1. Coagulation Cascade
Amplification
Initiation

2. Introduction
Congenital bleeding disorder caused by low levels of specific coagulation factors
Hemophilia A: 85%, factor VIII deficiency
Third most common X-linked disorder
Hemophilia B: 10%-15%, factor IX deficiency

3. Genetics X-linked recessive disorder
FVIII gene is on Xq28; most common (45%) defect is inversion and translocation of exons 1-22 away from 23-26, others: point mutation
1/10,000 live male births
女性也可能為symptomatic carriers (ex. extreme “Lyonisation” of the normal X chromosome)
約1/3為mutation

4. Classifications 依血液中凝血因子的剩餘含量而定 Severe: < 1 unit/dL (1% activity)
Moderate: 1%-5%
Mild: > 5%
Definition
1 unit = the amount found in 1ml of normal pool plasma
100% activity = the actvity found in 1ml of normal pool plasma

5. Bleeding Manifestations in Hemophilia
Sites of bleeding
Serious
Joints (hemarthrosis), muscle/soft tissue,
mouth/gum/nose, hematria
Life-threatening
CNS, GI, neck/throat, severe trauma
Incidence of different sites of bleeding
Hemarthrosis: 70-80%
Muscle/soft tissue: 5-10%
CNS: <5%

6. Clinical Manifestations
嚴重者，出生時就可能出現subgaleal hematoma and/or ICH〈應特別留意嬰兒室頭圍迅速增大的新生兒〉
症狀可能多在開始爬及走路時才出現
The hallmark of hemophilic bleeding:自發性的關節出血 (hemarthrosis) and intramuscular hematoma
1-2 % ICH

7. 其他出血的警訊 腦出血：infants with “meningitis” 後腹腔出血：嚴重腹痛，可能誤為盲腸炎
頸部、咽喉出血：喉痛、吞嚥困難，可能阻塞呼吸道
Toddler: ankle most, than knee
Child: knee most, than ankle

12. Diagnosis and Laboratory Tests
Family history
Normal platelet count, bleeding time, PT
Prolonged PTT
Specific factor assays
Genetic testing
Prenatal diagnosis

13. Management History of hemophilia treatment Decade Milestone (s) 1840s
First transfusion administered
1940s
Transfusion therapy estabilished
1950s
FFP; early factor concentrates
1960s
Cryoprecipitate
1970s
Intermediate-purify factor concentrates; DDAVP
1980s
Monoclonal antibody-purified and high-prify factor VIII concentrates; effective viral inactivation
1990s
High-purify factor IX concentrates; recombinant factor VIII and IX threapy
2000s
Improved recombinant products; gene therapy ?

14. 治療 A型： FFP，cryoprecipitate 或 factor VIII concentrate
(dose: desired rise level % × BW × 0.5)
B型：FFP或factor IX concentrate
(dose: desired rise level % × BW × 1.2~1.5)
Factor concentrate: plasma-derived or recombinant product
DDAVP for mild or moderate form
Antifibrinolytic therapy

15. On-demand Therapy
一有症狀出現就及早注射（即補充）凝血因子
劑量及次數視體重、病情輕重、出血程度及出血部位而定

16. Recommeded Plasma Factor Level and Duration of Administration
Type of hemorrhage
Hemophilia A
Hemophilia B
Desired level
Duration (days)
Joint
40-60%
1-2 or longer
Muscle
2-3 or longer
Iliopsoas
Initial
80-100%
1-2
60-80%
Maintenance
30-60%
3-5 or longer
CNS/head
1-7
50%
8-14
30%

17. Type of hemorrhage
Hemophilia A
Hemophilia B
Desired level
Duration (d)
Throat and neck
Initial
80-100%
1-7
60-80%
Maintenance
50%
8-14
30% GI
1-6
7-14
Kidney
3-5
40%
Surgery (major)
Pre-op
Post-op
40-60%
30-50%
1-3
4-6
20-40%

18. Prophylactic Therapy 原理：將重度缺乏者的凝血因子提升至 >1% 有效減少自發性出血 避免關節出血及進一步關節病變
瑞典最早開始， A型血友病自1958年起，B型血友病自1972年起

19. Prophylaxis
Initial observation: persons with moderate hemophilia (1-5% FVIII) have decreased joint disease
Hypothesis: converting a person from severe hemophilia to moderate with prophylaxis would decrease incidence of joint disease
Goat: to raise FVIII above 1% was commenced in Malmo, Sweden in 1958
Lovqvist, et al: J Intern Med 1997

20. When to Start: The Swedish Experience
Conclusion: prophylaxis should be started in the first years of life, before age Astermark et al: Br J Hematol 1999

21. 一般照護 預防注射: 最小的針頭接種 不可接受其他肌肉注射
勿吃含有阿斯匹靈的止痛藥， 但Panadol, Ponstan, Codeine可以服用
牙齒的保護

22. 長期的關節病痛問題 Target joints: 膝關節、踝關節及肘關節 惡性循環下，發生慢性關節炎
Arthropathy: most significant chronic morbidity
預防是最佳的處理方法
Arthroscopic synovectomy
Joint replacement

23. 輸血引發的感染 經加熱等特殊程序處理血液製品後，1985年以後出生的血友病患者，至今並無因注射凝血因子而感染愛滋病的報告
HBV, HCV infection
(vaccination using is recommended)
Recombinant product可完全免除這種潛在的危險

24. 凝血因子抗體 14-25% of severe hemophilia A, very rare in hemophilia B
可能與基因有關
輕者可能需要大量而頻繁的注射才可能止血
嚴重的就可能對注射凝血因子無效，必須使用其他凝血因子 (by-pass)

25. What are inhibitors ? Antibodies directed against coagulation factors
Alloantibody in patients with hemophilia A or B
Autoantibody in people without hemophilia
Incidence
Antifactor VIII inhibitors in hemophilia A: 25%
Antifactor IX inhibitors in hemophilia B: 1-3%
Antifactor VIII autoantibody inhibitors: 1/106/year
Usually result in loss of coagulation factor function

26. Factor VIII inhibitors
The most common inhibitor
Polyclonal IgG antibodies, esp IgG4
Bleeding is more severe in autoantibody patients than in hemophilia A inhibitor patients

27. Etiology Definite Factors Involved
FVIII gene mutation
No FVIII protein means high risk
Adjuvants in FVIII products
Race
Higher in African-Americans
HLA status
Immune modifiers
IL10 polymorphism

28. Classification of Inhibitors
Definitions
“High” responders
IgG inhibitors of titer > 5 Bethesda Units (BU)
Inability to overwhelm with native factor
“Low” responders
< 5 BU
Transient
Less likely to have anamnestic responses
Amenable to treatment by overwhelming
inhibitor with native factor VIII or XI

29. Treatment Options for High-responder Inhibitors
Bypassing agents
Low-purity, plasma-derived concentrates
Prothrombin complex concentrates
Activated prothrombin complex concentrates
Recombinant VIIa
Emergency treatments
Plasmapheresis
Porcine VIII and new recombinant procine VIII

30. Treatment Options for High-responder Inhibitors
Immune tolerance induction
Rituximab
Anti-CD20 chimeric antibody reliably depletes
peripheral B cells
Several reports of success in acquired
hemophilia (an autoimmune disorder)
NHLBI-sponsored clinical trial through
Transfusion Medicine/Hemostasis research
network to begin May 2006
Fox et al, Hemophilia 2006

31. von Willebrand Disease
Disorder first described by Erik von Willebrand in 1925 in persons living off the coast of Finland
Marked heterogeneity in phenotype, autosomal Dominant or Recessive Inheritance
Deletion in chromosome 12 is most common
Overall prevalence 1:100 to 1: 500
Incidence equal among Man and Women (chromosome 12)

32. 1994 Classifications of VWD by TSTH
1994 Term
1994 Definition
Genetics, Comment
Type 1
Partial quantitative deficiency
Dominant with variable expression; phenotype influenced by multiple genes
Type 2
Qualitative defect
Type 2A
Decreased platelet-dependent function with absence of largest multimers
Dominant
Type 2B
Increased VWF affinirty for platelet GPIb
Dominant. May be associated with thrombocytopenia, especially after DDAVP
Type 2M
Decreased platelet-dependent function with presence of largest multimers
Type 2N
Decreased VWF affinity for FVIII
Recessive, often mistaken for mild-moderate hemophilia A
Type 3
Virtually complete deficiency
Recessive: homozygous or doubly heterozygous
Platelet-type (pseudo-VWD)
Not a defect of VWF, not to be considered a form of VWD
Dominant. A platelet disorders: increased affinity of platelet GPIb for VWF. Thrombocytopeinia may be present.

33. Location of Gene: chromosome 12 (p13.3)
vWF Genetics
Location of Gene: chromosome 12 (p13.3)

34. vWF Protein A1: binds to Gp IB alpha A3: Collagen binding Domain
D’/D3: Interacts with Factor VIII
C2: Interacts with GpIIb/IIIa

35. vWF Protein A1: type 2B and 2M
A2: type 2A, cleavage site for ADAMTS 13
D’/D3: type 2N

37. Diagnosis

38. vWD Tests: Initial Work-up
Quantitative
Factor VIII level
vWF Antigen level
vWF Multimers
Qualitative
Ristocetin Cofactor Assay: studies function of Vwf/Platelet interaction

39. Lab Values in vWD Subtypes

40. Variants of vWD

41. Official Abbreviated Terms as Designated by ISTH
Factor VIII
Von Willebrand factor
Type of Test
Official
Old or informal
Immunological
(total amount, functional or not)
FVIII:Ag
FVIII:CAg
VWF:Ag
FVIIIR:Ag
AHF:Ag
Functional
(functional assay)
FVIII
FVIII:C, AHF, AHG
VWF:RCo
(ristocetin cofactor)
VWF:CB (collagen binding)
VWF:FVIIIB
(factor VIII binding)
FVIIIR:RCo and others
VWF:CBA
ISTH: International Society on Thrombosis and Hemostasis

42. Differential Diagnosis Hemophilia A & von Willebrand Disease

43. Management Education Cryoprocipitate DDAVP for type 1
(dose: desired rise level % × BW × 0.75)
DDAVP for type 1
Amicar (antifibrinolytic agent) for mucosal bleeds
Humate-P (factor 8 and vWF) for surgery, trauma
Platelet for pseudo-vWD
Recombinant factor 7a, correct underlying disorder (hypothyroidism) for acquired vWD

44. Platelet

45. Platelet Anatomy Disc-shaped, anuclear fragment Size: 1.5 μm
Normal maturation time 4-5 days
Circulating life span 9-10 days

47. Platelet Anatomy Peripheral zone Plasma membrane
Open canalicular system
Extension of the plasma membrane
Forms interconnecting network, greatly increases the
surface area
Membrane proteins: receptors for agonists and
adhesive glycoproteins, signal transduction molecules
IIb-IIIa: fibrinogen, vWF, fibronectin
Ib-IIa: collagen
Ib-IX-V: insoluble Vwf
VI: collagen

50. Platelet Anatomy Submembranous zone
Contractile protein system: regulates shape
and carry out events such as secretion of
granules and retraction of clots
Organelle zone
Platelet specific storage granules
Dense bodies: serotonin, ADP, ATP, Ca
α granules: platelet factor 4, thromboglobulin,
PDGF, vWF
Lysosomes, peroxisomes

51. Hemostasis: Adhesion Initial event in hemostasis
Platelets contact subendothelial components exposed after vessel injury
vWF secreted into extracellular matrix from endothelial cells binds to GPIb-V-IX on platelet surface
vWF on endothelial cells forms a bridge between the subendothelium and platelet

52. Hemostasis: Activation
Interaction between GP Ia-IIa and GP VI with collagen results in platelet arrest and activation
Forms a firm adherence
Leads to intracellular signaling processes that initiate secretion
Activated platelets express a procoagulant surface

53. Hemostasis: Secretion
Undergo shape change
Spherical
Pseudopods
Spread over the exposed subendothlium
Contents of platelet granules are released
α granules: fibrinogen, vWF, thrombospondin, factor V, vitronectin
Dense granules: ADP, ATP, serotonin, calcium

54. Hemostasis: Aggregation
Once activated, platelets become adhesive to each other
Interact via fibrinogen bound to their GPIIb-IIIa receptors
Microthrombus of aggregated platelets is formed

55. Presentation of Disorders of Platelet Function
Mucocutaneous bleeding
Gingiva
Epistaxis
Menorrhagia
Petechiae
Ecchymoses
Bleeding after trauma and surgery
Rare: ICH, joint, muscle

56. Clinical Presentation of Bleeding Disorder
Clinical signs
Disorders of coagulation
Disorder of platelets or vessles
Petechiae
Rare
Characteristics
Ecchymoses
Common, large
Characteristics, small
Bleeding from superficial cuts
Minimal
Persistent
Delayed bleeding
Common
Deep hematomas
Hemothrosis

57. Diagnostic work up Initial Platelet count and morphology
PT, PTT (mixing studies)
Platelet function analyzer (PFA)-100
Bleeding time
vWD panel
Platelet aggregation
Flow cytometry, electron microscopy
Detailed drug history

58. Inherited Platelet Function Disorders
Adhesion
Bernard Soulier Syndrome
Collagen receptor deficiency
Aggregation
Glamzman’s Thrombasthenia
Secretion
Storage pool disorders
Coagulant activity
Scott syndrome

60. Bernard-Soulier Syndrome
First described in 1948 AR
Present in infancy or early childhood
Thrombocytopenia, giant platelets, bleeding tendency
Abnormality of the GP Ib-IX-V complex
Normally binds to vWF
Initial platelet adhesion to the subendothelium
Mutations in Ibα, Ibβ, or IX

61. Bernard-Soulier Syndrome
Prolonged bleeding time
Thrombocytopenia, variable
Abnormal smear, enlarged platelets
Aggregation
Normal in response to ADP, epinephrine, arachadonic acid, collagen
Fails in response to ristocetin
Cannot be corrected by the addition of normal plasma containing vWF
Abnormal flow cytometry

62. Glanzmann Thrombasthenia
First described in 1918 AR
Present with mucocutaneous bleeding as neonate or infant
Bleeding tendency, normal platelet count
Deficiency of GPIIb/IIIa
Normally binds to fibrinogen and vWF
Cross links adjacent platelets to form platelet plug

63. Glanzmann Thrombasthenia
Normal platelet count and morphology
Prolonged bleeding time
PFA-100
COL/EPI abnormal
COL/ADP abnormal
Aggregation
Abnormal in response to all agonists except ristocetin
Flow cytometry abnormal

65. Storage Pool Disorders Gray Platelet Syndrome
Absence of αgranules (normal ~ 50) AR
Molecular defect unknown
Mild mucocutaneous bleeding
Variably prolonged bleeding time
Moderate thrombocytopenia
Reticulin fibrosis of BM
Large gray platelet
EM: small, empty or absent αgranules

66. Storage Pool Disorders Dense Granule Disorders
Normal dense granules
3-6/platelet
Serotonin, ADP, ATP, Ca
Heterogeneous group of disorders
Molecular defect unknown
Mild to moderate bleeding

67. Storage Pool Disorders
Two autosomal recessive syndromes associated with albinism
Chediak-Higash
Hermansky-Pudlack
Non-albino syndromes
Wiskott-Aldrich
Thrombocytopenia absent radii
Osteogenesis imperfecta

68. Storage Pool Disorders
Chediak-Higash
Partial oculocutaneous albinism
Frequent pyogenic infection
Giant lysosomal granules in cells
Thrombocytopenia
Dense granule deficiency
Hermansky-Pudlack
Oculocutaneous albinism
Inclusions in the cells of RES
Thrombocytopenia
Dense granule deficiency
Common in Puerto Rico

69. Storage Pool Disorders
Clinical presentation
Platelet morphology normal
Bleeding time usually, not always prolonged
Aggregation
Marked impairment with weak agonists ADP, epinephrine and low concentrations of collagen
Response to higher concentration may be normal
Absent second wave of aggregation when stimulated by ADP and epinephrine

70. Disorders of Procoagulant Activity Scott syndromeAR
Severe bleeding
Decrease transport of phospholipids to surface of activated platelet
Decreased expression of factor Xa binding sites
Failure of factor Xa to bind
Incapacity of the activated cell surface to transform prothrombin to thrombin
Prothrombin consumption test is the only abnormal test

71. Thrombocytopenia Increase platelet destruction Immune Non-immune
Decreased platelet production
Congenital
Acquired
Sequestration
Qualitative platelet disorders

72. Qualitative Platelet Disorders
Wiskott-Aldrich syndrome
X-linked; small platelet
Bernard-Soulier syndrome
AD, large platelets
May-Hegglin anomaly
AD, giant platelet, Dohle bodies
Gray platelet syndrome
Pale/oval platelet
Glandzmann’s thrombesthenia

73. Sequestration Kasabach-Merritt syndrome Hypersplenism
May be associated with infiltrative disease
(leukemia)
May arise from liver disease, portal hypertension
In Vitro platelet clumping
Easily diagnosed by peripheral smear evaluation

74. Decreased Platelet Production Congenital
Thrombocytopenia-Absent Radius syndrome
Absence of radii at birth
Association with congenital heart disorder
Amegakaryocytic Thrombocytopenia
Presents in neonatal period
No skeletal anomalies
Fanconi Anemia
Due to aplastic anemia
Short stature, thumb and radii hypoplasia,
microcephaly

75. Thrombocytopenia-Absent Radius

76. Decreased Platelet Production Acquired
Leukemia
Aplastic anemia
Neuroblastoma
Due to bone marrow metastasis
Drugs
Nutritional deficiency
Megaloblastic anemia

77. Increased Platelet Destruction Nonimmune
Hemolytic-uremic syndrome
Microangiopathic anemia
Bloody diarrhea (E coli O157:H7)
Disseminated intravascular coagulation
Microangiopathic anemia; low fibrinogen
Sepsis
Cyanotic heart disease

78. Increased Platelet Destruction Immune
HIV
Post transfusion
Drugs
Collagen-vascular disease
Neonatal alloimmune thrombocytopenia
Idiopathic thrombocytopenia

79. Heparin and Thrombocytopenia
Immune Heparin-induced thrombocytopenia
Initially presents as decrease in platelet with or without thrombosis
Two distinct syndromes:
1 Uaually mild and transient thrombocytopenia with rapid recovery upon discontinuation of heparin
2 Severe thrombocytopenia often complicated by thrombosis or DIC

80. Neonatal Thrombocytopenia
Child born to Mother with ITP
Mother with thrombocytopenia
Resolves within about 6 weeks
Risk of ICH 1%
Avoid maternal platelet transfusion
Neonatal alloimmune thrombocytopenia
Mother with normal platelet
Resolves with about 6 weeks
Risk of ICH 10-30%
Maternal platelet transfusion for bleeding
Severity increases with subsequent siblings

81. Idiopathic Thrombocytopenia Purpura
Diagnosis is based primarily on the history, PE, CBC, and peripheral smear examination
CBC must show isolated and usually severe thrombocytopenia
Bone marrow aspiration should be performed in patients with thrombocytopenia lasting more than 6 to 12 months, and in those unresponsive to IVIG therapy

83. Idiopathic Thrombocytopenia Purpura
Clinical features
M=F
Child is well with rapid onset of thrombocytopenia
Generally seen in children 1 to 9 years old
Peak incidence is between 2 to 5 y/o
1 in 1500 persons with get ITP in childhood
Seasonal presentation
More common in winter and fall
Platelet-specific autoantibodies seen 4-8 weeks following a viral illness or exposure

84. ITP Treatment Severe life-threatenin bleeding
IVIG, steroids, platelet transfusion
Platelet counts > 30k
Asymptomatic or only minor purpura: no treatment
Platelet counts < 20k
Significant mucosal bleeding
Treatment with IVIG or steroids
Platelet counts < 10k
Only minor purpura

85. ITP Treatment IVIG More rapid increase in platelet counts
The mean platelet count in the IVIG group was approximately 2.5 times than steroid gr
Average platelet count rose over 30k by 24 hrs in IVIG, and by 48 in steroid gr. At one week the levels were equal
IVIG will not affect subsequent BM biopsy results
Dosing: 1g/k on 1 day

86. ITP Treatment Steroids
IVIG costs about 150 times as much as treatment with steroids
IVIG can cause aseptic meningitis
Causing an emergent diagnostic evaluation to rule out ICH
Dosing: 2mg/k/day

87. Chronic ITP Defined as thrombocytopenia lasting longer than 6 months
Child may present with recurrent upper an lower respiratory tract infections, GERD, and FTT
Family history is often positive for ITP or other autoimmune disease (SLE)

88. Acquired Platelet Defects
Medications
Chronic renal failure
Abnormal platelet aggregation, reduced secretion in response to many agonists
May be caused by both dialyzable and nondialyzable substances
Cardiopulmonary bypass surgery
SLE
Chronic myeloproliferative disorders and acute leukemia

89. DIC

90. Clinical Conditions Associated with DIC
Sepsis/severe infection (any microorganism)
Trauma (polytrauma, fat embolism)
Organ destruction (severe pancreatitis)
Malignancy (solid tumors, hematological malignancy)
Obstetrical calamities (amniotic fluid embolism, abruptio placentae)
Vascular abnormalities (Kasabach-Merritt syndrome, large vascular aneurysms)
Severe hepatic faliure
Severe toxic or immunologic reactions (snake bites, transfusion reactions, transplant rejection)

91. Pathogenesis: Initiation of Fibrin Deposition
Hambleton, J. et al. Hematology 2002

92. Pathogenesis: Amplification of Fibrin Deposition
Hambleton, J. et al. Hematology 2002

93. Pathogenesis: Amplification of Fibrin Deposition
Hambleton, J. et al. Hematology 2002

94. Pathogenesis: Propagation of Fibrin Deposition
Fibrinolytic system is downregulated at the time of max. activation of coagulation
In baceremia, endothelial cells release plasminogen activators
Increase plasminogen activator inhibitor, type 1 (PAI-1) immediately to suppress of fibrinolytic activity
High PAI-1 level strongest predictors of mortality (ref 3)
4G/5G polymorphism, functional mutation of PAI-1 gene indicated higher PAI-1, increased risk of death in bacteremia (ref 38)

95. Diagnosis 1 Underlying disorder
2 Global coagulation tests (platelet; PT; fibrinogen; FDP)
Score 0 1 2
Platelet ()
> 100
< 100
< 50
FDP
No increase
Moderate
Strong
PT (sec.)
< 3
3-6
>6
Fibrinogen (g/L)
>1
<1
If score ≧ 5: DIC, repeat daily
If score < 5: non-overt DIC, repeat next 1-2 days

96. Management 1.Plasma and platelet substitution therapy
Only in active bleeding, requiring an invasive procedure, at risk for bleeding complications
2.Anticoagulants
3.Restoration of anticoagulant pathways