Medical condition
Von Willebrand disease (VWD) is the most common hereditary blood-clotting disorder in humans. An acquired form can sometimes result from other medical conditions. It arises from a deficiency in the quality or quantity of von Willebrand factor (VWF), a multimeric protein that is required for platelet adhesion. It is known to affect several breeds of dogs as well as humans. The three forms of VWD are hereditary, acquired, and pseudo or platelet type. The three types of hereditary VWD are VWD type 1, VWD type 2, and VWD type 3. Type 2 contains various subtypes. Platelet type VWD is also an inherited condition.
In 2008 a new diagnostic category of "Low VWF" was proposed to include those individuals whose von Willebrand factor levels were in the 30–50 IU/dL range, below the normal reference range but not low enough to be von Willebrand disease. Patients with low VWF were sometimes noted to experience bleeding, despite mild reductions in VWF levels. The 2021 ASH/ISTH guidelines re-classified patients with levels in the 30–50 IU/dl range as "Low VWF" if they have no bleeding, but as having VWD if they have bleeding.
VWD type 1 is the most common type of the disorder, with mild bleeding symptoms such as nosebleeds, though occasionally more severe symptoms can occur. Blood type can affect the presentation and severity of symptoms of VWD.
VWD type 2 is the second most common type of the disorder and has mild to moderate symptoms.
The factor is named after the Finnish physician Erik Adolf von Willebrand who first described the condition in 1926. Guidelines for the diagnosis and management of VWD were updated in 2021.
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Signs and symptoms.
The various types of VWD present with varying degrees of bleeding tendency, usually in the form of easy bruising, nosebleeds, and bleeding gums. Women may experience heavy menstrual periods and blood loss during childbirth.
Severe internal bleeding and bleeding into joints are uncommon in all but the most severe type, VWD type 3.
Genetics.
The VWF gene is located on the short arm "p" of chromosome 12 (12p13.2). It has 52 exons spanning 178 kbp. Types 1 and 2 are inherited as autosomal dominant traits. Occasionally, type 2 also inherits recessively. Type 3 is inherited as autosomal recessive. However, some individuals heterozygous for type 3 may be diagnosed with VWD type 1, indicating an intermediate inheritance in those cases. VWD occurs in approximately 1% of the population and affects men and women equally.
Genetic testing is typically not part of the initial workup for von Willebrand disease, and is not needed for people diagnosed with type 1 VWD based on clinical history and laboratory tests. It is mainly useful for:
Pathophysiology.
Von Willebrand factor is mainly active in conditions of high blood flow and shear stress. Deficiency of VWF, therefore, shows primarily in organs with extensive small vessels, such as skin, gastrointestinal tract, and uterus. In angiodysplasia, a form of telangiectasia of the colon, shear stress is much higher than in average capillaries, and the risk of bleeding is increased concomitantly.
In more severe cases of type 1 VWD, genetic changes are common within the VWF gene and are highly penetrant. In milder cases of type 1 VWD, a complex spectrum of molecular pathology may exist in addition to polymorphisms of the VWF gene alone.
The individual's ABO blood group can influence presentation and pathology of VWD. Those individuals with blood group O have a lower mean level than individuals with other blood groups. Unless ABO group-specific VWF:antigen reference ranges are used, normal group O individuals can be diagnosed as type I VWD, and some individuals of blood group AB with a genetic defect of VWF may have the diagnosis overlooked because VWF levels are elevated due to blood group.
Diagnosis.
Basic tests performed in any patient with bleeding problems are a complete blood count-CBC (especially platelet counts), activated partial thromboplastin time-APTT, prothrombin time with International Normalized Ratio-PTINR, thrombin time-TT, and fibrinogen level. Patients with abnormal tests typically undergo further testing for hemophilias. Other coagulation factor assays may be performed depending on the results of a coagulation screen. Patients with von Willebrand disease typically display a normal prothrombin time and a variable prolongation of APTT, depending on whether sufficient VWF is available to perform its carrier function for factor VIII.
When VWD is suspected, blood plasma of a patient must be investigated for quantitative and qualitative deficiencies of VWF. This is achieved by measuring the amount of VWF in a VWF antigen assay and the functionality of VWF with a glycoprotein (GP)Ib binding assay, VWF antibody assay, or a ristocetin cofactor activity (RiCof) assay. Factor VIII levels are also performed because factor VIII is bound to VWF which protects the factor VIII from rapid breakdown within the blood. Deficiency of VWF can then lead to a reduction in factor VIII levels, which explains the elevation in PTT. Normal levels do not exclude all forms of VWD, particularly type 2, which may only be revealed by investigating platelet interaction with subendothelium under flow, a highly specialized coagulation study not routinely performed in most medical laboratories. Ristocetin-induced platelet agglutination (RIPA), collagen binding, and/or VWF multimer assays may be performed to follow up abnormal screening tests. A platelet aggregation assay will show an abnormal response to ristocetin with normal responses to the other agonists used:
A platelet function assay may give an abnormal collagen/epinephrine closure time, and in most cases, a normal collagen/ADP time. Type 2N may be considered if factor VIII levels are disproportionately low, but confirmation requires a "factor VIII binding" assay. Additional laboratory tests that help classify sub-types of VWD include von Willebrand multimer analysis, modified ristocetin induced platelet aggregation assay and VWF propeptide to VWF propeptide antigen ratio. In cases of suspected acquired von Willebrand syndrome, a mixing study (analysis of patient plasma along with pooled normal plasma/PNP and a mixture of the two tested immediately, at one hour, and at two hours) should be performed. Detection of VWD is complicated by VWF being an acute-phase reactant with levels rising in infection, pregnancy, and stress.
The testing for VWD can be influenced by laboratory procedures. Numerous variables exist in the testing procedure that may affect the validity of the test results and may result in a missed or erroneous diagnosis. The chance of procedural errors are typically greatest during the preanalytical phase (during collecting storage and transportation of the specimen) especially when the testing is contracted to an outside facility and the specimen is frozen and transported long distances. Diagnostic errors are not uncommon, and the rate of testing proficiency varies amongst laboratories, with error rates ranging from 7 to 22% in some studies to as high as 60% in cases of misclassification of VWD subtype. To increase the probability of a proper diagnosis, testing should be done at a facility with immediate on-site processing in a specialized coagulation laboratory.
Types.
The four hereditary types of VWD described are type 1, type 2, type 3, and pseudo- or platelet-type. Most cases are hereditary, but acquired forms of VWD have been described. The International Society on Thrombosis and Haemostasis's classification depends on the definition of qualitative and quantitative defects.
Type 1.
Type 1 VWD (40-80% of all VWD cases) is a quantitative defect which is heterozygous for the defective gene. It arises from failure to secrete VWF into the circulation or, in the case of Type 1C, from VWF being cleared more quickly than normal. If VWF levels are greater than 50%, VWD can be ruled out. If VWF activity is below 30%, VWD is present. Patients with VWF activity between 0.30-0.50 IU/mL are classified based on their bleeding phenotype. If they have bleeding symptoms, they have VWD. If they have no bleeding, they are considered to have "Low VWF".
Many patients are asymptomatic or may have mild symptoms and not have clearly impaired clotting, which might suggest a bleeding disorder. Often, the discovery of low VWF occurs incidentally to other medical procedures requiring a blood work-up. Most cases of low VWF are never diagnosed due to its asymptomatic or mild presentation, and most people with type I VWD end up leading a normal life free of complications, with many being unaware that they have the disorder.
Trouble may, however, arise in some patients in the form of bleeding following surgery (including dental procedures), noticeable easy bruising, or menorrhagia (heavy menstrual periods). The minority of cases of type 1 may present with severe hemorrhagic symptoms.
Type 1C.
Type 1C VWD indicates patients with quantitative deficiency due to an enhanced VWF clearance, accounting for ∼15% to 20% of cases. Such patients may require VWF concentrate to treat/prevent bleeds.
Type 2.
Type 2 VWD (15-50% of cases) is a qualitative defect and the bleeding tendency can vary between individuals. Four subtypes exist: 2A, 2B, 2M, and 2N. These subtypes depend on the presence and behavior of the underlying multimers. Type 2 VWD (other than 2N) features an activity-to-antigen ratio of less than 0.7. This ratio is obtained by dividing the VWF activity by the VWF antigen.
Type 2A.
VWD Type 2A results from a loss-of-function mutation in von Willebrand factor (VWF), leading to reduced binding of VWF with Platelet GP1b receptors. This disorder follows an autosomal dominant inheritance pattern with only occasional cases following autosomal recessive pattern. It accounts for 10-15% of all VWD cases. It manifests with moderate to moderately severe bleeding. Diagnostic features of VWD Type 2A include greater reduction in VWF activity (measured by a functional assay) compared to VWF antigen (quantity). This results in a decreased VWF Activity to Antigen ratio. Additionally, high molecular weight multimers are either absent or very low on electrophoresis due to impaired multimer assembly or increased susceptibility to ADAMTS13 (a protease that cleaves VWF). Factor VIII activity can be normal or low. Ristocetin-induced platelet aggregation (RIPA) is typically low.
Type 2B.
This is a "gain of function" defect. The ability of the qualitatively defective VWF to bind to glycoprotein Ib (GPIb) receptor on the platelet membrane is abnormally enhanced, leading to its spontaneous binding to platelets and subsequent rapid clearance of the bound platelets and of the large VWF multimers. Thrombocytopenia may occur. Large VWF multimers are reduced or absent from the circulation.
The ristocetin cofactor activity is low when the patient's platelet-poor plasma is assayed against formalin-fixed, normal donor platelets. However, when the assay is performed with the patient's own platelets (platelet-rich plasma), a lower-than-normal amount of ristocetin causes aggregation to occur. This is due to the large VWF multimers remaining bound to the patient's platelets. Patients with this subtype are unable to use desmopressin as a treatment for bleeding, because it can lead to unwanted platelet aggregation and aggravation of thrombocytopenia.
Type 2M.
VWD Type 2M results from a loss-of-function mutation in von Willebrand factor (VWF). This mutation leads to reduced binding of VWF with GP1b (similar to VWD Type 2A) or with collagen. Like other Type 2 VWD subtypes, there is a decreased ratio of VWF Activity to antigen. Differentiating VWD Type 2M from Type 2A involves analyzing VWF multimers through electrophoresis. In VWD Type 2M, all multimers are identified but uniformly decreased in quantity, resembling the pattern seen in VWD Type 1. Conversely, in VWD Type 2A, high molecular weight multimers are either absent or present in very low quantities. VWD Type 2M can be further differentiated from VWD Type 1 based on the VWF Activity to antigen ratio. In Type 1, the ratio is ;0.7. In Type 2M, the ratio is ;0.7. In Type 2M, factor VIII activity can be normal or low while the ristocetin-induced platelet aggregation (RIPA) is typically low. It is uncommon and manifests with moderate to severe bleeding. The disease may follow either an autosomal dominant or recessive pattern of inheritance.
Type 2N (Normandy).
Type 2N VWD results from a loss-of-function mutation that reduces the binding of von Willebrand factor (VWF) to factor VIII. Although VWF antigen (quantity) and activity levels (Ristocetin cofactor assay) remain normal, factor VIII levels are typically low (usually 5-15%) due to impaired VWF binding. This vulnerability to proteolysis in the circulation leads to clinical manifestations resembling those of Hemophilia A. The significantly reduced factor VIII levels in VWD Type 2N can sometimes lead to misdiagnosis as mild Hemophilia A. Like Hemophilia A, VWD Type 2N presents with joint and soft tissue bleeds. It is an autosomal recessive disorder, requiring either homozygosity or double heterozygosity for disease manifestation. Diagnostic tools include assessing the