper MM, Budde U, Bode C, David S. Effect of therapeutic plasma exchange on endothelial activation and coagulation-related parameters in septic shock. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:71. [PMID: 32122366 PMCID: PMC7053051 DOI: 10.1186/s13054-020-2799-5] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 02/18/2020] [Indexed: 01/01/2023]
Abstract
Background A dysbalanced coagulation system is part of the pathological host response to infection in sepsis. Activation of pro-coagulant pathways and attenuation of anti-coagulant activity ultimately lead to microvascular stasis and consequent organ failure. No treatment approaches specifically targeting this axis are available. We explored the effects of therapeutic plasma exchange (TPE) on microvascular coagulation dysbalance in septic shock. Methods We conducted a prospective single-center study enrolling 31 patients with early septic shock (onset < 12 h) requiring high doses of norepinephrine (NE > 0.4 μg/kg/min). Clinical and biochemical data, including measurement of protein C; a disintegrin and metalloprotease with a thrombospondin type 1 motif, member 13 (ADAMTS13); and von Willebrand factor antigen (vWF:Ag), were obtained before and after TPE against fresh frozen plasma. Results Antithrombotic acting proteins such as antithrombin-III (ATIII) and protein C were markedly reduced in septic patients, but their activity increased after TPE (ATIII, 51% (41–61) vs. 63% (48–70), p = 0.029; protein C, 47% (38–60) vs. 62% (54–69), p = 0.029). Median ADAMTS13 activity was increased by TPE from 27 (21–42) % before to 47 (38–62) % after TPE (p < 0.001). In contrast, vWF:Ag was elevated and could be reduced by TPE (353 (206–492) IU/dL vs. 170 (117–232) IU/dL, p < 0.001). Regression analysis yielded a correlation between ADAMTS13 activity and platelet count (p = 0.001, R2 = 0.316). Conclusions Septic shock was associated with activation of pro-coagulant pathways and simultaneous depletion of anti-coagulant factors. TPE partially attenuated this dysbalance by removing pro- and by replacing anti-coagulant factors. Trial registration ClinicalTrials.gov, NCT03065751. Retrospectively registered on 28 February 2017.
Collapse
Affiliation(s)
- Klaus Stahl
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Julius J Schmidt
- Department of Nephrology and Hypertension, Hannover Medical School, Carl-Neuberg-Str.1, 30625, Hannover, Germany
| | - Benjamin Seeliger
- Department of Respiratory Medicine and German Centre of Lung Research (DZL), Hannover Medical School, Hannover, Germany
| | - Bernhard M W Schmidt
- Department of Nephrology and Hypertension, Hannover Medical School, Carl-Neuberg-Str.1, 30625, Hannover, Germany
| | - Tobias Welte
- Department of Respiratory Medicine and German Centre of Lung Research (DZL), Hannover Medical School, Hannover, Germany
| | - Hermann Haller
- Department of Nephrology and Hypertension, Hannover Medical School, Carl-Neuberg-Str.1, 30625, Hannover, Germany
| | - Marius M Hoeper
- Department of Respiratory Medicine and German Centre of Lung Research (DZL), Hannover Medical School, Hannover, Germany
| | | | - Christian Bode
- Department of Anaesthesiology and Critical Care, University Medicine Bonn, Bonn, Germany
| | - Sascha David
- Department of Nephrology and Hypertension, Hannover Medical School, Carl-Neuberg-Str.1, 30625, Hannover, Germany.
| |
Collapse
|
19
|
Hinterleitner C, Pecher AC, Kreißelmeier KP, Budde U, Kanz L, Kopp HG, Jaschonek K. Disease progression and defects in primary hemostasis as major cause of bleeding in multiple myeloma. Eur J Haematol 2019; 104:26-35. [PMID: 31541609 DOI: 10.1111/ejh.13331] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 09/12/2019] [Accepted: 09/17/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND OBJECTIVES In patients with multiple myeloma (MM), unexpected bleeding complications remain a major issue. Since routine coagulation parameters are often inconspicuous, diagnosis and treatment of the underlying coagulation disorders are challenging. PATIENTS AND METHODS In our single-center observational study, we analyzed 164 patients with MM for coagulation disorders and bleeding complications. RESULTS Prolonged closure times (CTs), measured by PFA-100, were the most common, abnormal coagulation test, found in 66% of bleeding patients vs 5% in non-bleeding, followed by qualitative defects of von Willebrand factor (VWF:CB/VWF:Ag ratios), found in 34% vs 1% in the non-bleeding group. Increased serum free light chains (SFLC) and SFLC ratios were significantly associated with prolonged CTs and acquired von Willebrand syndrome (AVWS). Prolonged CTs and AVWS were associated with disease progression, determined by dynamics of SFLC ratios (P < .001), serum creatinine level (P = .013), Beta-2 microglobulin (P = .03), LDH (P = .016), and bone marrow infiltration (P < .001). Of note, response to myeloma therapy was frequently correlated with normalization of coagulation parameters. CONCLUSIONS Bleeding complications in MM are predominantly caused by defects in primary hemostasis and associated with disease progression. In a peri-interventional workup, determination of CTs and VWF:CB/VWF:Ag ratios are of significant importance to assess bleeding risk.
Collapse
Affiliation(s)
- Clemens Hinterleitner
- Department of Medical Oncology, Hematology, Immunology, Rheumatology and Pulmonology, Eberhard-Karls University, Tuebingen, Germany
| | - Ann-Christin Pecher
- Department of Medical Oncology, Hematology, Immunology, Rheumatology and Pulmonology, Eberhard-Karls University, Tuebingen, Germany
| | - Klaus-Peter Kreißelmeier
- Department of Medical Oncology, Hematology, Immunology, Rheumatology and Pulmonology, Eberhard-Karls University, Tuebingen, Germany
| | - Ulrich Budde
- Medilys Laborgesellschaft mbH, Asklepios Klinik Hamburg-Altona, Hamburg, Germany
| | - Lothar Kanz
- Department of Medical Oncology, Hematology, Immunology, Rheumatology and Pulmonology, Eberhard-Karls University, Tuebingen, Germany
| | - Hans-Georg Kopp
- Department of Medical Oncology, Hematology, Immunology, Rheumatology and Pulmonology, Eberhard-Karls University, Tuebingen, Germany
| | - Karl Jaschonek
- Department of Medical Oncology, Hematology, Immunology, Rheumatology and Pulmonology, Eberhard-Karls University, Tuebingen, Germany
| |
Collapse
|
20
|
Bortot M, Ashworth K, Sharifi A, Walker F, Crawford NC, Neeves KB, Bark D, Di Paola J. Turbulent Flow Promotes Cleavage of VWF (von Willebrand Factor) by ADAMTS13 (A Disintegrin and Metalloproteinase With a Thrombospondin Type-1 Motif, Member 13). Arterioscler Thromb Vasc Biol 2019; 39:1831-1842. [DOI: 10.1161/atvbaha.119.312814] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Objective—
Acquired von Willebrand syndrome is defined by excessive cleavage of the VWF (von Willebrand Factor) and is associated with impaired primary hemostasis and severe bleeding. It often develops when blood is exposed to nonphysiological flow such as in aortic stenosis or mechanical circulatory support. We evaluated the role of laminar, transitional, and turbulent flow on VWF cleavage and the effects on VWF function.
Approach and Results—
We used a vane rheometer to generate laminar, transitional, and turbulent flow and evaluate the effect of each on VWF cleavage in the presence of ADAMTS13 (a disintegrin and metalloproteinase with a thrombospondin type-1 motif, member 13). We performed functional assays to evaluate the effect of these flows on VWF structure and function. Computational fluid dynamics was used to estimate the flow fields and forces within the vane rheometer under each flow condition. Turbulent flow is required for excessive cleavage of VWF in an ADAMTS13-dependent manner. The assay was repeated with whole blood, and the turbulent flow had the same effect. Our computational fluid dynamics results show that under turbulent conditions, the Kolmogorov scale approaches the size of VWF. Finally, cleavage of VWF in this study has functional consequences under flow as the resulting VWF has decreased ability to bind platelets and collagen.
Conclusions—
Turbulent flow mediates VWF cleavage in the presence of ADAMTS13, decreasing the ability of VWF to sustain platelet adhesion. These findings impact the design of mechanical circulatory support devices and are relevant to pathological environments where turbulence is added to circulation.
Collapse
Affiliation(s)
- Maria Bortot
- From the Department of Pediatrics (M.B., K.A., F.W., K.B.N., D.B., J.D.P.), University of Colorado Anschutz Medical Campus, Aurora
- Department of Bioengineering (M.B., K.B.N.), University of Colorado Anschutz Medical Campus, Aurora
| | - Katrina Ashworth
- From the Department of Pediatrics (M.B., K.A., F.W., K.B.N., D.B., J.D.P.), University of Colorado Anschutz Medical Campus, Aurora
| | - Alireza Sharifi
- Department of Mechanical Engineering (A.S., D.B.), Colorado State University, Fort Collins
| | - Faye Walker
- From the Department of Pediatrics (M.B., K.A., F.W., K.B.N., D.B., J.D.P.), University of Colorado Anschutz Medical Campus, Aurora
| | - Nathan C. Crawford
- Department of Material Characterization, Thermo Fisher Scientific, Madison, WI (N.C.C.)
| | - Keith B. Neeves
- From the Department of Pediatrics (M.B., K.A., F.W., K.B.N., D.B., J.D.P.), University of Colorado Anschutz Medical Campus, Aurora
- Department of Bioengineering (M.B., K.B.N.), University of Colorado Anschutz Medical Campus, Aurora
| | - David Bark
- From the Department of Pediatrics (M.B., K.A., F.W., K.B.N., D.B., J.D.P.), University of Colorado Anschutz Medical Campus, Aurora
- Department of Mechanical Engineering (A.S., D.B.), Colorado State University, Fort Collins
- School of Biomedical Engineering (D.B.), Colorado State University, Fort Collins
| | - Jorge Di Paola
- From the Department of Pediatrics (M.B., K.A., F.W., K.B.N., D.B., J.D.P.), University of Colorado Anschutz Medical Campus, Aurora
| |
Collapse
|
21
|
Advancing multimer analysis of von Willebrand factor by single-molecule AFM imaging. PLoS One 2019; 14:e0210963. [PMID: 30645640 PMCID: PMC6333368 DOI: 10.1371/journal.pone.0210963] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2018] [Accepted: 01/06/2019] [Indexed: 11/19/2022] Open
Abstract
The formation of hemostatic plugs at sites of vascular injury crucially involves the multimeric glycoprotein von Willebrand factor (VWF). VWF multimers are linear chains of N-terminally linked dimers. The latter are formed from monomers via formation of the C-terminal disulfide bonds Cys2771-Cys2773', Cys2773-Cys2771', and Cys2811-Cys2811'. Mutations in VWF that impair multimerization can lead to subtype 2A of the bleeding disorder von Willebrand Disease (VWD). Commonly, the multimer size distribution of VWF is assessed by electrophoretic multimer analysis. Here, we present atomic force microscopy (AFM) imaging as a method to determine the size distribution of VWF variants by direct visualization at the single-molecule level. We first validated our approach by investigating recombinant wildtype VWF and a previously studied mutant (p.Cys1099Tyr) that impairs N-terminal multimerization. We obtained excellent quantitative agreement with results from earlier studies and with electrophoretic multimer analysis. We then imaged specific mutants that are known to exhibit disturbed C-terminal dimerization. For the mutants p.Cys2771Arg and p.Cys2773Arg, we found the majority of monomers (87 ± 5% and 73 ± 4%, respectively) not to be C-terminally dimerized. While these results confirm that Cys2771 and Cys2773 are crucial for dimerization, they additionally provide quantitative information on the mutants' different abilities to form alternative C-terminal disulfides for residual dimerization. We further mutated Cys2811 to Ala and found that only 23 ± 3% of monomers are not C-terminally dimerized, indicating that Cys2811 is structurally less important for dimerization. Furthermore, for mutants p.Cys2771Arg, p.Cys2773Arg, and p.Cys2811Ala we found 'even-numbered' non-native multimers, i.e. multimers with monomers attached on both termini; a multimer species that cannot be distinguished from native multimers by conventional multimer analysis. Summarizing, we demonstrate that AFM imaging can provide unique insights into VWF processing defects at the single-molecule level that cannot be gained from established methods of multimer analysis.
Collapse
|
22
|
Di Pasquale I, Budde U, Tona F, Bertomoro A, Lombardi AM, Famoso G, Bertozzi I, Dittmer R, Schneppenheim S, Fabris F. Link between von Willebrand factor multimers, relapses and coronary microcirculation in patients with thrombotic thrombocytopenic purpura in remission. Thromb Res 2019; 173:42-47. [DOI: 10.1016/j.thromres.2018.11.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 10/18/2018] [Accepted: 11/05/2018] [Indexed: 01/06/2023]
|
23
|
Icheva V, Nowak-Machen M, Budde U, Jaschonek K, Neunhoeffer F, Kumpf M, Hofbeck M, Schlensak C, Wiegand G. Acquired von Willebrand syndrome in congenital heart disease surgery: results from an observational case-series. J Thromb Haemost 2018; 16:2150-2158. [PMID: 29908036 DOI: 10.1111/jth.14208] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Indexed: 12/18/2022]
Abstract
Essentials Bleeding complications during congenital heart disease surgery in neonatal age are very common. We report the perioperative incidence of acquired von Willebrand syndrome (aVWS) in 12 infants. aVWS was detected in 8 out of 12 neonates and infants intraoperatively after cardiopulmonary bypass. Ten patients received von Willebrand factor concentrate intraoperatively and tolerated it well. SUMMARY: Background Cardiac surgery of the newborn and infant with complex congenital heart disease (CHD) is associated with a high rate of intraoperative bleeding complications. CHD-related anatomic features such as valve stenoses or patent arterial ducts can lead to enhanced shear stress in the blood stream and thus cause acquired von Willebrand syndrome (aVWS). Objective To evaluate the intraoperative incidence and impact of aVWS after cardiopulmonary bypass (CPB) in neonates and infants with complex CHD. Patients/Methods We conducted a survey of patients aged < 12 months undergoing complex cardiac surgery in our tertiary referral center. Twelve patients, whose blood samples were analyzed for aVWS before CPB and immediately after discontinuation of CPB on a routine basis, were eligible for the analysis. von Willebrand factor antigen (VWF:Ag), ristocetin cofactor activity (VWF:RCo), collagen binding activity (VWF:CB), VWF:multimers and factor VIII activity (FVIII:C) were determined. Results aVWS was diagnosed by VWF multimer analysis in 10 out of 12 patients (83%) prior to surgery and intraoperatively at the end of CPB in 8 out of 12 patients (66%). Ten patients received VWF/FVIII concentrate intraoperatively as individual treatment attempts during uncontrolled bleeding. They tolerated it well without intraoperative thrombotic events. One patient suffered a transient postoperative cerebral sinuous vein thrombosis. Conclusions aVWS is of underestimated incidence in complex CHD surgery. These data may offer a new approach to reduce the risk of severe bleedings and to achieve hemostasis during high-risk pediatric cardiac surgery by tailoring the substitution with von Willebrand factor concentrate.
Collapse
Affiliation(s)
- V Icheva
- Department of Pediatric Cardiology and Intensive Care Medicine, University Children's Hospital Tübingen, Tuebingen, Germany
| | - M Nowak-Machen
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Tübingen, Tuebingen, Germany
| | - U Budde
- cMEDILYS Coagulation Laboratory mbH, Asklepios Clinic, Hamburg, Germany
| | - K Jaschonek
- Department of Internal Medicine, University Hospital Tübingen, Tuebingen, Germany
| | - F Neunhoeffer
- Department of Pediatric Cardiology and Intensive Care Medicine, University Children's Hospital Tübingen, Tuebingen, Germany
| | - M Kumpf
- Department of Pediatric Cardiology and Intensive Care Medicine, University Children's Hospital Tübingen, Tuebingen, Germany
| | - M Hofbeck
- Department of Pediatric Cardiology and Intensive Care Medicine, University Children's Hospital Tübingen, Tuebingen, Germany
| | - C Schlensak
- Department of Thoracic and Cardiovascular Surgery, University Hospital Tübingen, Tuebingen, Germany
| | - G Wiegand
- Department of Pediatric Cardiology and Intensive Care Medicine, University Children's Hospital Tübingen, Tuebingen, Germany
| |
Collapse
|
24
|
Leebeek FWG, Susen S. Von Willebrand disease: Clinical conundrums. Haemophilia 2018; 24 Suppl 6:37-43. [PMID: 29878657 DOI: 10.1111/hae.13508] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/02/2018] [Indexed: 12/22/2022]
Affiliation(s)
- F W G Leebeek
- Department of Hematology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - S Susen
- Inserm, U1011, Hemostasis and Transfusion Department, French Reference Center for Von Willebrand Disease, CHU Lille, Lille, France
| |
Collapse
|
25
|
Bowyer AE, Goodfellow KJ, Seidel H, Westhofen P, Stufano F, Goodeve A, Kitchen S, Makris M. Evaluation of a semi-automated von Willebrand factor multimer assay, the Hydragel 5 von Willebrand multimer, by two European Centers. Res Pract Thromb Haemost 2018; 2:790-799. [PMID: 30349898 PMCID: PMC6178608 DOI: 10.1002/rth2.12141] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Accepted: 06/14/2018] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND The phenotypic diagnosis of von Willebrand disease (VWD) is a multistep process with classification dependent on the quantification of von Willebrand factor (VWF) multimeric structure. VWF multimer analysis is a technically challenging, lengthy and non-standardised assay, usually performed in specialist laboratories. Recently, a new semi-automated multimer assay, the Hydragel 5 von Willebrand multimers (H5VWM) has become available. OBJECTIVES This study, performed in two European centres, compared existing in-house multimer assays to the H5VWM in individuals with and without VWD. RESULTS Overall agreement of 91.1% was observed in 74 individuals with normal VWF levels, 57 patients grouped as type 1 VWD, 33 type 2A, 16 type 2B, 28 type 2M, 11 type 2N. Patients tested following Desmopressin or VWF concentrate, with thrombotic thrombocytopenic purpura and acquired von Willebrand syndrome were also evaluated. Many of the discrepancies between methods were in patients with genetic mutations linked to more than one type of VWD including p.R1374C/H and p.R1315C. Quantifiable multimer results were available within one working day. Densitometry improved the interpretation of the multimers with slight structural variations that were not apparent by visual inspection of the in-house method. CONCLUSIONS 5VWM was a rapid, sensitive, standardised assay which used existing technology and could be included as an initial screen of VWF multimers in a VWD diagnostic algorithm in conjunction with traditional multimer analysis.
Collapse
Affiliation(s)
- Annette E. Bowyer
- Department of CoagulationSheffield Haemophilia and Thrombosis CentreSheffieldUK
| | - Karen J. Goodfellow
- Department of CoagulationSheffield Haemophilia and Thrombosis CentreSheffieldUK
| | - Holger Seidel
- Centrum für Blutgerinnungsstörungen und TransfusionsmedizinBonnGermany
| | - Philipp Westhofen
- Centrum für Blutgerinnungsstörungen und TransfusionsmedizinBonnGermany
| | - Francesca Stufano
- Angelo Bianchi Bonomi Hemophilia and Thrombosis CenterFondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico and Luigi Villa FoundationMilanItaly
| | - Anne Goodeve
- Department of Infection, Immunity and Cardiovascular DiseaseUniversity of Sheffield Medical SchoolSheffieldUK
| | - Stephen Kitchen
- Angelo Bianchi Bonomi Hemophilia and Thrombosis CenterFondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico and Luigi Villa FoundationMilanItaly
| | - Michael Makris
- Department of CoagulationSheffield Haemophilia and Thrombosis CentreSheffieldUK
| |
Collapse
|
26
|
Vangenechten I, Mayger K, Smejkal P, Zapletal O, Michiels JJ, Moore GW, Gadisseur A. A comparative analysis of different automated von Willebrand factor glycoprotein Ib-binding activity assays in well typed von Willebrand disease patients. J Thromb Haemost 2018; 16:1268-1277. [PMID: 29742318 DOI: 10.1111/jth.14145] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Indexed: 12/13/2022]
Abstract
Essentials Von Willebrand ristocetin cofactor activity (VWF:RCo) is not a completely reliable assay. Three automated VWF activity assays were compared within a von Willebrand disease (VWD) cohort. Raw values for all three assays were virtually the same. An overall problem within type 2A/IIE VWD using VWF:GPIb-binding activity/VWF:Ag was observed. SUMMARY Background von Willebrand disease (VWD) is an inherited bleeding disorder caused by quantitative (type 1 and 3) or qualitative (type 2) von Willebrand factor (VWF) defect. VWD diagnosis and classification require numerous laboratory tests. VWF: glycoprotein Ib (GPIb)-binding activity assays are used to distinguish type 1 from type 2 VWD. Objectives Three different automated VWF:GPIb-binding activity assays were compared. Patients and methods BC-VWF:RCo (Siemens Healthcare Diagnostics), HemosIL® VWF:RCo (Instrumentation Laboratory) and INNOVANCE® VWF:Ac (Siemens Healthcare Diagnostics) were performed in a well typed VWD cohort (n = 142). Results Based on the three most used VWD parameters (FVIII:C, VWF:Ag and VWF:GPIb-binding activity) and using a cut-off of <0.70 for type 2 VWD revealed sensitivity and specificity of, respectively, 92% and 72.4% for VWF:RCo/VWF:Ag, 84% and 89.7% for VWF:GPIbR/VWF:Ag, and 92% and 85.1% for VWF:GPIbM/VWF:Ag, whereas a lowered cut-off of < 0.60 resulted in reduced sensitivity with increased specificity for all assays. Conclusion VWD classification based on FVIII:C, VWF:Ag and VWF:GPIb-binding activity revealed an overall problem with normal VWF:GPIb-binding activity/VWF:Ag within type 2, especially type 2A/IIE. Although all assays were practically identical, BC-VWF:RCo had higher %CV compared with both new assays but comparable lower limit of quantification (LLOQ) ~4 IU dL-1 . No clear improved distinction between type 1 and 2 VWD with new assays was seen. BC-VWF RCo and HemosIL® are ristocetin dependent, whereas INNOVANCE® does not rely upon ristocetin and is not influenced by VWF polymorphisms increasing VWF:GPIb-binding activity levels. INNOVANCE® seems to be the best choice as a first-line VWF:GPIb-binding activity assay, providing the best balance between sensitivity and specificity for type 2 VWD.
Collapse
Affiliation(s)
- I Vangenechten
- Haemostasis Unit, Department of Haematology, Antwerp University Hospital, Edegem, Belgium
- Haemostasis Research Unit, Antwerp University, Antwerp, Belgium
- Blood Coagulation and Vascular Medicine Center, Goodheart Institute and Foundation in Nature Medicine, Rotterdam, the Netherlands
| | - K Mayger
- Diagnostic Haemostasis and Thrombosis Laboratory, Viapath Analytics, St Thomas' Hospital, London, UK
| | - P Smejkal
- Department of Clinical Hematology, University Hospital Brno, Brno, Czech Republic
- Department of Laboratory Methods, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - O Zapletal
- Department of Paediatric Haematology, University Hospital Brno, Brno, Czech Republic
| | - J J Michiels
- CSL Behring Chair in von Willebrand Disease, Antwerp University, Antwerp, Belgium
| | - G W Moore
- Diagnostic Haemostasis and Thrombosis Laboratory, Viapath Analytics, St Thomas' Hospital, London, UK
| | - A Gadisseur
- Haemostasis Unit, Department of Haematology, Antwerp University Hospital, Edegem, Belgium
- Haemostasis Research Unit, Antwerp University, Antwerp, Belgium
- CSL Behring Chair in von Willebrand Disease, Antwerp University, Antwerp, Belgium
| |
Collapse
|
27
|
Pérez-Rodríguez A, Batlle J, Corrales I, Borràs N, Rodríguez-Trillo Á, Lourés E, Cid AR, Bonanad S, Cabrera N, Moret A, Parra R, Mingot-Castellano ME, Navarro N, Altisent C, Pérez-Montes R, Marcellini S, Moreto A, Herrero S, Soto I, Fernández Mosteirín N, Jiménez-Yuste V, Alonso N, de Andrés Jacob A, Fontanes E, Campos R, Paloma MJ, Bermejo N, Berrueco R, Mateo J, Arribalzaga K, Marco P, Palomo Á, Castro Quismondo N, Iñigo B, Nieto MDM, Vidal R, Martínez MP, Aguinaco R, Tenorio M, Ferreiro M, García-Frade J, Rodríguez-Huerta AM, Cuesta J, Rodríguez-González R, García-Candel F, Dobón M, Aguilar C, Batlle F, Vidal F, López-Fernández MF. Role of multimeric analysis of von Willebrand factor (VWF) in von Willebrand disease (VWD) diagnosis: Lessons from the PCM-EVW-ES Spanish project. PLoS One 2018; 13:e0197876. [PMID: 29924855 PMCID: PMC6010290 DOI: 10.1371/journal.pone.0197876] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Accepted: 05/09/2018] [Indexed: 11/19/2022] Open
Abstract
The multimeric analysis (MA) of plasma von Willebrand factor (VWF) evaluates structural integrity and helps in the diagnosis of von Willebrand disease (VWD). This assay is a matter of controversy, being considered by some investigators cumbersome and only slightly informative. The centralised study ‘Molecular and Clinical Profile of von Willebrand Disease in Spain (PCM-EVW-ES)’ has been carried out by including the phenotypic assessment and the genetic analysis by next generation sequencing (NGS) of the VWF gene (VWF). The aim of the present study was to evaluate the role of MA to the diagnosis of these patients and their potential discrepancies. Two hundred and seventy out of 480 patients centrally diagnosed with VWD had normal multimers, 168 had abnormal multimers and 42 a total absence of multimers. VWF MA was of great significance in the diagnosis of 83 patients (17.3%), it was also of help in the diagnosis achieved in 365 additional patients (76%) and was not informative in 32 cases (6.7%). With regard to discrepancies, 110 out of 480 (23%) patients centrally diagnosed with VWD presented some kind of discordance between VWF:RCo/VWF:Ag and/or VWF:CB/VWF:Ag ratios, multimeric study and/or genetic results. The VWF MA was key in the presence of novel mutations as well as in cases with phenotypic discrepancies. A comparison between the contribution of MA and VWF:CB showed a clearly higher contribution of the former in the diagnostic process. These data seem to reinforce the relevance of the VWF MA in VWD diagnosis, despite all its limitations.
Collapse
Affiliation(s)
| | - Javier Batlle
- Servicio Hematología, Complexo Hospitalario Universitario A Coruña, INIBIC, A Coruña, Spain
- * E-mail:
| | - Irene Corrales
- Banc de Sang i Teixits, Barcelona, Spain
- Unitat d’Hemofilia, Vall d’Hebron Research Institute, Universitat Autònoma de Barcelona (VHIR-UAB), Barcelona, Spain
| | - Nina Borràs
- Banc de Sang i Teixits, Barcelona, Spain
- Unitat d’Hemofilia, Vall d’Hebron Research Institute, Universitat Autònoma de Barcelona (VHIR-UAB), Barcelona, Spain
| | | | - Esther Lourés
- Servicio Hematología, Complexo Hospitalario Universitario A Coruña, INIBIC, A Coruña, Spain
| | - Ana Rosa Cid
- Servicio Hematología, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Santiago Bonanad
- Servicio Hematología, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Noelia Cabrera
- Servicio Hematología, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Andrés Moret
- Servicio Hematología, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Rafael Parra
- Unitat d’Hemofilia, Vall d’Hebron Research Institute, Universitat Autònoma de Barcelona (VHIR-UAB), Barcelona, Spain
- Servicio Hematología, Hospital Universitari Vall d’Hebron, Barcelona, Spain
| | | | - Nira Navarro
- Servicio Hematología, Hospital Universitario Dr. Negrín, Las Palmas de Gran Canaria, Spain
| | - Carmen Altisent
- Servicio Hematología, Hospital Universitari Vall d’Hebron, Barcelona, Spain
| | - Rocío Pérez-Montes
- Servicio Hematología, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | | | - Ana Moreto
- Servicio Hematología, Hospital Universitario Cruces, Barakaldo, Spain
| | - Sonia Herrero
- Servicio Hematología, Hospital Universitario de Guadalajara, Guadalajara, Spain
| | - Inmaculada Soto
- Servicio Hematología, Hospital Universitario Central de Asturias, Oviedo, Spain
| | | | | | - Nieves Alonso
- Servicio Hematología, Hospital Infanta Cristina, Badajoz, Spain
| | | | - Emilia Fontanes
- Servicio Hematología, Hospital Universitario Lucus Augusti, Lugo, Spain
| | - Rosa Campos
- Servicio Hematología, Hospital Jerez de la Frontera, Cádiz, Spain
| | | | - Nuria Bermejo
- Servicio Hematología, Hospital San Pedro de Alcántara, Cáceres, Spain
| | - Rubén Berrueco
- Servicio Hematología, Hospital Sant Joan de Deu, Barcelona, Spain
| | - José Mateo
- Servicio Hematología, Hospital Sta Creu i St Pau, Barcelona, Spain
| | - Karmele Arribalzaga
- Servicio Hematología, Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | - Pascual Marco
- Servicio Hematología, Hospital General de Alicante, Alicante, Spain
| | - Ángeles Palomo
- Servicio Hematología, Hospital Regional Universitario de Málaga, Málaga, Spain
| | | | - Belén Iñigo
- Servicio Hematología, Hospital Clínico San Carlos, Madrid, Spain
| | | | - Rosa Vidal
- Servicio Hematología, Fundación Jiménez Díaz, Madrid, Spain
| | | | - Reyes Aguinaco
- Servicio Hematología, Hospital Joan XXIII, Tarragona, Spain
| | - Maria Tenorio
- Servicio Hematología, Hospital Ramón y Cajal, Madrid, Spain
| | - María Ferreiro
- Servicio Hematología, Hospital Montecelo, Pontevedra, Spain
| | | | | | - Jorge Cuesta
- Servicio Hematología, Hospital Virgen de la Salud, Toledo, Spain
| | | | | | - Manuela Dobón
- Servicio Hematología, Hospital Lozano Blesa, Zaragoza, Spain
| | - Carlos Aguilar
- Servicio Hematología, Hospital Santa Bárbara, Soria, Spain
| | - Fernando Batlle
- Department of Research, Lapisoft Project S.L., A Coruña, Spain
| | - Francisco Vidal
- Banc de Sang i Teixits, Barcelona, Spain
- Unitat d’Hemofilia, Vall d’Hebron Research Institute, Universitat Autònoma de Barcelona (VHIR-UAB), Barcelona, Spain
- CIBER de Enfermedades Cardiovasculares (CIBERCV), Barcelona, Spain
| | | |
Collapse
|
28
|
Crist RA, Heikal NM, Rodgers GM, Grenache DG, Smock KJ. Evaluation of a new commercial method for von Willebrand factor multimeric analysis. Int J Lab Hematol 2018; 40:586-591. [PMID: 29920949 DOI: 10.1111/ijlh.12869] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 05/08/2018] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Evaluation of von Willebrand factor (VWF) multimeric distribution is useful for subclassification of von Willebrand disease (VWD). Multimer analysis has historically been a manual, labor-intensive laboratory-developed test. The first commercial method for multimeric analysis was recently developed that utilizes a single instrument for gel electrophoresis, staining, and densitometry. The current study was undertaken to evaluate the performance characteristics of the new commercial method. METHODS Studies performed with the commercial method included evaluation of accuracy (method comparison), reference intervals (establishment of normal migration patterns in normal donor specimens), precision (multimer pattern reproducibility), and analytical sensitivity. RESULTS In the method comparison studies, concordant interpretations were obtained in 19 of 24 comparisons, including normal and abnormal specimens. The 5 specimens with discordant interpretations all involved slight differences and none were considered clinically significant. Thirty-eight normal donor specimens demonstrated normal multimer patterns. Multimer pattern reproducibility was demonstrated in normal and abnormal controls tested on each gel. In the sensitivity studies, adequate visualization of multimers was determined to require VWF protein concentrations of approximately 5%-10% of normal. CONCLUSION The commercial multimer method is a streamlined test that demonstrates comparable performance characteristics to our current laboratory-developed method and that provides the advantage of both electrophoresis gels and densitometry scans to aid interpretation.
Collapse
Affiliation(s)
- R A Crist
- ARUP Laboratories Institute for Clinical and Experimental Pathology, University of Utah, Salt Lake City, UT, USA
| | - N M Heikal
- ARUP Laboratories Institute for Clinical and Experimental Pathology, University of Utah, Salt Lake City, UT, USA.,Department of Pathology, University of Utah, Salt Lake City, UT, USA
| | - G M Rodgers
- ARUP Laboratories Institute for Clinical and Experimental Pathology, University of Utah, Salt Lake City, UT, USA.,Department of Pathology, University of Utah, Salt Lake City, UT, USA.,Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - D G Grenache
- ARUP Laboratories Institute for Clinical and Experimental Pathology, University of Utah, Salt Lake City, UT, USA.,Department of Pathology, University of Utah, Salt Lake City, UT, USA
| | - K J Smock
- ARUP Laboratories Institute for Clinical and Experimental Pathology, University of Utah, Salt Lake City, UT, USA.,Department of Pathology, University of Utah, Salt Lake City, UT, USA
| |
Collapse
|
29
|
How I treat type 2B von Willebrand disease. Blood 2018; 131:1292-1300. [PMID: 29378695 DOI: 10.1182/blood-2017-06-742692] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2017] [Accepted: 01/04/2018] [Indexed: 12/26/2022] Open
Abstract
Type 2B von Willebrand disease (VWD) is an inherited bleeding disorder caused by changes in von Willebrand factor (VWF) that enhance binding of VWF to GPIb on platelets. Although this disorder is seemingly well defined because of this single molecular defect, in reality type 2B VWD is a clinically heterogeneous disorder that can be difficult to identify and manage. Diagnostic criteria include a history of mucocutaneous bleeding, laboratory studies showing enhanced VWF binding of platelets and/or a 2B VWD genetic variant, and a family history consistent with autosomal dominant inheritance. Thrombocytopenia, although not always present, is common and can be exacerbated by physiologic stressors such as pregnancy. The mainstay of therapy for type 2B VWD is VWF replacement therapy. Adjunct therapies useful in other types of VWD, such as antifibrinolytics, are also used in type 2B VWD. 1-Desamino-8-d-arginine vasopressin (DDAVP) is controversial because of exacerbation of thrombocytopenia, but is, in practice, sometimes used for minor bleeding. Here we review the available evidence and provide 3 clinical cases to illustrate the intricacies of diagnosing type 2B VWD to describe the response to DDAVP and to review complexities and management during pregnancy.
Collapse
|
30
|
Aponte-Santamaría C, Obser T, Grässle S, Oyen F, Budde U, Schneppenheim S, Baldauf C, Gräter F, Schneider SW, Schneppenheim R, Brehm MA, Huck V. von Willebrand disease type 2A phenotypes IIC, IID and IIE: A day in the life of shear-stressed mutant von Willebrand factor. Thromb Haemost 2017; 112:96-108. [DOI: 10.1160/th13-11-0902] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2013] [Accepted: 02/11/2014] [Indexed: 11/05/2022]
Abstract
SummaryThe bleeding disorder von Willebrand disease (VWD) is caused by mutations of von Willebrand factor (VWF), a multimeric glycoprotein essential for platelet-dependent primary haemostasis. VWD type 2A–associated mutations each disrupt VWF biosynthesis and function at different stages, depending on the VWF domain altered by the mutation. These effects cause considerable heterogeneity in phenotypes and symptoms. To characterise the molecular mechanisms underlying the specific VWF deficiencies in VWD 2A/IIC, IID and IIE, we investigated VWF variants with patient-derived mutations either in the VWF pro-peptide or in domains D3 or CK. Additionally to static assays and molecular dynamics (MD) simulations we used microfluidic approaches to perform a detailed investigation of the shear-dependent function of VWD 2A mutants. For each group, we found distinct characteristics in their intracellular localisation visualising specific defects in biosynthesis which are correlated to respective multimer patterns. Using microfluidic assays we further determined shear flow-dependent characteristics in polymer-platelet-aggregate formation, platelet binding and string formation for all mutants. The phenotypes observed under flow conditions were not related to the mutated VWF domain. By MD simulations we further investigated how VWD 2A/IID mutations might alter the ability of VWF to form carboxy-terminal dimers. In conclusion, our study offers a comprehensive picture of shear-dependent and shear-independent dysfunction of VWD type 2A mutants. Furthermore, our microfluidic assay might open new possibilities for diagnosis of new VWD phenotypes and treatment choice for VWD patients with shear-dependent VWF dysfunctions that are currently not detectable by static tests.
Collapse
|
31
|
de Wee EM, Sanders YV, Mauser-Bunschoten EP, van der Bom JG, Degenaar-Dujardin MEL, Eikenboom J, de Goede-Bolder A, Laros-van Gorkom BAP, Meijer K, Hamulyák K, Nijziel MR, Fijnvandraat K, Leebeek FWG. Determinants of bleeding phenotype in adult patients with moderate or severe von Willebrand disease. Thromb Haemost 2017; 108:683-92. [DOI: 10.1160/th12-04-0244] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2012] [Accepted: 07/18/2012] [Indexed: 12/28/2022]
Abstract
SummaryWe performed a nation-wide cross-sectional study to evaluate determinants of bleeding symptoms in a large unselected cohort of adults with von Willebrand disease (VWD). VWD patients were included (n=664), based on lowest historically measured VWF:Ag and VWF:Act levels ≤30 U/dl. Menorrhagia (85%), cutaneous bleeding (77%), bleeding from minor wounds (77%) and oral-cavity bleeding (62%) occurred most frequently. Higher age was associated with a higher bleeding score (BS), determined according to Tosetto, in females. A 10 year increase in age was associated with 0.8 point (95% confidence interval [CI] 0.4–1.1) higher BS. Females had higher BS than males (median 12 vs. 10, p=0.012). BS differed significantly between VWD type 1, 2 and 3: median 9 (-2–31), 13 (-1–33) and 19.5 (1–35), respectively (p<0.001). BS was strongly associated with VWF and FVIII levels: individuals with VWF:Ag levels ≤10 IU/dl, VWF:Act ≤10 IU/dl and FVIII:C ≤10 IU/dl had, respectively, 5.3 point (95%CI 3.2–7.3), 4.3 point (95%CI 2.9–5.8) and 9.6 point (95%CI 6.5–12.7) higher BS, than those with levels >30 IU/dl. In type 3 patients 1 IU/dl FVIII:C decrease was associated with 0.6 point (95% CI 0.1–1.1) BS increase (p=0.021). In conclusion, in VWD patients the bleeding phenotype is strongly associated with type of VWD and VWF and FVIII levels.
Collapse
|
32
|
de Wee E, Knol H, Mauser-Bunschoten E, van der Bom J, Eikenboom J, Fijnvandraat K, Goede-Bolder AD, Laros-van Gorkom B, Ypma P, Zweegman S, Meijer K, Leebeek F. Gynaecological and obstetric bleeding in moderate and severe von Willebrand disease. Thromb Haemost 2017; 106:885-92. [DOI: 10.1160/th11-03-0180] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2011] [Accepted: 07/29/2011] [Indexed: 12/20/2022]
Abstract
SummaryA nation-wide cross-sectional study was initiated to assess gynaecological and obstetrical symptoms in an unselected cohort of women with moderate and severe von Willebrand disease (VWD) in the Netherlands. A total of 423 women aged ≥16 years were included. Bleeding severity was measured using the Tosetto Bleeding Score (BS). Menorrhagia, defined as occurrence of ≥2 menorrhagia symptoms, was reported by 81%. Of all VWD women, 78% received any kind of treatment for menorrhagia and 20% underwent a hysterectomy predominantly because of severe menstrual bleeding. Over half of the women reported more blood loss than can be expected with a normal delivery. In 52% of reported pregnancy losses curettage was needed because of bleeding. Mean number of live births was 1.9, which is comparable with the general Dutch population. In conclusion, women with moderate or severe VWD frequently have menorrhagia in need of treatment, and 20% of the VWD women underwent a hysterectomy. Bleeding complications occurred in over 50% of the women after childbirth or pregnancy loss. Progeny seems not to be affected in women with moderate or severe VWD.
Collapse
|
33
|
de Jong A, Eikenboom J. Von Willebrand disease mutation spectrum and associated mutation mechanisms. Thromb Res 2017; 159:65-75. [PMID: 28987708 DOI: 10.1016/j.thromres.2017.09.025] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Revised: 09/13/2017] [Accepted: 09/22/2017] [Indexed: 01/24/2023]
Abstract
Von Willebrand disease (VWD) is a bleeding disorder that is mainly caused by mutations in the multimeric protein von Willebrand factor (VWF). These mutations may lead to deficiencies in plasma VWF or dysfunctional VWF. VWF is a heterogeneous protein and over the past three decades, hundreds of VWF mutations have been identified. In this review we have organized all reported mutations, spanning a timeline from the late eighties until early 2017. This resulted in an overview of 750 unique mutations that are divided over the VWD types 1, 2A, 2B, 2M, 2N and 3. For many of these mutations the disease-causing effects have been characterized in vitro through expression studies, ex vivo by analysis of patient-derived endothelial cells, as well as in animal or (bio)physical models. Here we describe the mechanisms associated with the VWF mutations per VWD type.
Collapse
Affiliation(s)
- Annika de Jong
- Department of Internal Medicine, Division of Thrombosis and Hemostasis, Einthoven Laboratory for Vascular and Regenerative Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Jeroen Eikenboom
- Department of Internal Medicine, Division of Thrombosis and Hemostasis, Einthoven Laboratory for Vascular and Regenerative Medicine, Leiden University Medical Center, Leiden, The Netherlands.
| |
Collapse
|
34
|
Novel insights into the clinical phenotype and pathophysiology underlying low VWF levels. Blood 2017; 130:2344-2353. [PMID: 28916584 DOI: 10.1182/blood-2017-05-786699] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Accepted: 09/01/2017] [Indexed: 11/20/2022] Open
Abstract
Critical clinical questions remain unanswered regarding diagnosis and management of patients with low von Willebrand factor (VWF) levels (30-50 IU/dL). To address these questions, the Low VWF Ireland Cohort (LoVIC) study investigated 126 patients registered with low VWF levels. Despite marginally reduced plasma VWF levels, International Society of Thrombosis and Haemostasis Bleeding Assessment Tool (ISTH BAT) confirmed significant bleeding phenotypes in the majority of LoVIC patients. Importantly, bleeding tendency did not correlate with plasma VWF levels within the 30 to 50 IU/dL range. Furthermore, bleeding phenotypes could not be explained by concurrent hemostatic defects. Plasma factor VIII to VWF antigen (VWF:Ag) ratios were significantly increased in LoVIC patients compared with controls (P < .0001). In contrast, VWF propeptide to VWF:Ag ratios >3 were observed in only 6% of the LoVIC cohort. Furthermore, platelet-VWF collagen binding activity levels were both significantly reduced compared with controls (P < .05). In response to 1-desamino-8-D-arginine vasopressin (DDAVP), peak VWF:Ag levels exceeded 100 IU/dL in 88% of patients and was sustained >100 IU/dL after 4 hours in 72% of subjects. In conclusion, our novel data suggest that low VWF levels can be associated with significant bleeding and are predominantly due to reductions in VWF synthesis and/or constitutive secretion. Although enhanced VWF clearance may contribute to the pathophysiology in some individuals, the absolute reduction in VWF plasma half-life is usually mild and not sufficient to significantly impact upon the duration of DDAVP-induced VWF response. This trial was registered at www.clinicaltrials.gov as #NCT03167320.
Collapse
|
35
|
Liang Q, Qin H, Ding Q, Xie X, Wu R, Wang H, Hu Y, Wang X. Molecular and clinical profile of VWD in a large cohort of Chinese population: application of next generation sequencing and CNVplex ® technique. Thromb Haemost 2017; 117:1534-1548. [PMID: 28536718 DOI: 10.1160/th16-10-0794] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Accepted: 05/03/2017] [Indexed: 12/29/2022]
Abstract
Von Willebrand disease (VWD), the most common inherited bleeding disorder, is characterised by a variable bleeding tendency, heterogeneous laboratory phenotype and race specific distribution of mutations. The present study aimed to determine the correlation of genotype and phenotype in 200 Chinese individuals from 90 unrelated families with VWD. Next generation sequencing (NGS) of the whole coding VWF, copy number analysis of VWF by CNVplex® technique as well as a comprehensive phenotypic assessment were carried out in all index patients (IPs). We identified putative mutations in all IPs except five mild type 1 (85/90, 94.4 %). In total, 98 different mutations were detected, 62 (63.3 %) of which were reported for the first time (23 missense mutations, 1 regulatory mutation, 12 splice site mutations and 26 null mutations). Mutations p.Ser1506Leu and p.Arg1374His/Cys/Ser were the most frequent mutations in 2A (33 % of cases) and 2M VWD (67 % of cases), respectively. In addition, mutation p.Arg816Trp was detected repeatedly in type 2N patients, while mutation p.Arg854Gln, extremely common in Caucasians, was not found in our cohort. Thirty-three patients had two or more putative mutations. Unlike most cases of type 1 and type 2 VWD, which were transmitted dominantly, we presented seven severe type 1, two type 2A and one type 2M with autosomal recessive inheritance. Here the phenotypic data of patients with novel mutations will certainly contribute to the better understanding of the molecular genetics of VWF-related phenotypes.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | - Xuefeng Wang
- Xuefeng Wang, Department of Laboratory Medicine, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, No.197 Ruijin Second Road, Shanghai, 200025, China, Tel.: +86 21 54667770, Fax: +86 21 64333548, E-mail: , or, Yiqun Hu, Faculty of Medical Laboratory Science, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, No.197 Ruijin Second Road, Shanghai, 200025, China, Tel.: +86 21 64669971, Fax: +86 21 63851293, E-mail:
| |
Collapse
|
36
|
Aponte-Santamaría C, Lippok S, Mittag JJ, Obser T, Schneppenheim R, Baldauf C, Gräter F, Budde U, Rädler JO. Mutation G1629E Increases von Willebrand Factor Cleavage via a Cooperative Destabilization Mechanism. Biophys J 2017; 112:57-65. [PMID: 28076816 PMCID: PMC5232862 DOI: 10.1016/j.bpj.2016.11.3202] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Revised: 11/12/2016] [Accepted: 11/30/2016] [Indexed: 02/04/2023] Open
Abstract
The large multimeric glycoprotein von Willebrand Factor (VWF) plays a pivotal adhesive role during primary hemostasis. VWF is cleaved by the protease ADAMTS13 as a down-regulatory mechanism to prevent excessive VWF-mediated platelet aggregation. For each VWF monomer, the ADAMTS13 cleavage site is located deeply buried inside the VWF A2 domain. External forces in vivo or denaturants in vitro trigger the unfolding of this domain, thereby leaving the cleavage site solvent-exposed and ready for cleavage. Mutations in the VWF A2 domain, facilitating the cleavage process, cause a distinct form of von Willebrand disease (VWD), VWD type 2A. In particular, the VWD type 2A Gly1629Glu mutation drastically accelerates the proteolytic cleavage activity, even in the absence of forces or denaturants. However, the effect of this mutation has not yet been quantified, in terms of kinetics or thermodynamics, nor has the underlying molecular mechanism been revealed. In this study, we addressed these questions by using fluorescence correlation spectroscopy, molecular dynamics simulations, and free energy calculations. The measured enzyme kinetics revealed a 20-fold increase in the cleavage rate for the Gly1629Glu mutant compared with the wild-type VWF. Cleavage was found cooperative with a cooperativity coefficient n = 2.3, suggesting that the mutant VWF gives access to multiple cleavage sites of the VWF multimer at the same time. According to our simulations and free energy calculations, the Gly1629Glu mutation causes structural perturbation in the A2 domain and thereby destabilizes the domain by ∼10 kJ/mol, promoting its unfolding. Taken together, the enhanced proteolytic activity of Gly1629Glu can be readily explained by an increased availability of the ADAMTS13 cleavage site through A2-domain-fold thermodynamic destabilization. Our study puts forward the Gly1629Glu mutant as a very efficient enzyme substrate for ADAMTS13 activity assays.
Collapse
Affiliation(s)
- Camilo Aponte-Santamaría
- Molecular Biomechanics Group, Heidelberg Institute for Theoretical Studies, Heidelberg, Germany; Interdisciplinary Center for Scientific Computing, Heidelberg University, Heidelberg, Germany.
| | - Svenja Lippok
- Faculty of Physics and Center for NanoScience, Ludwig Maximilian University, Munich, Germany
| | - Judith J Mittag
- Faculty of Physics and Center for NanoScience, Ludwig Maximilian University, Munich, Germany
| | - Tobias Obser
- Department of Pediatric Hematology and Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Reinhard Schneppenheim
- Department of Pediatric Hematology and Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Carsten Baldauf
- Theory Department, Fritz-Haber-Institut der Max-Planck-Gesellschaft, Berlin, Germany
| | - Frauke Gräter
- Molecular Biomechanics Group, Heidelberg Institute for Theoretical Studies, Heidelberg, Germany; Interdisciplinary Center for Scientific Computing, Heidelberg University, Heidelberg, Germany
| | - Ulrich Budde
- Medilys Coagulation Laboratory, Asklepios Klinic Altona, Hamburg, Germany
| | - Joachim O Rädler
- Faculty of Physics and Center for NanoScience, Ludwig Maximilian University, Munich, Germany
| |
Collapse
|
37
|
Lippok S, Radtke M, Obser T, Kleemeier L, Schneppenheim R, Budde U, Netz RR, Rädler JO. Shear-Induced Unfolding and Enzymatic Cleavage of Full-Length VWF Multimers. Biophys J 2017; 110:545-554. [PMID: 26840720 DOI: 10.1016/j.bpj.2015.12.023] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Revised: 11/23/2015] [Accepted: 12/17/2015] [Indexed: 10/22/2022] Open
Abstract
Proteolysis of the multimeric blood coagulation protein von Willebrand Factor (VWF) by ADAMTS13 is crucial for prevention of microvascular thrombosis. ADAMTS13 cleaves VWF within the mechanosensitive A2 domain, which is believed to open under shear flow. In this study, we combine fluorescence correlation spectroscopy (FCS) and a microfluidic shear cell to monitor real-time kinetics of full-length VWF proteolysis as a function of shear stress. For comparison, we also measure the Michaelis-Menten kinetics of ADAMTS13 cleavage of wild-type VWF in the absence of shear but partially denaturing conditions. Under shear, ADAMTS13 activity on full-length VWF arises without denaturing agent as evidenced by FCS and gel-based multimer analysis. In agreement with Brownian hydrodynamics simulations, we find a sigmoidal increase of the enzymatic rate as a function of shear at a threshold shear rate γ˙1/2 = 5522/s. The same flow-rate dependence of ADAMTS13 activity we also observe in blood plasma, which is relevant to predict hemostatic dysfunction.
Collapse
Affiliation(s)
- Svenja Lippok
- Faculty of Physics and Center for NanoScience, Ludwig Maximilian University, Munich, Germany
| | - Matthias Radtke
- Department of Physics, Freie Universität Berlin, Berlin, Germany
| | - Tobias Obser
- Department of Pediatric Hematology and Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lars Kleemeier
- Faculty of Physics and Center for NanoScience, Ludwig Maximilian University, Munich, Germany
| | - Reinhard Schneppenheim
- Department of Pediatric Hematology and Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ulrich Budde
- Coagulation Lab, Medilys Laborgesellschaft Hamburg, Hamburg, Germany
| | - Roland R Netz
- Department of Physics, Freie Universität Berlin, Berlin, Germany
| | - Joachim O Rädler
- Faculty of Physics and Center for NanoScience, Ludwig Maximilian University, Munich, Germany.
| |
Collapse
|
38
|
Goodeve A. Diagnosing von Willebrand disease: genetic analysis. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2016; 2016:678-682. [PMID: 27913546 PMCID: PMC6065508 DOI: 10.1182/asheducation-2016.1.678] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Investigation of a patient with possible von Willebrand disease (VWD) includes a range of phenotypic analyses. Often, this is sufficient to discern disease type, and this will suggest relevant treatment. However, for some patients, phenotypic analysis does not sufficiently explain the patient's disorder, and for this group, genetic analysis can aid diagnosis of disease type. Polymerase chain reaction and Sanger sequencing have been mainstays of genetic analysis for several years. More recently, next-generation sequencing has become available, with the advantage that several genes can be simultaneously analyzed where necessary, eg, for discrimination of possible type 2N VWD or mild hemophilia A. Additionally, several techniques can now identify deletions/duplications of an exon or more that result in VWD including multiplex ligation-dependent probe amplification and microarray analysis. Algorithms based on next-generation sequencing data can also identify missing or duplicated regions. These newer techniques enable causative von Willebrand factor defects to be identified in more patients than previously, aiding in a specific VWD diagnosis. Genetic analysis can also be helpful in the discrimination between type 2B and platelet-type VWD and in prenatal diagnosis for families with type 3.
Collapse
Affiliation(s)
- Anne Goodeve
- Haemostasis Research Group, Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield and Sheffield Diagnostic Genetics Service, Sheffield Children's NHS Foundation Trust, Sheffield, United Kingdom
| |
Collapse
|
39
|
Prospective evaluation of ADAMTS-13 and von Willebrand factor multimers in cardiac surgery. Blood Coagul Fibrinolysis 2016; 27:886-891. [DOI: 10.1097/mbc.0000000000000510] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
40
|
Obser T, Ledford-Kraemer M, Oyen F, Brehm MA, Denis CV, Marschalek R, Montgomery RR, Sadler JE, Schneppenheim S, Budde U, Schneppenheim R. Identification and characterization of the elusive mutation causing the historical von Willebrand Disease type IIC Miami. J Thromb Haemost 2016; 14:1725-35. [PMID: 27344059 PMCID: PMC5035592 DOI: 10.1111/jth.13398] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Accepted: 06/15/2016] [Indexed: 11/28/2022]
Abstract
UNLABELLED Essentials Von Willebrand disease IIC Miami features high von Willebrand factor (VWF) with reduced function. We aimed to identify and characterize the elusive underlying mutation in the original family. An inframe duplication of VWF exons 9-10 was identified and characterized. The mutation causes a defect in VWF multimerization and decreased VWF clearance from the circulation. SUMMARY Background A variant of von Willebrand disease (VWD) type 2A, phenotype IIC (VWD2AIIC), is characterized by recessive inheritance, low von Willebrand factor antigen (VWF:Ag), lack of VWF high-molecular-weight multimers, absence of VWF proteolytic fragments and mutations in the VWF propeptide. A family with dominantly inherited VWD2AIIC but markedly elevated VWF:Ag of > 2 U L(-1) was described as VWD type IIC Miami (VWD2AIIC-Miami) in 1993; however, the molecular defect remained elusive. Objectives To identify the molecular mechanism underlying the phenotype of the original VWD2AIIC-Miami. Patients and Methods We studied the original family with VWD2AIIC-Miami phenotypically and by genotyping. The identified mutation was recombinantly expressed and characterized by standard techniques, confocal imaging and in a mouse model, respectively. Results By Multiplex ligation-dependent probe amplification we identified an in-frame duplication of VWF exons 9-10 (c.998_1156dup; p.Glu333_385dup) in all patients. Recombinant mutant (rm)VWF only presented as a dimer. Co-expressed with wild-type VWF, the multimer pattern was indistinguishable from patients' plasma VWF. Immunofluorescence studies indicated retention of rmVWF in unusually large intracellular granules in the endoplasmic reticulum. ADAMTS-13 proteolysis of rmVWF under denaturing conditions was normal; however, an aberrant proteolytic fragment was apparent. A decreased ratio of VWF propeptide to VWF:Ag and a 1-desamino-8-d-arginine vasopressin (DDAVP) test in one patient indicated delayed VWF clearance, which was supported by clearance data after infusion of rmVWF into VWF(-/-) mice. Conclusion The unique phenotype of VWD2 type IIC-Miami results from dominant impairment of multimer assembly, an aberrant structure of mutant mature VWF and reduced clearance in vivo.
Collapse
Affiliation(s)
- T Obser
- Department of Pediatric Hematology and Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - F Oyen
- Department of Pediatric Hematology and Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - M A Brehm
- Department of Pediatric Hematology and Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - C V Denis
- INSERM UMR_S 1176, Université Paris-Sud, Université Paris-Saclay, Le Kremlin-Bicetre, France
| | - R Marschalek
- Institute of Pharmaceutical Biology/ZAFES/DCAL, Biocenter, Johann-Wolfgang-Goethe-University Frankfurt, Frankfurt/Main, Germany
| | - R R Montgomery
- Blood Research Institute of Blood Center of Wisconsin and Medical College of Wisconsin, Milwaukee, WI, USA
| | - J E Sadler
- Departments of Medicine and Biochemistry and Molecular Biophysics, Washington University School of Medicine, St. Louis, MO, USA
| | - S Schneppenheim
- Medilys Central Laboratory Coagulation, Asklepios Clinic Altona, Hamburg, Germany
| | - U Budde
- Medilys Central Laboratory Coagulation, Asklepios Clinic Altona, Hamburg, Germany
| | - R Schneppenheim
- Department of Pediatric Hematology and Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| |
Collapse
|
41
|
Michiels JJ, Batorova A, Prigancova T, Smejkal P, Penka M, Vangenechten I, Gadisseur A. Changing insights in the diagnosis and classification of autosomal recessive and dominant von Willebrand diseases 1980-2015. World J Hematol 2016; 5:61-74. [DOI: 10.5315/wjh.v5.i3.61] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2015] [Accepted: 04/18/2016] [Indexed: 02/05/2023] Open
Abstract
The European Clinical Laboratory and Molecular (ECLM) criteria define 10 distinct Willebrand diseases (VWD): recessive type 3, severe 1, 2C and 2N; dominant VWD type 1 secretion/clearance defect, 2A, 2B, 2E, 2M and 2D; and mild type 1 VWD (usually carriers of recessive VWD). Recessive severe 1 and 2C VWD are characterized by secretion and multimerization defects caused by mutations in the D1-D2 domain. Recessive 2N VWD is a mild hemophilia due to D’-FVIII-von Willebrand factor (VWF) binding site mutations. Dominant 2E VWD caused by heterozygous missense mutations in the D3 domain is featured by a secretion-clearance-multimerization VWF defect. Dominant VWD type 2M due to loss of function mutations in the A1 domain is characterized by decreased ristocetin-induced platelet aggregation and VWF:RCo, normal VWF multimers and VWF:CB, a poor response of VWF:RCo and good response of VWF:CB to desmopressin (DDAVP). Dominant VWD type 2A induced by heterozygous mutations in the A2 domain results in hypersensitivity of VWF for proteolysis by ADAMTS13 into VWF degradation products, resulting in loss of large VWF multimers with triplet structure of each individual VWF band. Dominant VWD type 2B due to a gain of function mutation in the A1 domain is featured by spontaneous interaction between platelet glycoprotein Ib (GPIb) and mutated VWF A1 followed by increased proteolysis with loss of large VWF multimers and presence of each VWF band. A new category of dominant VWD type 1 secretion or clearance defect due to mutations in the D3 domain or D4-C1-C5 domains consists of two groups: Those with normal or smeary pattern of VWF multimers.
Collapse
|
42
|
Functional characterisation of the type 1 von Willebrand disease candidate VWF gene variants: p.M771I, p.L881R and p.P1413L. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2016; 15:548-556. [PMID: 27483487 DOI: 10.2450/2016.0034-16] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 02/06/2016] [Accepted: 04/05/2016] [Indexed: 09/28/2022]
Abstract
BACKGROUND Abnormalities in the biosynthetic pathway or increased clearance of plasma von Willebrand factor (VWF) are likely to contribute to decreased plasma VWF levels in inherited type 1 von Willebrand disease (VWD). Recent studies demonstrated that 65% of type 1 VWD patients have candidate VWF mutations, the majority of which are missense variants. The purpose of this study was to explore the effects of three VWF missense mutations (p.M771I, p.L881R and p.P1413L) located in different functional domains of VWF, reported as candidate mutations in type 1 VWD patients in the course of the MCMDM-1VWD study. MATERIALS AND METHODS The focus of these studies was on the intracellular biosynthetic processing and localisation of VWF in a heterologous cell system. Molecular dynamic simulation for p.M771I and p.P1413L was also performed to analyse the conformational effects of the changes. RESULTS As determined by immunofluorescence antibody staining and confocal microscopy of HEK293 cells, the intracellular localisation of recombinant VWF with the p.M771I variation was impaired. Transient transfection studies and phorbol myristate acetate stimulation in COS-7 cells revealed significant intracellular retention. In addition, major loss of VWF multimers was observed for only the p.M771I mutation. Molecular dynamic simulations on p.M771I mutant VWF revealed distinct structural rearrangements including a large deviation in the E' domain, and significant loss of β-sheet secondary structure. DISCUSSION The pathogenic effects of candidate VWF gene mutations were explored in this study. In vitro expression studies in heterologous cell systems revealed impaired secretion of VWF and a dominant negative effect on the processing of the wild-type protein for only the p.M771I mutation and none of the mutations affected the regulated secretion.
Collapse
|
43
|
Michiels JJ, Smejkal P, Penka M, Batorova A, Pricangova T, Budde U, Vangenechten I, Gadisseur A. Diagnostic Differentiation of von Willebrand Disease Types 1 and 2 by von Willebrand Factor Multimer Analysis and DDAVP Challenge Test. Clin Appl Thromb Hemost 2016; 23:518-531. [PMID: 27443694 DOI: 10.1177/1076029616647157] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
The European Clinical Laboratory and Molecular (ECLM) classification of von Willebrand disease (vWD) is based on the splitting approach which uses sensitive and specific von Willebrand factor (vWF) assays with regard to the updated molecular data on structure and function of vWF gene and protein defects. A complete set of FVIII:C and vWF ristocetine cofactor, collagen binding, and antigen, vWF multimeric analysis in low- and medium-resolution gels, and responses to desmopressin (DDAVP) of FVIII:C and vWF parameters are mandatory. The ECLM classification distinguishes recessive types 1 and 3 vWD from recessive vWD 2C due to mutations in the D1 and D2 domains and vWD 2N due to mutations in the D'-FVIII-binding domain of vWF. The ECLM classification differentiates between mild vWD type 1 with variable penetrance of bleedings from symptomatic dominant type 1 vWD secretion defect and/or clearance defect with normal vWF multimers versus vWD 1M and 2M with normal or smeary vWF multimers in low- and medium-resolution gels. High-quality multimeric analysis of vWF in medium-resolution gels based on a DDAVP challenge test clearly delineates and distinguishes each of the dominant type 2 vWDs 1/2E, 2M, 2B, 2A, and 2D caused by vWF gene mutations in the D3 multimerization domain, loss or gain-of-function mutations in the glycoprotein Ib receptor A1 domain, gene mutations in the A2 proteolytic domain, and the C-terminal dimerization domain, respectively.
Collapse
Affiliation(s)
- Jan Jacques Michiels
- 1 Goodheart Institute in Nature Medicine & Health, Blood Coagulation and Vascular Medicine Center, Rotterdam, The Netherlands.,2 Hemostasis Research Unit, Department of Hematology, Antwerp University Hospital, Belgium
| | - Petr Smejkal
- 3 Department of Clinical Hematology, University Hospital, Masaryk University, Brno, Czech Republic.,4 Faculty of Medicine, Department of Laboratory Methods, Masaryk University, Brno, Czech Republic
| | - Miroslav Penka
- 3 Department of Clinical Hematology, University Hospital, Masaryk University, Brno, Czech Republic.,4 Faculty of Medicine, Department of Laboratory Methods, Masaryk University, Brno, Czech Republic
| | - Angelika Batorova
- 5 Department of Hemostasis and Thrombosis, National Hemophilia Center, Medical School of Comenius University, Bratislava, Slovakia
| | - Tatiana Pricangova
- 5 Department of Hemostasis and Thrombosis, National Hemophilia Center, Medical School of Comenius University, Bratislava, Slovakia
| | - Ulrich Budde
- 6 Central Laboratory, Asklepios Kliniken, Hamburg, Germany
| | - Inge Vangenechten
- 2 Hemostasis Research Unit, Department of Hematology, Antwerp University Hospital, Belgium.,8 Hemostasis Research Unit, Antwerp University Hospital, Antwerp, Belgium
| | - Alain Gadisseur
- 2 Hemostasis Research Unit, Department of Hematology, Antwerp University Hospital, Belgium.,7 Department of Hematology, Antwerp University Hospital, Antwerp, Belgium.,8 Hemostasis Research Unit, Antwerp University Hospital, Antwerp, Belgium
| |
Collapse
|
44
|
Von Willebrand factor regulates complement on endothelial cells. Kidney Int 2016; 90:123-34. [PMID: 27236750 DOI: 10.1016/j.kint.2016.03.023] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2015] [Revised: 02/10/2016] [Accepted: 03/03/2016] [Indexed: 11/20/2022]
Abstract
Atypical hemolytic uremic syndrome and thrombotic thrombocytopenic purpura have traditionally been considered separate entities. Defects in the regulation of the complement alternative pathway occur in atypical hemolytic uremic syndrome, and defects in the cleavage of von Willebrand factor (VWF)-multimers arise in thrombotic thrombocytopenic purpura. However, recent studies suggest that both entities are related as defects in the disease-causing pathways overlap or show functional interactions. Here we investigate the possible functional link of VWF-multimers and the complement system on endothelial cells. Blood outgrowth endothelial cells (BOECs) were obtained from 3 healthy individuals and 2 patients with Type 3 von Willebrand disease lacking VWF. Cells were exposed to a standardized complement challenge via the combination of classical and alternative pathway activation and 50% normal human serum resulting in complement fixation to the endothelial surface. Under these conditions we found the expected release of VWF-multimers causing platelet adhesion onto BOECs from healthy individuals. Importantly, in BOECs derived from patients with von Willebrand disease complement C3c deposition and cytotoxicity were more pronounced than on BOECs derived from normal individuals. This is of particular importance as primary glomerular endothelial cells display a heterogeneous expression pattern of VWF with overall reduced VWF abundance. Thus, our results support a mechanistic link between VWF-multimers and the complement system. However, our findings also identify VWF as a new complement regulator on vascular endothelial cells and suggest that VWF has a protective effect on endothelial cells and complement-mediated injury.
Collapse
|
45
|
Distinct mechanisms account for acquired von Willebrand syndrome in plasma cell dyscrasias. Ann Hematol 2016; 95:945-57. [PMID: 27040683 DOI: 10.1007/s00277-016-2650-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Accepted: 03/18/2016] [Indexed: 02/01/2023]
Abstract
Acquired von Willebrand syndrome (AVWS) is a rare bleeding disorder that may cause life-threatening hemorrhages in patients with plasma cell dyscrasias (PCDs). Early diagnosis and treatment require a thorough understanding of its underlying pathophysiology. Two patients with IgG MGUS presented with dramatically decreased plasma von Willebrand factor (VWF) and a severe type-1 pattern on multimer analysis. A prompt response to intravenous immunoglobulins (IVIG), but not to VWF/FVIII, was consistent with accelerated immunologic clearance of plasma VWF. Another IgG MGUS patient showed a type-2 pattern and a less pronounced response to IVIG, suggesting that additional mechanism(s) contributed to AVWS evolution. In a patient with Waldenström's macroglobulinemia and severe depletion of plasma VWF, multimer analysis indicated association of the IgM paraprotein with VWF before, but not after plasmapheresis, resulting in destruction of the agarose gel and a characteristically distorted band structure of VWF multimers. A type-2 pattern with highly abnormal VWF triplets and laboratory evidence of excessive fibrinolytic activity suggested that plasmin-mediated VWF degradation contributed to AVWS in a patient with multiple myeloma (MM) and AL amyloidosis. Finally, in a patient with IgG MM, maximally prolonged PFA-100® closure times and a specific defect in ristocetin-induced platelet agglutination, both of which resolved after remission induction, indicated interference of the paraprotein with VWF binding to platelet GPIb. Importantly, in none of the six patients, circulating autoantibodies to VWF were detected by a specific in-house ELISA. In summary, when evaluating PCD patients with severe bleeding symptoms, AVWS due to various pathogenic mechanisms should be considered.
Collapse
|
46
|
Fidalgo T, Salvado R, Corrales I, Pinto SC, Borràs N, Oliveira A, Martinho P, Ferreira G, Almeida H, Oliveira C, Marques D, Gonçalves E, Diniz MJ, Antunes M, Tavares A, Caetano G, Kjöllerström P, Maia R, Sevivas TS, Vidal F, Ribeiro L. Genotype-phenotype correlation in a cohort of Portuguese patients comprising the entire spectrum of VWD types: impact of NGS. Thromb Haemost 2016; 116:17-31. [PMID: 26988807 DOI: 10.1160/th15-07-0604] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Accepted: 03/02/2016] [Indexed: 01/25/2023]
Abstract
The diagnosis of von Willebrand disease (VWD), the most common inherited bleeding disorder, is characterised by a variable bleeding tendency and heterogeneous laboratory phenotype. The sequencing of the entire VWF coding region has not yet become a routine practice in diagnostic laboratories owing to its high costs. Nevertheless, next-generation sequencing (NGS) has emerged as an alternative to overcome this limitation. We aimed to determine the correlation of genotype and phenotype in 92 Portuguese individuals from 60 unrelated families with VWD; therefore, we directly sequenced VWF. We compared the classical Sanger sequencing approach and NGS to assess the value-added effect on the analysis of the mutation distribution in different types of VWD. Sixty-two different VWF mutations were identified, 27 of which had not been previously described. NGS detected 26 additional mutations, contributing to a broad overview of the mutant alleles present in each VWD type. Twenty-nine probands (48.3 %) had two or more mutations; in addition, mutations with pleiotropic effects were detected, and NGS allowed an appropriate classification for seven of them. Furthermore, the differential diagnosis between VWD 2B and platelet type VWD (n = 1), Bernard-Soulier syndrome and VWD 2B (n = 1), and mild haemophilia A and VWD 2N (n = 2) was possible. NGS provided an efficient laboratory workflow for analysing VWF. These findings in our cohort of Portuguese patients support the proposal that improving VWD diagnosis strategies will enhance clinical and laboratory approaches, allowing to establish the most appropriate treatment for each patient.
Collapse
Affiliation(s)
- Teresa Fidalgo
- Teresa Fidalgo, Centro Hospitalar e Universitário de Coimbra (CHUC), Serviço de Hematologia Clínica, Unidade de Trombose e Hemostase, Av Afonso Romão Coimbra 3000-602, Portugal, Tel.: +351 239 480 370, Fax: +351 239 717 216, E-mail:
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
47
|
De Jong A, Eikenboom J. Developments in the diagnostic procedures for von Willebrand disease. J Thromb Haemost 2016; 14:449-60. [PMID: 26714181 DOI: 10.1111/jth.13243] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Indexed: 12/28/2022]
Abstract
Von Willebrand disease (VWD) is the most common inherited bleeding disorder but its diagnosis can be challenging due to the heterogeneity of the disease. VWD is mainly associated with mild mucocutaneous bleeding, although there are more severe phenotypes with bleeding from the gastrointestinal tract or even the joints. Also, surgical interventions and trauma may lead to critical bleeding events. These bleeding episodes are all related to quantitative or qualitative defects of von Willebrand factor (VWF), a multimeric glycoprotein produced by endothelial cells and megakaryocytes, which mediates platelet adhesion and aggregation and binds factor VIII (FVIII) in the circulation. This review describes the diagnostic procedures required for correct diagnosis. Accurate diagnosis and classification is required for proper treatment and counseling. Assessment of bleeding starts with the medical history. After a positive bleeding or family history, subsequent laboratory investigations will start with a panel of standard screening tests for hemostatic defects. Patients suspected of having VWD will be tested for plasma VWF antigen levels, the ability of VWF to bind platelets and FVIII activity. When VWD is confirmed, a set of subtyping tests can classify the patients as VWD types 1, 2 (A, B, M or N) or 3. The performance of some additional assays and analyses, such as VWF propeptide measurement or genetic analysis, may help in identifying the pathological mechanism behind certain defects or can guide in the choice of treatment.
Collapse
Affiliation(s)
- A De Jong
- Department of Thrombosis and Haemostasis, Einthoven Laboratory for Experimental Vascular Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - J Eikenboom
- Department of Thrombosis and Haemostasis, Einthoven Laboratory for Experimental Vascular Medicine, Leiden University Medical Center, Leiden, the Netherlands
| |
Collapse
|
48
|
Rapid discrimination of the phenotypic variants of von Willebrand disease. Blood 2016; 127:2472-80. [PMID: 26917779 DOI: 10.1182/blood-2015-11-664680] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Accepted: 02/15/2016] [Indexed: 11/20/2022] Open
Abstract
Approximately 20% to 25% of patients with von Willebrand disease (VWD) have a qualitative defect of the von Willebrand factor (VWF) protein activities. Variant VWD typically is classified as type 1C, 2A, 2B, 2M, or 2N depending on the VWF activity defect. Traditionally, diagnosis has relied on multiple clinical laboratory assays to assign VWD phenotype. We developed an enzyme-linked immunosorbent assay (ELISA) to measure the various activities of VWF on a single plate and evaluated 160 patient samples enrolled in the Zimmerman Program for the Molecular and Clinical Biology of von Willebrand Disease with type 2 VWD. Using linear discriminate analysis (LDA), this assay was able to identify type 1C, 2A, 2B, 2M, or 2N VWD with an overall accuracy of 92.5% in the patient study cohort. LDA jackknife analysis, a statistical resampling technique, identified variant VWD with an overall accuracy of 88.1%, which predicts the assay's performance in the general population. In addition, this assay demonstrated correlation with traditional clinical laboratory VWF assays. The VWF multiplex activity assay may be useful as a same-day screening assay when considering the diagnosis of variant VWD in an individual patient.
Collapse
|
49
|
Spangenberg T, Budde U, Schewel D, Frerker C, Thielsen T, Kuck KH, Schäfer U. Treatment of acquired von Willebrand syndrome in aortic stenosis with transcatheter aortic valve replacement. JACC Cardiovasc Interv 2016; 8:692-700. [PMID: 25946442 DOI: 10.1016/j.jcin.2015.02.008] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Revised: 02/02/2015] [Accepted: 02/27/2015] [Indexed: 12/11/2022]
Abstract
OBJECTIVES This study sought to investigate the prevalence of abnormal von Willebrand multimers (AbM) in patients undergoing transcatheter aortic valve replacement (TAVR) and the impact of TAVR on the underlying factor variances. BACKGROUND An association between the acquired von Willebrand syndrome (aVWS) and valvular aortic stenosis (AS) has been established in the past and surgical aortic valve replacement (SAVR) shown to lead to factor recovery. Prevalence and course of AbM in patients treated with TAVR though has not yet been described comprehensively. METHODS Ninety-five consecutive patients underwent TAVR at our institution. Hemostaseologic testing was performed before and up to 1 week after TAVR. Transvalvular and right heart hemodynamics as well as bleeding episodes were recorded and analyzed with descriptive statistics. RESULTS Baseline prevalence of AbM was 42% with an average high-molecular-weight multimer (HMWM) count of 16.2 ± 3.3%. Pressure gradients correlated significantly with the extent of HMWM deficiency (r = -0.63 [p < 0.0001]). Following valve implantation, HMWM increased proportional to the drop in mean pressure gradient and normalized in most of the patients. However, residual aortic regurgitation/leakage led to inferior HMWM recovery but prosthesis-patient mismatch (PPM) was rare and left HMWM uninfluenced. We saw no association of transfusion with AbM and 1-year mortality was unaffected by AbM. CONCLUSIONS AbM in patients with AS undergoing TAVR is frequent. However, TAVR is capable of correcting AbM and therefore possibly aVWS in patients with AS. As opposed to SAVR, bleeding and transfusion requirement in TAVR patients was not associated with severe HMWM deficiency; PPM was rare and HMWM were uninfluenced by the procedure. Aortic regurgitation after TAVR adversely influenced HMWM recovery.
Collapse
Affiliation(s)
- Tobias Spangenberg
- Division of Cardiology, Asklepios Klinik St. Georg Hospital, Hamburg, Germany.
| | - Ulrich Budde
- Medilys Laborgesellschaft mbH, Hemostaseology, Hamburg, Germany
| | - Dimitry Schewel
- Division of Cardiology, Asklepios Klinik St. Georg Hospital, Hamburg, Germany
| | - Christian Frerker
- Division of Cardiology, Asklepios Klinik St. Georg Hospital, Hamburg, Germany
| | - Thomas Thielsen
- Division of Cardiology, Asklepios Klinik St. Georg Hospital, Hamburg, Germany
| | - Karl-Heinz Kuck
- Division of Cardiology, Asklepios Klinik St. Georg Hospital, Hamburg, Germany
| | - Ulrich Schäfer
- Division of Cardiology, Asklepios Klinik St. Georg Hospital, Hamburg, Germany; Division of Cardiology, University Heart Center Eppendorf, Hamburg, Germany
| |
Collapse
|
50
|
Budde U, Scheppenheim S, Dittmer R. Treatment of the acquired von Willebrand syndrome. Expert Rev Hematol 2015; 8:799-818. [DOI: 10.1586/17474086.2015.1060854] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
|