BUTUAN DOCTORS COLLEGE

College of Medical Technology

Hematology 2 Lecture
Assignment No. 3

Name: Hilary Dianne Y. Tuto Date: March 13, 2021

Instructor: Ms. Rosevib R. Jacobe, RMT, MSMLS Section: BMLSIII-A

1. List and interpret laboratory tests that differentiate among acquired hemorrhagic
disorders of trauma and liver disease.

Screening Tests for a Generalized Hemostatic Disorder

Test
Hemoglobin, hematocrit; reticulocyte
count
Platelet count
Prothrombin time (PT)
Partial thromboplastin time (PTT)
Thrombin time or fibrinogen assay
Assesses
Anemia associated with chronic bleeding;
bone marrow response
Thrombocytopenia
Deficiencies of factors II (prothrombin), V,
VII, or X (clotting time prolonged)
Deficiencies of all factors except VII and
XIII (clotting time prolonged)
Hypofibrinogenemia and
dysfibrinogenemia

Hemostasis Laboratory Tests in Liver Disease

Assay Interpretation
Fibrinogen >400 mg/dL in early, mild liver disease; <200
mg/dL in moderate to severe liver disease,
causing hypofibrinogenemia or
dysfibrinogenemia
Thrombin time Prolonged in dysfibrinogenemia,
hypofibrinogenemia, elevation of fibrin
degradation products, and therapy with
unfractionated heparin
Reptilase time Prolonged in hypofibrinogenemia,
significantly prolonged in dysfibrinogenemia;
not affected by heparin; assay rarely used
Prothrombin time (PT Prolonged even in mild liver disease due to
des-g-carboxyl factors replacing normal
factors II (prothrombin), VII, IX, and X. Report
PT in seconds, notinternational normalized
ratio (INR), when testing for liver disease.
Partial thromboplastin time (PTT) Mildly prolonged in severe liver disease due
 to disseminated intravascular coagulation
(DIC) or des-g-carboxyl factors II
(prothrombin), IX, and X
Factor V assay Factor V level becomes reduced in liver
disease, but is unaffected by vitamin K
deficiency so the factor V level helps
distinguish the conditions
Platelet count Mild thrombocytopenia, platelet count
<150,000/mL
Platelet aggregometry Mild suppression of platelet aggregation and
secretion in response to most agonists
D-dimer >240 ng/mL by quantitative assay

2. Interpret laboratory assay results that diagnose, subtype and monitor the treatment of
von Willebrand disease.

Laboratory Detection and Classification of von Willebrand Disease:

Typical Results

Laboratory Test Type 1 Type 2 Type 3 Type 4

VWF activity via Low Low Low Very low or
ristocetin cofactor, absent
collagen binding, or
immunoactivity assay
VWF antigen Low Normal to Normal to Very low or
slightly slightly absent
decreased decreased
VWF activity to VWF > 0.5 > 0.5 > 0.5 N/A
antigen ratio
Platelet count Normal Normal Decreased Normal
Partial thromboplastin Normal to Normal Normal Prolonged
time (PTT) slightly
prolonged
RIPA Decreased Decreased Increased Absent
Factor VIII activity Mildly low Normal Normal <5%
VWF multimers Normal Large and Large forms All forms
pattern intermed absent absent

Types and Subtypes of Von Willebrand Disease:

 Type 1 von Willebrand Disease

It is a quantitative VWF deficiency caused by one of several autosomal
dominant frameshifts, nonsense mutations, or deletion which is seen in
approximately 75% of VWD patients. The plasma concentrations of all VWF
multimers and factor VIII are variably, although proportionally, reduced. There
is mild to moderate bleeding, usually following a hemostatic challenge such
as dental extraction or surgery. In women, menorrhagia is a common
complaint that leads to the diagnosis of VWD.
 Type 2 von Willebrand Disease
It comprises a variety of qualitative VWF abnormalities. VWF levels may be
normal or moderately decreased, but VWF function is consistently reduced.

 Subtype 2A von Willebrand Disease

10%-20% of VWD patients have subtype 2A, which arises from well
characterized autosomal dominant point mutations in the A2 structural
domain of the VWF molecule. These mutations render VWF more
susceptible to proteolysis by ADAMTS-13, which leads to a
predominance of small-molecular-weight multimers in the plasma Patients
with subtype 2A VWD have normal or slightly reduced VWF:Ag levels,
with markedly reduced VWF activity as a result of the loss of the high-
molecular-weight and intermediate-molecular-weight multimers essential
for platelet adhesion.

 Subtype 2B von Willebrand Disease

Are rare mutations within the A1 domain raise the affinity of VWF for
platelet glycoprotein Ib/IX/V, its customary binding site; these are thus
“gain-of-function” mutations. Large VWF multimers spontaneously bind
resting platelets and are unavailable for normal platelet adhesion.
Consequently, the electrophoretic multimer pattern is characterized by
lack of high-molecular-weight multimers but presence of intermediate
molecular-weight multimers. There also may be moderate
thrombocytopenia caused by chronic platelet activation because
multimer-coated platelets indiscriminately bind the endothelium.

 Subtype 2M von Willebrand Disease

It describes a qualitative variant of VWF that has decreased platelet
receptor binding but a normal multimeric pattern in electrophoresis. The
distinguishing feature of subtype 2M that separates it from type 1 is a
discrepancy between the concentration of VWF:Ag and its activity as
measured using the VWF: RCo assay.

 Subtype 2N von Willebrand Disease (Normandy Variant; Autosomal

Hemophilia).
A rare autosomal VWF missense mutation impairs its factor VIII binding
site. This condition results in factor VIII deficiency despite normal VWF:Ag
concentration and activity and a normal multimeric pattern. The disorder
is also known as autosomal hemophilia because its clinical symptoms are
indistinguishable from the symptoms of hemophilia except that it affects
both males and females. Subtype 2N is suspected when a girl or woman
is diagnosed with hemophilia after soft tissue bleeding symptoms. In boys
or men, subtype 2N is suspected when a patient misdiagnosed with
hemophilia A fails to respond to factor VIII concentrate therapy. The poor
response occurs because the factor has a plasma half-life of mere
minutes when it cannot be bound by VWF. The diagnosis of VWD
subtype 2N is confirmed using a molecular assay that detects the specific
mutation responsible for the abnormal factor VIII binding to VWF.
  Type 3 von Willebrand Disease.
Autosomal recessive VWF gene translation or deletion mutations produce severe
mucocutaneous and anatomic hemorrhage in compound heterozygotes or, in
consanguinity, homozygotes. In this rare disorder, VWF is absent or nearly
absent from plasma. Factor VIII is also proportionally diminished or absent, and
primary and secondary hemostasis is impaired.

Treatment of von Willebrand Disease:

Therapeutic dosages are monitored when necessary using serial VWF:Ag
concentration assays. Desmopressin acetate (1-desamino-8-D arginine vasopressin) is
an antidiuretic hormone analogue used to control incontinence in diabetes mellitus and
bed-wetting; release of VWF from storage organelles is a side effect. Desmopressin
acetate in its oral form, DDAVP, or nasal spray form, Stimate (both from CSL Behring,
King of Prussia, PA), is consistently effective for type 1 VWD and generally useful for
subtype 2A. It is contraindicated for subtype 2B, however, because it causes the release
of abnormal VWF with increased affinity for platelet receptors, which may intensify
thrombocytopenia and lead to increased platelet activation and consumption. Because of
its antidiuretic property, repeated doses may lead to hyponatremia (low serum sodium).
For this reason, it is necessary to monitor and regulate electrolytes during desmopressin
acetate therapy. The lysine analogues e-aminocaproic acid (EACA; Amicar) and TXA
(Cyklokapron) inhibit fibrinolysis and may help control bleeding when used alone or in
conjunction with desmopressin acetate. Therapy using nonbiological preparations is
preferred over human plasma-derived biologic therapy because nonbiologicals eliminate
the risk of viral disease transmission and circumvent religious objections to receipt of
human blood products.For treatment of severe VWD (type 3) and subtype 2B, 3
commercially prepared human plasma-derived high-purity preparations are available that
provide a mixture of VWF and coagulation factor VIII: Humate-P, Alphanate, and Wilate.
Laboratory monitoring by the VWF:Ag assay is essential to determine if the given
amount produced the target level of VWF and to follow its degradation between doses.

3. Distinguish between venous and arterial thrombosis.

 Venous Thrombosis
Deep vein thrombosis (DVT) is a serious condition that occurs when a blood clot
forms in a vein located deep inside your body. A blood clot is a clump of blood that's
turned to a solid state. Deep vein blood clots typically form in your thigh or lower leg, but
they can also develop in other areas of your body. The most prevalent VTE is deep vein
thrombosis, caused by clots that form in the iliac, popliteal, and femoral veins of the
calves and upper legs. Large occlusive thrombi also may form, although less often, in
the veins of the upper extremities, liver, spleen, intestines, brain, and kidneys.
Thrombosis symptoms include localized pain, the sensation of heat, redness, and
swelling. In deep vein thrombosis, the entire leg swells. Fragments of thrombi, called
emboli, may separate from the proximal end of a venous thrombus, move swiftly through
the right chambers of the heart, and lodge in the arterial pulmonary vasculature, causing
ischemia and necrosis of lung tissue.
  Arterial Thrombosis
Refers to a blood clot in an artery, which can be very serious because it can stop
blood reaching important organs. Arteries are blood vessels that carry blood from the
heart to the rest of the body and the heart muscle. One important mechanism for arterial
thrombosis is the well-described vessel wall unstable atherosclerotic plaque. Activated
platelets, monocytes, and macrophages embed the fatty plaque within the endothelial
lining, suppressing the normal release of antithrombotic molecules such as nitric oxide
and exposing prothrombotic substances such as tissue factor. The mediators activate
platelets, which combine with von Willebrand factor to form arterial platelet plugs which
the “white thrombi” that cause ischemia and necrosis of surrounding tissue. The
hemostasis-related lesions we associate with arterial thrombosis are blood vessel wall
destruction and platelet activation.

4. Discuss the value of quantitative D-dimer assays.

The quantitative D-dimer assay is essential for ruling out venous thromboembolic
disease in patients with low pretest probability and is required for detecting and
monitoring DIC. The D-dimer assay helps rule out acute myocardial infarction and
ischemic stroke and may be used to monitor the efficacy of Coumadin therapy. The
various quantitative D-dimer assays have negative predictive values of 90% to 95% and
may be used to rule out deep vein thrombosis and pulmonary thrombotic emboli in
patients at low risk without resorting to compression ultrasonography, tomography, or
venous imaging. Because of the high sensitivity but low specificity (60% to 70%) of the
quantitative D-dimer assay, laboratory practitioners do not use this assay to positively
diagnose venous thromboembolic disease but only to rule it out. Because any chronic or
acute inflammation is accompanied by elevated D-dimer concentrations, the assay
cannot be used to “rule in” thromboembolic disease. The upper limit of the reference
interval for the quantitative D-dimer assay varies with the methodology, ranging from 250
ng/mL to 500 ng/mL. In DIC, D-dimer levels may reach 10,000 to 20,000 ng/mL.

REFERENCE:
Rodak, B. F., Fritsma, G. A., & Keohane, E. M. (2012). Hematology: clinical principles
and applications. 5th ed. St. Louis, Mo.: Elsevier Saunders.