Management of acquired hemophilia A: results from the Spanish registry

The Spanish Acquired Hemophilia A (AHA) Registry is intended to update the status of AHA in Spain. One hundred and fifty-four patients were included and retrospectively followed for a median of 12 months. Patients were predominantly male (56.3%), with median age at diagnosis of 74 years. AHA was more frequently idiopathic (44.1%) and autoimmune disorder-associated (31.7%). Thirty-four percent of patients were on antithrombotic therapy at diagnosis. Hemostatic treatment was used in 70% of patients. Recombinant activated factor VII was more frequently infused (60.3% vs 20.6% activated prothrombin complex concentrate). Only 1 patient did not achieve control of hemorrhage. Complete remission (CR) was achieved by 84.2% of cases after immunosuppressive therapy. Steroids alone were less efficient than the other strategies (68.2% vs 87.2%, P = .049), whereas no differences existed among these (steroids/cyclophosphamide, 88.5%, vs steroids/calcineurin inhibitors, 81.2%, vs rituximab-based regimens, 87.5%). Female sex and high inhibitor levels influenced CR negatively. Thirty-six deaths (23.8%) were reported. Main causes of death were infection (15 patients, 9.9%) and hemorrhage (5 patients, 3.3%). All hemorrhage-related and half the infection-related deaths occurred within 2 months of diagnosis. Prior antithrombotic therapy was inversely associated with survival, irrespective of age. Median age of nonsurvivors was significantly higher (79 vs 73 years in survivors). Patients dying of infection were older than the other nonsurvivors (85 vs 78 years). In summary, fatal infection in the first months is common in our series. Antithrombotic therapy is associated with mortality. Particular care should be taken to avoid misdiagnosis

Role of multimeric analysis of von Willebrand factor (VWF) in von Willebrand disease (VWD) diagnosis: Lessons from the PCM-EVW-ES Spanish project - Fig 2

<p><b>Comparison between the diagnostic definition contribution of VWF:CB (in step “screening tests” [a]) and the multimeric analysis (MA) instead of VWF:CB first step, (step “screening tests” [b]).</b> A greater degree of efficiency was observed for MA (50.4% <i>versus</i> 33.1% for VWF:CB).</p

Role of multimeric analysis of von Willebrand factor (VWF) in von Willebrand disease (VWD) diagnosis: Lessons from the PCM-EVW-ES Spanish project

<div><p>The multimeric analysis (MA) of plasma von Willebrand factor (VWF) evaluates structural integrity and helps in the diagnosis of von Willebrand disease (VWD). This assay is a matter of controversy, being considered by some investigators cumbersome and only slightly informative. The centralised study ‘Molecular and Clinical Profile of von Willebrand Disease in Spain (PCM-EVW-ES)’ has been carried out by including the phenotypic assessment and the genetic analysis by next generation sequencing (NGS) of the VWF gene (VWF). The aim of the present study was to evaluate the role of MA to the diagnosis of these patients and their potential discrepancies. Two hundred and seventy out of 480 patients centrally diagnosed with VWD had normal multimers, 168 had abnormal multimers and 42 a total absence of multimers. VWF MA was of great significance in the diagnosis of 83 patients (17.3%), it was also of help in the diagnosis achieved in 365 additional patients (76%) and was not informative in 32 cases (6.7%). With regard to discrepancies, 110 out of 480 (23%) patients centrally diagnosed with VWD presented some kind of discordance between VWF:RCo/VWF:Ag and/or VWF:CB/VWF:Ag ratios, multimeric study and/or genetic results. The VWF MA was key in the presence of novel mutations as well as in cases with phenotypic discrepancies. A comparison between the contribution of MA and VWF:CB showed a clearly higher contribution of the former in the diagnostic process. These data seem to reinforce the relevance of the VWF MA in VWD diagnosis, despite all its limitations.</p></div

Multimeric analysis of von Willebrand factor (VWF) in low-resolution SDS-agarose gels in patients with type 2A/2M VWD and some discrepancy.

<p>VWF from platelet lysate (NPt), plasmas of a normal subject (NP), patients with type 2A/2M VWD and a patient with VWD type 2A (IIA) used as a control 2A are shown. <b>(a-c)</b> Patients that showed discrepancy between ratios and multimeric analysis. In the case of the patients C30P012F07, C30P013F08 and C37P003F03 the mutations had not been described previously and the multimeric analysis (smeary) was of great significance to establish the diagnosis.</p

Demographic data of the cohort of patients.

<p>Demographic data of the cohort of patients.</p

Evaluation of the contribution of different laboratory steps in the diagnosis definition.

<p>Four different successive laboratory assessment steps are considered. The progress in the diagnostic definition of the patients according to each step is shown. After the first and second steps, the multimeric analysis (MA) was of great significance in the diagnosis definition of 83 additional patients. Moreover, MA was in agreement with the diagnostic definition accomplished in steps 1 and 2 (179 patients). Finally, MA was also in agreement with the diagnostic definition achieved by molecular analysis in 186 additional patients. Thus, MA contributed to the diagnosis definition in a total of 448 (93.3%) patients.</p

Distribution of patients according to their coincidence between ratios and multimeric analysis before genetic study and between multimeric analysis and mutation after genetic study.

<p>Of 110 patients with some type of discrepancy, in 76 (48 + 28) the MA was in line with the molecular study while in 18 (14+4) patients there was not concordance. In the remaining 16, the similarity could not be demonstrated because the mutation found has not been described previously.</p

Patients with consistency between VWF:RCo/VWF:Ag-VWF:CB/VWF:Ag-multimeric pattern but not with genetic analysis.

<p>Patients with consistency between VWF:RCo/VWF:Ag-VWF:CB/VWF:Ag-multimeric pattern but not with genetic analysis.</p

Multimeric analysis of von Willebrand factor (VWF) in low-resolution SDS-agarose gels in patients with type 2A VWD and some discrepancy.

<p>VWF from platelet lysate (NPt), plasmas of a normal subject (NP), patients with type 2A VWD and a patient with VWD type 2A (IIA) used as a control 2A are shown. <b>(a-b):</b> Patients with discrepancy between ratios and multimeric analysis; <b>(c-d):</b> Patients re-classified as type 2A on the basis of the genetic study.</p

Patients with discordance between VWF:RCo/VWF:Ag-VWF:CB/VWF:Ag-multimeric pattern.

<p>Patients with discordance between VWF:RCo/VWF:Ag-VWF:CB/VWF:Ag-multimeric pattern.</p