1. Factor VII Deficiency Diagnosis and Management
Hamid Hoorfar MD
Inherited Blood Disorders Clinic
Esfahan Medical Sciences University
2014

2. Introduction
Factor VII is a vit K dependent clotting factor belonging to the extrinsic pathway.( serocovertin , stable factor)
FVII is a protein with 406 AA single chain ( 50 kDa).
In the bloodtream FVIIa is the active portion of the FVII mass and is detectable in normal concentration as low as 5-10 ng.(1-2% of zymogen)
The factor VII gen is located on chromosome 13 upstream of factor X and contains 9 exons.

3. Congenital factor VII Deficiency
The bleeding disorder was first described by Alexander in 1951.
Congenital FVII deficiency is the commonest among the rare inherited bleeding disorders with prevalence of 1 in individual.
It is an autosomal recessive disease . Bleedings is uncommon in FVII heterozygotes.
Complete absence of functional FVII is incompatible with life.
Numerous mutations underlying the disease have been described , which are predictive for a considerable heterogeneity in both clotting and clinical phenotypes.
Missense are most frequent mutations (70 -80%)

4. Clinical manifestations
Heterozygotes are usually asymptomatic while homozygotes and compound heterozygotes are develop hemorrhagic tendency.
Age and type of first bleeding are variables and correlate with clinical severity.
Bleeding symptoms ranging from severe to mild or even asymptomatic forms as the activity of Factor VII does not correlate well with bleeding tendency.
IRF7 research group proposed the classification of bleeding phenotype as hemophilia like , platelet like & asymptomatic.
ICH, GI and joint bleeds classified as severe bleedings associated with FVII levels < 5IU/dl ,without a clear relationship to the type of gene defect.
Menorrhagia is a very frequent type of bleeding in women with F7 deficiency (63%)

6. Clinical manifestations IRF7 database (228 patients)
Symptomes
No. %
Epistaxis
190 83
Easy bruising
Gum bleeding
Muscle hematoma
Hemarthrosis
Gastrointestinal
Hematuria
CNS bleeding
Postoperative bleeding
143 95 57 58 44 26 17 78 62 42 21 22 14 12 7 34

7. Clinical manifestations IRF7 database (174 female)
Symptomes
No. %
Epistaxis 98 56
Easy bruising
Gum bleeding
Muscle hematoma
Hemarthrosis
GI bleedings
Hematuria
CNS bleedings
Thrombosis
Postoperative bleedings
Menorrhagia 83 59 28 24 9 8 5 40
100 48 34 16 14 3 30 63

8. Diagnosis of Factor VII deficiency
Prolonged PT from moderate to markedly prolonged and normal PTT
FVIIc is the confirmatory test for diagnosis
Factor VII deficiency has been found to be associated with hepatic congenital enzymic defects ( dubin – johnson and gilbert syndromes)
Only 51.4% of subjects with Factor VII deficiency were diagnosed within 6 months after the first symptoms.

9. Treatment of bleeding in FVII deficiency
Prevention and treatment of bleeding resides in the replacement of the missing factor.
Because of short biological half life of FVII repeated administration every 6-8 hours is needed.
FFP, Prothrombin complex(PCC), plasma derived FVII concentrate and recombinant FVIIa available options.
Factor VIIa is today considered the first line product for replacement therapy in FVII deficiency .

10. Treatment materials for congenital FVII deficiency
Potency
Dosage
Advantages
Disadvantages
FFP 1
10 ml/Kg
Low cost
Easy avaiable
Limited effectiveness,risk of overload,risk of virus transmission
PCC
5-10
25-35 iu/kg
Suitable for surgery,virally attenuated
Risk of thrombosis,Other vit K dependent factors have higher concentrates
pd FVII concentrate
20-30
10-30 IU/kg
Suitable for surgery, virally safe,effective
Other Vit K dependent factors, risk of thrombosis
Recombinant FVIIa
>25000
15-30μg/kg
Very effective for all indications, no risk of viral
High cost

11. Surgery in FVII deficiency
Several reports on surgical intervention under FVII replacement have been published.
A FVII level between 10-15IU/dl considered to be heamostatic level.
Neither a true minimum level nor the optimum duration of factor substitution are well known.
In the STER study have been shown that postoperative haemostatic can be secured by rFVII a at a dose of at least 13μg/kg 3 times/day.
In patients with FVII level < 1 IU/dl the mean duration postoperative replacement was 5.8 .

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