Stellenwert der Thrombelastometrie für das Monitoring von Faktor XIII

Recently published studies give evidence, that an increased maximum lysis in the APTEM® – test (ML60 > 12%) of the ROTEM® (Tem International GmbH, Munich, Germany) might indicate a factor XIII deficiency (FXIII < 70%). It was the aim of this study to investigate the feasibility of thrombelastometric measurements with the ROTEM device to reflect the isolated influence of FXIII on clot stability and therefore to indicate potential factor XIII deficiencies. Patients, method: After approval by the local Scientific and Ethic Review Board, 26 consecutive patients, scheduled for elective craniotomy for tumour resection, were prospectively enrolled into this study. Blood samples were taken for conventional laboratory coagulation analyses, FXIII analyses and thrombelastometric measurements (EXTEM, FIBTEM and APTEM tests) after induction of general anaesthesia (T1), before skin incision (T2) as well as at (T3) and 24 hours after (T4) postoperative admission to ICU, respectively. Statistical analyses included Spearman rank order correlations and multiple linear regressions. Results: FXIII concentrations did not correlate with the ML60 in the APTEM test at any measuring point. Neither platelet count nor fibrinogen nor FXIII concentrations were of predictive value for ML60 of the APTEM test. Conclusion: The results lead to the assumption that thrombelastometric measurements may not be appropriate for the perioperative monitoring of FXIII concentration.

Untersuchung zum postoperativen Verlauf bei Patienten mit Hämophilie

Thromboembolic complications may occur in patients with major operations even after routine thromboprophylaxis with low-molecularweight-heparin. In this retrospective, single center survey the post-operative course of patients with haemophilia was investigated. Patients, methods Overall, the postoperative course in 85 patients with haemophilia A and B (median age: 43 years, 18–73 years) and 139 surgical procedures was analyzed. The surgical procedures mainly consist of major orthopedic surgery (58 total knee replacement, 15 hip replacement, 17 other major orthopedic surgery, 15 minor orthopedic procedures). Additional surgical procedures were abdominal-surgical (18), urological (8), neurosurgical (5). Results During the post-operative observation period a small number of wound healing complications occurred (4%). None of the patients developed symptomatic deep vein thrombosis or lung embolism. Conclusion There seems to a decreased risk of postoperative thromboembolism in patients with haemophilia.

Hemmkörperentwicklung bei Hämophilie-Patienten nach Präparate wechsel

The retrospective observational study surveys the relationship between development of inhibitors in the treatment of haemophilia patients and risk factors such as changing FVIII products. A total of 119 patients were included in this study, 198 changes of FVIII products were evaluated. Results: During the observation period of 12 months none of the patients developed an inhibitor, which was temporally associated with a change of FVIII products. A frequent change of FVIII products didn’t lead to an increase in inhibitor risk. The change between plasmatic and recombinant preparations could not be confirmed as a risk factor. Furthermore, no correlation between treatment regimens, severity, patient age and comorbidities of the patients could be found.

Patients with isolated prolonged in vitro bleeding time

In patients with isolated prolonged in vitro bleeding time there is no standardised treatment concept. With this study we characterized the extent of bleeding symptoms.

Patients, methods All diagnoses known to cause prolonged in vitro bleeding time (PFA-100) (epinephrine-cartridge >160 s, ADP-cartridge > 120 s) have been excluded, such as platelet function disorders, effects of medications, nutrition or von Willebrand disease. 75 patients (77%, n = 58 women; 23%, n = 17 men, median age 46 (16–81) years were included. All bleeding symptoms have been stored in a databank with help of a comprehensive questionnaire.

Results 78% (n = 54) of all patients reported of having had an operation, 69.8% (n = 37) of them described postoperative bleedings (p = 0.0373). 13.5% (n = 5) of the 54 could remember having been randomly treated by the administration of a transfusion and only 2.7% (n = 1) were treated by substitution of von Willebrand factor. 71% (n = 51) patients indicated haematoma (p = 0.8116). About 33.8% (n = 24) patients had gum bleeding and 40.8% (n = 29, p = 0.7808) patients reported bleeding after the dentist. 41.4% (n = 29) patients suffered under frequent epistaxis (p = 0.0212). There was no correlation between prolonged epinephrine bleeding time to VWF : Ag (rho = 0.16) nor to VWF : RCo (rho = 0.12) nor between prolonged epinephrine and ADP bleeding time (rho = 0.01) nor to ROTEM® analysis.

Conclusion Patients with isolated prolonged PFA are mainly women and can be affected by all kinds of bleedings while haematoma is the main symptom. VWD might not be causal

Clinical assessment of efficacy and safety of DDAVP

The efficacy of DDAVP (1-deamino-8-D-argi-nine-vasopressin, desmopressin) in mild haemophilia A and von Willebrand disease (VWD) has been established and the use of this well tolerated drug has become clinical routine. In case of increased fluid intake and based on very rarely occurring hyponatraemia, the indication of administration of DDAVP intravenously (i. v.) has to be performed diligently in elderly patients and in children below the age of five years. Aim, patients: Due to clinical practice we were interested in finding prospective parameter potentially correlating with adverse reactions of DDAVP and initiated this study. From 2007 to 2008, we included 49 patients suspicious to suffer from mild haemophilia A (n = 1) or VWD (n = 48) and investigated efficacy and safety of DDAVP after intravenous administration (mean: 0.29 ± 0.032 μg/kg body weight). They underwent clinical and laboratory investigation and were questioned with regard to potential adverse reactions immediately and three days after administration of DDAVP.: Results, conclusion: Most adverse reactions were mild and no serious adverse drug reactions were either observed or reported by the subjects. We identified significant changes of heart rate, blood pressure and leucocytes after conduct of the DDAVP test. The value of these findings has to be investigated in later prospective randomized studies. Further research on identification of prospective parameter is currently ongoing.

[Prevalence of Elevated Lipoprotein (a) Levels in Patients < 60 Years of Age with Retinal Vein Occlusion]

BACKGROUND

The potential impact of elevated Lipoprotein (a) [Lp(a)] levels on retinal venous occlusive (RVO) diseases with regard to age and various risk factors has not been studied extensively.

PATIENTS AND METHODS

In a retrospective case-control study, thrombophilia data of 106 young patients (< 60 years at the time of the RVO or a previous thromboembolic event) with RVO and 76 healthy subjects were evaluated.

RESULTS

Elevated Lp(a) plasma levels were significantly more prevalent among RVO patients (29.2 %) than among controls (9.2 %; p = 0.0009). Lp(a) levels were found to be significantly (p = 0.012) different between patients and controls. Moreover, we found that an unusual personal or family history of thromboembolism was a strong predictor of elevated Lp(a) (p = 0.03). We observed a significant correlation between elevated Lp(a) and other coagulation disorders (p = 0.005). Multivariate analysis showed that elevated lipoprotein(a) levels (OR: 3.5; p = 0.003) were an independent risk factor for the development of RVO.

CONCLUSIONS

Elevated plasma levels of Lp(a) are associated with the development of RVO. Selective screening of young patients and subjects with a personal or family history of thromboembolism may be helpful in identifying RVO patients with elevated Lp(a).

Safety and pharmacokinetics of anti-TFPI antibody (concizumab) in healthy volunteers and patients with hemophilia: a randomized first human dose trial

BACKGROUND

Prophylaxis with either intravenous (i.v.) factor VIII (FVIII) or FIX is the gold standard of care for patients with severe hemophilia. A monoclonal antibody (concizumab) targeting tissue factor pathway inhibitor (TFPI) that can be administered subcutaneously (s.c.) has the potential to alter current concepts of prophylaxis in hemophilia.

OBJECTIVES

To evaluate the safety and describe the pharmacokinetics and pharmacodynamics of single-dose concizumab in healthy volunteers and patients with hemophilia A or B.

METHODS

In this first human dose, phase 1, multicenter, randomized, double-blind, placebo-controlled trial escalating single i.v. (0.5-9000 μg kg(-1) ) or s.c. (50-3000 μg kg(-1) ) doses of concizumab were administered to healthy volunteers (n = 28) and hemophilia patients (n = 24).

RESULTS

Concizumab had a favorable safety profile after single i.v. or s.c. administration. There were no serious adverse events and no anti-concizumab antibodies. No clinically relevant changes in platelets, prothrombin time, activated partial thromboplastin time, fibrinogen, or antithrombin were found. A dose-dependent procoagulant effect of concizumab was seen as increased levels of D-dimers and prothrombin fragment 1 + 2. Nonlinear pharmacokinetics of concizumab was observed due to target-mediated clearance. A maximum mean AUC0-∞ of 33 960 h μg mL(-1) and a maximum mean concentration of 247 μg mL(-1) was measured at the highest dose.

CONCLUSIONS

Concizumab showed a favorable safety profile after i.v. or s.c. administration and nonlinear pharmacokinetics was observed due to target-mediated clearance. A concentration-dependent procoagulant effect of concizumab was observed, supporting further study into the potential use of s.c. concizumab for hemophilia treatment.

Rare bleeding disorders are associated with depression and anxiety

Thrombotic thrombocytopenic purpura (TTP), immune thrombocytopenia (ITP) and acquired haemophilia are very rare haemorrhagic disorders (1) associated with surgery, hospitalization (2) and death being reported (3). Despite the rapid development of interventional techniques, therapeutic options for patients with these illnesses remain limited. We suppose that depression and anxiety disorders appear more frequently than in the normal population in patients with rare haemorrhagic disorders.

Leben mit Hämophilie

Patienten mit Hämophilie können altersbedingte Probleme und Erkrankungen entwickeln. Um Fragestellungen des zunehmenden Alters bei Patienten mit Hämophilie besser einschätzen zu können, wurde ein Fragebogen an die Patientenorganisationen DHG und IGH versandt.

Insgesamt 466 Personen nahmen an der Umfrage Teil (mittleres Alter: 50 Jahre, 21–85 Jahre), meist mit schwerer Hämophilie. Die Mehrheit der Befragten schätzte die Möglichkeit zur Substitution im Blutungsfall als sehr wichtig ein und äußerte Bedenken bezüglich der finanziellen Lage und der medizinischen Versorgung im Alter. Insgesamt gaben die Ergebnisse der Untersuchung Einblick in aus Patientensicht wichtige Themen der Versorgung der Hämophilie im Alter.

[Life with haemophilia. The patient's perspective of ageing]

Patients with haemophilia are growing older and may be faced with age-dependent co-morbidities. To evaluate the impact of growing age in patients with haemophilia, a questionaire was sent to members of German patients' organisations DHG and IGH with focus on medical care and psychosocial questions. This questionnaire was answered by 466 individuals (aged 50 years, 21-85 years), predominantly suffering from severe haemophilia. The majority of individuals considered the question of substitution of factor concentrates in case of bleeding as most important. Concerns were expressed regarding the financial situation and lack of medical care in higher age. The results provide an insight into issues of growing age from the patient's perspective.

[Massive subretinal hemorrhage and anticoagulants. An unfortunate combination?]

Exudative age-related macular degeneration (ARMD) is one of the conditions which has been shown to be associated with a risk of massive subretinal hemorrhage. Patients with thick submacular hemorrhage complicating ARMD typically have a poor visual prognosis. Antiplatelet therapy with aspirin, clopidogrel or ticlopidine has significant benefits in the secondary prevention of fatal and non-fatal coronary and cerebrovascular events. Anticoagulation is frequently used in this elderly age group for a variety of other comorbidities including prosthetic heart valves, atrial fibrillation, ischemic heart disease, cerebrovascular disease and venous thromboembolism. However, it is a well established observation that the longer patients remain on anticoagulant therapy, the higher the cumulative risk of bleeding. Over the past years, there has been a rapidly growing body of literature concerning the risk of hemorrhagic ocular complications with ophthalmic surgery in patients receiving anticoagulant therapy. By contrast, there are still little data on the relationship between anticoagulation or antiplatelet therapy and spontaneous ocular hemorrhages and only few reports have focused on patients with ARMD. Just recently, several authors reported a strong association of anticoagulants and antiplatelet agents with the development of large subretinal hemorrhages in ARMD patients. Moreover, arterial hypertension is a high risk factor for large subretinal hemorrhages in ARMD patients receiving anticoagulants or antiplatelet agents. Physicians should be aware of an increased risk of extensive subretinal hemorrhage in ARMD patients when deciding on the initiation and duration of anticoagulant and antiplatelet therapy.

von Willebrand's disease: a report from a meeting in the Åland islands

von Willebrand's disease (VWD) is probably the most common bleeding disorder, with some studies indicating that up to 1% of the population may have the condition. Over recent years interest in VWD has fallen compared to that of haemophilia, partly the result of focus on blood-borne diseases such as HIV and hepatitis. Now the time has come to revisit VWD, and in view of this some 60 international physicians with clinical and scientific interest in VWD met over 4 days in 2010 in the Åland islands to discuss state-of-the-art issues in the disease. The Åland islands are where Erik von Willebrand had first observed a bleeding disorder in a number of members of a family from Föglö, and 2010 was also the 140th anniversary of his birth. This report summarizes the main papers presented at the symposium; topics ranged from genetics and biochemistry through to classification of VWD, pharmacokinetics and laboratory assays used in the diagnosis of the disease, inhibitors, treatment guidelines in different age groups including the elderly who often have comorbid conditions that present challenges, and prophylaxis. Other topics included managing surgeries in patients with VWD and the role of FVIII in VWF replacement, a controversial subject.

Mortality and inherited thrombophilia: results from the European Prospective Cohort on Thrombophilia

BACKGROUND

Data on the survival of individuals with hereditary thrombophilia are rare and only come from retrospective studies.

OBJECTIVE

The aim of the present study was to assess mortality in individuals with known thrombophilia with and without a history of thrombosis in comparison to a control group.

PATIENTS/METHODS

The European Prospective Cohort on Thrombophilia (EPCOT) study is a prospective, multi-center observational study performed to assess the risk of thrombosis in persons with inherited thrombophilia. In an extension of the present study, the vital status was assessed in 1240 individuals with thrombophilia (mean age 40.9 years, 59% women, 196 with antithrombin, 341 with protein C, 276 with protein S-deficiency, 330 with factor (F)V Leiden and 97 with combined defects, and 62% with a history of venous thrombosis [VT]) and 875 controls (mean age 42.5 years, 48% women, 7% with a history of VT).

RESULTS

Seventy-two individuals with thrombophilia and 45 controls died during follow-up. The risk of death, adjusted for gender, thrombosis history and center, was not associated with thrombophilia (hazard ratio [HR] thrombophilia individuals vs. controls: 1.09, 95% confidence interval [CI] 0.66-1.78). When individuals with thrombophilia were evaluated separately, a history of thrombosis was not associated with mortality: the risk of death after adjustment for gender, anticoagulation and center was HR 0.79 (95% CI, 0.41-1.54).

CONCLUSIONS

No increased risk of death in individuals with thrombophilia, not even in those with a history of thrombosis, was observed.

[Inhibitor development after changing FVIII/IX products in patients with haemophilia]

The retrospective observational study surveys the relationship between development of inhibitors in the treatment of haemophilia patients and risk factors such as changing FVIII products. A total of 119 patients were included in this study, 198 changes of FVIII products were evaluated.

RESULTS

During the observation period of 12 months none of the patients developed an inhibitor, which was temporally associated with a change of FVIII products. A frequent change of FVIII products didn't lead to an increase in inhibitor risk. The change between plasmatic and recombinant preparations could not be confirmed as a risk factor. Furthermore, no correlation between treatment regimens, severity, patient age and comorbidities of the patients could be found.

[Incidence of thromboembolic events after major operations in patients with haemophilia]

Thromboembolic complications may occur in patients with major operations even after routine thromboprophylaxis with low-molecular-weight-heparin. In this retrospective, single center survey the post-operative course of patients with haemophilia was investigated.

PATIENTS, METHODS

Overall, the postoperative course in 85 patients with haemophilia A and B (median age: 43 years, 18-73 years) and 139 surgical procedures was analyzed. The surgical procedures mainly consist of major orthopedic surgery (58 total knee replacement, 15 hip replacement, 17 other major orthopedic surgery, 15 minor orthopedic procedures). Additional surgical procedures were abdominal-surgical (18), urological (8), neurosurgical (5).

RESULTS

During the post-operative observation period a small number of wound healing complications occurred (4%). None of the patients developed symptomatic deep vein thrombosis or lung embolism.

CONCLUSION

There seems to a decreased risk of postoperative thromboembolism in patients with haemophilia.

[Does FVIII-activity increase with age in patients with haemophilia A and carriers of haemophilia A?]

The retrospective cohort study surveys the influence of age, co-morbidity and laboratory values on FVIII-activity (FVIII:C) in patients with haemophilia A with (mild n = 48, moderate n = 10, severe n = 7 and carriers n = 23). Median observation was 19 years for patients with haemophilia A and 9,5 years for carriers.

RESULTS

FVIII:C levels collected from patients with mild haemophilia A displayed a significant median increase of 6.5% with proceeding age (p = 0.0013). Patients with moderate haemophilia A (and carriers of haemophilia A) showed a non significant median increase of 1.05% (carriers 8%). Eight patients showed FVIII:C levels at last blood withdrawal that indicated a change of severity from moderate to mild haemophilia A. A significant correlation was found between FVIII:C and VWF:RCo (p = 0.0203) and AFP (p < 0.0005). The correlation between FVIII:C and triglycerides and LDH was significant negative (p < 0.0005). No significant correlation could be found for FVIII:C and co-morbidity, fibrinogen, cholesterol and VWF:Ag.

Patients with isolated prolonged in vitro bleeding time. Clinical symptoms

In patients with isolated prolonged in vitro bleeding time there is no standardised treatment concept. With this study we characterized the extent of bleeding symptoms.

PATIENTS, METHODS

All diagnoses known to cause prolonged in vitro bleeding time (PFA-100) (epinephrine-cartridge >160 s, ADP-cartridge > 120 s) have been excluded, such as platelet function disorders, effects of medications, nutrition or von Willebrand disease. 75 patients (77%, n = 58 women; 23%, n = 17 men, median age 46 (16-81) years were included. All bleeding symptoms have been stored in a databank with help of a comprehensive questionnaire.

RESULTS

78% (n = 54) of all patients reported of having had an operation, 69.8% (n = 37) of them described postoperative bleedings (p = 0.0373). 13.5% (n = 5) of the 54 could remember having been randomly treated by the administration of a transfusion and only 2.7% (n = 1) were treated by substitution of von Willebrand factor. 71% (n = 51) patients indicated haematoma (p = 0.8116). About 33.8% (n = 24) patients had gum bleeding and 40.8% (n = 29, p = 0.7808) patients reported bleeding after the dentist. 41.4% (n = 29) patients suffered under frequent epistaxis (p = 0.0212). There was no correlation between prolonged epinephrine bleeding time to VWF:Ag (rho = 0.16) nor to VWF:RCo (rho = 0.12) nor between prolonged epinephrine and ADP bleeding time (rho = 0.01) nor to ROTEM® analysis.

CONCLUSION

Patients with isolated prolonged PFA are mainly women and can be affected by all kinds of bleedings while haematoma is the main symptom. VWD might not be causal.

Safety and pharmacokinetics of subcutaneously administered recombinant activated factor VII (rFVIIa)

BACKGROUND

 Recombinant activated factor VIIa (rFVIIa) is used to treat bleeds in hemophilia patients with inhibitors. A subcutaneous formulation could potentially improve its half-life and make it suitable for prophylactic treatment.

OBJECTIVES

 A study was conducted to determine the safety of subcutaneously administered rFVIIa in patients with hemophilia and the pharmacokinetic profile (including bioavailability).

PATIENTS/METHODS

 This was a multicenter, open-label, cross-over comparison of single doses of intravenous rFVIIa 90μgkg(-1) and a new formulation of rFVIIa for subcutaneous injection at dose levels of 45, 90, 180, 270 and 360μgkg(-1) . Sixty subjects (12 per dose cohort) with hemophilia A or B were enrolled.

RESULTS

 Subcutaneously administered rFVIIa showed lower mean peak plasma concentrations and prolonged FVII activity (C(max) , 0.44-5.16IU mL(-1) [across doses]; t(1/2) , 12.4h; t(max) , 5.6h) compared with intravenously administered rFVIIa (C(max) , 51.7IUmL(-1) ; t(1/2) , 2.7h; t(max) , <10min). The absolute bioavailability of subcutaneous rFVIIa ranged from 21.1 to 30.1% across dose levels. Dose proportionality was observed within a 2-fold dose increase but not across the full dose range. No thromboembolic events, drug-related serious adverse events, severe injection-site reactions or neutralizing antibodies were reported (primary endpoint). Mild and moderate injection-site reactions were more frequent with subcutaneous than with intravenous injections.

CONCLUSION

 This phase I clinical trial did not identify safety concerns of prolonged exposure to rFVIIa administered subcutaneously in single doses to hemophilia patients.

[Thrombophilic and systemic risk factors in patients with retinal vein occlusion]

Over the past years there has been a dramatic increase in the number of identifiable causes of thrombophilia. However, as retinal vein occlusions (RVO) have a strong pathogenic correlation with the presence of hypertension or arteriosclerosis and the average age of affected patients is usually within the sixth or seventh decade of life, thrombophilia screening of RVO patients poses a particularly difficult diagnostic challenge. It is clear that to use medical resources appropriately and improve the level of interdisciplinary patient care in RVO, subgroup analysis is required. Just recently, some studies have demonstrated the significant role of coagulation disorders in specific subgroups of RVO patients and have provided recommendations for clinical practice. These results indicate that thrombophilic risk factors are significantly more prevalent among patients equal or less than 45 years of age at the time of RVO or a previous thromboembolic event, among patients with a remarkable family history of thromboembolism prior to the age of 45 years, or among patients without cardiovascular risk factors. According to these data, thrombophilia screening should be considered in these selected subgroups.

Hämophilie-A-Patienten und Konduktorinnen für Hämophilie A

The retrospective cohort study surveys the influence of age, co-morbidity and laboratory values on FVIII-activity (FVIII : C) in patients with haemophilia A with (mild n = 48, moderate n = 10, severe n = 7 and carriers n = 23). Median observation was 19 years for patients with haemophilia A and 9,5 years for carriers.

Results FVIII : C levels collected from patients with mild haemophilia A displayed a significant median increase of 6.5% with proceeding age (p = 0.0013). Patients with moderate haemophilia A (and carriers of haemophilia A) showed a non significant median increase of 1.05% (carriers 8%). Eight patients showed FVIII : C levels at last blood withdrawal that indicated a change of severity from moderate to mild haemophilia A. A significant correlation was found between FVIII : C and VWF : RCo (p= 0.0203) and AFP (p < 0.0005). The correlation between FVIII : C and triglycerides and LDH was significant negative (p < 0.0005). No significant correlation could be found for FVIII : C and co-morbidity, fibrinogen, cholesterol and VWF : Ag.

Association between phenotype and genotype in carriers of haemophilia A

Female carriers of haemophilia might suffer from increased bleeding tendency therefore the assessment of the bleeding risk is very important for improving care. This single-centre study documents the occurrence of bleedings in 46 carriers of haemophilia A including bleeding after tooth extraction (77%), easy bruising (67%), postsurgical bleeding (61%), menorrhagia (50%) or prolonged postpartum bleeding (43%). The F8 gene mutation of all 46 carriers (median age: 36.5 years, 15-80 years; mean FVIII:C activity: 59 ± 24.45%; normal range: 64-167%) was determined, and family history of haemophilia was recorded. For analysis, the bleeding tendency of the carriers was differentiated by severity into three groups. There was no statistically significant difference of FVIII:C between these groups. However, a correlation was found between the severity of bleeding tendency and the type of F8 gene mutation (P < 0.05) as well as the severity of haemophilia in affected male relatives (P < 0.0005). Results show that even carriers with a FVIII:C activity as high as 50-60% are at increased risk of bleeding. Incidence and intensity of bleeding symptoms of haemophilia A carriers are high and correlated with the phenotype of the male haemophilic relative and the underlying F8 gene mutation.

Prolactin’s role in the pathogenesis of the antiphospholipid syndrome

Increased levels of serum prolactin have been reported in patients with various autoimmune diseases and have been associated with lupus disease activity. Currently, there is a lack of data regarding hyperprolactinaemia in patients with the antiphospholipid syndrome. Hence, this study was carried out in order to evaluate the prevalence and clinical significance of hyperprolactinaemia in antiphospholipid syndrome. A total of 172 European patients with antiphospholipid syndrome and 100 geographically and sex-matched healthy controls were included in the study; none had obvious causes of hyperprolactinaemia. All patients underwent clinical assessment for disease manifestations, in addition to laboratory assessment for serum prolactin, antiphospholipid antibodies and some other biomarkers of autoimmune diseases. The tests were performed utilizing the LIAISON® Analyzer (DiaSorin, Sallugia Italy). Hyperprolactinaemia was detected in 21/172 patients with antiphospholipid syndrome and 0/100 controls (p < 0.001). This significant difference was present in both genders and was obvious even after subgrouping the patients into primary and secondary antiphospholipid syndrome. When clinical features were compared, hyperprolactinaemia was associated with reproductive failure, including early and late pregnancy loss (p < 0.05), as well as intrauterine growth retardation (p < 0.05). Hyperprolactinaemia was negatively related to arthralgias, venous thrombosis, pulmonary microthrombosis, pulmonary hypertension in both primary antiphospholipid syndrome and antiphospholipid syndrome secondary to other diseases, and to neurological manifestations in primary antiphospholipid syndrome (p<0.05). The data indirectly imply that prolactin may play a role in the pathogenesis of antiphospholipid syndrome, especially antiphospholipid syndrome-related reproductive failure.

Clinical assessment of efficacy and safety of DDAVP

The efficacy of DDAVP (1-deamino-8-D-arginine-vasopressin, desmopressin) in mild haemophilia A and von Willebrand disease (VWD) has been established and the use of this well tolerated drug has become clinical routine. In case of increased fluid intake and based on very rarely occurring hyponatraemia, the indication of administration of DDAVP intravenously (i. v.) has to be performed diligently in elderly patients and in children below the age of five years. Aim, patients: Due to clinical practice we were interested in finding prospective parameter potentially correlating with adverse reactions of DDAVP and initiated this study. From 2007 to 2008, we included 49 patients suspicious to suffer from mild haemophilia A (n = 1) or VWD (n = 48) and investigated efficacy and safety of DDAVP after intravenous administration (mean: 0.29±0.032 &mu;g/kg body weight). They underwent clinical and laboratory investigation and were questioned with regard to potential adverse reactions immediately and three days after administration of DDAVP.

RESULTS, CONCLUSION

Most adverse reactions were mild and no serious adverse drug reactions were either observed or reported by the subjects. We identified significant changes of heart rate, blood pressure and leucocytes after conduct of the DDAVP test. The value of these findings has to be investigated in later prospective randomized studies. Further research on identification of prospective parameter is currently ongoing.

[Total knee replacement in haemophilic arthropathy. A clinical and radiological evaluation of 30 patients]

Purpose of this retrospective study was to evaluate our own results after total knee replacement in patients with haemophilia. Patients, material, method: 30 patients with haemophilia who underwent total knee replacement between 1987 and 2005 were included. We used the clinical and radiological Knee Society Score. Furthermore, the Petterson and the Arnold and Hilgartner score were applied.

RESULTS

The mean age at the time of surgery was 43.2 (27-66). At the time of follow-up examination the mean age was 51.6 (30-82) years. The mean follow-up was 7.1 (2-20) years. Preoperative, he mean Arnold and Hilgartner score was 4.17 (±0.59) and the mean Petterson-Score was 9±2.29. Compared to the preoperative deficiency in knee function (KSS-Score 88.17±33.58) an improvement with 166.67 (±22.73) points was seen. 1 patient showed an aseptic loosening after 11 years.

DISCUSSION

Total knee replacement in patients with haemophilia improves knee function and quality of life. The results of our study represent results in earlier published studies. Compared to a non-haemophilic normal population the rate of perioperative complications was not increased.

Vitamin D: an instrumental factor in the anti-phospholipid syndrome by inhibition of tissue factor expression

BACKGROUND AND AIMS

Antiphospholipid syndrome (APS) is a systemic autoimmune disease characterised by thrombosis, obstetric complications and the presence of anti-phospholipid antibodies such as anti-β2GPI-Abs. These antibodies may set off the coagulation cascade via several mechanisms, including the induction of tissue factor (TF) expression. Vitamin D has recently emerged as an immunomodulator that might exert an anti-thrombotic effect. Therefore, we studied serum vitamin D levels in a cohort of APS patients, as well as the effect of vitamin D in an in vitro model of APS-mediated thrombosis.

METHODS

Serum vitamin D levels were measured in 179 European APS patients and 141 healthy controls using the LIAISON chemiluminescent immunoassay, and the levels were evaluated in conjunction with a wide spectrum of clinical manifestations. In an vitro model, anti-β2GPI antibodies were purified from four patients with APS to evaluate the expression of TF in activated starved human umbilical vein endothelial cells. The effect of vitamin D (1,25-dihydroxyvitamin D, 10 nm) on anti-β2GPI-Abs mediated TF expression was analysed by immunoblot.

RESULTS

Vitamin D deficiency (serum level ≤15 ng/ml) was documented in 49.5% of our APS patients versus 30% of controls (p<0.001) and was significantly correlated with thrombosis (58% vs 42%; p<0.05), neurological and ophthalmic manifestations, pulmonary hypertension, livedo reticularis and skin ulcerations. In vitro vitamin D inhibited the expression of TF induced by anti-β2GPI-antibodies.

CONCLUSIONS

Vitamin D deficiency is common among APS patients and is associated with clinically defined thrombotic events. Vitamin D inhibits anti-β2GPI-mediated TF expression in vitro. Thus, vitamin D deficiency might be associated with decreased inhibition of TF expression and increased coagulation in APS. Evaluation of vitamin D status and vitamin D supplementation in APS patients should be considered.

Kniegelenksendoprothetik bei hämophiler Arthropathie

Purpose Purpose of this retrospective study was to evaluate our own results after total knee replacement in patients with haemophilia. Patients, material, method: 30 patients with haemophilia who underwent total knee replacement between 1987 and 2005 were included. We used the clinical and radiological Knee Society Score. Furthermore, the Petterson and the Arnold and Hilgartner score were applied. Results: The mean age at the time of surgery was 43.2 (27–66). At the time of follow- up examination the mean age was 51.6 (30–82) years. The mean follow-up was 7.1 (2–20) years. Preoperative, he mean Arnold and Hilgartner score was 4.17 (± 0.59) and the mean Petterson-Score was 9 ± 2.29. Compared to the preoperative deficiency in knee function (KSS-Score 88.17 ± 33.58) an improvement with 166.67 (± 22.73) points was seen. 1 patient showed an aseptic loosening after 11 years. Discussion: Total knee replacement in patients with haemophilia improves knee function and quality of life. The results of our study represent results in earlier published studies. Compared to a non-haemo-philic normal population the rate of perioper-ative complications was not increased.

Treatment of haemophilia in the elderly

Treatment of elderly patients with haemophilia is an upcoming challenge in haemophilia care. We included patients with haemophilia A older than 60 years of age, who visited our haemophilia centre between 2006 and 2008. We conducted a retrospective study focussing on the patients' co-morbidities as well as changes in their bleeding patterns between 2003 and 2008.

RESULTS

There is a tendency of increasing bleeding symptoms with increasing age of the patients due to more frequent spontaneous joint bleedings, malignancies or treatment with phenprocoumon or ASS. In consequence, FVIII dosage had to be increased for 8 patients (28%). Chronic hepatitis C, coronary heart disease and malignancies are the most frequent co-morbidities.

Age-dependent increase of FVIII:C in mild haemophilia A

Variability of FVIII:C levels in healthy individuals and age-dependent increase are a known phenomenon. In haemophilia, increasing FVIII:C levels with age have not been described yet. In our study, we evaluated this issue retrospectively in a cohort older than 45 years of 29 patients with mild haemophilia and 14 patients with moderate or severe haemophilia at last visit at the haemophilia centre Frankfurt. The median duration of observation evaluated in this study was 17 years (range 5-28). Results show a significant correlation of increasing FVIII:C levels with age in mild haemophilia (P = 0.000041) and a non-significant tendency to a higher increase in higher age (P = 0.085652). The median difference of FVIII:C level between the first and last measurement was 8% of normal plasma concentration (range -3% to +35%). Median FVIII:C level increase of patients younger than 62 years was 7.5% (range -3 to 22), median increase in older patients was 12% (range 0-35). This tendency could not be correlated to decreased number of bleedings, but FVIII substitution dosage should be adapted to changing plasma levels at higher age to prevent overdosing or thrombotic risks. Possible causes and contributing factors for increasing FVIII:C levels are discussed. Statistical significance remains to be confirmed in larger prospective studies also including younger patients.

Treatment of haemophilia in the elderly

Treatment of elderly patients with haemophilia is an upcoming challenge in haemophilia care. We included patients with haemophilia A older than 60 years of age, who visited our haemophilia centre between 2006 and 2008. We conducted a retrospective study focussing on the patients’ co-morbidities as well as changes in their bleeding patterns between 2003 and 2008. Results: There is a tendency of increasing bleeding symptoms with increasing age of the patients due to more frequent spontaneous joint bleedings, malignancies or treatment with phenprocoumon or ASS. In consequence, FVIII dosage had to be increased for 8 patients (28%). Chronic hepatitis C, coronary heart disease and malignancies are the most frequent co-morbidities

Recurrent deep vein thrombosis, ovarian carcinoma and antibodies to mitochondria M5 in a patient with asymptomatic primary "plus" antiphospholipid syndrome: an unusual combination

An asymptomatic thirty-eight-year-old female developed recurrent DVT at the latter end of her first pregnancy and in the puerperium. Blood tests revealed a moderately elevated ANF (1:640) with a speckled pattern, hyperglobulinemia, and antibodies to thyroid tissues. Two months postpartum, following neurological disturbances she was found to have a patent foramen ovale and had developed paradoxical emboli to the brain causing multiple arterial occlusions. However, she also had cerebral venous occlusions as well as deep venous thromboses and pulmonary emboli, indicating a generalised prothrombotic state. Abdominal ultrasound examination revealed the presence of tumour which, on surgical removal, proved to be an ovarian carcinoma. The only antiphospholipid antibodies detectable were antibodies to mitochondria Type M5 in moderately elevated titres.

The role of malignancies in patients with catastrophic anti-phospholipid (Asherson’s) syndrome

The catastrophic anti-phospholipid syndrome (CAPS) differs from the anti-phospholipid syndrome in its accelerated systemic involvement leading to multi-organic failure. In this study, the occurrence of malignancies in patients with CAPS was evaluated and the clinical findings of CAPS patients with and without malignancies were compared. We investigated the web site-based international registry of patients with CAPS for all cases in which both CAPS and underlying malignancies were present. The clinical characteristics of these cases were subsequently evaluated to establish common characteristics. The CAPS registry included information on a total of 262 cases. Twenty-three (9%) patients suffered from malignancies. In 78% of these patients, the malignancy itself or the treatment modalities instituted for the carcinoma was the precipitating factor of CAPS. Only 39% of CAPS patients with malignancies recovered in comparison to 58% of patients without malignancies (p = 0.07). Treatment modalities, however, did not differ significantly between these patients. Infections were not evident as precipitating factors for any of the malignancy patients. The mean age of patients with malignancies was 9 years older than the average age of other patients with CAPS and the prevalence of SLE was significantly less common than in patients without malignancy. Malignancy may play a pathogenic role in patients with CAPS, whereas infections are more important as triggering factors in patients without malignancies. CAPS patients with malignancies are generally older than CAPS patients without malignancies; they generally have the worst prognosis of the entire CAPS cohort.

The catastrophic antiphospholipid (Asherson's) syndrome and malignancies

The catastrophic antiphospholipid syndrome is characterised by the rapid chronological development of fulminant thrombotic complications that predominantly affect small vessels. It has been reported as frequently occurring in patients with underlying malignancies. We analysed the web site-based international registry of patients with catastrophic APS. The clinical characteristics of patients with CAPS and an underlying malignancy were evaluated. Of the 262 patients included in the CAPS registry, information on associated malignancies was available in 23 (9%) cases. Haematological malignancies were present in 6 (26%) patients. Four of the patients suffered from lung carcinoma (17%), and two patients (9%) from colon carcinoma. In most of the patients (61%), malignancy was the precipitating factor for CAPS. In 4 patients (17%), however, surgical procedures related to the carcinoma were noted as precipitating factors. In one patient CAPS occurred during allogenic stem cell transplantation after diagnosis of acute lymphoblastic leukemia (ALL). Cerebral manifestations were most common and consisted mainly of cerebral infarcts and encephalopathy. Recovery occurred in 9/23 (39%) patients. Malignancy may be an important risk factor for CAPS. 9% of patients with CAPS presented with an underlying malignancy. In most of these patients, the malignancy and/or surgical procedures were the precipitating factors for CAPS.

High titres of IgM-antiphospholipid antibodies are unrelated to pathogenicity in patients with non-Hodgkin’s lymphoma

Heterogeneity in the mechanisms of coagulation may contribute to an increased thrombotic risk for patients with malignancies. The coincidence of malignancies and antiphospholipid antibodies (aPL) have been described in several important epidemiological studies. The pathological significance of aPL in patients with malignancies is, however, still unclear. In this study, we investigated the clinical manifestations of four patients with elevated IgM-aPL titres lying outside the region signifying 95% of normal cases and with a history of non-Hodgkin's lymphoma. The patients had elevated IgG- and IgM-anticardiolipin antibodies (aCL) and also tested positive for lupus anticoagulants. Other aPL were measured, and we found high positive results for all tested antibodies in three patients. The production of aPL, however, occurred in the absence of thrombotic complications. No thromboembolic manifestations occurred during the follow-up period either. It could also be demonstrated that the degree to which the aCL titre was elevated resembles the elevation of the non-classical antiphospholipid antibodies, but not that of beta2-GP-1 or anti-annexin antibodies. Therefore, it can be postulated that these extremely high levels of IgM-aCL antibodies do not enhance the risk of thrombosis and may be completely different from aCL antibodies in an antiphospholipid syndrome patient population without malignancies. In particular, haematological and lymphoproliferative malignancies may indeed be associated with the generation of aPL, but do not necessarily enhance the thrombophilic risk in these patients.

[The antiphospholipid syndrome]

Antiphospholipid antibody syndrome (APS) is characterised by the presence of frequently recurring venous and/or arterial thrombosis, abortions and repeated evidence of lupus anticoagulants and/or anticardiolipin (aCL)-antibodies. The presence of lupus anticoagulants and/or high levels of aCL-antibodies in particular increases the risk of thrombosis. At present there are several models for the systemic and cell-damaging pathogenesis of phospholipid-antibodies. Where there are repeated occurrences of thrombo-embolic complications long-term anticoagulant treatment is indicated. For patients who have APS in pregnancy, the use of low-molecular heparin and acetylsalicylic acid (ASS) is recommended. According to recent research, a large number of antibodies can be found in APS patients, which are directed against phospholipids and plasmaproteins, but partly also against individual genetic polymorphism, which suggests focussing in future on the genetic basis of APS as well as on influencing "auto-immune thrombosis" by modulating the immune system.

Recurrent life-threatening thromboembolism and catastrophic antiphospholipid syndrome in a patient despite sufficient oral anticoagulation

We report on a 32-year old female patient with primary antiphospholipid syndrome (PAPS) and several thromboembolic events despite stable doses of oral anticoagulation, good patient compliance and maintained INR values of >3. Over the preceding 3 years the patient had presented a wide spectrum of manifestations of APS, including recurrent venous and arterial thromboses, cardiac, gynecological (HELLP syndrome), neurological involvements, livedo reticularis, a mild thrombocytopenia and the most feared manifestation of the catastrophic antiphospholipid syndrome (CAPS). Life-threatening bilateral subdural bleeding occurred while she was anticoagulated. The clinical features appeared to be refractory to oral anticoagulation with phenprocoumon. They were life threatening on each occasion and she developed repetitive episodes of organ damage with cardiac insufficiency (NYHA III), pulmonary hypertension and other residual defects. Even during heparinization recurrent thromboembolism supervened as well as livedo reticularis of the extremities. Lupus anticoagulants (LAC), anticardiolipin (aCL) antibodies and anti-β₂-glycoprotein-1 (β₂GPI) titers were all markedly elevated. This case report shows that recurrent episodes of thrombosis can occur despite seemingly adequate anticoagulation in patients with CAPS.

[Cardiac and cerebral manifestations of antiphospholipid syndrome]

We describe cardiac and cerebral manifestations in 27 patients with the antiphospholipid syndrome and give a review of the literature.

PATIENTS AND METHODS

We studied 27 patients with either cardiac, cerebral or both manifestations, who also were diagnosed with the antiphospholipid syndrome (APS). All patients fulfilled the proposed classification criteria for the APS according to the Scientific Standardisation Committee of the International Society of Thrombosis and Haemostasis (1). Three patients died.

RESULTS

Eighteen of the 27 patients had coronary artery disease with either thrombotic coronary occlusions, high grade stenosis or complete vessel occlusion. In three patients the left main artery was involved. Ten patients had involvement of the left anterior descending artery (LAD), 6 patients of the circumflex artery (RCX) and 5 patients had involvement of the right coronary artery (RCA). As valvular lesions have been described in association with the APS it should be noted that in 16 cases there was mitral- and/or aortic valve disease and in 3 cases tricuspid valve disease. Four patients underwent mitral- and/or aortic- and/or tricuspid valve replacement. 7 patients presented with a history of cerebrovascular involvement; 5 of these patients had cerebral infarction, one patient recurrent cerebral bleeding under oral anticoagulation and another patient presented with cognitive disorders. Three of the 7 patients had a prior history of myocardial infarction, whereas 3 patients underwent mitral or aortic valve replacement.

CONCLUSION

The frequent occurrence of coronary disease, cardiac valvular disease and cerebral disease in patients diagnosed with APS may suggest a causative relationship between the presence of PL antibodies and vascular disease.