1

HEMATOLOGY II- LABORATORY

MODULE 5: SECONDARY HEMOSTATIC DISORDER
Differential diagnosis of abnormal coagulation screening tests
APTT [abnormal] PT [abnormal] APTT and PT [abnormal]
 Associated with bleeding: VIII,  Factor VII defects  Medical conditions:
IX, and XI defects Anticoagulants, disseminated intravascular
 Not associated with bleeding: XII, coagulation [DIC], liver disease, Vitamin K
prekallikrein [PK], HMWK, lupus deficiency, massive transfusion
anticoagulant  Rarely dysfibrinogenemia; factor X, V, and
II defects

Deficiency of Factor VIII [Hemophilia A] or Factor IX [Hemophilia B]

Hemophilia A
 FVIII deficiency
 Most common severe congenital bleeding disorder
 In patients with vWD- a secondary deficiency of FVII may occur
o FVIII is normally bound to vWF in the plasma
 Von willebrand disease “Normandy”/ Type 2N
o Unique vWF abnormality- missense mutation in vWF that impairs its capacity to bind to and promote
FVIII secretion into plasma
Hemophilia B
 FIX deficiency
 Christmas disease
 Causes a severe congenital bleeding disorder
 Hemophilia B Leyden: Rare form of FIX deficiency

FVIII and FIX genes- located on the X chromosome

 X-linked recessive disorders primarily affecting males
 Females carrying a hemophilia mutation on one of their 2 X chromosomes [carriers]

Laboratory evaluation: APTT and PT as screening tests

Diagnosis is confirmed by: FVIII and FIX assay
Treatment: Recombinant Factor Products

Characterization of Coagulation Factors and their Deficiencies

Factor Gene location Inheritance Bleeding severity
Fibrinogen 4q31.3-q32.1 Recessive Mild-Severe
II 11p11.2 Recessive Mild-Moderate
V 1q24.2 Recessive Moderate
V & VIII combined LMAN1: 18q21.32 Recessive Mild-Moderate
MCFD2:2p21
VII 13q34 Recessive Mild-Severe
VIII Xq28 Sex-linked Mild-Severe
IX Xq27 Sex-linked Mild-Severe
X 13q34 Recessive Mild-Severe
XI 4q35.2 Recessive Mild-Moderate
XII 5q33-qter Recessive No- Bleeding
PK 4q33-q35 Recessive No- Bleeding
2
HEMATOLOGY II- LABORATORY
HK 3q27 Recessive No- Bleeding
XIII A:6p25.1 Recessive Moderate- Severe
B:1q31.3

Disorders with Prolonged APTT/ Normal PT

FXI deficiency
 Common in Ashkenazi Jews
 Rarely have spontaneous hemorrhage
 Bleeding typically occurs following injury or surgery
 Replacement therapy: FFP

FXII, prekallikrein, and HMWK

 Associated with prolonged PTT but are not associated with any bleeding risk
 Most common, occurring in all racial and ethnic backgrounds
 No replacement therapy for hemostasis is necessary for FXII, PK, or HK deficiency- it is important to recognize
these defects to prevent unnecessary transfusion

Disorders with Prolonged APTT and PT

Disorders of fibrinogen
 Prolonged APTT and PT- plasma concentration of protein [<100 mg/dL]
 Afibrogenemia- autosomal recessive; total absence of fibrinogen
 Hypofibrogenemia- decreased level of normal fibrinogen
 Dysfibrogenemia- qualitative fibrinogen deficiency characterized by the production of dysfunctional fibrinogen
o Commonly acquired in associated with liver disease
 Replacement: Cryoprecipitate

FII Deficiency
 Rarest inherited coagulation factor deficiency [1:2,000,000]
 True prothrombin deficiency [mouse]- incompatible with life after birth
 Hypoprothrombinemia [type I deficiency]- manifests as a concomitant reduction in prothrombin activities and
antigen levels
 Dysprothrombinemia [Type II deficiency] –presents with reduced activity and normal antigen levels
 Treatment
o Prothrombin Complex Concentrates
o FFP- alternative
FV Deficiency
 Heterozygous- asymptomatic
 Homozygous- rare/ presenting in children with easy bruising and mucosal bleeding
 Prolonged APTT and PT
 Normal TT
 Confirmed by: PT reagent-based or single stage FV Assay
 Replacement product: FFP

FX Deficiency
 Heterozygous- asymptomatic
 Homozygous- severe bleeding disorders that present in infancy
 One stage PT-based FX assay –sufficient for diagnosis
3
HEMATOLOGY II- LABORATORY
 Most common factor deficiency associated with primary amyloidosis
 Current therapy
o Prothrombin Complex Concentrates
o Recombinant FVIIa- treatment of FX deficiency associated with amyloidosis

Combined FV and FVII Deficiency

 Rare autosomal recessive disorder that results from a single gene defect rather than from coinheritance of defects
in both FV and FVII genes
 Testing usually demonstrated disproportionate prolongation of the PTT compared with the PT
 Replacement Therapy:
o FVIII concentrates
o FFP [as source of FV]

Combined Deficiency of Vitamin K- dependent Clotting Factors

 Affecting multiple vitamin K- dependent coagulation factors [II, VII, IX, and X] occurs with Vitamin K deficiency
and hepatic dysfunction
 Also results from heritable dysfunction of hepatic enzyme y-glutamyl carboxylase [type i] or the vitamin K
epoxide reductase enzyme complex [type II]
 Diagnosis
o Established by prolongation of both the APTT and PT and associated reductions in levels of Vitamin K-
dependent clotting factors.
o These patients may respond to Vitamin K [oral or parenteral] with normalization of the APTT, PT and
factor levels, as well resolution of bleeding symptoms

Disorders with Normal APTT/ Prolonged PT

FVII Deficiency
 Common compared with the other rare hereditary coagulation factor deficiencies
 Severe FVII deficiency- autosomal recessive; often presenting shortly after birth, and may have dramatic
presentation with intracranial hemorrhage
 Diagnosis: Prolonged PT
 Functional FVII activity is measured by a PT-based, FVII- deficient plasma clotting assay
 Therapy:
o FFP, Prothrombin Complex Concentrates, and Recombinant FVIIa

Disorders with Normal APTT and PT

FXIII Deficiency
 FXIII- stabilizes the clot after the fibrin clot is formed
 Normal APTT and PT- severe FXIII deficiency
 Diagnosis: 5M urea clot solubility test or a chromogenic assay
 5M urea Clot Solubility Test
o Normal FXII- clot remains stable in %M urea
o FXIII deficiency- clot dissolved in %m urea
o Simple to perform but is sensitive only to low levels of FXIII
 Replacement
o FFP
o FXIII Concentrates/ Recombinant FXIII- currently being evaluated in a clinical trial
4
HEMATOLOGY II- LABORATORY

Acquired Coagulation Disorders

Disseminated Intravascular Coagulation [DIC]
 Activation of the coagulation and fibrinolysis systems results in the simultaneous formation of thrombin and
plasmin with consumption o coagulation factors and inhibitors of the system
 Laboratory feature:
o Prolonged APTT and PT
o Thrombocytopenia
 Diagnosis
o Prolonged APTT and PT
o Reduced fibrinogen and platelet count

ISTH Diagnostic Scoring System for DIC

Risk assessment: does the patient have an underlying disorder known to be associated with overt DIC?
 If yes, proceed
 If not, do not use this algorithm
Order global coagulation tests [PT. platelet count, fibrinogen, D-dimer]
Score the tests results
 Platelet count [>100 k/Ul = 0, <100 k/uL = 1, <50 k/uL = 2]
 Elevated D-dimer [<0.4 ug/mL = 0, 0.4 – 4.0 ug/ mL = > 4.0 ug/mL = 3]
 Prolonged PT [< 3 sec = 0, > 3 sec but <6 sec = 1, > 6 sec = 2]
 Fibrinogen level [>100 mg/dL = 0, <100 mg/dL = 1]
Calculation score
 If equal or greater than 5, compatible with overt DIC: Repeat score daily
 If less than 5, suggestive [not affirmative] for nonovert DIC: Repeat next 1-2 days

Liver disease
 It is important for liver disease to be recognized in patients because most coagulation factors are synthesized in the
liver
 Prolonged APTT and Pt- serious in the liver
 PK- 1st protein to decreases
 Fibrinogen- last protein to decreased
 FV and FVIII- absent anhepatic stage of liver transplantation
 FVIII- elevated in patients with inflammatory hepatocellular disease
 Anti-thrombin and Other serpin Plasma Protein Inhibitors is decreased

Vitamin K deficiency
 Vitamin K- lipid soluble vitamin, is provided by dietary intake of leafy green vegetables and by synthesis of
intestinal flora
 Vitamin K has a critical role in the y-carboxylation reaction of a number of glutamic acid residues within
coagulation factors II, VII, IX, X, and proteins C, S, and Z.
 Reduced clottable factor levels for the Vitamin K- dependent factors II, VII, IX, and X

Massive transfusion
 Massive transfusion- defined as the replacement of more than 1. 5 blood volume in 24 hours
5
HEMATOLOGY II- LABORATORY
 Hemostatic failure can result from dilution of clotting factors, DIC, or acquired platelet dysfunction
 Dilutional coagulopathy results from replacement with packed red blood cells and normal saline and lack of
clotting factors or platelets
 Tests of hemostaisi typically show prolongation of the PT and APTT, reduced fibrinogen, and thrombocytopenia

Acquired Coagulation Protein Inhibitors and Lupus Anticoagulant

 Most common severe acquired coagulation protein inhibitor is that against FVIII
 Systemic amyloidosis- associated with decrease in plasma factor X or IX as a result of adsorption of the
coagulation proteins onto the amyloid protein
 Hypergammaglobulinemic states- seen with multiple myeloma or Waldenstrom’s macroglobulinemia [IgM] can
be associated with pan-inhibitors to coagulation protein function

Lupus Anticoagulant or Antiphospholipid Antibody

 Influences coagulation protein reactions
 Variably interfere with APTT, less common in PT