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Genetics and Mechanisms of

Hemophilia
Prepared by: Morad Merwan Abed
Supervised by: Dr. Basim Ayesh

Background
Hemophilia: derived from haima meaning blood, and
philia meaning affection

The word hemophilia introduced by Hopff at


University of Zurich in 1828
Blood does not clot normally
Bleed for a longer time NOT more profusely or
quickly
There are 3 known types (A, B, C)

The Royal Disease

Queen Victoria (18371901) was a carrier


Her son Leopold suffered
from frequent hemorrhages
before dying from a brain
hemorrhage at 31
Queen Victorias daughters
passed the disease to the
Spanish, German and
Russian Royal Families

Genetics

Sex-linked recessive
genetic disorder
affecting X chromosome
(type A & B)
Only females can be
carriers; men are
affected or unaffected

Clinical Manifestations

Hemarthroses (bleeding into muscles and joints ),


deep muscle hematomas, hematuria and easy
bruising
Mild forms may be asymptomatic
Moderate forms usually bleed after surgery or trauma
Severe forms show spontaneous bleeding

Brain hemorrhaging is a frequent cause of death

Diagnosis

Diagnosis prompted by unusual bleeding/bruising or


positive family history
2 approaches to genetic diagnosis:

Linkage analysis (to track defective X-chromosome in family)


Direct mutation detection

Must be confirmed by specific factor analysis or by tests


that reveal the presence of a dysfunctional protein

Coagulation

Primary Hemostasis

Begins after injury to blood vessel endothelium


Platelets immediately plug the site
Called the platelet plug

Secondary Hemostasis

Occurs simultaneously to primary


Proteins called coagulation/clotting factors
respond to complex cascade forming fibrin strands
the coagulation cascade
Strengthen platelet plug

Coagulation Cascade

Divided into 3 pathways:

Contact activation (intrinsic) pathway


Tissue factor (extrinsic) pathway
Common pathway

Contact Activation (intrinsic)


Pathway
CS: collagen surface
HMWK: high
molecular weight
kininogen
Ca2+
Ca2+

PL: phospholipids

PL

Upon injury blood vessel is damaged


Plasma is exposed to negatively charged surfaces
such as collagen which activates the pathway
Hemophilia A, B and C affect factors VIII, IX and XI
respectively

Tissue Factor (extrinsic)


Pathway

Following damage to blood vessel, tissue factor is


released
Tissue factor is a lipoprotein present in many tissues
including high concentrations in brain, lung and
placental tissues.

Ca2+

The Common Pathway

Ca2+
PL

Intrinsic and extrinsic pathway come together at


factor X to start the common pathway
Results in a clot being formed by fibrin monomers

Hemophilia A
Factor VIII Deficiency

Most common type


Frequency of 1 per 10,000 males
In 1/3 of cases there is no family history
Patients with mild to moderate hemophilia may not
exhibit abnormal bleeding until later in life
>80% of children with severe hemophilia experience
clinically significant bleeding during the first year of
life
Once children with severe hemophilia begin to walk
they typically experience recurrent hemarthroses

Genetics of Hemophilia A

Inherited as an X-linked recessive disorder


Mutations including a variety of deletions, insertions,
missense, nonsense and splice site mutations have
been reported
Commonly an inversion of intron 1 and 22
Sporadic cases result from de novo mutations

Factor VIII Gene and Protein

F8 Intron 22 Inversion

This split F8 gene cannot encode


functional FVIII protein; severe hemophilia A always results.

F8 Intron 22 Inversion Analysis

Results from homologous intrachromosomal


recombination
Inversion mutation occurs de novo once per
10,000 male meioses
Every ejaculate contains at least one sperm
with a F8 intron 22 inversion mutation
Responsible for 45% of severe hemophilia A

F8 intron 1 inversion

F8 Intron 1 Inversion Analysis

Similar to intron 22 inversion


900 bp region 5 to F8 gene crosses
over with homologous region in intron 1
Results in F8 gene lacking a promoter
and first exon
Responsible for approx 2% of severe
hemophilia A

Intrachromosomal inversions
cause 50% of cases of severe
hemophilia A
???

The majority of non-inversion cases of


hemophilia A, and nearly all cases of
hemophilia B result from point
mutations, affecting a single nucleotide.

Examples of Point Mutation

-Cys Arg Lys Lys Thr Gln- Normal


-TGC CGA AAA AAA ACG CAG sequence
-Tyr Arg Lys Lys Thr Gln- Missense
-TAC CGA AAA AAA ACG CAG-Val Stop
Nonsense
-GTC TGA AAA AAA ACG CAG-Val Arg Lys Lys Arg Met- Frameshift
-GTC CGA AAA AAA CGC AGT- (eg A8>

Ways to Eliminate FVIII Activity


(severe disease)

Intron 1 or 22 inversion
Delete part of gene
Insert extra nucleotides
Nonsense mutation
Splice site defect
Missense mutation at strategic amino
acid

Ways to Reduce FVIII Production


(moderate/mild disease)

Missense mutation, less important


amino acid
Splice site defect
Most families have a private mutation
Mutation not identified in ~2% of
patients

Hemophilia B
Factor IX Deficiency
Prevalence: 1 per 50 000 males
70% of cases-true deficiency of coagulation factor IX
30% of cases-presence of a dysfunctional protein
Classification:
severe (IX activity <1% of normal)
moderate (IX activity 1-5%)
mild (IX activity 5-25%)

Hemophilia B: Genetics

The gene for Factor IX is located on the longarm of the X-chromosome


Mutations: deletions, insertions, inversions and
point mutations (represent 90% of all
alterations)
All regions of Factor IX gene have been
involved.

Factor IX
single chain vitamin K-dependent glycoprotein
415 amino acids
Mechanism:

Factor IX Gene and Protein

There are no mutations equivalent to the


inversions seen in hemophilia A.
The same general profile of non-inversion
mutations is seen as in hemophilia A, with
one important exception, hemophilia B
Leiden.
The majority of patients have point
mutations, most resulting in missense
mutations

Hemophilia B Leiden

Most hemophilia is lifelong disorder of same


severity
Small proportion of hemophilia B patients
have FIX levels which increase at puberty
Hemophilia B Leiden 3% of hemophilia
B
This is the only situation where hemophilia
gets better

Hemophilia C
Factor XI deficiency

In the USA, it is thought to affect 1 in 100,000 of the


adult population
Distinguished from Hemophilia A and B by the
absence of bleeding into joints and muscles
Occurrence in both sexes .

Hemophilia C: Genetics

The gene encoding FXI is located on the distal arm of


chromosome 4 (4q35)
The deficiency is inherited as an autosomal recessive
trait

Mutations of the FXI gene:


Majority are missense mutations
Nonsense mutations
Deletions/insertions
Splice site mutations

Factor XI: Pathway

Treatments

Factor Replacement therapy

isolated from human blood plasma


o

Plasma-derived factor VIII and IX are made from human


plasma pooled together then separated into different
products

a genetically engineered cell line made by DNA


technology, called recombinant factors

The human factor VIII (or IX) gene is isolated through


genetic engineering which is inserted into non-human
cells
It is cultured then purified for human use

Treatment Frequency

Depending on disease severity, factor


replacements can be given daily, weekly,
monthly or almost never

On-demand

infusion of factor concentrates immediately after the


beginning of a bleed to stop the bleeding quickly

Prophylaxis

hemophiliacs receive factor concentrates one or more


times a week to prevent bleeding

Treatments (cont)

Desmopressin synthetic drug which is a copy of a


natural hormone
Treats mild/moderate hemophilia A
Acts by recruiting Factor VIII to the site of blood
vessel damage
Used by injection or as nasal spray
Cyklokapron and Amicar
Treat both hemophilia A and B
Dont actually help form a clot, only help hold a
clot in place therefore, cannot be used instead of
desmopressin or replacement therapy
Available as tablets

Case..

38 year old female


Uncle died from the dz
Brother with hemophilia lieden
Risk for having a child with the dz??

Summary

Hemophilia occurs when the blood does not clot normally; an


affected individual bleeds for a longer time, not more profusely
or quickly
Clinical manifestations could include hemarthroses, deep muscle
hematomas, hematuria, easy bruising and spontaneous
bleeding, while brain hemorrhage is a frequent cause of death.
Hemophilia A and B are caused by rare recessive traits, with the
defective gene (the Factor VIII and IX, respectively) located on
the X-chromosome. As a result males with a defective X
chromosome exhibit hemophilia, while females (with 1 mutant
copy) are carriers of the mutation (but do not exhibit overt
hemophilia).
Mutations could be due to deletions, insertions, missense,
nonsense, splice site, and point mutations.
Hemophilia C is a Factor XI deficiency inherited as an autosomal
recessive trait. The gene Factor XI is located on chromosome 4
and therefore can occur in both sexes

Summary (cont)

It is also distinguished from Hemophilia A and B by the absence


of bleeding into joints and muscles.
The normal clotting pathways are a series of reactions activated
by factors that then catalyze the next reaction in the cascade,
ultimately resulting in cross-linked fibrin.
Therefore a deficiency in these factors (VIII, IX) lead to
improper clotting
Treatment: Factor VIII or IX Replacement Therapy

It is isolated from human blood plasma or genetically engineered cell line


made by DNA technology, called recombinant factors
Depending on disease severity, factor replacements can be on-demand or
prophylaxis

Desmopressin treats hemophilia A


Cyklokapron and Amicar treats hemophilia A and B

Thank you