1. von Willebrand Disease
Theera Ruchutrakool, MD Division of Hematology Department of Medicine Faculty of Medicine Siriraj Hospital Mahidol University March 4, 2018

2. Outline Biology Genotype, phenotype and classification Diagnosis
Management

3. Biology

4. abnormal platelet adhesion
Ristocetin found
prolonged BT
first report
vWF found
1926
1953
1957
1960
1971
1976
1985
abnormal platelet adhesion
cDNA cloned
low FVIII
1.von Willebrand EA. Fin Lakaresallsk. Handl.1926; 67: 7-12.
2.Zimmerman TS, et al. J Exp Med.1973; 138:
3.Lynch DC, et al. Cell.1985; 41:
4.Ginsburg D, et al. Science.1985; 228:

5. von Willebrand Disease (vWD)
the most common hereditary bleeding disorder
different inheritance pattern from hemophilia
inherited by either autosomal dominant (AD) or autosomal recessive (AR)
the incidence % in Western country
von Willebrand factor (vWF) gene is located on short arm of chromosome 12
180 kb (0.1% of chromosome 12)
composed of 52 exons (size range from 40 bp to 1.4 kb)

6. vWF: hemostatic function
Promote platelet adhesion
Protect proteolysis of F.VIII
Red blood cell
Platelet
von Willebrand factor

7. vWF: hemostatic function
Promote platelet adhesion
Protect proteolysis of F.VIII
platelet and collagen
Red blood cell
Platelet
von Willebrand factor

8. vWF: hemostatic function
Promote platelet adhesion
Protect proteolysis of F.VIII
platelet and collagen
Red blood cell
Platelet
von Willebrand factor

9. vWF: hemostatic function
Promote platelet adhesion
Protect proteolysis of F.VIII
platelet and collagen
Red blood cell
Platelet
von Willebrand factor
Fibrin polymer

10. vWF: mature subunit & binding siteC
D’ D3 A A2 A D4 B C
Factor VIII GPIb/IX/V collagen GPIIb/IIIa
heparin type I and III
sulfatide
collagen type VI

11. Genotype, phenotype and classification

12. vWD: Type & Genetic Mutation
Defect
Genetic Transmission 1
Quantitative
AD with incomplete penetrance 2
Qualitative 2A 2B 2M 2N
AD, variability of expression, highly penetrance AD
AR, homozygous, compound heterozygous, FVIII binding mutation + null mutation 3
Combination AR
Sadler JE, et al. J Thromb Haemost.2006;4:

13. vWD: Incidence <5% <5% 20-25% 65-75% type 2M rare type 3
1-5:1,000,000
Robertson J, et al. Pediatr Clin North Am.2008;55:
Nichols WL, et al. Haemophilia.2008;14:

14. N C
D’ D3 A1 A2 A D4 B C
Factor VIII GPIb/IX/V collagen GPIIb/IIIa
heparin type I and III
sulfatide
collagen type VI
James P, et al. Semin Thromb Hemost.2006;32:546–52.

15. vWD: Type & Genetic Mutation
Type 1: only 65% of case have identified mutations
70% of vWF variants are missense mutation influencing trafficking, storage, secretion and clearance (high vWF:propeptide/vWF:Ag ratio as a surrogate marker)
additional transcription and splicing vWF mutations
Type 3: mutations found in 85-90% of cases, recessive fashion
large gene deletion
null mutation, missense mutation
other factors outside
the vWF gene
Sharma R, et al. Blood. 2017;130:

16. vWD: Type & Genetic Mutation
D’ D3 A A2 A D4 B C
Factor VIII GPIb/IX/V Collagen GPIIb/IIIa
Heparin type I and III
Sulfatide
Collagen type VI
type 1 and type 3
Sharma R, et al. Blood. 2017;130:

17. vWD: Type & Genetic Mutation
Type 2- point mutation-most common
2A - missense mutation (exon 28-D’D3, A2 and C domain influenced assembly of multimer, secretion and storage
- missense mutation in A2 domain that enhanced
ADAMTS13 proteolysis
2B - missense mutation in A1 domain which is platelet GPIb/IX/V binding domain that enhanced binding to GPIb, and caused thrombocytopenia
2M - missense mutation in A1 domain which is platelet GP Ib/IX/V binding domain that decreased platelet binding affinity and impaired collagen type VI binding
- missense mutation in A3 domain will impaired collagen
type I and III binding (rare)
2N - missense mutation in D'-D3 domain which is factor VIII binding site that caused low FVIII:C
Sharma R, et al. Blood. 2017;130:

18. von Willebrand Disease
type 2B, 2M
type 2M
type 2A
type 2N
type 2A
type 2A N C
D’ D3 A A2 A D4 B C
Factor VIII GPIb/IX/V Collagen GPIIb/IIIa
Heparin type I and III
Sulfatide
Collagen type VI
type 1 and type 3
Sharma R, et al. Blood. 2017;130:

19. Diagnosis

20. vWD: Diagnosis clinical phenotype
quantitative bleeding assessment tools (BAT)
hemostasis laboratory phenotype
vWF:Ag
vWF:Rco or direct GPIb-binding assays
vWF:CB
vWF:FVIIIB
vWF:propeptide (vWF:pp)
vWF:multimer
ristocetin-induced platelet aggregation (RIPA)
genotype
type 1 not routinely used
type 2A not usually needed
type 2B sometime helpful
type 2M sometime helpful
type 2N differentiated from mild hemophilia
type 3 very helpful

21. vWD: Clinical Manifestations
age at presentation
sex
familial history
asymptomatic: prolonged bleeding after surgery
primary hemostatic defects
mucosal bleeding, gastrointestinal bleeding (type 2A)
ecchymosis
hypermenorrhea
secondary hemostatic defects
musculoskeletal bleeding
hemarthrosis is rare (type 2N and type 3)
Castaman G, et al. J Thromb Haemost.2012;10:632-8.

22. vWD: Clinical Manifestations
10 cases
13 cases
9 cases
Total 32 cases

23. vWD: Clinical Manifestations
Age at first presentation 12 7 5
N = 10
N = 7
N = 7

24. vWD: Clinical Manifestations
Sex 2
5:1 3 2
3.5:1
2:1 11 7 7
men
women

25. vWD: Clinical Manifestations%
Bleeding symptoms
Tosetto A, et al. J Thromb Haemost.2006;4:

26. vWD: Clinical Manifestations
clinical phenotype
quantitative bleeding assessment tools (BAT)
hemostasis laboratory phenotype
vWF:Ag
vWF:Rco or direct GPIb-binding assays
vWF:CB
vWF:FVIIIB
vWF:propeptide (vWF:pp)
vWF:multimer
ristocetin-induced platelet aggregation (RIPA)
genotype
type 1 not routinely used
type 2A not usually needed
type 2B sometime helpful
type 2M sometime helpful
type 2N differentiated from mild hemophilia
type 3 very helpful

27. vWD: Bleeding Questionnaires (BQ)
molecular and clinical markers for the diagnosis and management of type 1 vWD
Srámek A, et al (1995)
Vicenza BS (2005)
MCMDM-1 VWD BQ (2006)
Condensed MCMDM-1 VWD BQ (2008)
ISTH-BAT (2010)
Srámek A, et al. Arch Intern Med.1995;155:1409–15.
Rodeghiero F, et al. J Thromb Haemost.2005;3:2619–26.
Tosetto A, et al. J Thromb Haemost.2006;4;
Bowman M, et al. J Thromb Haemost.2008; 6:2062–6.
Rodeghiero F, et al. J Thromb Haemost.2010;8:2063–5.

28. vWD: Bleeding Questionnaires (BQ)
bleeding questionnaire (BQ)
score for each bleeding symptom
cutoff
remark
Vicenza (2005)
0 - +3
>3 males
>5 females
first BQ, 40 minutes
screening type 1 vWD (specificity 98% sensitivity 69%)
MCMDM-1 (2006)
> 3
adding negative score for increased sensitivity, 40 minutes
Condensed MCMDM-1 (2008)
5-10 minutes (specificity 81-98% sensitivity %) NPV 0.99 for type 1 and type 3 OC from normal control
Pediatric BQ (2009)
≥ 3
pediatric specific bleeding symptoms
20 minutes
ISTH-BAT (2010)
0 - 4
4 males
6 females
3 children
remove -1 score, 20 minutes

29. vWD: Bleeding Questionnaires (BQ)
12.1
7.7
5.0
N = 140
N = 11
N = 7
N = 9

30. vWD: Laboratory clinical phenotype
quantitative bleeding assessment tools (BAT)
hemostasis laboratory phenotype
vWF:Ag
vWF:Rco or direct GPIb-binding assays
vWF:CB
vWF:FVIIIB
vWF:propeptide (vWF:pp)
vWF:multimer
ristocetin-induced platelet aggregation (RIPA)
genotype
type 1 not routinely used
type 2A not usually needed
type 2B sometime helpful
type 2M sometime helpful
type 2N differentiated from mild hemophilia
type 3 very helpful

31. vWD: Laboratory clinical phenotype
quantitative bleeding assessment tools (BAT)
hemostasis laboratory phenotype
vWF:Ag
vWF:Rco or direct GPIb-binding assays
vWF:CB
vWF:FVIIIB
vWF:propeptide (vWF:pp)
vWF:multimer
ristocetin-induced platelet aggregation (RIPA)
genotype
type 1 not routinely used
type 2A not usually needed
type 2B sometime helpful
type 2M sometime helpful
type 2N differentiated from mild hemophilia
type 3 very helpful
poor standardization
unreliable if vWF:Ag < 10 U/dL
bleeding time
aPTT

32. vWD: Laboratory prolonged aPTT 66.67% 66.67% 100% N = 13 N = 9 N = 8
66.67% % %
53.3 sec.
31.7 sec.
33.0 sec.
N = 13
N = 9
N = 8

33. vWD: Laboratory vWF:Ag or vWF:Rco (U/dL) normal 100 low vWF 50 30
5-10
normal
low vWF
type 1 or 2 vWD
Type 3 vWD
Sadler JE. Blood.2003;101:

34. vWD: Laboratory Factors that may interfere vWF level age blood group
inflammation

35. vWD: vWF:Ag and FVIII:C
Healthy blood donor

36. vWD: Blood group in patients
Blood group (O:non-O) 3
2.3:1 5
0.8:1 7 2
1:1 4 2
O blood group
Non O blood group

37. vWD: Laboratory vWF: Ag <5-10% 10-30% Type 3 vWF:Rco/vWF:Ag
FVIII:C/vWF:Ag
≤0.6
>0.6
 0.5
< 0.5
Low dose RIPA
Type 1
Type 2N
Sadler JE, et al. J Thromb Haemost 2006;4:
Berntorp E, et al. Haemophilia 2012,18 (Suppl.6):1–13.

38. vWD: Laboratory low dose RIPA  proteolysis assembly defect present
absent
aggregation
no aggregation
plasma vWF multimer
platelet vWF multimer
present
absent
Type 2B
Type 2M
Type 2A
Sadler JE, et al. J Thromb Haemost 2006;4:
Berntorp E, et al. Haemophilia 2012,18 (Suppl.6):1–13.

39. vWD: vWF:Ag and FVIII:C
130
130 50 55 39 44
1.6 4
1.5
1.2
0.8
0.5
0.5

40. vWD: vWF:Ag and vWF:Rco87
130 29 50 39 16 4 4
0.94
0.8
0.8
0.6
0.27

41. vWD: vWF:Ag and vWF:CB
135
130 40 30 7 50 39 4
1.5
1.2
1.0
0.6
0.4

42. Schematic Plasma vWF Multimers
normal A B M N normal
large
small
Schematic Plasma vWF Multimers

43. vWD: Laboratory clinical phenotype
quantitative bleeding assessment tools (BAT)
hemostasis laboratory phenotype
vWF:Ag
vWF:Rco or direct GPIb-binding assays
vWF:CB
vWF:FVIIIB
vWF:propeptide (vWF:pp)
vWF:multimer
ristocetin-induced platelet aggregation (RIPA)
genotype
type 1 not routinely used
type 2A not usually needed
type 2B sometime helpful
type 2M sometime helpful
type 2N differentiated from mild hemophilia
type 3 very helpful

44. Management

45. vWD: Management Considering factors type of vWD: 1, 2 or 3
available products
clinical situation:
acute hemorrhage
preoperative preparation
pregnancy, delivery and puerperium

46. vWD: Management Non-replacement therapy Replacement therapy
estrogen: increased endogenous FVIII:C and
vWF
DDAVP: increased endogenous FVIII:C and vWF
antifibrinolysis: increased clot stability
Replacement therapy
cryoprecipitate
FVIII concentrate: increased exogenous
FVIII:C and vWF

47. vWD: Management Estrogen increased endogenous FVIII and vWF
endometrial changes
benefit in vWD with hypermenorrhea

48. vWD: Management DDAVP (1-Deamino-8-D-Arginine Vasopressin)
antidiuretic hormone derivative
first used in 1977
increased FVIII and vWF release from endothelium
must document response of DDAVP at 1, 2, 4 hours prior to use
three times higher than baseline and must be above hemostatic level
indication
type 1 (baseline vWF >10 U/dL)
type 2A, 2N (some)
contraindication
type 2B and type 3

49. vWD: Management DDAVP (1-Deamino-8-D-Arginine Vasopressin)
Intravenous (single dose)
4 µg/mL/vial
dosage 0.3 µg/kg/dose
intravenous infusion in minutes
time to peak minutes
3-5 times of baseline value
plasma half life is 5-8 hours for FVIII and
8-10 hours for vWF
Intranasal (single dose)
300 µg/kg
time to peak minutes
not available in Thailand

50. FVIII:C vWF:Ag vWF:Rco 40 IU/dl 170 IU/dl 4.3 times 36 IU/dl 105 IU/dl

51. vWD: Management DDAVP (1-Deamino-8-D-Arginine Vasopressin)
Side Effects
flushing
tachycardia
water intoxication (hyponatremia)
tachyphylaxis
individual response

52. vWD: Management Antifibrinolytic agents Tranexamic acid
orally 25 mg/kg/day tid
intravenous 10 mg/kg/dose
benefit in bleeding of high fibrinolytic activity organs e.g. oral cavity, urinary tract

53. vWD: Replacement Therapy
10-20% of vWD need replacement therapy
sources of vWF
cryoprecipitate
factor VIII concentrate (vWF:Rco/vWF:Ag ratio more than 0.7)
intermediate purity
high purity (either monoclonal immunoaffinity chromatography or recombinant technology) not suitable for vWD
vWF concentrate (vWF:Rco/FVIII:C ratio more than 10, Wilfactin® ) in European countries

54. vWD: Replacement Therapy
Factor concentrate
vWF:FVIII ratio
Alphanate®
0.5:1
Wilate®
1:1
Humate-P®
2.4:1
Wilfactin®
10:1

55. vWD: Replacement Therapy
Dose Recommendation of FVIII/vWF concentrate
Type of bleeding
Dose FVIII
(IU/kg)
Number of infusion
Target
major surgery
40-60 OD
maintain trough FVIII:C >50 IU/dL until healing
is complete (5-10 days)
minor surgery
30-50
OD or AD
maintain trough FVIII:C >30 IU/dL until healing
is complete (2-4 days)
dental extraction
20-30
single
FVIII:C>30 IU/dL at least 12 hours
spontaneous bleeding
FVIII:C>30 IU/dL 2-3 days
delivery and puerperium 40
daily before delivery and postpartum period
FVIII:C > 50 IU/dL 3-4 days
Mannucci PM. N Engl J Med.2004;351:

56. 47-year-old vWD type 3 patient with pseudotumor of right thigh resection
25 IU/Kg, AD
15 IU/Kg, AD
25 IU/Kg, OD

57. vWD: Monitoring aPTT FVIII:C Bleeding time vWF:Rco sensitivity + +++
convenient ++
real time
related to clinical bleeding

58. vWD: Pregnancy, delivery and puerperium
higher FVIII:C and vWF normally found during pregnancy
produced from placenta
postpartum hemorrhage is times higher than normal women
keep FVIII:C and vWF:Rco > 50 IU/dL during peripartum and postpartum period
James AH, et al. Obstet Gynecol.2009;114:674–8.

59. Conclusion vWD is the most common hereditary bleeding disorder.
Most of the patients are mild bleeders.
BS is benefit to determine if investigation should be started (especially NPP).
A number of factors to be considered prior to laboratory interpretation such as age, blood group, inflammation.
Hemostasis can easily be achieved.
Thrombosis can occur if FVIII:C is elevated > 150IU/dL.

60. Thank you for your attention