Von Willebrand disease (VWD) is a type of blood-clotting disorder. It is the most common hereditary coagulopathy in humans, affecting 1% of the population. An acquired form of VWD can sometimes result from other medical conditions. Most people with VWD have no symptoms. Those that do usually have bleeding of varying intensity, including repeated bruising and nosebleeds.
VWD arises from a deficiency in the quality or quantity of von Willebrand factor (VWF), a protein required for platelet adhesion through the binding to other proteins, particularly factor VIII. The disease is known to affect several breeds of dogs as well as humans. Four types of hereditary VWD have been described, including platelet-type VWD, with VWD type 1 being the most common. Types 1 and 2 are inherited through an autosomal dominant pattern, meaning at least one parent must also have the disease.
Diagnosis is typically confirmed through blood tests. Managing VWD includes the use of desmopressin after minor trauma or before surgery, which allows the body to release more VWF. The disease is named after the Finnish physician Erik Adolf von Willebrand, who first described the condition in 1926.
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. Symptoms of VWD vary depending on age, sex, and VWD type. In children, bruising and nosebleeds are common symptoms. In adults, easy bruising, heavy menstrual bleeding, and bleeding from minor wounds are more common. Sixty to eighty percent of people with VWD have excessive bleeding after surgery or dental extractions.
Gastrointestinal bleeding from dilated blood vessels lining the gut (angiodysplasia) can result in severe, lifethreatening gastrointestinal bleeding. This most commonly occurs in seniors with type 2 or 3 VWD.
Von Willebrand factor levels normally increase with age, so disease severity often decreases with older age.
In women with VWD, 80% have heavy menstrual bleeding with 20% requiring removal of the uterus (hysterectomy). Due to its association with heavy menstrual bleeding, VWD is more commonly diagnosed in women. Women with VWD may also experience heavy bleeding after delivery (postpartum bleeding).
Severe internal bleeding and bleeding into joints are rare in those with VWD, but they are more common in those with the more severe type 3 disease. Bleeding in the brain or spinal cord is exceedingly rare in all 3 types of VWD.
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: Evaluating family members of individuals who have known variants. Differentiating between type 2B and platelet-type VWD, as well as between type 2N VWD and hemophilia A.
Pathophysiology
Von Willebrand factor is normally synthesized in the endoplasmic reticulum of endothelial cells lining blood vessels (and also in megakaryocytes), and it is then packaged into multimers (many strands of vWF connected by disulfide bonds) by the Golgi and stored in Weibel-Palade bodies as a helical spiral of multiple multimers. When vWF is secreted by endothelial cells, the multimers are cleaved by the enzyme ADAMTS13 and vWF circulates in the plasma in a coiled and inactive form. When there is damage to a blood vessel (due to trauma or other factors) collagen under the blood vessel lining is exposed. When vWF comes into contact with exposed collagen it uncoils and binds to the collagen. Circulating platelets bind to vWF using their GpIb-alpha surface protein which binds to a specific area on the uncoiled vWF strand (The A1 domain binding site). Upon binding, the platelets become activated and irregularly shaped which attracts more platelets to the area of vascular damage to form a platelet plug in the blood vessel wall and stop the bleeding. In VWD, vWF is either deficient (type 1 disease), dysfunctional (type 2 disease), or is completely absent (the severe type 3 disease) leading to dysfunction in the above mechanism to stop bleeding.
Circulating vWF also binds to coagulation factor VIII preventing it from being degraded. Factor VIII is involved in the coagulation cascade to also prevent excessive bleeding.
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 VWD is diagnosed by a combination of a personal or family history of excessive bleeding plus lab tests showing abnormalities in either the amount or function of vWF or factor VIII.
Basic tests performed in any patient with bleeding problems are a complete blood count, activated partial thromboplastin time (aPTT), prothrombin time with an International Normalized Ratio, thrombin time, and fibrinogen level. People with abnormal tests typically undergo further testing for hemophilias. Other coagulation factor assays may be performed depending on the results of a coagulation screen. People 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