Hemophilia - Factor VIII or IX Deficiency

  • Diagnosis
  • Background
  • Lab Tests
  • References
  • Related Topics

Indications for Testing

  • Spontaneous or prolonged bleeding suggestive of coagulation disorder
  • Family history of hemophilia
  • Acute or recent onset bleeding accompanied by prolonged partial thromboplastin time (PTT)

Initial Laboratory Testing for Coagulation Disorders

  • CBC with platelet count – normal in hemophilia A, B
  • Prothrombin time (PT)/PTT
    • PT – normal in hemophilia A, B
    • PTT – prolonged in moderate and severe hemophilia
      • Often normal in mild cases or in female carriers
      • PTT that corrects with mixing study suggests factor deficiency
      • PTT that does not correct with mixing study suggests an inhibitor
        • Incubated mixing studies are often necessary to identify FVIII inhibitors
  • Thrombin clotting time and plasma concentration of fibrinogen – normal in hemophilia A and B

Laboratory Testing for Hemophilia

  • FVIII activity level – decreased in hemophilia A, normal in hemophilia B
  • FIX activity level – decreased in hemophilia B, normal in hemophilia A
    • Not reliable for carrier status detection in females
    • Measurement in neonate may need to be repeated when family history of mild disease exists
  • von Willebrand factor (VWF) level – normal
    • Because VWF is a carrier for FVIII, von Willebrand disease (VWD) should be ruled out in patients with decreased FVIII levels
    • A rare subtype of VWD (type 2N) has isolated low FVIII activity with normal VWF level and mimics hemophilia A
      • Specialized coagulation or genetic testing can be used to distinguish these disorders
  • Genetic testing
    • Patient risk should be calculated by a clinical geneticist using laboratory results and family history
    • Indications
      • Confirm the causative F8 or F9 gene mutation in affected individuals
      • Determine carrier status in at-risk females

Prognosis

  • Improved prognosis with the advent of FVIII and FIX replacement
  • Major disability from bleeding – joint disease
  • Leading cause of death from bleeding – intracranial hemorrhage

Differential Diagnosis

Hemophilia A and hemophilia B are bleeding disorders caused by genetic mutations in the F8 or F9 gene that result in deficiencies of factor VIII (FVIII) or factor IX (FIX), respectively. These disorders are clinically indistinguishable and present with bleeding symptoms ranging from mild to severe, depending on the underlying defect.

Epidemiology

  • Incidence
    • Hemophilia A – 1/4,000-5,000 male births worldwide; rare in females
    • Hemophilia B – 1/25,000 male births worldwide; rare in females
    • Acquired hemophilia – 1-2/million worldwide
      • <1/million in children
  • Age
    • Severe disease – usually detected in first year of life
    • Moderate disease – detected before age 5
    • Mild disease – detected later in life
    • Acquired disease – bimodal peaks at 20-40 years and 60-90 years
  • Types
    • Hemophilia A – FVIII deficiency
    • Hemophilia B – FIX deficiency
    • Acquired hemophilia – autoimmune disorder caused by antibodies to FVIII or, rarely, FIX

Inheritance

  • Clinical Presentation

    • Presentation of hemophilia A is clinically indistinguishable from hemophilia B
    • Excessive bleeding – occurs spontaneously or from trivial injury
      • Common bleeding manifestations – hemarthrosis, hematomas, gastrointestinal bleeding, genitourinary bleeding
    • Frequency and severity of excessive bleeding based on FVIII or FIX activity
      • Mild disease (6-40% factor activity) – bleeding may occur with major trauma or surgery; no spontaneous bleeding
        • Often not diagnosed until adulthood
        • Carrier females – 10% have mild disease (<40% factor activity) and are at risk for excessive bleeding
      • Moderate disease (1-5% factor activity) – bleeding may occur with minimal trauma or minor surgery; spontaneous bleeding rare
        • Typically diagnosed by 6 years
      • Severe disease (<1% factor activity) – high risk of severe, spontaneous bleeding
        • Usually diagnosed in first year of life due to spontaneous muscle and joint bleeding
    • Acquired disease is indistinguishable from inherited disease except that it rarely occurs in children
    Tests generally appear in the order most useful for common clinical situations. Click on number for test-specific information in the ARUP Laboratory Test Directory.

    CBC with Platelet Count and Automated Differential 0040003
    Method: Automated Cell Count/Differential

    Recommended Use 

    Initial test for suspected bleeding disorder

    Prothrombin Time 0030215
    Method: Electromagnetic Mechanical Clot Detection

    Recommended Use 

    Initial test for suspected bleeding disorder

    Partial Thromboplastin Time 0030235
    Method: Electromagnetic Mechanical Clot Detection

    Recommended Use 

    Initial test for suspected bleeding disorder

    Factor VIII, Activity 0030095
    Method: Electromagnetic Mechanical Clot Detection

    Recommended Use 

    Diagnose hemophilia A

    Not recommended when screening for thrombophilia

    Limitations 

    Not reliable for hemophilia A carrier determination in at-risk females 

    Factor VIII Activity with Reflex to Bethesda Quantitative, Factor VIII 0030026
    Method: Electromagnetic Mechanical Clot Detection

    Recommended Use 

    Order to diagnose factor VIII deficiency, detect factor VIII inhibitors, and monitor factor VIII replacement therapy.

    Reflex – if FVIII is >20%, no further testing will be performed; if FVIII activity is ≤20%, Bethesda quantitative (FVIII) will be added

    Factor IX, Activity 0030100
    Method: Electromagnetic Mechanical Clot Detection

    Recommended Use 

    Diagnose hemophilia B

    Monitor factor IX replacement therapy

    Limitations 

    Not reliable for hemophilia B carrier determination in at-risk females

    Factor IX Activity with Reflex to Bethesda Quantitative, Factor IX 0030032
    Method: Electromagnetic Mechanical Clot Detection

    Recommended Use 

    Order to diagnose factor IX deficiency, detect factor IX inhibitors, and monitor factor IX replacement therapy

    Reflex – if FIX is >20%, no further testing will be performed; if FIX activity is ≤20%, Bethesda quantitative (FIX) will be added

    Hemophilia A (F8) 2 Inversions with Reflex to Sequencing and Reflex to Deletion/Duplication 2001614
    Method: Inverse Polymerase Chain Reaction/Sequencing/Multiplex Ligation-dependent Probe Amplification

    Recommended Use 

    Detect the causal F8 variant in established cases of hemophilia A

    Determine carrier status for females with a family history of hemophilia A

    Reflex – if inversion testing does not explain clinical scenario, F8 gene sequencing will be performed; if gene sequencing does not explain clinical scenario, deletion/duplication testing will be performed

    Clinical sensitivity – 51% for inversion testing, 43% for sequencing, and 6% for deletion/duplication analysis

    Limitations 

    Breakpoints of large F8 deletions/duplications will not be determined

    F8 deep intronic or promoter variants, with the exception of the common intron 1 and 22A inversions, will not be detected

    Rare diagnostic errors may occur due to primer- or probe-site variants

    Deletions/duplications in exon 23 will not be detected

    Hemophilia B (F9) Sequencing and Deletion/Duplication 2010494
    Method: Polymerase Chain Reaction/Sequencing/Multiplex Ligation-dependent Probe Amplification

    Recommended Use 

    Most comprehensive test to confirm diagnosis or determine carrier status for F9 gene variants

    Detect causal F9 variant in established cases of hemophilia B

    Determine carrier status for women with a family history of hemophilia B

    Contraindicated for diagnostic or carrier testing of individuals with a previously identified familial F9 variant 

    Limitations 

    Deep intronic variants will not be detected

    Rare diagnostic errors may occur due to primer-site variants

    Large deletions/duplications in exon 1 may not be detected

    Guidelines

    de Moerloose P, Fischer K, Lambert T, Windyga J, Batorova A, Lavigne-Lissalde G, Rocino A, Astermark J, Hermans C. Recommendations for assessment, monitoring and follow-up of patients with haemophilia. Haemophilia. 2012; 18(3): 319-25. PubMed

    James AH. Diagnosis and management of women with bleeding disorders--international guidelines and consensus from an international expert panel. Haemophilia. 2011; 17 Suppl 1: 3-5. PubMed

    WFH Guidelines for the Management of Hemophilia. World Federation of Hemophilia. Montréal, Canada [Updated Aug 2014; Accessed: Feb 2016]

    General References

    Coppola A, Favaloro EJ, Tufano A, Di Minno MN, Cerbone AM, Franchini M. Acquired inhibitors of coagulation factors: part I-acquired hemophilia A. Semin Thromb Hemost. 2012; 38(5): 433-46. PubMed

    de Brasi C, El-Maarri O, Perry DJ, Oldenburg J, Pezeshkpoor B, Goodeve A. Genetic testing in bleeding disorders. Haemophilia. 2014; 20 Suppl 4: 54-8. PubMed

    Fijnvandraat K, Cnossen MH, Leebeek FW, Peters M. Diagnosis and management of haemophilia. BMJ. 2012; 344: e2707. PubMed

    Franchini M, Favaloro EJ, Lippi G. Mild hemophilia A. J Thromb Haemost. 2010; 8(3): 421-32. PubMed

    Franchini M, Zaffanello M, Lippi G. Acquired hemophilia in pediatrics: a systematic review. Pediatr Blood Cancer. 2010; 55(4): 606-11. PubMed

    Hemophilia - Bleeding and Clotting Disorders Surveillance. Centers for Disease Control and Prevention. Atlanta, GA [Last updated Jul 2014; Accessed: Jan 2017]

    Mulliez SM, Vantilborgh A, Devreese KM. Acquired hemophilia: a case report and review of the literature. Int J Lab Hematol. 2014; 36(3): 398-407. PubMed

    Verbruggen B, Meijer P, Novákova I, Van Heerde W. Diagnosis of factor VIII deficiency. Haemophilia. 2008; 14 Suppl 3: 76-82. PubMed

    Wagenman BL, Townsend KT, Mathew P, Crookston KP. The laboratory approach to inherited and acquired coagulation factor deficiencies. Clin Lab Med. 2009; 29(2): 229-52. PubMed

    References from the ARUP Institute for Clinical and Experimental Pathology®

    Flanders MM, Crist RA, Roberts WL, Rodgers GM. Pediatric reference intervals for seven common coagulation assays. Clin Chem. 2005; 51(9): 1738-42. PubMed

    Heikal NM, Murphy KK, Crist RA, Wilson AR, Rodgers GM, Smock KJ. Elevated factor IX activity is associated with an increased odds ratio for both arterial and venous thrombotic events. Am J Clin Pathol. 2013; 140(5): 680-5. PubMed

    Miranda GG, Rodgers GM. Treatment of an acquired factor VIII inhibitor with sequential recombinant factor VIIa and FEIBA. Haemophilia. 2009; 15(1): 383-5. PubMed

    Nance D, Rodgers GM. Switching haemophilia products and inhibitor risk: a United States' perspective Eur J Haematol. 2015; 94(4): 283. PubMed

    Peerschke EI, Castellone DD, Ledford-Kraemer M, Van Cott EM, Meijer P, NASCOLA Proficiency Testing Committee. Laboratory assessment of factor VIII inhibitor titer: the North American Specialized Coagulation Laboratory Association experience. Am J Clin Pathol. 2009; 131(4): 552-8. PubMed

    Rodgers GM. Prothrombin complex concentrates in emergency bleeding disorders. Am J Hematol. 2012; 87(9): 898-902. PubMed

    Sborov DW, Rodgers GM. How I manage patients with acquired haemophilia A. Br J Haematol. 2013; 161(2): 157-65. PubMed

    Yaish H, Rodgers GM. A haemophilia B patient with severe burn injury: increased requirement for factor IX replacement therapy associated with venous thromboembolism. Haemophilia. 2008; 14(3): 607-9. PubMed

    Medical Reviewers

    Heikal, Nahla, MD, MS, Assistant Medical Director, Immunology and Hemostasis/Thrombosis at ARUP Laboratories; Assistant Professor of Clinical Pathology, University of Utah

    Lyon, Elaine, PhD, Medical Director, Genetics, and Co-Medical Director, Pharmacogenomics at ARUP Laboratories; Associate Professor of Clinical Pathology, University of Utah

    Miller, Christine E., MS, LCGC, Genetic Counselor, Molecular Genetics at ARUP Laboratories; Faculty, Graduate Program in Genetic Counseling, University of Utah

    Rodgers III, George M., MD, PhD, Medical Director, Hemostasis and Thrombosis at ARUP Laboratories; Professor of Internal Medicine and Adjunct Professor of Clinical Pathology, University of Utah

    Smock, Kristi J., MD, Medical Director, Hemostasis/Thrombosis at ARUP Laboratories; Associate Professor of Clinical Pathology, University of Utah

    Velden, Sara, MS, LCGC, Genetic Counselor, Molecular Genetics and Cytogenetics at ARUP Laboratories

    Last Update: May 2017