Hemophilias

Learning Objectives – Upon completion of required reading,

after careful study, and following this lecture the learner will be able to:

1. Characterize the three types of hemophilia by inheritance pattern,

prevalence, clinical manifestations, and laboratory findings.
2. Explain the occurrence of female hemophiliacs despite its x-linked
recessive inheritance pattern.
3. Discuss the utilization of single factor assays to confirm suspected cases
of hemophilia.
4. Interpret results of a single factor assay.
5. Given a set of lab data and a patient history, correctly diagnose
hemophilia A, B or C.
6. Justify the treatment regimens for hemophilia A, B, and C.
7. Recommend with explanation a laboratory testing approach to aid the
diagnosis of bleeding disorders associated with deficiencies of factors
VIII, IX, and XI.
8. Interpret lab data, correlate it with patient information, and synthesize
knowledge of the hemophilia to correctly respond to test questions and
solve subject-matter related case studies.
 Review 1
•All coagulation pathways
lead to activation of
prothrombin and formation
of fibrin clot!
•The activity = enzyme
action
•Enzyme action depends
on amount of protein
present and the structure of
protein

Graphic accessed http://www.ganfyd.org/images/3/32/CoagulationAndFibrolyticPathways.png, 2009.

Review 2 – Genetics and Inheritance
X-linked Recessive
 X-linked genes are never passed
from father to son
 An affected female must have an
affected father
 Males are always hemizygous for X
linked traits, that is, they can never
be heterozygoses or homozygotes
 Males are never carriers
 In a male a single dose of a
mutant allele will produce a
mutant phenotype in the male
 In a female will be either
homozygous for the normal allele,
heterozygous (carrier), or
homozygous (have trait) for the
mutant allele.

,
Information and graphic accessed http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=gene&part=glossary&rendertype=box&id=further_illus-226 .
2009
Review 2 – Genetics and Inheritance
Autosomal Dominant
 Every affected individual has an affected
biological parent. There is no skipping of
generations.
 Males and females have an equally likely
chance of inheriting the mutant allele and
being affected.
 The recurrence risk of each child of an
affected parent is 1/2.
 Normal siblings of affected individuals do
not transmit the trait to their offspring.
 The defective product of the gene is
usually a structural protein, not an
enzyme. Structural proteins are usually
defective when one of the allelic products
is nonfunctional; enzymes usually require
both allelic products to be nonfunctional
to produce a mutant phenotype.

Information and graphic accessed from URL http://www.uic.edu/classes/bms/bms655/lesson3.html#DOMINANT

Hemophilias Introduction
 Hemophilia
 Inherited
 X-linked (recessive)
 A&B
 Autosomal
 C
 Single factor
deficiencies
 Anatomic soft tissue
bleeding

Graphic accessed URL http://www.daviddarling.info/images/hemophilia_inheritance_1.gif, 2008.

Hemophilias Introduction:
Genetics
A& B
 genes for both FVIII and FIX are located
on the long arm of chromosome X
 The gene for FVIII (F8C) is unusually
large
 FVIII contains 2332 amino acids
 Approximately 40% of cases of severe C
FVIII deficiency arise from a large  gene for factor XI is on the distal arm of
inversion that disrupts the FVIII gene. chromosome 4 (4q35)
Deletions, insertions, and point
mutations account for the remaining  mutations include missense
50-60% of hemophilia A defects mutations, nonsense mutations, deletions
and/or insertions, and splice-site mutations
 The FIX gene (F9) is small
 Mutations described so far are associated
 FIX contains 415 amino acids with mainly failed or reduced production
 Point mutations and deletions in the of the active protein, and only a few are
FIX gene are the most common causes related to the production of a
of hemophilia B dysfunctional molecule.

Graphic accessed http://www.biochem.arizona.edu/classes/bioc471/pages/Lecture25/TktR-2.jpeg, 2009.

Hemophilias Introduction
 Prevalence  Severity Classification
 North America & Europe
 A - 1 in 5000 male births  Clinical bleeding
 US 21 cases per 100,000 male
individuals w/ 60% severe symptoms
disease
 B – 1 in 25,000 male births Or
 US 5.3 cases per 100,000 male
individuals w/ 44% severe
disease
 Plasma procoagulant levels
 C – 1 in 100,000 population  < 1% normal factor activity
 High prevalence in Ashkenzai  Severe
and Iraqi Jews
 Israel – 8% rate  1 – 5% normal factor
 United Kingdom 383 in 58
million population activity
 Moderately severe
 5 – 40% normal factor
activity
 Mild hemophilia
Classic Hemophilia – VIII
Deficiency
 FVIII 2-chain
glycoprotein produced
by liver and endothelium
 Cleaved by thrombin
producing a calcium
dependent heterodimer
that complexes with IXa
 VIIIa-IXa (Tenase)
cleaves X
 Deficiency of VIII slows
production of thrombin
 hemorrhage

Graphic accessed http://kuwaitmd.hsc.edu.kw/main/files/images/Coagulation_cascade.png, 2009.

Hemophilia A Genetics
 Gene mutations lead to
quantitative and qualitative
disorders
 Male hemizygotes w/
mutation of X
 Positive anatomic bleeding
 Female heterozygote carriers
 Negative for anatomic
bleeding
 All sons of hemophiliac male
are not hemophiliacs
 All daughters of hemophiliac
male are carriers
 30% new cases arise from
spontaneous mutation
 No family history

Graphic accessed at URL

http://www.nwabr.org/studentbiotech/winners/studentwork/2007/WB_BA_TRONGTHAM/picfamilytree.jpg, 2008.
Hemophilia A Genetics:
Female Hemophiliacs
 True homozygosity or
double heterozygosity
Causation
1. Spontaneous germline
mutation
2. Extreme lyonization -
Random, disproportional
inactivation of an X-
chromosomes with normal
genes
3. VWD, Normandy subtype

Graphic accessed http://www.thereforyou.com/content-img/genetics3c.gif, 2009.

Hemophilia A: Clinical Manifestations
 Anatomic Bleeds
 Deep muscle
 Joint
 Wound oozing
 CNS bleeds – can be the
fatal event in those
younger than 18 years of
age
 Body cavity hemorrhage

 Loss of mobility
 Neurological symptoms
http://www.kelleycom.com/blog/uploaded_images/synovitis-784213.jpg

Graphic accessed URL http://library.thinkquest.org/05aug/00112/Images/knee.jpg, 2008.

Hemophilia A Diagnosis
 Clinical Presentation
 Family history
 Abnormal neonatal bleeding
 Umbilicus
 Circumcision
 Intracranial
 Laboratory
 Prolonged PTT
 PT prolonged in newborns
 Factor assay
 VIII, IX, XI
 Rule out:
 vWD
 PLT disorders
 Other factor deficiencies
 Hypo/dysfibrinogenenia

Graphic accessed URL http://labtestsonline.org/understanding/analytes/coag_cascade/Coag%20Testing%20Cascade.pdf, 2008.

Single Factor Assay: STD Curve
 Dilute reference plasma
1:5 – 1:500
 1:10 assigned factor
activity value given by
manufacturer
 Mix dilutions with VIII-
depleted plasma
 Test dilutions in duplicate
using PTT assay
 Plot time (s) on y-axis
versus % activity on x-
axis using log-log or log- Factor VIII assay dilution table and
linear paper reference curve on linear-log

Graphic accessed URL http://coursewareobjects.elsevier.com/objects/elr/Rodak3e/IC/jpg/Chapter45/045012.jpg, 2008.

Treatment
 Goal – reduce morbidity, prevent
complications
Before treatment begins, physician needs
to know:
 severity of factor deficiency
 the nature of the hemorrhage or the
planned procedure
 the patient's previous treatments
with blood products
 the presence and possible titers of
inhibitors
 the patient's previous history of
desmopressin acetate (DDAVP)
use
 Responsiveness
 Did it work or not
 Products available
 Recombinant FVIII
 Factor VIII concentrate
 Recombinant VIIa
 DDAVP – increase vWF
 Aminocaproic acid – anti-fibrinolytic
 FVIII 1 U/kg increases FVIII plasma levels
by 2%. The reaction half-time is 8-12 hours.
 Treatment regimen examples
 Severe epistaxis
 Factor concentrate until 50% level
achieved
 Also consider aminocaproic acid 1-2
days
 Surgery
 Factor VII concentrate until 80%
level achieved
 10-14 days
Treatment w/ VIII Inhibitor
 The treatment of patients with inhibitors of FVIII is difficult.
 High dose versus low dose responders
 Attempts to overwhelm the inhibitor with large doses of human FVIII have been tried in
attempts to induce immune tolerance, especially if inhibitor concentrations are below 5
BU.
 Porcine FVIII, which has low cross-reactivity with human factor VIII antibody, has also
been administered.
 FVIII inhibitor-bypassing agents (FEIBA), including FIX complex, activated prothrombin
complex concentrate (aPCC), and activated FVII has also been used.
 Plasmapheresis, IVIG, or immunosuppressive therapy with cyclophosphamide and
prednisone, have showed some success in achieving long-term control.
 Rituximab with prednisone plus or minus the addition of mycophenolate mofetil when
standard therapy has failed.

Bottom line:
Minimize AB production/suppress immune response
Augment coagulation
Increase factor VIII levels
Hemophilia B a.k.a Christmas Disease
 X-linked, recessive
disorder
 Factor IX deficiency,
dysfunctional factor IX, or
factor IX inhibitors
 spontaneous hemorrhage
 excessive hemorrhage in
response to trauma
 Occurrence
 1 in 25,000 males in US
 1 in 60,000 males
worldwide

Graphic accessed URL http://coursewareobjects.elsevier.com/objects/elr/Rodak3e/IC/jpg/Chapter41/041005.jpg, 2008.

Hemophilia B – Differential Diagnosis
 Hemophilia A  Lab Studies
 VWD  CBC
 PLT count – NL
Vitamin K and other factor
deficiencies  PT - NL
 Afibrinogenemia
 PTT - prolonged
 Factor XI - severe disease
 Fibrinolytic diseases less than 1%; moderate
 Platelet disorders disease 1-5%; mild disease
greater than 5%.
Treatment
 Recombinant factor IX - level should be corrected to 100% of normal
for potentially serious hemorrhage
 Goal to keep trough level > 50% activity

 Coagulation factor IX concentrates - used to correct the patient's native

deficiency
 Goals: 1) achieve a normal hematologic response to hemorrhage; 2)
prevent hemorrhage
 Factor IX complex concentrates (II, X, VII)
 Circumvent inhibitor issue

 FFP
 Coagulation Factor VIIa (Recombinant) - activate coagulation factor X
to factor Xa as well as coagulation factor IX to IXa
 Epsilon aminocaproic acid (Amicar)
Hemophilia C a.k.a Rosenthal Syndrome
 Factor XI deficiency (THINK variable bleeding usually following trauma/surgical
interventions)
 Autosomal inheritance
 1 per 100,000 persons
 Even heterozygotes can have bleeds
 Mild to moderate bleeding
 bleeding risk in hemophilia C is not always influenced by the severity of the
deficiency
 Prevalence in Ashkenzai Jews
 Severity of bleeding episode not correlated with factor levels
 PT, TT – normal
 PTT – prolonged

 Rule out
 PLT dysfunction
 Other factor deficiencies
Hemophilia C Treatment
 “The basic principle of management consists of
altering the balance between bleeding and clotting.
 Therapy consists of replacing the deficient factor
and using other measures, such as fibrin glue and
antifibrinolytics.”
 Factor XI concentrates
 FFP 
 Fibrin glue (e.g., Tisseel VH)
 Aminocaproic acid

Matthew Prasad, MB, BS, DCH - Director, Hemostasis and Hematology Program, Professor of Pediatrics, University of New Mexico