CONGENITAL COAGULOPATHIES

Von Willebrand Disease ecchymosis, menorrhagia, hematemesis, GI bleeding,

surgical bleeding
- 1st described by Finnish professor
- ______________________________ creates factor
______________________in 1926.
VIII deficiency as a result of the inability to protect
- Is the most prevalent inherited mucocutaneous
unbound factor VIII from proteolysis.
bleeding disorder
- _________________________________: anatomic
- ________________________: quantitative (type 1)
bleeding into joints and body cavities accompanies
and qualitative (type 2)
typical mucocutaneous bleeding pattern of VWD.
- Both abnormalities can lead to decreased platelet
adhesion to injured vessel walls, impairing primary
hemostasis • VWD types and subtype
Type 1
- 40-70%
• Molecular Biology and Functions of VWF
- Quantitative VWF deficiency caused by autosomal
- A multimeric glycoprotein with
dominant frameshift, nonsense or deletion mutation
____________________________.
- Plasma concentration: _______________________.
- ___________________________ in human plasma.
- Common complaints: mild to moderate systemic
- Plasma concentration: _______________________
bleeding, menorrhagia which predicts postpartum
- Synthesized in the __________________________.
hemorrhage
- Stored in EC cytoplasmic _____________________.
- Consists of 52 exons spanning 178 kilobase pairs in
Type 2
chromosome 12
- Encompasses four qualitative abnormalities
- Translated protein is a monomer of 2813 amino
- Plasma levels: _____________________________.
acids composed of four structural domains, A to D.
- Function: _________________________________.
- VWD mutations may occur anywhere on the VWF
gene.
Subtype 2A
- ______________________ cleaves VWF multimers.
- 10-20%
- __________________________ is the basis for TTP.
- autosomal dominant point mutations in the _______
- _________________________ supports receptor
and _________ structural domains
site for collagen and ligand for GP IB/IX/V.
- Susceptible to ______________________________.
- _________________________ provides a site that
- Levels in immunoassay are ____________________.
binds GP IIb/ IIIa.
- Activity is __________________________ as a result
- _________________________ provides the carrier
of the loss of the HMW and IMW multimers essential
site for factor VIII.
for platelet adhesion.
- Half-life: ____________ (bound); _________ (free)
- Process
Subtype 2B
1. VWF release. Unfolds and binds fibrillar intimal
- 5%
collagen exposed during the desquamation of
- Mutations within the A1 domain which raise the
endothelial cells or in a blood injury
affinity of VWF and GPIb/IX/V binding (gain of
2. Platelet adhere through their GP Ib/IX/V to VWF
function)
carpet (HMW-VWF) which are best equipped to serve
- Confirmed using ristocetin-concentration,
the adhesion function
ristocetin-induced platelet aggregation (RIPA)
3. Platelet activation and GP IIb/IIIa binding.
- Pseudo-VWD/Platelet type VWD
4. Binding to arginine-glycine-aspartic acid (RDG)
▪ Platelet mutation that raises affinity for
sequences that mediated irreversible aggregation.
normal HMW-VWF multimer
▪ Creates clinical similarity to subtype 2B VWD
• Pathophysiology
▪ Often mistaken for ITP
- Abnormalities ________________________ which
leads to _________________________: epistaxis,

1|Hematology 2 Far Eastern University - Manila

Department of Medical Technology
MTY1215 – Lecture
By: Mr. Lance Edilbert G. Veloso, RMT
Subtype 2M
- describes a qualitative VWF variant that possesses
__________________________________________.
- Discrepancy between the concentration of
__________________ and its activity using
____________________ (distinguishing feature of
2M to type 1)
- Incorrectly identified as ________ or ____________.
Subtype 2N (Normandy variant; autosomal
hemophilia)
- 5%
- autosomal missense mutation in the _______
domain which impairs factor VIII binding site function
- Known as _________________________ because its
clinical symptoms are indistinguishable from the
symptoms of hemophilia except that it affects both
genders.
- Failure to respond __________________________.
Type 3
- _________________________ translation or
deletion mutations
- Produce severe mucocutaneous and anatomic
hemorrhage in compound heterozygotes or in
consanguinity homozygotes
- _________________________________________.
- VWF concentration is _____________ wherein
proportional diminished or absent VWF.
• Laboratory Detection
Important Lab Test:
1. CBC – ___________________________________.
2. PT / PTT – _______________________________.
3. VWF:Rco – employs ristocetin with platelet
aggregometers; automation using HemosIL Acutar
(labelle VWF:GPIbR)
4. Quantitative VWF:Ag assay – cycle.
___________________________________________
employed by __________ (traditional method),
___________ (automated by Liatest [Stago]), and
___________ (automated [HemosIL Acustar] and
possesses the best sensitivity)
5. Factor VIII assay – parallel VWF:Ag and VWF:Rco
results
6. VWF:GPIbM – promising alternative for
__________________________________________.
2|Hematology 2
7. VWF:Ag : VWF:Ag, VWF:GPIbR, or VWF:GPIbR ratio
- _____________________________ = qualitative or
type 2 VWD
• Follow up Lab Tests:
1. Low dose RIPA (Ristocetin Response Curve) –
identifies _____________ (positive for agglutination)
and ________________ (no agglutination)
• Confirmatory:
1. Sodium dodecyl sulfate-polycrylamide gel
electrophoresis – establish __________________ and
differentiates _______________________________.
• Pitfalls in VWD diagnosis
Varying genetic penetrance, ABO blood group,
inflammation, hormones, age, and physical stress
influence VWF activity
- _______________________ during the second and
third trimesters of pregnancy nearly normalize
plasma VWF activity even in women with moderate
VWF deficiency which rapidly decreased after
delivery and may lead to acute postpartum
hemorrhage in VWD
- Oral contraceptives and HRT also _______________
and activity ___________________ with menstrual
- VWF activity ______________ substantially in acute
inflammation and physical traumas (venipuncture
and tourniquet application) and ______________ if
specimen stored in the refrigerator before testing.
- VWF:Rco assay has variable results hence poor
reproducibility of results which led to the
development of VWF collagen binding assay
(VWF:CB).
- VWF:CB employs type III collagen as its solid-phase
target that will bind to predominantly HMW-VWF
multimers. This assay is pending for approval.
Far Eastern University - Manila
Department of Medical Technology
MTY1215 – Lecture
By: Mr. Lance Edilbert G. Veloso, RMT
- To reduce false-positive type 1 VWD diagnoses, low 3.
VWF was coined by NHBLI VWD guidelines in 2009 for
the condition in which VWF activity and ag Plasma
concentration are between 30% - 50% of normal - Recombinant and affinity-purified factor VIII
- Type 1 VWD – VWF activity of 30%; VWF:Rco to concentrates – contain __________________ and
VWF:ag ratio >0.5; factor VIII activity >50 U/dL cannot be used to treat VWD
- 2009 NHBLI VWD guidelines have recommended - Cryoprecipitate and plasma – less desirable
against ABO vation with VWF, noting that, “despite alternatives because of the risk for
the ABO blood groupings and associated references, __________________ and ____________________.
the major determinant of bleeding risk is
_______________________.”

• Treatment Hemophilia
- Therapeutic dosages are monitored using serial - _________________________________________
__________________________________________. - 1 in 800 (mostly males)
- 85% are factor VIII deficient, 14% are factor XI
__________________________________________. deficient, 1% are factor XI deficient or other
- An antidiuretic hormone analog used to control coagulation factors
incontinence in DM and bedwetting,
- Effective for ___________ and ___________ VWD Hemophilia A (Factor VIII Deficiency or Classic
and generally useful for _______________________. hemophilia)
- Contraindicated for ___________________ – Structure and function
because it releases abnormal VWF with increased Factor VIII
affinity for GPIb/IX/V receptors, which may intensify - two-chain, 285,000-Dalton protein translated from
platelet activation and consumption the X chromosome
- Oral form: _________________________________. Thrombin cleaves to FVIII
- Oral spray form: ____________________________. ↓
- Causes hyponatremia thus sodium monitoring and B domain release from the molecule
regulation is necessary. ↓
Detachment from VWF and leaves calcium-
E-aminocaproic acid (EACA) and Tranexamic acid dependent heterodimer
(TXA) ↓
- inhibit fibrinolysis and may help control bleeding Bind to phosphatidyl serin and factor IX
when used alone or in conjunction with desmopressin ↓
acetate. Factor X activation from tenase complex cleavage

Commercially prepared treatment for type 3 and - Factor VIII deficiency significantly slows the
subtype 2B (human plasma-derived-high-purity) coagulation pathway’s production of thrombin and
1. leads to hemorrhage.
2.

3|Hematology 2 Far Eastern University - Manila

Department of Medical Technology
MTY1215 – Lecture
By: Mr. Lance Edilbert G. Veloso, RMT
- Factor VIII deteriorates in storage. Extremely labile
factor.
Complications
- Hemophilia patients often experience debilitating an
progressive musculoskeletal lesions and deformities
and neurologic deficiencies subsequent to
intracranial hemorrhage
- Other chronic diseases effects, such as limited
productivity, low self-esteem, poverty, drug
dependency, and depression are common problems
- Chronic Hepatitis often resulted from repeated
exposure to blood products

Laboratory Diagnosis
- It starts with
___________________________________________
__________________________________________.
- Continues with ___________________________ on
the results of the initial tests
Genetics - ___________________________________ have
- 186 kilobases of the X chromosome and is the site of __________________ to bleeding
various deletions, stop codons, and nonsense and
missense mutation.
- Most mutations result in quantitative and qualitative
(cross-reacting material positive) disorders
- Commonly affects males. Females are
______________________. Sons are affected at 25%
- All sons of men with hemophilia A and non-carrier
women are normal, whereas all daughters are
obligate carriers.
- Rarely, symptoms of hemophilia A may be seen in
females due to true homozygosity or double
heterozygosity.

Clinical Manifestation
- _____________________: Acute joint bleeds are
exquisitely painful and
cause temporary immobilization.
- Chronic joint bleeds cause inflammation and
eventual permanent loss of mobility. Bleeding into
muscles may cause nerve compression injury
- ____________________ lead to severe, debilitating, Carrier Detection
and durable neurologic symptoms, such as loss of
- 90% of female carriers of hemophilia A are detected
memory, paralysis, seizures, and coma, and may be
by measuring the ratio of
rapidly fatal.
__________________________________________.
The diagnosis of hemophilia A begins with (effective because VWF production is unaffected by
___________________________________________ FVIII deficiency)
___________________________________________ - Carrier: __________________________________.
__________________________________________.

4|Hematology 2 Far Eastern University - Manila

Department of Medical Technology
MTY1215 – Lecture
By: Mr. Lance Edilbert G. Veloso, RMT

Therapy
• Human plasma-derived FVIII (pdFVIII)
concentrates
- Prepared from healthy plasma donors using
chemical fraction. Traditionally been employed for
on-demand therapy
- Goal is to raise the patients FVIII activity to
hemostatic levels which is to reach activity
__________________________________________.
- Target activity should be maintained until the threat
is resolved.
Examples: Alphanate (Grifols), Humate-P (Behring),
Wilate (Octapharm), Kogenate FS (Bayer), Hemofil-M
(Shire)
• Recombinant FVIII (rFVIII) concentrates
Less immunogenic thus deleting the large central B
domain to shorten it
Administered ______________________________ to
maintain their FVIII activity at hemostatic levels.
Examples:
BDD-rFVIIIFc (Eloctate)
- first extended half-life rFVIII nearly ______________
- reduced infusion (once every 4-5 days)
- fused with the Fc region of human IgG1
PEG rFVIII (Adynovate)
- full length rFVIII covalently conjugated with
polyethylene glycol
- extends half-life ___________________________.
- reduced infusion ( _________________________)
rFVIII-Single Chain (Afstyla)
- full length single-chain rFVIII
- claims to closely resemble native FVIII
- extended half-life
Computation
- Physicians treating hemophilia base on FVIII
concentrate dosage calculations on the definition of
an international unit (IU) of FVIII activity
- Global mean activity – ________ normal plasma =
____________________.
- Calculation may also be used to treat VWD
- The key reason for careful dosage calculation is to
__________________________________________.
- ___________________________________does not
accurately measure BDD-rFVIII or the extended half-
life rFVIII formulations
5|Hematology 2
Formula:
Hemophilia A and FVIII inhibitors
- Patients suspected with an inhibitor have
___________________________________________
__________________________________________.
- FVIII inhibitors are ___________, non-complement
fixing, warm-reacting antibodies.
- First step in inhibitor detection is
__________________________________________.
Result
No inhibitor: ______________________________.
Presence of inhibitor: _______________________.
- In <30, proceed with _______________________.
- ______________________________ is suggestive
to quantitate titers of FVIII inhibitors and monitor
therapy
NP (100 units/dL) is mixed at increasing dilutions =
NBU
____________ is the reciprocal of the dilution that
caused neutralization of 50% of the NP FVIII
▪ _____________________: <5 NBU (no
significant increase after therapy)
▪ _____________________: >5 NBU (ab
further rise to therapy)
Treatment in patients with inhibitors
- Low responders often experience cessation of
bleeding on administration of large doses of FVIII
concentrate
- High responders may gain no benefit from FVIII
concentrates, instead are treated with activated PCC
or rFVIIa, all which generate thrombin despite the
presence of FVIII inhibitors
__________________________ (HemLibra) – factor
VIII mimetic biphasic antibody that bypasses factor
VIII by binding factor X with IXa
Hemophilia B (Factor IX Deficiency)
- aka ______________________________________.
- Caused by ________________________________.
- Factor IX is a substrate for both factors XIa and VIIa
- _________________________________ and cause
anatomic bleeding that is indistinguishable from that
in Hemophilia A.
Far Eastern University - Manila
Department of Medical Technology
MTY1215 – Lecture
By: Mr. Lance Edilbert G. Veloso, RMT
- Sex-linked
- Determination of female carrier status is less
successful because of the large number of factor IX
mutations and the lack of a linked molecule such as
VWF that can be used as a normalization index.
Lab findings:
PTT: ______________________________________.
PT, Fibrinogen, TT: __________________________.
Clinical symptoms
If suggestive of hemophilia B,
__________________________ should be performed
even if PTT is within reference range, because PTT rgt
may be insensitive to factor IX deficiencies at the level
of _______________________________________.
Treatment
• Immunine (Shire) and Monomine (Behring)
- Immunopurified FIX concentrates
- Calculated the same way as FVIII concentrates in
hemophilia A except the calculated initial dose is
_______________ to compensate for FIX distribution
- Repeated doses are ____________________,
reflecting the half-life of the factor
- Second subsequent doses are
___________________________ provided that the
target level of FIX was achieved.
• rFIX (Benefix)
- infusion rate of ___________________________.
• rFIX-Fc (Alprolix) and albumin-fusion Idelvion
(Behring)
- extended half-life preparations that extend
administration ______________________________.
FIX therapy may be measured using one-stage clot
assay; however, chromogenic assays with improved
accuracy, low-level sensitivity, and reproducibility are
in development.
FIX inhibitors arise in 3% may be detected using
Nijmen-Bethesda assay and treated using activated
PCC or rFVIIa and immunomodulation therapy
6|Hematology 2
Hemophilia C (Rosenthal Syndrome, Factor XI
Deficiency)
- autosomal dominant hemophilia with mild to
moderate bleeding symptoms
- more than half of the cases have been described in
__________________________________________.
- the frequency and severity of bleeding episodes do
not correlate with factor XI levels, and laboratory
monitoring of treatment serves little purpose after
diagnosis is established.
- Treatment involves frequent plasma infusions
during bleeds and times of hemostatic challenge.
- PTT: Prolonged
- PT: Normal
Other Congenital Single-Factor
Deficiencies
- Cause by __________________________________.
- PT, PTT, and TT may be employed
- In qualitative disorders (dysproteinemia), factor
activity to antigen is __________________________.
- Severe bleeding symptoms in dysproteinemias than
quantitative deficiencies, but the risk of inhibitor
formation is theoretically smaller.
Factor II and X – clot-based measurement
Factor I – Clauss clot-based assay (modified TT)
Factor V – prolonged PT and PTT treated with Factor
V concentrate
Factor VII – moderate to severe anatomic bleeding
where it does not reflect from factor levels
- Half-life: ~6 hours
- Treatment: NovoSeven at 30 ug/mL and non-
activated four-factor PCC
- Target level: 10 units/dL to 30 units/dL.
- Lab findings are PT: normal; PTT: prolonged
Factor X – moderate to severe anatomic hemorrhage.
Acquired Factor X has been described in
______________________ and antifungal therapy.
- Half-life: 24-24 hours
- Treatment: Plasma or non-activated PCC
- Therapeutic levels: 10 units/dL to 40 units/dL.
- Lab findings:
▪ PT and PTT are prolonged.
▪ Russel Viper venom time is prolonged (factor
X, V, II, I). Factor VII is normal.
Far Eastern University - Manila
Department of Medical Technology
MTY1215 – Lecture
By: Mr. Lance Edilbert G. Veloso, RMT
Factor XIII – with a-chain (active enzyme site) and b-chain (binding and stabilizing portion). Deficiency occurs in three
forms related to the affected chains
- Lab findings: normal PT, PTT, and TT
▪ __________________________ – traditional screening test
Clot dissolves within 2 hours when suspended in 5M of urea solution
▪ Confirmatory test: chromogenic assay (Behrichrom FXIII assay)

a2-antiplasmin and plasminogen activator inhibitor-1 (PAI-1) are rare cases that cause moderate to severe bleeding
and diagnosed using chromogenic substrate assays.

***end of discussion***

7|Hematology 2 Far Eastern University - Manila

Department of Medical Technology
MTY1215 – Lecture
By: Mr. Lance Edilbert G. Veloso, RMT