Journal of Blood Medicine Dovepress

open access to scientific and medical research

Open Access Full Text Article

REVIEW

Obstacles to Early Diagnosis and Treatment of

Inherited von Willebrand Disease: Current
Perspectives
Journal of Blood Medicine downloaded from https://www.dovepress.com/ on 24-Jan-2023

This article was published in the following Dove Press journal:

Journal of Blood Medicine

Giancarlo Castaman Abstract: Von Willebrand disease (VWD), the most common inherited bleeding disorder,
Silvia Linari is highly heterogeneous, and its early diagnosis may be difficult, especially for mild cases
and in qualitative von Willebrand factor (VWF) defects. Appropriate VWD diagnosis
Center for Bleeding Disorders and
Coagulation, Department of Oncology, requires the combination of personal and/or family history of bleeding and abnormal
For personal use only.

Careggi University Hospital, Florence, VWF laboratory testing. The use of bleeding assessment tools has been helpful in
Italy
standardizing bleeding history collection and quantification of bleeding symptoms to
select patients who may benefit of further hemostatic testing. Type 1 and 3 VWD
which represent quantitative VWD variants are relatively easy to diagnose. The diagnosis
of type 2 VWD requires multiple assessments to evaluate the effects induced by the
responsible abnormality on the heterogeneous functions of VWF. Sensitive and reprodu­
cible tests are needed to evaluate different VWF activities, starting from measuring
VWF-platelet interaction. In the recent years, several increasingly sensitive, rapid and
automated assays have been developed, but they are not widely available so far. Genetic
testing for VWD diagnosis is not a common practice because VWF gene is very large
and highly polymorphic and therefore it is used only in specific cases. It is evident that
the early and correct VWD diagnosis allows optimal management of bleeding and
situations at risk. Tranexamic acid, desmopressin, replacement therapy with plasma-
derived concentrates with a variable content of VWF and FVIII, or the new recombinant
VWF are the different therapeutic options available. Careful VWD classification guides
treatment because desmopressin is widely used in type 1 while replacement therapy is the
cornerstone of treatment for type 2 and 3 variants.
Keywords: von Willebrand disease, von Willebrand factor, bleeding history, laboratory
assays, desmopressin, replacement therapy

Introduction
Von Willebrand disease (VWD) is the most common inherited bleeding disorder,
characterized by an extreme variability of clinical manifestations and laboratory
phenotypes. The clinical spectrum varies from subjects with dubious, mild symp­
toms to patients with spontaneous, severe, sometimes life-threatening bleeds. Due
Correspondence: Giancarlo Castaman
Center for Bleeding Disorders and to the complexities of clinical and laboratory assessment, the diagnosis can be
Coagulation, Department of Oncology, difficult, especially in mild forms, so that the disease may be under-diagnosed also
Careggi University Hospital, Largo
G. Brambilla 3, Florence, 50134, Italy among symptomatic patients.
Tel +39 055 7947587 In this paper, we analyze the actual obstacles to early diagnosis and subsequent
Fax +39 055 7947794
Email giancarlo.castaman@unifi.it treatment of VWD.

submit your manuscript | www.dovepress.com Journal of Blood Medicine 2021:12 165–175 165
DovePress © 2021 Castaman and Linari. This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/
http://doi.org/10.2147/JBM.S232758
terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License (http://creativecommons.org/licenses/by-nc/3.0/). By accessing
the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed.
For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms (https://www.dovepress.com/terms.php).
 Castaman and Linari Dovepress

VWD domain contains the cleavage site which regulates post-

VWD is a bleeding disorder characterized by a deficiency secretion processing of VWF size by the VWF-cleaving
and/or an abnormality of von Willebrand factor (VWF), an protease, ADAMTS13. The A3 domain contains a binding
adhesive glycoprotein that plays an essential function in site for collagen. The C1 domain contains a unique RGDS
both primary and secondary hemostasis. VWF is required (Arg-Gly-Asp-Ser) sequence responsible for binding to the
for platelet adhesion to the subendothelium exposed by glycoprotein GPIIb/IIIa complex on platelet surface.
a vascular injury and also in mediating platelet–platelet The cleavage of the signal peptide prompts the VWF
interactions together with fibrinogen, thus enhancing the subunits to dimerize at the C-terminal region through
hemostatic process. Furthermore, VWF is the carrier of intermolecular disulfide bridges in the endoplasmic reticu­
coagulation factor VIII (FVIII), driving it to the site of lum. Then, the acidic pH and high calcium concentration
vascular damage and modulating its proteolytic in the Golgi induce the building of VWF multimers
degradation.1,2 VWD is extremely heterogeneous from through bridging through disulfide residues between D3
a genetic and clinical point of view. The inheritance can domains. The propeptide remains non-covalently bound to
be autosomal dominant or recessive, although VWD the VWF multimer inside the cell until fully cleavage
usually presents with an autosomal dominant inheritance. allows for the separate release into plasma. VWF is stored
Thus, patients often report other relatives with a history of in α-granules of platelets or endothelial Weibel-Palade
bleeding, although severity may differ among affected bodies11 and secreted in plasma or abluminally to suben­
members belonging to same family. In epidemiological dothelium through a constitutive and a regulated pathway.
studies, VWF deficiency is identified in about 1% of the The subsequent proteolysis by ADAMTS13 produces vari­
general population, but only about 0.01% has clinically ably sized multimers,12 whose clearance occurs later by
significant bleeding symptoms.3,4 The actual prevalence is macrophages in the liver and spleen.13
probably between these two extreme values and some
people could have undiagnosed VWD-related bleeding. VWD Clinical Manifestations and
Classification
Biology of VWF The quantitative deficiency and/or qualitative abnormality
VWF is a large multimeric adhesive plasma glycoprotein of VWF lead to a variable risk of bleeding, depending on
synthesized in megakaryocytes and endothelial cells.5–7 severity of the deficiency of VWF and FVIII. VWD clin­
The biosynthesis and organization of VWF involves ical manifestations include predominantly mucosal bleed­
a complex intracellular pathway and defects at any step ing (epistaxis, menorrhagia, gastrointestinal bleeds),
of which may cause a decreased plasma VWF level or surgery or trauma-related bleeding and joint bleeding,
dysfunction. The gene coding for VWF is located on the especially for patients with more severe FVIII deficiency.
short arm of chromosome 12 (12p13.2) and it includes 52 VWD is classified into three main types categorizing
exons.8 VWF has a partial pseudogene located on chromo­ quantitative (type 1 and 3) or qualitative (type 2) VWF
some 22 with 97% homology with the authentic VWF abnormalities (Table 1).14,15
gene.9 The presence of this pseudogene can complicate Unlike type 3, type 1 VWD (60–70% of cases) presents
genetic analysis and contribute to a pathophysiological milder VWF deficiency (10–30 U/dL), with normal or
mechanism of gene conversion. slightly reduced FVIII levels. The inheritance transmission
The primary translation protein contains 2813 amino is autosomal dominant and missense amino acid changes
acids, composed by a prepeptide of 22 amino acid, represent the majority of causative mutations. Bleeding
a propeptide 741 amino acid long and the mature VWF manifestations are mild. VWF is virtually absent in
subunit of 2050 amino acids. The different binding abil­ patients with type 3 (1–2% of cases), and FVIII levels
ities of VWF are scattered over four repeated domains are usually very low. Most of these patients are homozy­
(D1, D2, D’, D3, A1, A2, A3, D4, C1-C6, CK).10,11 The gous or compound heterozygous for null alleles in the
D’-D3 domains are essential for binding to FVIII. The VWF gene.16 The remaining 20–25% of patients have
VWF A1 domain is important in binding VWF to platelets Type 2VWD, further divided into four subtypes which
through the platelet receptor glycoprotein, GPIb, and con­ take into account distinct pathophysiological mechanisms
tains binding sites for heparin and collagen. The A2 and laboratory features.14,17

166 submit your manuscript | www.dovepress.com Journal of Blood Medicine 2021:12

DovePress

Powered by TCPDF (www.tcpdf.org)

 Dovepress Castaman and Linari

Table 1 Classification of Von Willebrand Disease or replacing missing VWF with plasma-derived (pd) coa­
Quantitative Deficiency of VWF gulation factor concentrates containing FVIII and VWF.
Type 1 Partial quantitative deficiency of VWF- autosomal DDAVP (1-deamino-8-D-arginine-vasopressin) is
dominant transmission (~60–70% of all cases) a synthetic analog of the antidiuretic hormone
Type 3 Virtually complete deficiency of VWF - autosomal vasopressin18,19 which can be given by intravenous, sub­
recessive transmission (~ 1–2% of all cases)
cutaneous, or intra-nasal route. In responsive patients,
Qualitative Deficiency of VWF a peak of the released FVIII and VWF > 50 U/dL is
Type 2 Qualitative deficiency of VWF (~ 25–30% of all cases) usually obtained 60 minutes after its administration.
Type 2A Qualitative variants with decreased platelet-dependent
Usually, 0.3 µg/kg is used for intravenous or subcutaneous
function associated with the absence of high and
administration, and 300 µg in adults and 150 µg in chil­
intermediate-molecular–weight VWF multimers
Type 2B Qualitative variants with increased affinity for platelet dren with intranasal spray. DDAVP is cheap and carries no
GpIb risk of viral transmission; however, progressive reduction
Type 2M Qualitative variants with decreased platelet-dependent in magnitude of response (tachyphylaxis) is observed after
function not caused by the absence of high- repeated closely spaced doses due to the cellular depletion
molecular–weight VWF multimers
of VWF/FVIII. DDAVP is mostly efficacious in patients
Type 2N Qualitative variants with markedly decreased affinity
with type 1 VWD with normal VWF content in cells and
for FVIII
baseline VWF and FVIII levels >10 U/dL.20 In type 2B,
Note: Adapted with permission from Sadler JE, Budde U, Eikenboom JC, et al.
Update on the pathophysiology and classification of von Willebrand disease: a DDAVP causes a transient occurrence or aggravation of
report of the subcommittee on von Willebrand factor. J Thromb Haemost. thrombocytopenia and is considered contraindicated21
2006;4:2103–2114.15.
while heterogeneous patterns are observed in other type
2 varieties.14,22 Type 3 patients do not show any significant
Typically, type 2A is caused by mutations resulting in increase post-administration.
a decreased binding to platelets caused by the absence of Plasma-derived VWF-FVIII (pd-VWF/FVIII) concen­
significant reduction of high and intermediate-molecular- trates are the treatment of choice when DDAVP is not
weight VWF multimers and. In type 2B, the mutant VWF useful.14,22 Several intermediate and high-purity pd-VWF
shows an increased affinity for GpIb on platelet surface, /FVIII concentrates are available (Table 2). All these con­
which induces a rapid clearance of VWF. Type 2M is centrates proved effective and safe in VWD although they
characterized by a decreased in or absent binding to have different VWF and FVIII content and show variable
GpIb, with an apparently intact VWF multimer structure. lack of high molecular weight (HMW) multimers.23 There
Type 2N (Normandy) VWF presents variable binding abil­ are several national or international guidelines on the
ity for FVIII with a shortened FVIII half-life. Most type 2 dosages to be used according to different clinical
are usually inherited as a dominant trait with high pene­ situations.14,24,25 A significant accumulation of FVIII
trance and expressivity apart from type 2N which is trans­ may occur after repeated infusions of pd-VWF/FVIII
mitted in a recessive manner. since FVIII endogenously synthesized is stabilized by the
infused VWF thus adding to that exogenously
VWD Treatment provided.26,27 This phenomenon may lead to the risk of
The correction of the dual hemostatic defect represents the deep vein thrombosis or cardiovascular complications,
aim of treatment in VWD. Bleeding history together with especially if other pro-thrombotic risk factors are
FVIII and VWF and levels in plasma allow to define the present.28 Thus, daily monitoring of FVIII:C to maintain
bleeding risk in each patient. When FVIII level is greater plasma levels below 150 U/dL is recommended to prevent
than 40–50 U/dL, the risk of serious bleeding is limited thrombotic risk especially during major surgery. Also,
and tranexamic acid alone may allow to control most a pd-VWF high purity concentrate containing little FVIII
minor bleeds. In patients with a more severe defect or (Wilfactin ®; LBF, Les Ulis, France) could be chosen in
VWF as in qualitative variants, VWF and FVIII plasma patients with mild FVIII reduction. In this case, the co-
levels must be corrected to allow for effective hemostasis. administration of a priming dose of FVIII is recommended
The available therapeutic strategies are based on increas­ in patients with basal FVIII:C levels <30 U/dL, when
ing VWF and FVIII by releasing VWF from stores in immediate hemostasis is required, since 6–8 hours are
endothelial cells triggered with desmopressin (DDAVP) necessary for endogenous FVIII to reach levels higher

submit your manuscript | www.dovepress.com

Journal of Blood Medicine 2021:12 167
DovePress

Powered by TCPDF (www.tcpdf.org)

 Castaman and Linari Dovepress

Table 2 Pd-VWF/FVIII Concentrates Licensed in Europe

Product Brand Purification Viral Inactivation VWF:RCo/Ag VWF:RCo/FVIII
(Ratio) (Ratio)

Alphanate Grifols Heparin ligand chromatography S/D + dry heat (80°, 72h) 0.47 ± 0.1 0.91 ± 0.2

Fanhdi Grifols Heparin ligand chromatography S/D + dry heat (80°, 72h) 0.47 ± 0.1 1.04 ± 0.1

Haemate P CSL Behring Multiple precipitation Pasteurization (60°, 10h) 0.59 ± 0.1 2.45 ± 0.3

Immunate Baxter Ion exchange chromatography S/D + vapor heat (60°, 10h) 0.47 1.1

Wilate Octapharma Ion exchange + size exclusion S/D + dry heat (100°, 2h) – 0.9
chromatography

Wilfactin LFB Ion exchange + affinity S/D, 35 nm filtration, dry 0.95 50

heat (80°, 72h)

Veyvondi/ Shire/ Chinese Hamster Ovary (CHO) cell line None 1.16 ± 0.25 >100
VonVendi Takeda co-expressing the VWF and FVIII genes,
in absence of any animal or other human
plasma proteins; purified by immune-
affinity chromatography
Abbreviations: VWF, von Willebrand factor; RCo, ristocetin co-factor; Ag, antigen; FVIII, factor VIII; S/D, solvent/detergent.

than 50–60 U/dL after infusion.29 Recently, a human individuals than in those with other blood groups.35 Subjects
recombinant VWF (r-VWF) Vonicog alpha has been pro­ with blood group 0 show a VWF accelerated clearance36 and
duced by using a genetically engineered Chinese Hamster an enhanced ADAMTS13-mediated proteolysis.37 Thus,
Ovary (CHO) cell line co-expressing VWF and FVIII low VWF level alone does not suggest the presence of
genes and purified by immune-affinity chromatography VWD and the cut-off for the diagnosis especially in type 1
and approved in some countries.30 Vonicog alpha is is still discussed.38 However, it has been proposed as
a >99% pure r-VWF molecule with the full range of a diagnostic threshold the presence of VWF level <30 U/
VWF multimers because ADAMTS13 is not present dur­ dL14,24 because an increased risk of bleeding is evident39
ing the manufacturing process. Therefore, also the ultra- and the chance of detecting a causative mutation is very
large multimers (ULMs) are present, which are the most high.40 Subjects with levels between 30 and 50 U/dL may
active forms,31 similarly to those observed after release in represent a difficult challenge.41,42 These subjects, and espe­
plasma from Weibel-Palade bodies of endothelial cells. cially the females, may have increased bleeding scores, but
These ULMs are however rapidly cleaved by ADAMTS- inconsistent linkage to VWF locus and mutations identified
13 when infused for treatment. Several studies in VWD roughly in 50% only and they have mostly blood group
patients have demonstrated the efficacy and safety for 0.41,42 The category “Low VWF” has been designed for
treating spontaneous bleeding and during surgery.32–34 these very frequent individuals.41 From the therapeutic
Two Phase III studies are assessing its safety and efficacy point of view, these patients can be safely and effectively
in children and for prophylaxis. managed by using antifibrinolytics and/or DDAVP.43
Therefore, the definite diagnosis of VWD requires the
VWD Diagnosis combination of personal history of bleeding, family history
The diagnosis of VWD may be complex, especially in mild of bleeding or diagnosed VWD and abnormal laboratory
form, due to the extreme clinical variability, the difficult testing for VWD.
standardization of diagnostic tests, the presence of physio­
logical and pathological variables influencing the plasma Bleeding Assessment Tools
level of VWF. VWF plasma levels vary with age, increase Mild bleeding events may frequently occur also in subjects
during pregnancy, physical activity, inflammation, infections without a specific bleeding disorder. Furthermore, report­
and cancer. Furthermore, plasma VWF levels are influenced ing and interpreting bleeding episodes may be subjective.
by blood group with VWF levels 25–30% lower in type-0 The development of bleeding assessment tools (BATs) has

168 submit your manuscript | www.dovepress.com Journal of Blood Medicine 2021:12

DovePress

Powered by TCPDF (www.tcpdf.org)

 Dovepress Castaman and Linari

allowed to standardize bleeding history collection and to complex not only for the number of tests that may be
assign a quantitative score to bleeding symptoms.44 These necessary, but also for the poor reproducibility for some
questionnaires generate a cumulative score of different of them. Furthermore, some tests are still limited to a few
bleeding symptoms according to their severity and fre­ selected laboratories.
quency. The ISTH-BAT is designed for both pediatric VWF:Ag measurement is usually carried out with auto­
and adult subjects and it evaluates 12 different bleeding mated ELISA or latex immunoassays (LIA).49 Although
symptoms, scoring from −1 (eg, no bleeding after invasive these tests have a high reproducibility, they are of limited
procedures) to +4 (eg, blood transfusion required after value for type 2 VWD in which sometimes they could be
invasive procedures) according to the presence and sever­ normal and must be used with other functional assays.
ity of a specific symptom. An ISTH-BAT score ≥3 in VWF:RCo activity is the time-honored assay for asses­
children, ≥4 in males, ≥6 in females is considered positive sing the interaction of VWF with its platelet GpIb receptor.
for the presence of a significant bleeding history.45 BAT is Ristocetin induces a conformational change in VWF, thus
an important mean to gather a detailed and standardized exposing the A1 domain which binds to GpIb and pro­
bleeding history thus selecting patients requiring addi­ duces platelet agglutination proportional to the function of
tional hemostatic evaluation.46 VWF. A VWF:RCo/VWF:Ag ratio <0.6 suggests the pre­
sence of a qualitatively abnormal VWF (type 2 VWD).24
Laboratory Testing for VWD However, traditional VWF:RCo assays using normal fresh
Among the hemostatic screening tests, the aPTT (activated or formalin-fixed platelets have low inter-laboratories
partial thromboplastin time) and PFA-100 (Platelet reproducibility,50 high coefficient of variation and poor
Function Analyzer) may be used as an initial screen for sensitivity for very low VWF values. The optimal ristoce­
possible VWD patients. However, the aPTT may be pro­ tin concentration may be another limitation of the test,51 as
longed only in those patients in whom FVIII plasma level well as also the erroneous low levels in presence with p.
is reduced (Type 3 or Type 2N VWD). The PFA-100 P1467S and p.D1472H VWF polymorphisms.52
mimicks in vivo primary hemostasis after small vessel The search for assays with less variability and
wall injury and has a high sensitivity (90%) when VWF increased sensitivity than VWF:RCo has prompted the
is significantly reduced (<20–25 U/dL) and thus most development of new tests. VWF:GPIbR uses recombinant
patients with type 2 are also identified.47 However, PFA- GPIbα fragments (rGPIb) adhered to microparticles, elim­
100 is normal in type 2N and in many patients with VWF inating the use of whole platelets.53 Instead, VWF:GPIbM
levels only slightly reduced. Furthermore, a complete uses recombinant GPIbα fragments containing two gain-of
blood count is also required to assess the presence of -function variants to induce spontaneous binding of VWF
thrombocytopenia which may suggest type 2B VWD. without ristocetin,54 but introducing a non-physiologic
The appropriate VWD diagnosis is based on several mutant GPIb receptor. Both assays have an excellent coef­
laboratory assays, which explore the different functions of ficient of variation, a more sensitive lower limit of detec­
VWF14 (Table 3). Laboratory testing for VWD initially tion, and excellent correlation with VWF:RCo,55 besides
includes VWF antigen determination (VWF:Ag), a VWF- not being affected by some common VWF variants.56
platelet binding test, usually VWF-ristocetin cofactor FVIII:C assay must also be performed because VWF is
activity assay (VWF:RCo) or less widely used newer the carrier for FVIII and usually a reduction of VWF
tests (VWF:GPIbM, VWF:GPIbR), and the measurement causes also a variable reduction of FVIII. FVIII:C/VWF:
of coagulant activity of FVIII (FVIII:C). Ag ratio is around 1 in normal subjects while in type 2N it
Type 1 and 3 VWD are characterized by equally low or is decreased (<0.5). In type 3 patients, FVIII:C is typically
absent VWF:Ag and VWF-platelet binding activity. The <10 U/dL.
qualitative type 2 variants require additional tests to make The VWF multimer pattern analysis is useful to identify
an appropriate diagnosis, like VWF:collagen binding type 2 cases, although the traditional procedure with agarose
activity (VWF:CB), platelet-rich plasma agglutination at gel electrophoresis is technically difficult and time
different ristocetin concentrations (RIPA), VWF-FVIII consuming.57 Recently a semiautomated rapid, and sensitive
binding (VWF:FVIIIB) and VWF propeptide (VWFpp). method58 has been made available. All size multimers are
The assessment of VWF multimer pattern may be also present in Type 1 VWD, although reduced in concentration,
needed.48 VWD laboratory diagnosis can therefore be while they are absent in type 3. The absence of HMW

submit your manuscript | www.dovepress.com

Journal of Blood Medicine 2021:12 169
DovePress

Powered by TCPDF (www.tcpdf.org)

 Castaman and Linari Dovepress

Table 3 Laboratory Pattern in Von Willebrand Disease

Laboratory Type 1 Type 2A Type 2B Type 2M Type 2N Type 3
Assay

APTT Prolonged or Prolonged or normal Normal or Normal or prolonged Prolonged Prolonged

normal prolonged or normal

Platelet count Normal Normal Low or Normal Normal Normal

normal

PFA-100 Prolonged or Prolonged, no Prolonged, Prolonged, no closure Normal Prolonged,

(closure time; normal closure no closure no closure
CT)

FVIII:C Low or normal Low or normal Low or Normal or low Low Low (<10
normal U/dL)

VWF:Ag Low (<50 U/ Low or normal Low or Normal or low Normal or Very low
dL) normal low (<3 U/dL)

VWF:RCo Low,rarely Low (<30 U/dL) Low,rarely Low or normal Normal or Very low
VWF:GPIbR normal normal low (<3 IU/dL)
VWF:GPIbM

VWF:CB Low,rarely Very low (<15 U/dL) Low (<40 Low or normal Normal or Very low
normal U/dL) low (<3 U/dL)

VWF:RCo/ Normal (>0.7) Low (<0.7) Low (<0.7) Low or normal Normal Variable
VWF:Ag ratio (>0.7)

RIPA using Reduced or Reduced or normal Increased Reduced or normal Normal Absent
patient normal
platelets

VWF Normal Large to Large Normal VWF multimer distribution Normal Multimers
multimer pattern, VWF intermediate multimers (but with possible abnormal bands) absent
pattern reduced multimers lacking missing

VWFpp/VWF: Normal, Normal or increased Increased Normal Normal Absent

Ag ratio Increased in
type 1C
Abbreviations: APTT, activated partial thromboplastin time; FVIII:C, factor VIII coagulant; VWF:Ag, VWF antigen; VWF:RCo, VWFristocetin cofactor; VWF:GPIbR, VWF
recombinant GPIbα fragments; VWF:GPIbM, VWF recombinant GPIbα fragments with two mutations; VWF:CB, VWF collagen binding; RIPA, ristocetin-induced platelet
agglutination; VWFpp, VWF propeptide.

multimers is observed in type 2A and 2B VWD, while VWF:CB is usually tested by an ELISA but recently an
a normal pattern is present in type 2M and 2N.59 automated and rapid chemiluminescence method has become
VWF:CB measures the VWF ability to bind to exposed available.61 Typically, a mixture of type I or type III collagen
collagen at the site of vascular injury. This ability correlates is used because it increases specificity.62 The A3 VWF
with the presence of HMW multimers, and patients with type domain binds type I and type III collagen, while the A1
2A or 2B VWD have reduced VWF:CB.60 In Type 1, VWF: domain binds type IV and type VI collagen, but assays testing
CB/VWF:Ag ratio is approximately 1, while a VWF:CB/ this latter interaction are not widely available.63
VWF:Ag ratio <0.6 suggests the deficiency of HMW multi­ The VWF-platelet binding assessed in platelet-rich-
mers as in type 2A or more rarely a specific collagen binding plasma at different ristocetin concentrations (RIPA) may
defect without loss of HMW multimers. The ratio is normal help in distinguishing type 2B from type 2A because in
in type 2 M which has a normal VWF multimer pattern. type 2 B (and platelet-type VWD) platelet aggregation

170 submit your manuscript | www.dovepress.com Journal of Blood Medicine 2021:12

DovePress

Powered by TCPDF (www.tcpdf.org)

 Dovepress Castaman and Linari

occurs even at low-dose ristocetin concentration gene and the time required. Furthermore, VWF is highly
(≤0.6 mg/m).14 polymorphic.14,66 Therefore, it is used in specific cases,
The VWF-FVIII binding (VWF:FVIIIB) test is where it may have implications for diagnosis, patient’s
required to diagnose type 2N, characterized by an abnor­ management or counseling.14 Genetic testing in type 1
mal VWF-FVIII binding.64 The ELISA microplate assay VWD is poorly informative, because an average of 62%
explores the capacity of patient’s plasma VWF to bind to of subjects shows a sequence variant in VWF gene. In
recombinant FVIII. particular, when VWF is <30 U/dL, the detection rate of
The VWF propeptide (VWFpp) is in a 1:1 ratio with identifiable sequence variants is around 80%67 and in
VWF in plasma.65 Its measurement is used as a surrogate patients with VWF:Ag >30 U/dL, mutations in VWF
marker of VWF synthesis and secretion. An increased gene are not consistently identified.40,68 Mutations are
VWFpp/VWF:Ag ratio identifies those patients with more detectable in type 2 and type 3 VWD. Mutations
a shortened VWF half-life from plasma, commonly causing type 2A usually are located in A2 domain, near
referred as Type 1 C (clearance), like the Vicenza variant. the site of ADAMTS13 cleavage, or in the N or C terminal
VWFpp/VWF:Ag ratio is usually slightly elevated multimerization domains.69 In type 2B and 2M, mutations
increased in type 2A and 2B. The assay is still not widely are mainly identified in the A1 domain and in type 2N
performed. mutations are located in the VWF D’ and D3 domains.
Finally, genetic analysis for VWD diagnosis is not Identifying mutations responsible for type 2 B rule out the
common practice because of the large size of the VWF possible diagnosis of platelet-type VWD. Identifying

Figure 1 Algorithm for laboratory diagnosis of von Willebrand disease, modified with permission of Nancy International Ltd Subsidiary AME Publishing Company, from Von
Willebrand disease in the United States: perspective from the Zimmerman program, Flood VH, Abshire TC, Christopherson PA, et al, volume 3, 2018]; permission
conveyed through Copyright Clearance Center, Inc.54

submit your manuscript | www.dovepress.com

Journal of Blood Medicine 2021:12 171
DovePress

Powered by TCPDF (www.tcpdf.org)

 Castaman and Linari Dovepress

mutations responsible for type 2 N is helpful to exclude This algorithm starts with the evaluation of bleeding his­
the possible diagnosis of mild/moderate hemophilia tory in the patient and take advantage of the different
A. Mutations responsible for type 1 and 3 are scattered laboratory assays used in different steps for a possible
over the entire VWF gene. In type 3 VWD, genetic ana­ diagnosis of VWD (Figure 1).
lysis may help to determine the risk of alloantibodies When not all laboratory assays are available for
development with possible anaphylactic reactions upon a definitive VWD diagnosis, minimal diagnostic criteria
treatment, a complication more common in presence of may be considered an increased BS and VWF:RCo <40 U/
homozygous large gene deletions.70 The online ISTH dL. Based on the significance of these two criteria, an
VWF database includes most of the mutations and poly­ adequate VWD management may be provided
morphisms so far identified (http://www.vwf.group.shef. (Figure 2).72
ac.uk).16
Conclusion
Diagnostic Flow-Chart and VWD is a common inherited bleeding disorder; however,
Therapeutic Management its early diagnosis still may be complex. Several reasons
VWD is a frequent and very heterogeneous bleeding dis­ are responsible for these diagnostic and consequently ther­
order. Bleeding severity increases from type 1 to 3 and apeutic difficulties. The first difficulty lies in understand­
treatment differs. Several laboratory assays are available to ing the significance of the reported bleeding. Mild
properly diagnose VWD. In clinical practice, a flow-chart bleeding symptoms may occur also in normal subjects
can be very useful to support a laboratory diagnosis.71 and interpretation of hemorrhagic events erratic. For this

Figure 2 Clinical spectrum of VWD: implications for management.

Notes: Copyright ©2019. Taylor & Francis Online. Adapted from Castaman G, Linari S. Advances in diagnosis of VWD. Expert Opinion on Orphan Drugs. 2019;7(4):147-155.59

172 submit your manuscript | www.dovepress.com Journal of Blood Medicine 2021:12

DovePress

Powered by TCPDF (www.tcpdf.org)

 Dovepress Castaman and Linari

reason, the use of BATs helps to standardize bleeding Disclosure

history collection and to quantify bleeding frequency and Dr Giancarlo Castaman reports personal fees from CSL
severity. ISTH-BAT represents a valid tool to identify Behring, personal fees from Kedrion, personal fees from
patients for further laboratory evaluation. An important Grifols, personal fees from Takeda, outside the submitted
issue in early VWD diagnosis is represented by those work. The authors report no other conflicts of interest in this
individuals with slightly reduced VWF levels, which may work.
vary over time and be significantly influenced by several
physiological variables. The definition “low VWF” should
be restricted to subjects with consistent VWF levels ran­ References
ging from 30 to 50 U/dL and personal and/or family 1. De Meyer SF, Deckmyn H, Vanhoorelbeke K. von Willebrand factor
to the rescue. Blood. 2009;113:5049–5057. doi:10.1182/blood-2008-
evidence of bleeding symptoms. Therefore, again 10-165621
a careful evaluation of bleeding history is of utmost sig­ 2. Yee A, Kretz CA. Von Willebrand factor: form for function.
nificance in the diagnostic and prognostic work-up of Semin Thromb Hemost. 2014;40:17–27. doi:10.1055/s-0033-
1363155
a patient with suspected VWD or low VWF. 3. De Jong A, Eikenboom J. Developments in the diagnostic procedures
Severe quantitative VWF deficiencies are easy to be for von Willebrand disease. J Thromb Haemost. 2016;14:449–460.
doi:10.1111/jth.13243
identified diagnose, while type 2 qualitative abnormalities 4. Rodeghiero F, Castaman G, Dini E. Epidemiological investigation of
are more challenging from the diagnostic point of view. the prevalence of von Willebrand’s disease. Blood. 1987;69:454–459.
Therefore, several assays s are required to evaluate the doi:10.1182/blood.V69.2.454.454
5. Sadler JE. Biochemistry and genetics of von Willebrand factor. Annu
whole spectrum of VWF activities and interactions with Rev Biochem. 1998;67:395–424. doi:10.1146/annurev.
specialized cellular receptors. These assays are becoming biochem.67.1.395
6. Wagner DD, Marder VJ. Biosynthesis of von Willebrand protein by
more and more specific, accurate and available also for
human endothelial cells. Identification of a large precursor polypep­
non-specialized laboratories. The first step is to assess the tide chain. J Biol Chem. 1983;258:2065–2067. doi:10.1016/S0021-
ability of VWF to bind platelets. New tests are now 9258(18)32879-5
7. Sporn LA, Chavin SI, Marder VJ, Wagner DD. Biosynthesis of von
increasingly available, which improve sensitivity and Willebrand protein by human megakaryocytes. J Clin Invest.
avoid laboratory artifacts. However, all the necessary 1985;76:1102–1106. doi:10.1172/JCI112064
8. Mancuso DJ, Tuley EA, Westfield LA, et al. Structure of the gene for
assays are not widely available and VWF:RCo still repre­
human von Willebrand factor. J Biol Chem. 1989;264:19514–19527.
sents the standard for measuring VWF activity, despite it doi:10.1016/S0021-9258(19)47144-5
does not reflect the range of physiologic VWF activities. 9. Mancuso DJ, Tuley EA, Westfield LA, et al. Human von Willebrand
factor gene and pseudogene: structural analysis and differentiation by
The correct typing of VWD allows the identification of polymerase chain reaction. Biochemistry. 1991;30:253–269.
the most appropriate treatment for the patient. For this pur­ doi:10.1021/bi00215a036
pose, DDAVP trial is also useful to identify the most suitable 10. Zhou YF, Eng ET, Zhu J, et al. Sequence and structure relationships
within von Willebrand factor. Blood. 2012;120:449–458.
patient candidates. Type 1 patients are the ideal candidates doi:10.1182/blood-2012-01-405134
for its use which could be considered also in some type 2 11. Haberichter SL. Biosynthesis and organization of von Willebrand
factor. In: Federici AB, Lee CA, Berntorp EE, editors. Von
M and 2 N cases on the basis of the results of the infusion Willebrand Disease: Basic and Clinical Aspects. Oxford: Wiley-
test. Type 2 B cases should not be treated with the compound Blackwell; 2011:7–29.
because of the risk of thrombocytopenia. Replacement ther­ 12. Dong JF. Cleavage of ultra-large von Willebrand factor by
ADAMTS-13 under flow conditions. J Thromb Haemost.
apy is the cornerstone of treatment for type 2 A and B and 3 2005;3:1710–1716. doi:10.1111/j.1538-7836.2005.01360.x
patients. Genetic testing is particularly indicated when the 13. Sadler JE. Low von Willebrand factor: sometimes a risk factor and
sometimes a disease. Hematology Am Soc Hematol Educ Program.
identification of a specific mutation guides clinical and 2009;2009:106–112. doi:10.1182/asheducation-2009.1.106
laboratory monitoring after treatment (eg, assessing risk for 14. Castaman G, Goodeve A, Eikenboom JC; on behalf of the European
alloantibody with use of factor concentrates), or for genetic Group on von Willebrand disease (EUVWD). Principles of care for
diagnosis and treatment of von Willebrand disease. Haematologica.
counseling (eg, discriminating between mild/moderate 2013;98:667–674. doi:10.3324/haematol.2012.077263
hemophilia A versus type 2N VWD). Laboratory methods 15. Sadler JE, Budde U, Eikenboom JC, et al. Update on the pathophy­
siology and classification of von Willebrand disease: a report of the
are being developed to permit rapid testing and more accu­
subcommittee on von Willebrand factor. J Thromb Haemost.
rate measurements improving sensitivity, but some of them 2006;4:2103–2114. doi:10.1111/j.1538-7836.2006.02146.x
are still not widely used. Therefore, bleeding history still 16. Hampshire DJ, Goodeve AC. The International Society on
Thrombosis and Haemostasis von Willebrand disease database: an
represents the crucial key in order to induce an early diag­ update. Semin Thromb Hemost. 2011;37:470–479. doi:10.1055/
nosis and consequent optimal treatment of affected patients. s-0031-1281031

submit your manuscript | www.dovepress.com

Journal of Blood Medicine 2021:12 173
DovePress

Powered by TCPDF (www.tcpdf.org)

 Castaman and Linari Dovepress

17. Favaloro EJ. Von Willebrand disease: local diagnosis and manage­ 33. Gill JC, Castaman G, Windyga J, et al. Hemostatic efficacy, safety,
ment of a globally distributed bleeding disorder. Semin Thromb and pharmacokinetics of a recombinant von Willebrand factor in
Hemost. 2011;37:425–426. doi:10.1055/s-0031-1280567 severe von Willebrand disease. Blood. 2015;126(17):2038–2046.
18. Rodeghiero F, Castaman G, Tosetto A. How I treat von Willebrand doi:10.1182/blood-2015-02-629873
disease. Blood. 2009;114(6):1158–1165. doi:10.1182/blood-2009-01- 34. Peyvandi F, Mamaev A, Wang JD, et al. Phase 3 study of recombi­
153296 nant von Willebrand factor in patients with severe von Willebrand
19. Leissinger C, Carcao M, Gill JC, Journeycake J, Singleton T, disease who are undergoing elective surgery. J Thromb Haemost.
Valentino L. Desmopressin (DDAVP) in the management of patients 2019;17(1):52–62. doi:10.1111/jth.14313
with congenital bleeding disorders. Haemophilia. 2014;20 35. Albanez S, Ogiwara K, Michels A, et al. Aging and ABO blood type
(2):158–167. doi:10.1111/hae.12254 influence von Willebrand factor and factor VIII levels through inter­
20. Castaman G, Lethagen S, Federici AB, et al. Response to desmo­ related mechanisms. J Thromb Haemost. 2016;14:953–963.
pressin is influenced by the genotype and the phenotype in type 1 von doi:10.1111/jth.13294
Willebrand disease (VWD): results from the European study 36. Gallinaro L, Cattini MG, Sztukowska M, et al. A shorter von
MCMDM-1 VWD. Blood. 2008;111:3531–3539. doi:10.1182/blood- Willebrand factor survival in 0 blood group subjects explains how
2007-08-109231 AB0 determinants influence plasma von Willebrand factor. Blood.
21. Federici AB, Mannucci PM, Castaman G, et al. Clinical and 2008;111:3540–3545. doi:10.1182/blood-2007-11-122945
molecular predictors of thrombocytopenia and risk of bleeding in 37. Bowen DJ. An influence of AB0 group on the rate of proteolysis of
patients with von Willebrand disease type 2B: a cohort study of 67 von Willebrand factor by ADAMTS13. J Thromb Haemost.
patients. Blood. 2009;113(3):526–534. doi:10.1182/blood-2008-04- 2003;1:33–40. doi:10.1046/j.1538-7836.2003.00007.x
152280 38. Sadler JE. Slippery criteria for von Willebrand disease type 1.
22. Mannucci PM. New therapies for von Willebrand disease. J Thromb Haemost. 2004;2:1720–1723. doi:10.1111/j.1538-
Hematology Am Soc Hematol Educ Program. 2019;2019:590–595. 7836.2004.00933.x
doi:10.1182/hematology.2019000368 39. Tosetto A, Rodeghiero F, Castaman G, et al. A quantitative analysis
23. Batlle J, Lopez-Fernandez MF, Fraga EL, et al. Von Willebrand of bleeding symptoms in type 1 von Willebrand disease: results from
factor/factor VIII concentrates in the treatment of von Willebrand a multicenter European study (MCMDM-1 VWD). J Thromb
disease. Blood Coagul Fibrinolysis. 2009;20:89–100. doi:10.1097/ Haemost. 2006;4:766–773. doi:10.1111/j.1538-7836.2006.01847.x
MBC.0b013e3283254570 40. Goodeve A, Eikenboom J, Castaman G, et al. Phenotype and geno­
24. Nichols WL, Hultin MB, James AH, et al. von Willebrand disease type of a cohort of families historically diagnosed with type 1 von
(VWD): evidence-based diagnosis and management guidelines, the Willebrand disease in the European study, Molecular and Clinical
National Heart, Lung, and Blood Institute (NHLBI) Expert Panel Markers for the Diagnosis and Management of Type 1 von
report (USA). Haemophilia. 2008;14(2):171–232. doi:10.1111/ Willebrand Disease(MCMDM-1VWD). Blood. 2007;109:112–121.
j.1365-2516.2007.01643.x doi:10.1182/blood-2006-05-020784
25. Laffan MA, Lester W, O’Donnell JS, et al. The diagnosis and man­ 41. Flood VH, Christopherson PA, Gill JC, et al. Clinical and laboratory
agement of von Willebrand disease: a United Kingdom Haemophilia variability in a cohort of patients diagnosed with type 1 VWD in the
Centre Doctors Organization guideline approved by the British United States. Blood. 2016;127:2481–2488. doi:10.1182/blood-2015-
Committee for Standards in Haematology. Br J Haematol. 2014;167 10-673681
(4):453–465. doi:10.1111/bjh.13064 42. Lavin M, Aguila S, Schneppenheim S, et al. Novel insights into the
26. Franchini M. Surgical prophylaxis in von Willebrand’s disease: clinical phenotype and pathophysiology underlying low VWF levels.
a difficult balance to manage. Blood Transfus. 2008;6(Suppl Blood. 2017;130:2344–2353. doi:10.1182/blood-2017-05-786699
2):33–38. 43. Lavin M, O’Donnell JS. How I treat low von Willebrand factor
27. O’Donnell JS, Lavin M. Perioperative management of patients with levels. Blood. 2019;133:795–804. doi:10.1182/blood-2018-10-
von Willebrand disease. Hematology Am Soc Hematol Educ 844936
Program. 2019;2019:604–609. doi:10.1182/hematology.2019000065 44. Rydz N, James PD. The evolution and value of bleeding assessment
28. Coppola A, Franchini M, Makris M, Santagostino E, Di Minno G, tools: the evolution and value of bleeding assessment tools. J Thromb
Pannucci PM. Thrombotic adverse events to coagulation factor con­ Haemost. 2012;10:2223–2229. doi:10.1111/j.1538-7836.2012.04923.x
centrates for treatment of patients with haemophilia and von 45. Rodeghiero F, Tosetto A, Abshire T, et al. ISTH/SSC bleeding
Willebrand disease: a systematic review of prospective studies. assessment tool: a standardized questionnaire and a proposal for
Haemophilia. 2012;18(3):e173–e187. doi:10.1111/j.1365- a new bleeding score for inherited bleeding disorders: ISTH/SSC
2516.2012.02758.x bleeding assessment tool. J Thromb Haemost. 2010;8:2063–2065.
29. Borel-Derlon A, Federici AB, Roussel-Robert V, et al. doi:10.1111/j.1538-7836.2010.03975.x
Pharmacokinetic studies on Wilfactin, a von Willebrand factor con­ 46. Spradbrow J, Letourneau S, Grabell J, et al. Bleeding assessment
centrate with a low FVIII content treated with three tools to predict von Willebrand disease: utility of individual bleeding
virus-inactivation/removal methods. J Thromb Haemost. 2005;3 symptoms. Res Pract Thromb Haemost. 2020;4:92–99. doi:10.1002/
(10):2219–2227. doi:10.1111/j.1538-7836.2005.01435.x rth2.12256
30. Turecek PL, Mitterer A, Matthiessen HP, et al. Development of a plasma- 47. Favaloro EJ. The Platelet Function Analyser (PFA)-100 and von
and albumin-free recombinant von Willebrand factor. Hamostaseologie. Willebrand disease: a story well over 16 years in the making.
2009;29(Suppl 1):S32–S38. doi:10.1055/s-0037-1617202 Haemophilia. 2015;21:642–645. doi:10.1111/hae.12710
31. Stockschlaeder M, Schneppenheim R, Budde U. Update on von 48. Sharma R, Haberichter SL. New advances in the diagnosis of von
Willebrand factor multimers: focus on high-molecular-weight multi­ Willebrand disease. Hematology Am Soc Hematol Educ Program.
mers and their role in hemostasis. Blood Coagul Fibrinolysis. 2019;2019:596–600. doi:10.1182/hematology.2019000064
2014;25:206–216. doi:10.1097/MBC.0000000000000065 49. Castaman G, Tosetto A, Cappelletti A, et al. Validation of a rapid test
32. Mannucci PM, Kempton C, Millar C, et al. Pharmacokinetics and (VWF-LIA) for the quantitative determination of the von Willebrand
safety of a novel recombinant human von Willebrand factor manu­ factor antigen in type 1 von Willebrand disease diagnosis within the
factured with a plasma-free method: a prospective trial. Blood. European multicenter study MCMDM-1VWD. Thromb Res.
2013;122(5):648–657. doi:10.1182/blood-2013-01-479527 2010;126:227–231. doi:10.1016/j.thromres.2010.06.013

174 submit your manuscript | www.dovepress.com Journal of Blood Medicine 2021:12

DovePress

Powered by TCPDF (www.tcpdf.org)

 Dovepress Castaman and Linari

50. Meijer P, Haverkate F. An external quality assessment program for 61. Jousselme E, Jourdy Y, Rugeri L, et al. Comparison of an automated
von Willebrand factor laboratory analysis: an overview from the chemiluminescent assay to a manual ELISA assay for determination
European concerted action on thrombosis and disabilities of von Willebrand Factor collagen binding activity on VWD plasma
foundation. Semin Thromb Haemost. 2006;32:485–491. patients previously diagnosed through molecular analysis of VWF.
doi:10.1055/s-2006-947862 Int J Lab Hematol. 2018;40:77–83. doi:10.1111/ijlh.12743
51. Vanhoorelke K, Cauwenberghs N, Vauterin S, et al. A reliable and 62. Keesler DA, Flood VH. Current issues in diagnosis and treatment of
reproducible ELISA method to measure ristocetin cofactor activity of von Willebrand disease. Res Pract Thromb Haemost. 2018;2:34–41.
von Willebrand factor. Thromb Haemost. 2000;83:107–113. doi:10.1002/rth2.12064
doi:10.1055/s-0037-1613765 63. Flood VH, Gill JC, Christopherson PA, et al. Critical von Willebrand
52. Flood VH, Gill JC, Morateck PA, et al. Common VWF exon 28 factor A1 domain residues influence type VI collagen binding.
polymorphisms in African Americans affecting the VWF activity J Thromb Haemost. 2012;10:1417–1424. doi:10.1111/j.1538-
assay by ristocetin cofactor. Blood. 2010;116:280–286. doi:10.1182/ 7836.2012.04746.x
blood-2009-10-249102 64. Nishino M, Girma JP, Rothschild C, et al. New variant of von
53. Verfaillie CJ, De Witte E, Devreese KM. Validation of a new panel of Willebrand disease with defective binding to factor VIII. Blood.
automated chemiluminescence assays for von Willebrand factor anti­ 1989;74:1591–1599. doi:10.1182/blood.V74.5.1591.1591
gen and activity in the screening for von Willebrand disease. 65. Haberichter SL, Balistreri M, Christopherson R, et al. Assay of the
Int J Lab Hematol. 2013;35:555–565. doi:10.1111/ijlh.12087 von Willlebrand factor (VWF) propeptide to identify type 1 von
54. Flood VH, Abshire TC, Christopherson PA, et al. Von Willebrand Willebrand disease patients with decreased VWF survival. Blood.
disease in the United States: perspective from the Zimmerman 2006;108:3344–3351. doi:10.1182/blood-2006-04-015065
program. Ann Blood. 2018;3:7. doi:10.21037/aob.2017.12.05 66. Bellissimo DB, Christopherson PA, Flood VH, et al. VWF mutations
55. Bodò I, Eikenboom J, Montgomery R, Patzke J, Schneppenheim R, and new sequence variations identified in healthy controls are more
Di Paola J. von Willebrand factor Subcommittee of the frequent in the African-American population. Blood.
Standardization and Scientific Committee of the International 2012;119:2135–2140. doi:10.1182/blood-2011-10-384610
Society for Thrombosis and Haemostasis. Platelet-dependent von 67. Sharma R, Flood VH. Advances in the diagnosis and treatment of
Willebrand factor activity. Nomenclature and methodology: commu­ von Willebrand disease. Hematology Am Soc Hematol Educ
nication from the SSC of the ISTH. J Thromb Haemost. 2015;13 Program. 2017;2017(1):379–384. doi:10.1182/asheducation-
(7):1345–1350. doi:10.1111/jth.12964 2017.1.379
56. Boender J, Eikenboom J, van der Bom JC, et al. Clinically relevant 68. James PD, Notley C, Hegardon C, et al. The mutational spectrum of
differences between assays for von Willebrand factor activity. type 1 von Willebrand disease: results from a Canadian cohort study.
J Thromb Haemost. 2018;16(12):2413–2424. Blood. 2007;109:145–154. doi:10.1182/blood-2006-05-021105
57. Ruggeri ZM, Zimmerman TS. Variant von Willebrand’s disease:
69. Goodeve AC. The genetic basis of von Willebrand disease. Blood
characterization of two subtypes by analysis of multimeric composi­ Rev. 2010;24:123–134. doi:10.1016/j.blre.2010.03.003
tion of FVIII/von Willebrand factor in plasma and platelets. J Clin 70. Christopherson PA, Perry CL, Bellissimo DB, et al. Genotype-
Invest. 1980;65:1318–1325. doi:10.1172/JCI109795 phenotype relationship and the role of alloantibodies in type 3
58. Bowyer AE, Goodfellow KJ, Seidel H, et al. Evaluation of
VWD in the Zimmerman Program. Blood. 2017;130(suppl 1):19.
a semiautomated von Willebrand factor multimer assay, the hydragel
71. Boender J, Eikenboom J, van der Bom JG, et al. Clinically relevant
von Willebrand multimer, by two European Centers. Res Pract
differences between assays for von Willebrand factor activity.
Thromb Haemost. 2018;2:790–799. doi:10.1002/rth2.12141
J Thromb Haemost. 2018;16:2413–2424.
59. Castaman G, Linari S. Advances in diagnosis of von Willebrand
72. Castaman G. How I treat von Willebrand disease. Thromb Res.
disease. Exp Opin Orphan Drugs. 2019;7:147–155. doi:10.1080/
2020;196:618–625. doi:10.1016/j.thromres.2020.07.051
21678707.2019.1609352
60. Favaloro EJ, Grispo L, Exner T, et al. Development of a simple
collagen based ELISA assay aids in the diagnosis of, and permits
sensitive discrimination between type I and II, von Willebrand’s
disease. Blood Coagul Fibrinolysis. 1991;2:285–291. doi:10.1097/
00001721-199104000-00011

Journal of Blood Medicine Dovepress

Publish your work in this journal
The Journal of Blood Medicine is an international, peer-reviewed, therapeutics; Hematology; Biotechnology/nanotechnology of blood
open access, online journal publishing laboratory, experimental and related medicine; Legal aspects of blood medicine; Historical per­
clinical aspects of all aspect pertaining to blood based medicine spectives. The manuscript management system is completely
including but not limited to: Transfusion Medicine; Blood collec­ online and includes a very quick and fair peer-review system.
tion, Donor issues, Transmittable diseases, and Blood banking Visit http://www.dovepress.com/testimonials.php to read real quotes
logistics; Immunohematology; Artificial and alternative blood based from published authors.
Submit your manuscript here: http://www.dovepress.com/journal-of-blood-medicine-journal

submit your manuscript | www.dovepress.com

Journal of Blood Medicine 2021:12 175
DovePress

Powered by TCPDF (www.tcpdf.org)