Journal of Thrombosis and Haemostasis, 13: 909–919

DOI: 10.1111/jth.12916

REVIEW ARTICLE

Dysfibrinogenemia: from molecular anomalies to clinical manifestations and management A. CASINI,* M. NEERMAN-ARBEZ,† R. A. ARI€ EN S ‡ and P . D E M O E R L O O S E * *Angiology and Hemostasis Division, University Hospitals and Faculty of Medicine; †Department of Genetic Medicine and Development, Faculty of Medicine, University of Geneva, Geneva, Switzerland; and ‡Theme Thrombosis, Division of Cardiovascular and Diabetes Research, Leeds Institute of Cardiovascular and Metabolic Medicine and Multidisciplinary Cardiovascular Research Centre, Faculty of Medicine and Health, University of Leeds, Leeds, UK

To cite this article: Casini A, Neerman-Arbez M, Ari€ens RA, de Moerloose P. Dysfibrinogenemia: from molecular anomalies to clinical manifestations and management. J Thromb Haemost 2015; 13: 909–19.

Summary. Congenital dysfibrinogenemia is a qualitative congenital fibrinogen disorder characterized by normal antigen levels of a dysfunctional fibrinogen. The diagnosis is usually based on discrepancies between fibrinogen activity and antigen levels, but could require more specialized techniques for the assessment of fibrinogen function, owing to some limitations in routine assays. Molecular abnormalities, which are frequently heterozygous missense mutations localized in exon 2 of FGA and exon 8 of FGG, lead to defects in one or more phases of fibrinogen to fibrin conversion, fibrin network formation, and other important functions of fibrinogen. The clinical phenotype is highly heterogeneous, from no manifestations to bleeding and/or thrombotic events. Asymptomatic propositi and relatives with the predisposing genotype are at risk of developing adverse outcomes during the natural course of the disease. Correlations between genotype and phenotype have not yet been clearly established, with the exception of some abnormal fibrinogens that severely increase the risk of thrombosis. Functional analysis of polymerization and fibrinolysis, structural studies of the fibrin network and the viscoelastic properties of fibrin clot could help to predict the phenotype of congenital dysfibrinogenemia, but have not yet been evaluated in detail. The management is essentially based on personal and family history; however, even individuals who are still asymptomatic and without a family history should be carefully assessed and monitored. Particular situations, such as pregnancy, delivery, and surgery, require a multidisciplinary approach. Correspondence: Alessandro Casini, Angiology and Hemostasis Division, University Hospitals of Geneva, 1211 Geneva 14, Switzerland. Tel.: +41 22 37 29 751; fax: +41 22 37 29 891. E-mail: [email protected] Received 19 January 2015 Manuscript handled by: F. R. Rosendaal Final decision: F. R. Rosendaal, 24 March 2015 © 2015 International Society on Thrombosis and Haemostasis

Keywords: bleeding; dysfibrinogenemia, congenital; fibrinogen; pregnancy; thrombosis.

Introduction Congenital fibrinogen disorders comprise two classes of plasma fibrinogen defects: type I, afibrinogenemia or hypofibrinogenemia, in which there are absent or low plasma fibrinogen antigen levels (quantitative fibrinogen deficiencies); and type II, dysfibrinogenemia or hypodysfibrinogenemia, in which there are normal or reduced antigen levels associated with disproportionately low functional activity (qualitative fibrinogen deficiencies) [1]. Regarding congenital dysfibrinogenemia, since the first patient was identified in 1958 [2] and the first point mutation was demonstrated in fibrinogen Detroit I in 1968 [3], more than 100 mutations and 400 families have been reported. Overall, the study of such cases has improved our understanding of the fibrinogen–fibrin structure [4], and of the mechanisms of polymerization [5] and fibrinolysis [6]. Moreover, they have provided insights into the mechanisms underpinning fibrin network structure and function [7], and have increased our experience in the management of the disease [8]. However, hematologists caring for patients with congenital dysfibrinogenemia still have to deal with several difficulties and unanswered questions. The diagnosis of congenital dysfibrinogenemia is generally based on the assessment of functional and antigenic fibrinogen, but can be complicated by the lack of sensitivity of some fibrinogen assays [9] and the need to confirm the diagnosis by genetic analysis. The clinical management is also challenging, as few genotypes are clearly correlated with a clinical phenotype [10], and even asymptomatic persons are at risk of developing cardiovascular and/or major bleeding events during the natural course of the disease [11]. The aims of this review are to discuss the laboratory strategies used to identify congenital dysfibrinogenemia, to summarize the molecular

910 A. Casini et al

features of the most frequent mutations, and to give an overview of the management of patients with congenital dysfibrinogenemia. Hypodysfibrinogenemia, which is defined by low levels of a dysfunctional protein (below the reference range, according to the assays used), is often associated with a more pronounced bleeding phenotype that is proportional to the decreased amount of circulating fibrinogen. It presents specific molecular features that are distinct from those of congenital dysfibrinogenemia. These are: (i) heterozygosity for a single mutation leading to synthesis of an abnormal fibrinogen chain that is secreted less efficiently than normal fibrinogen; or (ii) compound heterozygosity for two different mutations, with one mutation being responsible for the fibrinogen deficiency, and one mutation being responsible for the abnormal function of the molecule [1]. Given these differences, hypodysfibrinogenemias will not be further discussed here. Diagnosis of congenital dysfibrinogenemia Patients with congenital dysfibrinogenemia can be identified during the clinical investigation of bleeding [12] or thrombosis [13], or following miscarriage [14]. However, most individuals are asymptomatic, and are usually discovered by the prolongation of routine parameters of coagulation, such as prothrombin time (PT) and activated partial thromboplastin time (APTT) [15] (Table 1). In a compilation from 1994, 138 of 250 (55%) of patients with congenital dysfibrinogenemia were detected incidentally [16]. Similarly, in a series of 35 subjects identified at two UK centers, 20 (57%) were asymptomatic [17], and in our recent long-term study of 101 patients the majority of propositi (39/67, 58%) had an incidental diagnosis, either during routine laboratory testing or before surgery [11]. Congenital dysfibrinogenemia is usually suspected if there is a discrepancy between clottable and immunologic fibrinogen levels. A ratio of functional activity to antigen lower than 0.7 was arbitrarily considered to be suggestive of congenital dysfibrinogenemia following the findings of the study of Krammer et al. [18], and, indeed, other studies have shown that a ratio of 0.7 would permit the

identification of almost all cases of congenital dysfibrinogenemia [9,11,17]. However, neither the sensitivity nor the specificity of this cutoff value has been prospectively validated [19]. As shown in Fig. 1, when a congenital dysfibrinogenemia is suspected, the initial work-up should include PT, APTT, functional and antigenic fibrinogen, thrombin time (TT), and reptilase time (RT). Recently, several studies have shown that the sensitivity of routine screening tests for congenital dysfibrinogenemia depends on specific mutations, reagents, and techniques [9,17,20– 23]. Whereas fibrinogen antigen levels determined with radial immunodiffusion and heat precipitation assays generally show similar values, a clear discordance is observed between the values of the Clauss and the PT-derived fibrinogen assays. In the study of Miesbach et al. [9], which included 27 patients (25 with congenital dysfibrinogenemia and two with acquired dysfibrinogenemia), the PT-derived method overestimated the fibrinogen by approximately six times the value obtained with the Clauss assay (medians of 2.41 g L 1 and 0.40 g L 1, respectively). Furthermore, Shapiro et al. [17] showed that delayed fibrin polymerization and a reduced rate of clot formation, which are typical of most cases of congenital dysfibrinogenemia, cause a delay in reaching the PT endpoint, thus prolonging PT. Coagulometers with PT endpoints determined by plasma viscosity or turbidity curve parameters would thus be less perturbed in cases of congenital dysfibrinogenemia. The discrepancy between the clotting time assays and the PT-derived methods is highly suggestive of functional defects in the fibrinogen molecule, including polymerization abnormalities [20]. RT and TT are more specific, even though TT lacks sensitivity, as some cases of congenital dysfibrinogenemia can have a normal TT [14,24]. Other diseases or anticoagulants with activity against thrombin can also affect TT [15]. When a congenital dysfibrinogenemia is suspected, a genetic analysis is useful to confirm the diagnosis, because it may predict the risk of clinical complications (Fig. 1). Highly specialized and research laboratories may perform additional analyses, either functional (i.e. measurement of the rate of fibrinopeptide cleavage, analysis of

Table 1 Clinical and molecular characteristics of patients with congenital dysfibrinogenemia

Author, year

Total, n

Propositi, n (%)

Incidental diagnosis*, n (%)

Asymptomatic, n (%)

Bleeding symptoms, n (%)

Haverkate, 1995 [10] Santacroce, 2006 [61] Miesbach, 2010 [60] Shapiro, 2012 [17] Casini, 2014 [11]

85‡ 16 37 35 101

20 9 12 23 67

NA 8 (88.8) NA 11 (48) 39 (58)

NA 13 (81.3) 9 (24) 10 (29) 36 (35)**

5 1 21 22 53

(23.5) (56) (32) (66) (66)

(6.3) (6.3) (57) (63) (52)**

Thrombotic events, n (%)

Hotspot mutations†, n (%)

Overall FGA exon 2 and FGG exon 8 mutations, n (%)

40 2 9 3 28

5 7 27 14 77

39 7 30 33 90

(47) (12.5) (24) (9) (27.7)**

(5.9)§ (43.8)¶ (73) (40) (76)

(45.6)§ (43.8)¶ (81) (94) (87)

NA, not analyzed. *Among propositi. †FGA R35C (R16C), FGA R35H (R16H), FGG R301H (R275H), and FGG R301C (R275C). ‡The original study comprised 26 probands and 99 relatives, including five families with hypodysfibrinogenemia that are not reported in the table. §Genotype not available in nine of 20. ¶Genotype not available in one of 16. **Including follow-up (median of 8.8 years). © 2015 International Society on Thrombosis and Haemostasis

912 A. Casini et al

Molecular abnormalities in other sites may impair other aspects of fibrin(ogen) function and metabolism, such as assembly of the proteases involved in fibrinolysis [6,32], interactions with platelets [37], interactions with endothelial cells [38], or calcium binding [39]. Several reviews have indexed causative mutations leading to congenital dysfibrinogenemia reported before 2012 [36,40], and an updated extensive list of identified mutations with their phenotype is shown in Table S1. We will focus here on the most frequent mutations (hotspots) that clinicians will encounter, as well as on mutations associated with thrombotic events. Mutation hotspots

The two most frequently mutated residues (mutation hotspots) are FGA Arg35 (Arg16 in the mature chain lacking the signal peptide, c.103C?T or c.104G?A) and FGG Arg301 (Arg275, c.901C?T or c.902G?A) (Table 1; Fig. 2). Including the surrounding residues, mutations in exon 2 of FGA and exon 8 of FGG account for almost 85% of all congenital dysfibrinogenemia mutations [11], so these are the first exons to be examined in a genetic screen. FGA Arg35 (Arg16) is part of the thrombin cleavage site at the N-terminal end of the fibrinogen Aa chain. This arginine is frequently [41] mutated to either histidine or cysteine, causing delayed [42] or absent [43] fibrinopeptide A release and subsequent prolonged polymerization. Functional and structural studies of Arg35 (Arg16) mutant fibrinogens have also shown decreased binding to platelets [44], fibrinolytic resistance [45], and disordered fibrin networks

Hole ‘a’ γD364V (Melun)

Thrombin binding AaR16C (metz I) AaR16H (Bicêtre I)

αC domain AαR554H (Dusart/Paris V) AαS532C (Caracas V)

FpA γ nodule

β nodule

E region

γ nodule

β nodule FpB

Thrombin binding BβR14C (Ijmuiden) BβDeI9–72 (New York I) BβR44C (Nijmegen) BβA68T (Naples)

D:D interface gR275C (Baltimore IV) gR275H (Barcelona IV)

Fig. 2. Schematic representation of molecular sites of hotspot mutations and mutations clearly associated with thrombosis. The central nodule contains the N-terminal portions of all three polypeptide chains, whereas the b nodule and the c nodule contain the C-terminal portion of each Bb and c chain, respectively. The aC domain contains the C-terminal portion of each Aa chain. Hotspot mutations are in italic, and thrombotic mutations are in bold. Substitutions in the mature chain lacking the signal peptide are described, and the fibrinogen name is in parentheses. Not all recurrent mutations are referenced, owing to limited space. A complete list is available at www.geht.org, and mutations associated with thrombosis are shown in Table 2. FpA, fibrinopeptide A; FpB, fibrinopeptide B.

with thinner fibrils [7]. Some patients have been found to be homozygous for these mutations [46,47] or phenotypically homozygous, owing to compound heterozygosity for an Arg35 (Arg16) missense mutation and the large 11-kb FGA deletion first identified in afibrinogenemic patients [43]. FGG Arg301 (Arg275) is the first residue situated at the outer portion of the fibrinogen c nodule that is necessary for proper end-to-end alignment of fibrinogen or fibrin molecules in assembling polymers [4,48]. Replacement of this arginine by cysteine or, less frequently, by histidine [41] leads to increased fiber branching, resulting from slower fibrin assembly and inaccurate end-to-end positioning in the assembly of fibrin monomers [49]. Recombinant protein studies have shown that R301C (R275C) causes greater impairment of factor XIIIa-catalyzed c–c dimer formation and a more aberrant fibrin clot structure, with thicker fibrin bundles, than R301H (R275H) [50,51]. Hotspot mutations have been reported with a broad range of clinical manifestations, including major bleeding and thrombosis. However, according to data compiled in www.geht.org/ databaseang/fibrinogen/, it seems that most patients with hotspot mutations are asymptomatic (73%). Recently, in a large series of patients, hotspot mutations were not statistically correlated with the incidence of major bleeding or thrombotic events [11]. Mutations associated with thrombotic events

Several abnormal fibrinogens have been clearly identified as predisposing patients to thrombosis (Table 2). In 1994, Haverkate and Samama [10], on behalf of the SCC Subcommittee on Fibrinogen of the ISTH, performed an important study focusing on 26 propositi (including five index cases with hypodysfibrinogenemia) who had venous thrombosis at a young age without any other inherited thrombophilia detected at the time of the study. Analysis of 187 relatives showed that 20 of 99 individuals in the group of family members with congenital dysfibrinogenemia had suffered from thrombosis, whereas no thrombosis was reported in the group of 88 relatives without the defect. Convincing evidence for an association between congenital dysfibrinogenemia and thrombophilia was found for five abnormal fibrinogens: Caracas V, Vlissingen, Melun, Naples, and Dusart [10] (Fig. 2). However, the same causative deletion for fibrinogen Vlissingen was later reported in one family without thrombotic events [52]. Different mechanisms, often overlapping, may account for the increased risk of thrombosis in congenital dysfibrinogenemia: elevated levels of circulating thrombin resulting from the failure in fibrinogen binding [53], altered strength, architecture and stability of the fibrin network [25], and decreased fibrinolysis resulting from impaired binding of plasminogen or tissue-type plasminogen activator to abnormal fibrinogen [54]. More recently, several novel mutant fibrinogens have been identified in patients with thrombosis [32,53,55–57], but a direct asso© 2015 International Society on Thrombosis and Haemostasis

912 A. Casini et al

Molecular abnormalities in other sites may impair other aspects of fibrin(ogen) function and metabolism, such as assembly of the proteases involved in fibrinolysis [6,32], interactions with platelets [37], interactions with endothelial cells [38], or calcium binding [39]. Several reviews have indexed causative mutations leading to congenital dysfibrinogenemia reported before 2012 [36,40], and an updated extensive list of identified mutations with their phenotype is shown in Table S1. We will focus here on the most frequent mutations (hotspots) that clinicians will encounter, as well as on mutations associated with thrombotic events. Mutation hotspots

The two most frequently mutated residues (mutation hotspots) are FGA Arg35 (Arg16 in the mature chain lacking the signal peptide, c.103C?T or c.104G?A) and FGG Arg301 (Arg275, c.901C?T or c.902G?A) (Table 1; Fig. 2). Including the surrounding residues, mutations in exon 2 of FGA and exon 8 of FGG account for almost 85% of all congenital dysfibrinogenemia mutations [11], so these are the first exons to be examined in a genetic screen. FGA Arg35 (Arg16) is part of the thrombin cleavage site at the N-terminal end of the fibrinogen Aa chain. This arginine is frequently [41] mutated to either histidine or cysteine, causing delayed [42] or absent [43] fibrinopeptide A release and subsequent prolonged polymerization. Functional and structural studies of Arg35 (Arg16) mutant fibrinogens have also shown decreased binding to platelets [44], fibrinolytic resistance [45], and disordered fibrin networks

Hole ‘a’ γD364V (Melun)

Thrombin binding AaR16C (metz I) AaR16H (Bicêtre I)

αC domain AαR554H (Dusart/Paris V) AαS532C (Caracas V)

FpA γ nodule

β nodule

E region

γ nodule

β nodule FpB

Thrombin binding BβR14C (Ijmuiden) BβDeI9–72 (New York I) BβR44C (Nijmegen) BβA68T (Naples)

D:D interface gR275C (Baltimore IV) gR275H (Barcelona IV)

Fig. 2. Schematic representation of molecular sites of hotspot mutations and mutations clearly associated with thrombosis. The central nodule contains the N-terminal portions of all three polypeptide chains, whereas the b nodule and the c nodule contain the C-terminal portion of each Bb and c chain, respectively. The aC domain contains the C-terminal portion of each Aa chain. Hotspot mutations are in italic, and thrombotic mutations are in bold. Substitutions in the mature chain lacking the signal peptide are described, and the fibrinogen name is in parentheses. Not all recurrent mutations are referenced, owing to limited space. A complete list is available at www.geht.org, and mutations associated with thrombosis are shown in Table 2. FpA, fibrinopeptide A; FpB, fibrinopeptide B.

with thinner fibrils [7]. Some patients have been found to be homozygous for these mutations [46,47] or phenotypically homozygous, owing to compound heterozygosity for an Arg35 (Arg16) missense mutation and the large 11-kb FGA deletion first identified in afibrinogenemic patients [43]. FGG Arg301 (Arg275) is the first residue situated at the outer portion of the fibrinogen c nodule that is necessary for proper end-to-end alignment of fibrinogen or fibrin molecules in assembling polymers [4,48]. Replacement of this arginine by cysteine or, less frequently, by histidine [41] leads to increased fiber branching, resulting from slower fibrin assembly and inaccurate end-to-end positioning in the assembly of fibrin monomers [49]. Recombinant protein studies have shown that R301C (R275C) causes greater impairment of factor XIIIa-catalyzed c–c dimer formation and a more aberrant fibrin clot structure, with thicker fibrin bundles, than R301H (R275H) [50,51]. Hotspot mutations have been reported with a broad range of clinical manifestations, including major bleeding and thrombosis. However, according to data compiled in www.geht.org/ databaseang/fibrinogen/, it seems that most patients with hotspot mutations are asymptomatic (73%). Recently, in a large series of patients, hotspot mutations were not statistically correlated with the incidence of major bleeding or thrombotic events [11]. Mutations associated with thrombotic events

Several abnormal fibrinogens have been clearly identified as predisposing patients to thrombosis (Table 2). In 1994, Haverkate and Samama [10], on behalf of the SCC Subcommittee on Fibrinogen of the ISTH, performed an important study focusing on 26 propositi (including five index cases with hypodysfibrinogenemia) who had venous thrombosis at a young age without any other inherited thrombophilia detected at the time of the study. Analysis of 187 relatives showed that 20 of 99 individuals in the group of family members with congenital dysfibrinogenemia had suffered from thrombosis, whereas no thrombosis was reported in the group of 88 relatives without the defect. Convincing evidence for an association between congenital dysfibrinogenemia and thrombophilia was found for five abnormal fibrinogens: Caracas V, Vlissingen, Melun, Naples, and Dusart [10] (Fig. 2). However, the same causative deletion for fibrinogen Vlissingen was later reported in one family without thrombotic events [52]. Different mechanisms, often overlapping, may account for the increased risk of thrombosis in congenital dysfibrinogenemia: elevated levels of circulating thrombin resulting from the failure in fibrinogen binding [53], altered strength, architecture and stability of the fibrin network [25], and decreased fibrinolysis resulting from impaired binding of plasminogen or tissue-type plasminogen activator to abnormal fibrinogen [54]. More recently, several novel mutant fibrinogens have been identified in patients with thrombosis [32,53,55–57], but a direct asso© 2015 International Society on Thrombosis and Haemostasis

Dysfibrinogenemia: genetic and outcomes 913

ciation with the fibrinogen anomalies could not be established, because: (i) the history of relatives was negative; (ii) the same mutation was reported in other asymptomatic families; and (iii) the criteria proposed by the aforementioned study were not fulfilled [10], i.e. the first episode of thrombosis at an age of < 41 years in cases of venous thrombosis and an age of < 51 years in cases of arterial thrombosis, and the absence of known associated diseases that are likely to cause thrombosis. Clinical features of dysfibrinogenemia The clinical manifestations of patients with congenital dysfibrinogenemia are highly heterogeneous. Mutant fibrinogen molecules in heterozygous propositi can circulate as homodimers (that is, both identical chains are mutated) or heterodimers (that is, only one chain is mutated). The proportions of these will affect fibrinogen function, and the reliable effects of the causative mutations can be confused by accompanying altered concentrations of fibrinogen in the blood [58]. As the diagnosis can be made at a young age, some patients will not have had the time to develop thrombotic or bleeding symptoms at the time of published reports, and will thus be considered to be asymptomatic. On the other hand, asymptomatic patients for whom the diagnosis is made at an advanced age will probably never become symptomatic. With the exception of some families with clear thrombotic genotypes, the penetrance of the clinical phenotype is often incomplete. A large amount of clinical data is available (www.geht.org/databaseang/fibrinogen/) [59], although the data are often limited to published case reports without follow-up. Through a systematic literature review, five large series of patients were identified [10,11,17,60,61], the clinical characteristics of which are

summarized in Table 1. The lack of a standardized bleeding definition and bias resulting from the retrospective design may explain the differences in the prevalence of bleeding. The frequency of thrombotic events is obviously higher in the study of Haverkate and Samama [10], as only patients with suspected thrombophilia were included. Only one study provided long-term follow-up leading to a reliable evaluation of the incidence of adverse outcomes [11]. Bleeding in most cases of congenital dysfibrinogenemia is generally mild. Indeed, in the UK study of Shapiro et al. [17], the ISTH bleeding assessment score in subjects with congenital dysfibrinogenemia (median of 1, range of 0–5) was similar to that in matched healthy controls (median of 1, range of 0–3; P > 0.05). However, more severe phenotypes [62,63] and even life-threatening events have been reported [11]. Figure 3 summarizes the patients’ bleeding patterns in the aforementioned studies, except for the series of Haverkate and Samama [10], which included only patients with a thrombotic phenotype. Women are a particular concern, with a high prevalence of menorrhagia as well as obstetric bleeding (discussed below). Concomitant mild bleeding disorders, including thrombopathies, could even reveal or exacerbate a bleeding phenotype. In our study of 101 congenital dysfibrinogenemia patients followed for a median of 8.8 years, the overall incidence rate (IR) of major bleeding was 3.5 per 1000 patient-years, without a statistical association with gender, whereas the cumulative incidence of major bleeding was 19.2 (95% confidence interval [CI] 11.1–31.9) at 50 years [11]. The prevalence of dysfibrinogenemia in patients with venous thrombosis is very low, and systematic testing for dysfibrinogenemia in patients with thrombophilia is therefore not recommended [64]. However, as previously dis-

Table 2 Published mutations with clinical features showing a relationship with thrombosis Fibrinogen name

Gene

Exon

cDNA

Nascent

Mature

Suggested mechanism of thrombosis

Dusart/Paris V [89], Chapel Hill III [90]

FGA

5

c.1717C?G

R573C

R554C

Caracas V [91]

FGA

5

c.1595C>G

S551C

S532C

Ijmuiden [92], Christchurch II [93], London VIII [94], St-Germain III [13], Vicenza III [95] New Yor I [96]

FGB

2

c.130C?T

R44C

R14C

Impaired fibrinolysis caused by defective binding of plasminogen and impaired t-PA-mediated plasminogen activation related to abnormal fibrin structure Impaired fibrinolysis caused by defective binding of plasminogen and impaired t-PA-mediated plasminogen activation related to abnormal fibrin structure Not identified

FGB

2

del39–102

del9–72

Defective binding of thrombin to abnormal fibrin

Nijmegen [97]

FGB

2

Deletion of exon 2 c.220C?T

R74C

R44C

Naples* [98]

FGB

2

c.292G?A

A98T

A68T

Melun [99]

FGG

8

c.1169A?T

D390V

D364V

Impaired fibrinolysis caused by defective binding of t-PA and impaired t-PA-mediated plasminogen activation Defective binding of thrombin to abnormal fibrin and impaired fibrinolysis Not identified

t-PA, tissue-type plasminogen activator. *Homozygous; heterozygous carriers did not have thrombosis. © 2015 International Society on Thrombosis and Haemostasis

914 A. Casini et al

cussed, thrombophilia-associated mutations increase the risk of venous and arterial thrombosis, often at a young age. Among the five distinct families affected by Dusart syndrome published to date, all had an impressive history of thrombosis, which was sometimes fatal [6,65–68]. The incomplete penetrance of the thrombotic phenotype in some families affected with congenital dysfibrinogenemia, even among families sharing the same genotype, is highly suggestive of other genetic or environmental confounders being present [69]. Inherited additional thrombophilia in patients with dysfibrinogenemia can substantially increase the thrombotic risk [70,71]. In our study, the IR of overall thrombosis was 13.9 per 1000 patient-years (adults > 18 years of age), and the cumulative incidence was 30.1% (95% CI 20.1–43.5) at 50 years, without a statistical difference according to gender [11]. It should be noted that asymptomatic relatives seem to have the same risk as index cases of developing adverse outcomes [11]. Recently, in a series of 33 patients, five abnormal fibrinogens leading to impaired fibrinolysis were found to be associated with an increased risk of developing chronic thromboembolic pulmonary hypertension [72]. However, additional large cohort studies are required to confirm these findings. Management There is a lack of strong evidence, owing to the rarity of congenital dysfibrinogenemia and the consequent absence of controlled studies. Thus, recommendations for patient clinical management are derived from expert consensus [19,73–75]. Any treatment considered in patients with congenital dysfibrinogenemia should first be based on the personal and family history (Table 3). Even patients who are asymptomatic at the time of the diagnosis are at risk of developing symptoms during the

50 45 40 35 30 25 20 15 10 5 0

43

30 24

12

Surgery

10 1

ag e bl ee di ng Po st su rg er y Af Ep te is rt ta oo xi th s ex t G ra as ct io tro n in te st in al C er eb ra H em l ar th ro si s

2

ca rri

ag ia

ty

ca vi

m of

ra l O

ry ive

5

Af

te

rv ag i

na

ld

el

is

or rh

br

ui si

ng

5

M en

Ea sy

12

natural course of the disease [11]. A regular follow-up should be offered, as well as, if available, more sophisticated analyses in specialized laboratories, in order to better define the phenotype. Patients with a bleeding phenotype should be referred to a hemophilia center for management. In cases of bleeding, according to their availability, fresh frozen plasma (FFP), cryoprecipitate or fibrinogen concentrates can be administered [76]. Fibrinogen concentrates that have been subjected to appropriate viral inactivation procedures clearly constitute the best choice, as they are safer in terms of viral infections than cryoprecipitate and FFP. Moreover, cryoprecipitate and FFP, for which precise concentrations of fibrinogen are not standardized, can be associated with transfusion reactions or volume overload [77]. To date, with the exception of some case reports, there are no evidence-based data to provide guidelines for the best use of fibrinogen concentrates in congenital dysfibrinogenemia in cases of bleeding [8]. By extrapolation from recommendations on quantitative fibrinogen disorders, fibrinogen concentrates are given in cases of severe bleeding, to maintain fibrinogen activity above 1 g L 1 [74], although this level can be subject to discussion. In cases of mild bleeding and/or menorrhagia, tranexamic acid may be considered if there are no contraindications. The risk of thrombosis related to fibrinogen substitution is a major concern, and should always be considered [8]. To prevent thrombosis, some clinicians combine small doses of heparin or low molecular weight heparin (LMWH) with the administration of fibrinogen [1]. If treatment for thrombosis is required, anticoagulation with LMWH rather than oral anticoagulation with vitamin K antagonists is suggested, as the International Normalized Ratio is not a valuable measurement in cases of a prolonged baseline PT. No data are available on the use of new oral anticoagulants in congenital dysfibrinogenemia. The length of treatment should be carefully evaluated in light of the mutation, the personal and family history, and the possibility of other associated thrombophilias; indeed, long-term anticoagulation should be discussed for patients who have mutations associated with thrombophilia [36]. Strict thromboprophylaxis in highrisk thrombotic situations should be administered [74].

Fig. 3. Sites of bleeding in four studies [11,17,60,61] of patients with congenital dysfibrinogenemia (n = 189; females, n = 111).

In cases of surgery, patients with a known bleeding phenotype should be treated with a fibrinogen concentrate to elevate and maintain the fibrinogen level at 1 g L 1 above baseline until hemostasis is secured and at 0.5 g L 1 above baseline until wound healing is complete [73], without omitting the use of compression stockings and prophylactic anticoagulation, according to the type of surgery [74]. For patients with a thrombotic phenotype, the need for fibrinogen replacement has to be counterbalanced with the risk of thrombosis associated with © 2015 International Society on Thrombosis and Haemostasis

Journal of Thrombosis and Haemostasis, 13: 909–919

DOI: 10.1111/jth.12916

REVIEW ARTICLE

Dysfibrinogenemia: from molecular anomalies to clinical manifestations and management A. CASINI,* M. NEERMAN-ARBEZ,† R. A. ARI€ EN S ‡ and P . D E M O E R L O O S E * *Angiology and Hemostasis Division, University Hospitals and Faculty of Medicine; †Department of Genetic Medicine and Development, Faculty of Medicine, University of Geneva, Geneva, Switzerland; and ‡Theme Thrombosis, Division of Cardiovascular and Diabetes Research, Leeds Institute of Cardiovascular and Metabolic Medicine and Multidisciplinary Cardiovascular Research Centre, Faculty of Medicine and Health, University of Leeds, Leeds, UK

To cite this article: Casini A, Neerman-Arbez M, Ari€ens RA, de Moerloose P. Dysfibrinogenemia: from molecular anomalies to clinical manifestations and management. J Thromb Haemost 2015; 13: 909–19.

Summary. Congenital dysfibrinogenemia is a qualitative congenital fibrinogen disorder characterized by normal antigen levels of a dysfunctional fibrinogen. The diagnosis is usually based on discrepancies between fibrinogen activity and antigen levels, but could require more specialized techniques for the assessment of fibrinogen function, owing to some limitations in routine assays. Molecular abnormalities, which are frequently heterozygous missense mutations localized in exon 2 of FGA and exon 8 of FGG, lead to defects in one or more phases of fibrinogen to fibrin conversion, fibrin network formation, and other important functions of fibrinogen. The clinical phenotype is highly heterogeneous, from no manifestations to bleeding and/or thrombotic events. Asymptomatic propositi and relatives with the predisposing genotype are at risk of developing adverse outcomes during the natural course of the disease. Correlations between genotype and phenotype have not yet been clearly established, with the exception of some abnormal fibrinogens that severely increase the risk of thrombosis. Functional analysis of polymerization and fibrinolysis, structural studies of the fibrin network and the viscoelastic properties of fibrin clot could help to predict the phenotype of congenital dysfibrinogenemia, but have not yet been evaluated in detail. The management is essentially based on personal and family history; however, even individuals who are still asymptomatic and without a family history should be carefully assessed and monitored. Particular situations, such as pregnancy, delivery, and surgery, require a multidisciplinary approach. Correspondence: Alessandro Casini, Angiology and Hemostasis Division, University Hospitals of Geneva, 1211 Geneva 14, Switzerland. Tel.: +41 22 37 29 751; fax: +41 22 37 29 891. E-mail: [email protected] Received 19 January 2015 Manuscript handled by: F. R. Rosendaal Final decision: F. R. Rosendaal, 24 March 2015 © 2015 International Society on Thrombosis and Haemostasis

Keywords: bleeding; dysfibrinogenemia, congenital; fibrinogen; pregnancy; thrombosis.

Introduction Congenital fibrinogen disorders comprise two classes of plasma fibrinogen defects: type I, afibrinogenemia or hypofibrinogenemia, in which there are absent or low plasma fibrinogen antigen levels (quantitative fibrinogen deficiencies); and type II, dysfibrinogenemia or hypodysfibrinogenemia, in which there are normal or reduced antigen levels associated with disproportionately low functional activity (qualitative fibrinogen deficiencies) [1]. Regarding congenital dysfibrinogenemia, since the first patient was identified in 1958 [2] and the first point mutation was demonstrated in fibrinogen Detroit I in 1968 [3], more than 100 mutations and 400 families have been reported. Overall, the study of such cases has improved our understanding of the fibrinogen–fibrin structure [4], and of the mechanisms of polymerization [5] and fibrinolysis [6]. Moreover, they have provided insights into the mechanisms underpinning fibrin network structure and function [7], and have increased our experience in the management of the disease [8]. However, hematologists caring for patients with congenital dysfibrinogenemia still have to deal with several difficulties and unanswered questions. The diagnosis of congenital dysfibrinogenemia is generally based on the assessment of functional and antigenic fibrinogen, but can be complicated by the lack of sensitivity of some fibrinogen assays [9] and the need to confirm the diagnosis by genetic analysis. The clinical management is also challenging, as few genotypes are clearly correlated with a clinical phenotype [10], and even asymptomatic persons are at risk of developing cardiovascular and/or major bleeding events during the natural course of the disease [11]. The aims of this review are to discuss the laboratory strategies used to identify congenital dysfibrinogenemia, to summarize the molecular

916 A. Casini et al

observed 19 (21.4%) postpartum hemorrhages, with a statistical association with the bleeding phenotype defined as one hemorrhage event outside of pregnancy (odds ratio 5.8; 95% CI 1.2–28.0; P = 0.03) [11]. Postpartum venous thrombosis is relatively frequent in women with congenital dysfibrinogenemia resulting from mutations associated with thrombophilia [10], but also in women with usually asymptomatic mutations [11]. The management of pregnant women is highly dependent on the phenotype (Table 3). A multidisciplinary team consisting of hematologists, gynecologists and anesthetists should provide the care for dysfibrinogenemic pregnant women [75]. Asymptomatic women without a family history should be followed closely, and an iterative ultrasound assessment for monitoring fetal growth should be recommended. Women with a bleeding phenotype should be carefully observed during the postpartum period, and fibrinogen concentrate should be administered in order to elevate the fibrinogen level to 1.5 g L 1 [74], or even more. In cases with a thrombophilia-associated mutation or previous thrombosis, thromboprophylaxis with LMWH should be discussed throughout the pregnancy and the postpartum period. The risk of performing regional anesthesia is difficult to assess [78,88]. Cesarean sections should be performed under fibrinogen replacement, and invasive monitoring and procedures should be avoided, owing to the neonate’s own risk of being affected by congenital dysfibrinogenemia [73]. Conclusion Congenital dysfibrinogenemia emphasizes the crucial role of the fibrinogen molecule in coagulation, and highlights the complexity of the role of fibrin structure in hemostasis and thrombosis. Increased knowledge of the properties of fibrin clots provides insights into the fundamental mechanisms of the formation and dissolution of hemostatic clots and obstructive thrombi in vivo [5]. However, major efforts are still necessary to improve our comprehension of the clinical features of congenital dysfibrinogenemia, and more studies are needed to understand the functional and clinical consequences of muations causing congenital dysfibrinogenemia. The contributions of individual treatment centers to national databases, and participation in international prospective studies, such as the ongoing project proRBDD (http://eu.rbdd.org/), will help all clinicians in the management of patients with congenital dysfibrinogenemia. Disclosure of Conflict of Interests The authors state that they have no conflict of interest. Supporting Information Additional Supporting Information may be found in the online version of this article:

Table S1. Mutations resulting in congenital dysfibrinogenemia*. References 1 de Moerloose P, Casini A, Neerman-Arbez M. Congenital fibrinogen disorders: an update. Semin Thromb Hemost 2013; 39: 585–95. 2 Imperato C, Dettori AG. Congenital hypofibrinogenemia with fibrinoasthenia. Helv Paediatr Acta 1958; 13: 380–99. 3 Blomback M, Blomback B, Mammen EF, Prasad AS. Fibrinogen Detroit – a molecular defect in the N-terminal disulphide knot of human fibrinogen? Nature 1968; 218: 134–7. 4 Mosesson MW. Fibrinogen and fibrin structure and functions. J Thromb Haemost 2005; 3: 1894–904. 5 Weisel JW, Litvinov RI. Mechanisms of fibrin polymerization and clinical implications. Blood 2013; 121: 1712–19. 6 Soria J, Soria C, Caen P. A new type of congenital dysfibrinogenaemia with defective fibrin lysis – Dusard syndrome: possible relation to thrombosis. Br J Haematol 1983; 53: 575–86. 7 Sugo T, Endo H, Matsuda M, Ohmori T, Madoiwa S, Mimuro J, Sakata Y. A classification of the fibrin network structures formed from the hereditary dysfibrinogens. J Thromb Haemost 2006; 4: 1738–46. 8 Bornikova L, Peyvandi F, Allen G, Bernstein J, Manco-Johnson MJ. Fibrinogen replacement therapy for congenital fibrinogen deficiency. J Thromb Haemost 2011; 9: 1687–704. 9 Miesbach W, Schenk J, Alesci S, Lindhoff-Last E. Comparison of the fibrinogen Clauss assay and the fibrinogen PT derived method in patients with dysfibrinogenemia. Thromb Res 2010; 126: e428–33. 10 Haverkate F, Samama M. Familial dysfibrinogenemia and thrombophilia. Report on a study of the SSC Subcommittee on Fibrinogen. Thromb Haemost 1995; 73: 151–61. 11 Casini A, Blondon M, Lebreton A, Koegel J, Tintillier V, de Maistre E, Gautier P, Biron C, Neerman-Arbez M, de Moerloose P. Natural history of patients with congenital dysfibrinogenemia. Blood 2015; 125: 553–61. 12 Brennan SO, Mosesson MW, Lowen R, Frantz C. Dysfibrinogenemia (fibrinogen Wilmington) due to a novel Aalpha chain truncation causing decreased plasma expression and impaired fibrin polymerisation. Thromb Haemost 2006; 96: 88–9. 13 de Raucourt E, Fischer AM, Meyer G, de Mazancourt P. A Bbeta 14 Arg –> Cys fibrinogen variant in a patient with thrombotic complications (fibrinogen St-Germain III). J Thromb Haemost 2006; 4: 2722–3. 14 Dempfle CE, George PM, Borggrefe M, Neumaier M, Brennan SO. Demonstration of heterodimeric fibrinogen molecules partially conjugated with albumin in a novel dysfibrinogen: fibrinogen Mannheim V. Thromb Haemost 2009; 102: 29–34. 15 Cunningham MT, Brandt JT, Laposata M, Olson JD. Laboratory diagnosis of dysfibrinogenemia. Arch Pathol Lab Med 2002; 126: 499–505. 16 Ebert RF. Index of Variant Human Fibrinogens. Boca Raton, Ann Arbor, Boston: CRC Press, 1994. 17 Shapiro SE, Phillips E, Manning RA, Morse CV, Murden SL, Laffan MA, Mumford AD. Clinical phenotype, laboratory features and genotype of 35 patients with heritable dysfibrinogenaemia. Br J Haematol 2013; 160: 220–7. 18 Krammer B, Anders O, Nagel HR, Burstein C, Steiner M. Screening of dysfibrinogenaemia using the fibrinogen function versus antigen concentration ratio. Thromb Res 1994; 76: 577– 9. 19 Peyvandi F. Epidemiology and treatment of congenital fibrinogen deficiency. Thromb Res 2012; 130(Suppl. 2): S7–11.

© 2015 International Society on Thrombosis and Haemostasis

Dysfibrinogenemia: genetic and outcomes 917 20 Llamas P, Santos AB, Outeirino J, Soto C, Tomas JF. Diagnostic utility of comparing fibrinogen Clauss and prothrombin time derived method. Thromb Res 2004; 114: 73–4. 21 Loreth RM, Meyer M, Albert FW. Fibrinogen kaiserslautern III: a new case of congenital dysfibrinogenemia with aalpha 16 arg–>cys substitution. Haemostasis 2001; 31: 12–17. 22 Lefkowitz JB, DeBoom T, Weller A, Clarke S, Lavrinets D. Fibrinogen Longmont: a dysfibrinogenemia that causes prolonged clot-based test results only when using an optical detection method. Am J Hematol 2000; 63: 149–55. 23 Franzblau EB, Punzalan RC, Friedman KD, Roy A, Bilen O, Flood VH. Use of purified fibrinogen concentrate for dysfibrinogenemia and importance of laboratory fibrinogen activity measurement. Pediatr Blood Cancer 2013; 60: 500–2. 24 Thorsen LI, Brosstad F, Solum NO, Stormorken H. Increased binding to ADP-stimulated platelets and aggregation effect of the dysfibrinogen Oslo I as compared with normal fibrinogen. Scand J Haematol 1986; 36: 203–10. 25 Ariens RA. Fibrin(ogen) and thrombotic disease. J Thromb Haemost 2013; 11(Suppl. 1): 294–305. 26 Galanakis DK, Neerman-Arbez M, Brennan S, Rafailovich M, Hyder L, Travlou O, Papadakis E, Manco-Johnson MJ, Henschen A, Scharrer I. Thromboelastographic phenotypes of fibrinogen and its variants: clinical and non-clinical implications. Thromb Res 2014; 133: 1115–23. 27 Kalina U, Stohr HA, Bickhard H, Knaub S, Siboni SM, Mannucci PM, Peyvandi F. Rotational thromboelastography for monitoring of fibrinogen concentrate therapy in fibrinogen deficiency. Blood Coagul Fibrinolysis 2008; 19: 777–83. 28 Brennan SO, Mangos H, Faed JM. Benign FGB (148Lys– >Asn, and 448Arg–>Lys), and novel causative gamma211Tyr– >His mutation distinguished by time of flight mass spectrometry in a family with hypofibrinogenaemia. Thromb Haemost 2014; 111: 679–84. 29 Lounes KC, Soria C, Mirshahi SS, Desvignes P, Mirshahi M, Bertrand O, Bonnet P, Koopman J, Soria J. Fibrinogen Ales: a homozygous case of dysfibrinogenemia (gamma-Asp(330)– >Val) characterized by a defective fibrin polymerization site ‘a’. Blood 2000; 96: 3473–9. 30 Niwa K, Takebe M, Sugo T, Kawata Y, Mimuro J, Asakura S, Sakata Y, Mizushima J, Maeda A, Endo H, Matsuda M. A gamma Gly-268 to Glu substitution is responsible for impaired fibrin assembly in a homozygous dysfibrinogen Kurashiki I. Blood 1996; 87: 4686–94. 31 Kotlin R, Suttnar J, Capova I, Hrachovinova I, Urbankova M, Dyr JE. Fibrinogen Sumperk II: dysfibrinogenemia in an individual with two coding mutations. Am J Hematol 2012; 87: 555–7. 32 Westbury SK, Duval C, Philippou H, Brown R, Lee KR, Murden SL, Phillips E, Reilly-Stitt C, Whalley D, Ariens RA, Mumford AD. Partial deletion of the alphaC-domain in the Fibrinogen Perth variant is associated with thrombosis, increased clot strength and delayed fibrinolysis. Thromb Haemost 2013; 110: 1135–44. 33 Furlan M, Steinmann C, Jungo M, Bogli C, Baudo F, Redaelli R, Fedeli F, Lammle B. A frameshift mutation in exon V of the A alpha-chain gene leading to truncated A alpha-chains in the homozygous dysfibrinogen Milano III. J Biol Chem 1994; 269: 33129–34. 34 Okumura N, Terasawa F, Takezawa Y, Hirota-Kawadobora M, Inaba T, Fujita N, Saito M, Sugano M, Honda T. Heterozygous Bbeta-chain C-terminal 12 amino acid elongation variant, BbetaX462W (Kyoto VI), showed dysfibrinogenemia. Blood Coagul Fibrinolysis 2012; 23: 87–90. 35 Rosenberg JB, Newman PJ, Mosesson MW, Guillin MC, Amrani DL. Paris I dysfibrinogenemia: a point mutation in intron 8 results in insertion of a 15 amino acid sequence in © 2015 International Society on Thrombosis and Haemostasis

36

37

38

39

40

41

42

43

44

45

46

47

48

49

50

the fibrinogen gamma-chain. Thromb Haemost 1993; 69: 217– 20. Neerman-Arbez M, de Moerloose P. Hereditary fibrinogen abnormalities. In: Kaushansky K, Lichtman M, Beutler E, Kipps T, Prchal J, Seligsohn U, eds. Williams Hematology, 8th edn. New York, NY: McGraw-Hill, 2010:1–33. Hogan KA, Gorkun OV, Lounes KC, Coates AI, Weisel JW, Hantgan RR, Lord ST. Recombinant fibrinogen Vlissingen/ Frankfurt IV. The deletion of residues 319 and 320 from the gamma chain of fibrinogen alters calcium binding, fibrin polymerization, cross-linking, and platelet aggregation. J Biol Chem 2000; 275: 17778–85. Koopman J, Haverkate F, Grimbergen J, Egbring R, Lord ST. Fibrinogen Marburg: a homozygous case of dysfibrinogenemia, lacking amino acids A alpha 461–610 (Lys 461 AAA–>stop TAA). Blood 1992; 80: 1972–9. Park R, Ping L, Song J, Hong SY, Choi TY, Choi JR, Gorkun OV, Lord ST. Fibrinogen residue gammaAla341 is necessary for calcium binding and ‘A-a’ interactions. Thromb Haemost 2012; 107: 875–83. Galanakis D. Afibrinogenemias and dysfibrinogenemias. In: Marder V, White GC, Aird WC, eds. Hemostasis and Thrombosis: Basic Principles and Clinical Practice, 6th edn. Philadelphia: Lippincott Williams & Wilkins, 2012: 693–708. Hill M, Dolan G. Diagnosis, clinical features and molecular assessment of the dysfibrinogenaemias. Haemophilia 2008; 14: 889–97. Lane DA, Southan C, Ireland H, Thompson E, Kehl M, Henschen A. Delayed release of an abnormal fibrinopeptide A from fibrinogen Manchester: effect of the A alpha 16 Arg leads to His substitution upon fibrin monomer polymerization and the immunological crossreactivity of the peptide. Br J Haematol 1983; 53: 587–97. Galanakis DK, Neerman-Arbez M, Scheiner T, Henschen A, Hubbs D, Nagaswami C, Weisel JW. Homophenotypic Aalpha R16H fibrinogen (Kingsport): uniquely altered polymerization associated with slower fibrinopeptide A than fibrinopeptide B release. Blood Coagul Fibrinolysis 2007; 18: 731–7. Galanakis DK, Henschen A, Peerschke EI, Kehl M. Fibrinogen Stony Brook, a heterozygous A alpha 16Arg—Cys dysfibrinogenemia. Evaluation of diminished platelet aggregation support and of enhanced inhibition of fibrin assembly. J Clin Invest 1989; 84: 295–304. Flood VH, Al-Mondhiry HA, Farrell DH. The fibrinogen Aalpha R16C mutation results in fibrinolytic resistance. Br J Haematol 2006; 134: 220–6. Alving BM, Henschen AH. Fibrinogen giessen I: a congenital homozygously expressed dysfibrinogenemia with A alpha 16 Arg—His substitution. Am J Hematol 1987; 25: 479–82. Mosesson MW, DiOrio JP, Muller MF, Shainoff JR, Siebenlist KR, Amrani DL, Homandberg GA, Soria J, Soria C, Samama M. Studies on the ultrastructure of fibrin lacking fibrinopeptide B (beta-fibrin). Blood 1987; 69: 1073–81. Cote HC, Lord ST, Pratt KP. gamma-Chain dysfibrinogenemias: molecular structure–function relationships of naturally occurring mutations in the gamma chain of human fibrinogen. Blood 1998; 92: 2195–212. Mosesson MW, Siebenlist KR, DiOrio JP, Matsuda M, Hainfeld JF, Wall JS. The role of fibrinogen D domain intermolecular association sites in the polymerization of fibrin and fibrinogen Tokyo II (gamma 275 Arg–>Cys). J Clin Invest 1995; 96: 1053–8. Ishikawa S, Hirota-Kawadobora M, Tozuka M, Ishii K, Terasawa F, Okumura N. Recombinant fibrinogen, gamma275Arg–>Cys, exhibits formation of disulfide bond with cysteine and severely impaired D:D interactions. J Thromb Haemost 2004; 2: 468–75.

918 A. Casini et al 51 Hirota-Kawadobora M, Terasawa F, Suzuki T, Tozuka M, Sano K, Okumura N. Comparison of thrombin-catalyzed fibrin polymerization and factor XIIIa-catalyzed cross-linking of fibrin among three recombinant variant fibrinogens, gamma 275C, gamma 275H, and gamma 275A. J Thromb Haemost 2004; 2: 1359–67. 52 Terasawa F, Hogan KA, Kani S, Hirose M, Eguchi Y, Noda Y, Hongo M, Okumura N. Fibrinogen Otsu I: a gammaAsn319, Asp320 deletion dysfibrinogen identified in an asymptomatic pregnant woman. Thromb Haemost 2003; 90: 757–8. 53 Meh DA, Mosesson MW, Siebenlist KR, Simpson-Haidaris PJ, Brennan SO, DiOrio JP, Thompson K, Di Minno G. Fibrinogen naples I (B beta A68T) nonsubstrate thrombinbinding capacities. Thromb Res 2001; 103: 63–73. 54 Collet JP, Soria J, Mirshahi M, Hirsch M, Dagonnet FB, Caen J, Soria C. Dusart syndrome: a new concept of the relationship between fibrin clot architecture and fibrin clot degradability: hypofibrinolysis related to an abnormal clot structure. Blood 1993; 82: 2462–9. 55 Meyer M, Franke K, Richter W, Steiniger F, Seyfert UT, Schenk J, Treuner J, Haberbosch W, Eisert R, Barthels M. New molecular defects in the gamma subdomain of fibrinogen D-domain in four cases of (hypo)dysfibrinogenemia: fibrinogen variants Hannover VI, Homburg VII, Stuttgart and Suhl. Thromb Haemost 2003; 89: 637–46. 56 Robert-Ebadi H, Le Querrec A, de Moerloose P, Gandon-Laloum S, Borel D, Neerman-Arbez M. A novel Asp344Val substitution in the fibrinogen gamma chain (fibrinogen Caen) causes dysfibrinogenemia associated with thrombosis. Blood Coagul Fibrinolysis 2008; 19: 697–9. 57 Kotlin R, Pastva O, Stikarova J, Hlavackova A, Suttnar J, Chrastinova L, Riedel T, Salaj P, Dyr JE. Two novel mutations in the fibrinogen gamma nodule. Thromb Res 2014; 134: 901–8. 58 Weisel JW. Why dysfibrinogenaemias still matter. Thromb Haemost 2009; 102: 426–7. 59 Hanss M, Biot F. A database for human fibrinogen variants. Ann N Y Acad Sci 2001; 936: 89–90. 60 Miesbach W, Scharrer I, Henschen A, Neerman-Arbez M, Spitzer S, Galanakis D. Inherited dysfibrinogenemia: clinical phenotypes associated with five different fibrinogen structure defects. Blood Coagul Fibrinolysis 2010; 21: 35–40. 61 Santacroce R, Cappucci F, Pisanelli D, Perricone F, Papa ML, Santoro R, Grandone E, Margaglione M. Inherited abnormalities of fibrinogen: 10-year clinical experience of an Italian group. Blood Coagul Fibrinolysis 2006; 17: 235–40. 62 Rein CM, Anderson BL, Ballard MM, Domes CM, Johnston JM, Madsen RJ Jr, Wolper KK, Terker AS, Strother JM, Deloughery TG, Farrell DH. Severe bleeding in a woman heterozygous for the fibrinogen gammaR275C mutation. Blood Coagul Fibrinolysis 2010; 21: 494–7. 63 Siebenlist KR, Prchal JT, Mosesson MW. Fibrinogen Birmingham: a heterozygous dysfibrinogenemia (A alpha 16 Arg —His) containing heterodimeric molecules. Blood 1988; 71: 613–18. 64 Hayes T. Dysfibrinogenemia and thrombosis. Arch Pathol Lab Med 2002; 126: 1387–90. 65 Shen YM, Trang V, Sarode R, Brennan S. Fibrinogen Dusart presenting as recurrent thromboses in the hepatic portal system. Blood Coagul Fibrinolysis 2014; 25: 392–4. 66 Tarumi T, Martincic D, Thomas A, Janco R, Hudson M, Baxter P, Gailani D. Familial thrombophilia associated with fibrinogen paris V: Dusart syndrome. Blood 2000; 96: 1191–3. 67 Ramanathan R, Gram J, Feddersen S, Nybo M, Larsen A, Sidelmann JJ. Dusart syndrome in a Scandinavian family characterized by arterial and venous thrombosis at young age. Scand J Clin Lab Invest 2013; 73: 585–90.

68 Carrell N, Gabriel DA, Blatt PM, Carr ME, McDonagh J. Hereditary dysfibrinogenemia in a patient with thrombotic disease. Blood 1983; 62: 439–47. 69 Lim BC, Ariens RA, Carter AM, Weisel JW, Grant PJ. Genetic regulation of fibrin structure and function: complex gene–environment interactions may modulate vascular risk. Lancet 2003; 361: 1424–31. 70 Travlou A, Gialeraki A, Merkouri E, Politou M, Sfyridaki A, Neerman-Arbez M. Coexisting dysfibrinogenemia (gamma Arg275His) and FV Leiden associated with thrombosis (Fibrinogen Crete). Thromb Res 2010; 126: e162–4. 71 Siebenlist KR, Mosesson MW, Meh DA, DiOrio JP, Albrecht RM, Olson JD. Coexisting dysfibrinogenemia (gammaR275C) and factor V Leiden deficiency associated with thromboembolic disease (fibrinogen Cedar Rapids). Blood Coagul Fibrinolysis 2000; 11: 293–304. 72 Morris TA, Marsh JJ, Chiles PG, Magana MM, Liang NC, Soler X, Desantis DJ, Ngo D, Woods VL Jr. High prevalence of dysfibrinogenemia among patients with chronic thromboembolic pulmonary hypertension. Blood 2009; 114: 1929–36. 73 Bolton-Maggs PH, Perry DJ, Chalmers EA, Parapia LA, Wilde JT, Williams MD, Collins PW, Kitchen S, Dolan G, Mumford AD. The rare coagulation disorders – review with guidelines for management from the United Kingdom Haemophilia Centre Doctors’ Organisation. Haemophilia 2004; 10: 593–628. 74 Mumford AD, Ackroyd S, Alikhan R, Bowles L, Chowdary P, Grainger J, Mainwaring J, Mathias M, O’Connell N, BCSH Committee. Guideline for the diagnosis and management of the rare coagulation disorders: a United Kingdom Haemophilia Centre Doctors’ Organization guideline on behalf of the British Committee for Standards in Haematology. Br J Haematol 2014; 167: 304–26. 75 Peyvandi F, Bidlingmaier C, Garagiola I. Management of pregnancy and delivery in women with inherited bleeding disorders. Semin Fetal Neonatal Med 2011; 16: 311–17. 76 de Moerloose P, Neerman-Arbez M. Treatment of congenital fibrinogen disorders. Expert Opin Biol Ther 2008; 8: 979–92. 77 Bevan DH. Cryoprecipitate: no longer the best therapeutic choice in congenital fibrinogen disorders? Thromb Res 2009; 124(Suppl. 2): S12–16. 78 Pike GN, Bolton-Maggs PH. Factor deficiencies in pregnancy. Hematol Oncol Clin North Am 2011; 25: 359–78 viii–ix. 79 Iwaki T, Sandoval-Cooper MJ, Paiva M, Kobayashi T, Ploplis VA, Castellino FJ. Fibrinogen stabilizes placental–maternal attachment during embryonic development in the mouse. Am J Pathol 2002; 160: 1021–34. 80 Snir A, Brenner B, Paz B, Ohel G, Lanir N. The role of fibrin matrices and tissue factor in early-term trophoblast proliferation and spreading. Thromb Res 2013; 132: 477–83. 81 Pretorius E, Bronkhorst P, Briedenhann S, Smit E, Franz RC. Comparisons of the fibrin networks during pregnancy, nonpregnancy and pregnancy during dysfibrinogenaemia using the scanning electron microscope. Blood Coagul Fibrinolysis 2009; 20: 12–16. 82 Miesbach W, Galanakis D, Scharrer I. Treatment of patients with dysfibrinogenemia and a history of abortions during pregnancy. Blood Coagul Fibrinolysis 2009; 20: 366–70. 83 Wang X, Chen C, Wang L, Chen D, Guang W, French J. Conception, early pregnancy loss, and time to clinical pregnancy: a population-based prospective study. Fertil Steril 2003; 79: 577–84. 84 Yamanaka Y, Takeuchi K, Sugimoto M, Sato A, Nakago S, Maruo T. Dysfibrinogenemia during pregnancy treated successfully with fibrinogen. Acta Obstet Gynecol Scand 2003; 82: 972–3. 85 Franchini M, Raffaelli R, Musola M, Memmo A, Poli G, Franchi M, Pizzolo G, Veneri D. Management of inherited © 2015 International Society on Thrombosis and Haemostasis

Dysfibrinogenemia: genetic and outcomes 919

86

87

88 89

90

91

92

dysfibrinogenemia during pregnancy: a description of four consecutive cases. Ann Hematol 2007; 86: 693–4. Mathonnet F, Guillon L, Detruit H, Mazmanian GM, Dreyfus M, Alvarez JC, Giudicelli Y, de Mazancourt P. Fibrinogen Poissy II (gammaN361K): a novel dysfibrinogenemia associated with defective polymerization and peptide B release. Blood Coagul Fibrinolysis 2003; 14: 293–8. Kotlin R, Zichova K, Suttnar J, Reicheltova Z, Salaj P, Hrachovinova I, Dyr JE. Congenital dysfibrinogenemia Aalpha Gly13Glu associated with bleeding during pregnancy. Thromb Res 2011; 127: 277–8. Meldrum DJ, Evans G, Popham P. Spinal anaesthesia and dysfibrinogenaemia. Int J Obstet Anesth 2001; 10: 64–7. Koopman J, Haverkate F, Grimbergen J, Lord ST, Mosesson MW, DiOrio JP, Siebenlist KS, Legrand C, Soria J, Soria C, Caen JP. Molecular basis for fibrinogen Dusart (A alpha 554 Arg–>Cys) and its association with abnormal fibrin polymerization and thrombophilia. J Clin Invest 1993; 91: 1637–43. Wada Y, Lord ST. A correlation between thrombotic disease and a specific fibrinogen abnormality (A alpha 554 Arg–>Cys) in two unrelated kindred, Dusart and Chapel Hill III. Blood 1994; 84: 3709–14. Marchi R, Lundberg U, Grimbergen J, Koopman J, Torres A, de Bosch N, Haverkate F, Arocha P. Fibrinogen Caracas V, an abnormal fibrinogen with an Aalpha 532 Ser–>Cys substitution associated with thrombosis. Thromb Haemost 2000; 84: 263–70. Koopman J, Haverkate F, Grimbergen J, Engesser L, Novakova I, Kerst AF, Lord ST. Abnormal fibrinogens IJmuiden (B beta Arg14—Cys) and Nijmegen (B beta Arg44—Cys) form disulfide-linked fibrinogen–albumin complexes. Proc Natl Acad Sci USA 1992; 89: 3478–82.

© 2015 International Society on Thrombosis and Haemostasis

93 Brennan SO, Hammonds B, Spearing R, George PM. Electrospray ionisation mass spectrometry facilitates detection of fibrinogen (Bbeta 14 Arg –> Cys) mutation in a family with thrombosis. Thromb Haemost 1997; 78: 1484–7. 94 Vakalopoulou S, Mille-Baker B, Mumford A, Manning R, Laffan M. Fibrinogen Bbeta14 Arg–>Cys: further evidence for a role in thrombosis. Blood Coagul Fibrinolysis 1999; 10: 403– 8. 95 Castaman G, Ghiotto R, Tosetto A, Rodeghiero F. Bbeta 14 Arg –> Cys variant dysfibrinogen and its association with thrombosis. J Thromb Haemost 2005; 3: 409–10. 96 Liu CY, Koehn JA, Morgan FJ. Characterization of fibrinogen New York 1. A dysfunctional fibrinogen with a deletion of B beta(9–72) corresponding exactly to exon 2 of the gene. J Biol Chem 1985; 260: 4390–6. 97 Engesser L, Koopman J, de Munk G, Haverkate F, Novakova I, Verheijen JH, Briet E, Brommer EJ. Fibrinogen Nijmegen: congenital dysfibrinogenemia associated with impaired t-PA mediated plasminogen activation and decreased binding of tPA. Thromb Haemost 1988; 60: 113–20. 98 Koopman J, Haverkate F, Lord ST, Grimbergen J, Mannucci PM. Molecular basis of fibrinogen Naples associated with defective thrombin binding and thrombophilia. Homozygous substitution of B beta 68 Ala—Thr. J Clin Invest 1992; 90: 238–44. 99 Bentolila S, Samama MM, Conard J, Horellou MH, Ffrench P. Association of dysfibrinogenemia and thrombosis. Apropos of a family (Fibrinogen Melun) and review of the literature. Ann Med Interne (Paris) 1995; 146: 575–80. 100 Kadir R, Chi C, Bolton-Maggs P. Pregnancy and rare bleeding disorders. Haemophilia 2009; 15: 990–1005.