322.

DISORDERS OF COAGULATION OR FIBRINOLYSIS: POSTER II | DECEMBER 07, 2017

Platelet-Dependent Thrombin Generation Is Correlated

with Phenotypic Severity in Severe Hemophilia a
1 *,2 3,4
Amy L. Dunn, MD, Traci Leong, PhD, Shawn M. Jobe, MD PhD
1
Division of Hematology/Oncology/BMT, Nationwide Childrens Hospital, Columbus, OH
2
Department of Biostatistics and Bioinformatics, Emory University, Atlanta, GA
3
Pediatrics, Medical College of Wisconsin, Milwaukee, WI
4
Blood Research Institute, Blood Center of Wisconsin, Milwaukee, WI

Blood blood (2017) 130 (Suppl_1) : 2355.

http://doi.org/10.1182/blood.V130.Suppl_1.2355.2355

Abstract
Hemophilias A and B are classified into mild (>5-40%), moderate (2-5%) and severe (<1%) disease
based upon plasma factor activity levels. Severity of bleeding is commensurate with the baseline factor
levels in general. However, heterogeneity of bleeding pattern and severity in patients with severe
disease is well described. The biologic mechanism responsible for this phenotypic heterogeneity has
yet to be thoroughly explained. A role of platelets, as key contributors to hemostatic plug formation and
coagulation, has been investigated in previous small cohorts of patients with severe hemophilia with
variable results.

A single-center cohort of 94 patients with severe hemophilia A were enrolled into an IRB approved study.
Patients with concomitant bleeding disorders or thrombocytopenia (<100K/µL) were excluded. Flow
cytometry was utilized to assess multiple aspects of platelet function, including 1) granule release (P-

selectin) and integrin αIIbβ3 activation (PAC-1 high) at low and high doses of thrombin and the GPVI
agonist convulxin and 2) procoagulant platelet formation (Annexin V high, PAC-1 low) with combined
thrombin and convulxin stimulation. In 46 patients who had not received factor prophylaxis in the 96 hours
prior to laboratory assessment, a thrombin generation profile, initiated by low concentration tissue factor,
was obtained in both platelet-rich (PRP) and platelet-poor (PPP) plasma. To assess phenotypic severity,
the Hemophilia Severity Score (Schulman S et al, 2008) was determined for each patient. The HSS
score integrates bleeding rate, joint damage, and factor usage to obtain a composite measure of disease
severity. Regression analysis was utilized to assess association (significance = p<0.05).

No association with HSS was found with either granule release or integrin activation. This lack of
association with bleeding phenotype in severe hemophilia is consistent with previously reported
results. The formation of coated, or procoagulant platelets, has previously been linked with phenotype
in hemophilia A. In this large single-center cohort, no association of procoagulant platelet formation
with HSS was noted, either in the whole population, or when analyzed by genotype or prophylaxis
versus on-demand therapy. Measures of thrombin generation in PRP have been weakly linked with
phenotype in severe hemophilia A. In our single-center cohort, in severe hemophilia A patients with
large genetic mutations a strong association was noted between HSS and both time to peak (r = .410)
and lag time (r=.450). This association persisted in PPP for time to peak, but was lost in PPP for lag
time demonstrating the critical modulatory role of platelets in this association. No significant association
was noted with other measures of thrombin generation. The results presented here indicate a critical
modulatory role for platelet-dependent initiation of thrombin generation in determining phenotypic severity
in patients with severe hemophilia A. Confirmation of these results would identify a potentially early
biologic signal that could be used to differentiate phenotypic severity in young patients with severe
hemophilia A and suggest the potential utility of modulation of platelet function in severe hemophilia A
patients, especially those with large genetic mutations.

Disclosures
Dunn: Biogen: Other: Unrestricted educational grant, Research Funding; Octapharma: Other:
Unrestricted educational grant; NovoNordisk: Other: Unrestricted educational grant; Shire: Consultancy,
Other: Unrestricted educational grant, Research Funding; Bayer: Consultancy, Other: Unrestricted
educational grant; Alnylam: Other: Unrestricted educational grant; World Federation of Hemophilia USA:
Membership on an entity's Board of Directors or advisory committees; CSL Behring: Consultancy, Other:
Unrestricted educational grant; Kedrion: Other: Unrestricted educational grant.

Author notes
*Asterisk with author names denotes non-ASH members.

© 2017 by the American Society of Hematology