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Diagnosis and Evaluation

Von Willebrand Disease: Diagnosis and Evaluation

Diagnosing Von Willebrand Disease is a nuanced and often iterative process. Unlike conditions diagnosed with a single binary test, VWD requires a panel of assays interpreted in the context of the patient’s history. Levels of VWF fluctuate dynamically in response to physiological stress, inflammation, and hormones, meaning a “normal” result on one day does not definitively rule out the disease. Conversely, a “low” result does not always mean the patient has a genetic disorder. At Liv Hospital, we employ a rigorous, multi-step diagnostic algorithm adhering to international guidelines to ensure precision in diagnosis and subtyping.

The Diagnostic Algorithm

The evaluation typically follows a tiered approach: screening, confirmation, and subtyping.

  • Step 1: Clinical History Assessment: Before blood is drawn, a detailed bleeding history is taken. Tools like the “Bleeding Assessment Tool” (BAT) or “ISTH Bleeding Score” help quantify the severity of symptoms. A score above a certain threshold (e.g., >3 for adult males, >5 for adult females) triggers laboratory testing.
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Hemostasis Screening Tests

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These initial tests evaluate the overall clotting system but are not specific for VWD.

  • Complete Blood Count (CBC): This is performed to check the platelet count. Platelet counts are typically normal in VWD, except in Type 2B where thrombocytopenia is often present. It also checks for anemia.
  • Prothrombin Time (PT): This measures the extrinsic pathway and is usually normal in VWD.
  • Activated Partial Thromboplastin Time (aPTT): This measures the intrinsic pathway. It may be prolonged if Factor VIII levels are significantly low (as in Type 2N or Type 3), but it is often normal in Type 1 and Type 2 variants, making it an unreliable screening tool on its own.

PFA-100 (Platelet Function Analyzer): This test simulates blood flow in a vessel. It is sensitive to VWD but not specific; a normal result does not rule out mild VWD.

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Specific VWF Assays (The "VWD Panel")

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If screening or history is suggestive, the specific VWD panel is ordered. This triad of tests is essential.

    • VWF Antigen (VWF:Ag): This immunological assay measures the total quantity of VWF protein circulating in the plasma. It does not tell us if the protein is working, only how much is there. Low levels (<30 IU/dL) confirm deficiency. Levels 30 to 50 IU/dL are termed “Low VWF.”
    • VWF Activity (VWF:RCo or VWF:GPIbM): This is a functional assay measuring how well the VWF binds to platelets. Historically, the Ristocetin Cofactor (VWF:RCo) assay was used, which utilizes the antibiotic ristocetin to induce binding. Newer assays like VWF:GPIbM are more precise. This test determines the quality of the protein.
    • Factor VIII Activity (FVIII:C): This measures the functional level of Factor VIII. It assesses the ability of VWF to carry and protect Factor VIII.

Interpretation and Ratios

Comparing the results of these three tests allows for initial typing.

  • Type 1 Pattern: VWF Antigen and VWF Activity are both low, but they are concordant (ratio > 0.6). Factor VIII may be mildly reduced.
  • Type 2 Pattern: There is a discordance between quantity and quality. The VWF Antigen might be normal or borderline, but the VWF Activity is disproportionately low (Activity/Antigen ratio < 0.6), indicating the protein is present but defective.
  • Type 3 Pattern: All three values (Antigen, Activity, Factor VIII) are extremely low or undetectable.

Specialized Subtyping Tests

Once a diagnosis of VWD is confirmed, sophisticated tests distinguish the specific subtype.

  • VWF Multimer Analysis: This gel electrophoresis technique visualizes the size distribution of VWF molecules.
    • Type 1: All multimer sizes present, just faint.
    • Type 2A/2B: Loss of high molecular weight (large) multimers.
    • Type 2M: Normal multimer distribution despite low activity.
  • Ristocetin Induced Platelet Aggregation (RIPA): This tests the sensitivity of VWF to low concentrations of ristocetin.
    • Type 2B: Platelets aggregate at very low concentrations because the VWF is hyper-adhesive (gain of function).
    • Type 2A: Platelets fail to aggregate.
  • VWF Collagen Binding (VWF:CB): This measures the ability of VWF to bind to collagen, aiding in the diagnosis of Type 2M defects.
  • VWF Factor VIII Binding Assay (VWF:FVIIIB): This specific test checks the affinity of VWF for Factor VIII. A defect here confirms Type 2N (Normandy).

Molecular Genetic Testing

DNA sequencing of the VWF gene provides the ultimate confirmation.

  • Targeted Exon Sequencing: Specific exons (like exon 28) are sequenced to identify mutations associated with Type 2A, 2B, and 2M.
  • Full Gene Sequencing: Used for Type 1, Type 3, or difficult cases.
  • Carrier Testing: Essential for families with Type 3 VWD to identify carriers.
  • Differentiation: Genetic testing is the gold standard for distinguishing Type 2N VWD from Hemophilia A carriers, which is crucial for genetic counseling.

Pre-Analytical Challenges

To ensure accuracy, timing is everything.

  • Stress and Exercise: Patients should be resting and calm, as stress releases VWF stores, masking deficiency.
  • Inflammation: Testing should be avoided during active infections or acute illness, as VWF is an acute phase reactant and levels will be artificially high.
  • Estrogen: Women should be tested when not on high-dose estrogen birth control, or during the early follicular phase of the menstrual cycle when hormone levels are lowest.
  • Repeat Testing: Because of variability, a diagnosis often requires two concordant abnormal values from samples drawn 2 to 4 weeks apart.

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FREQUENTLY ASKED QUESTIONS

Why do I need to stop aspirin before the test?

Aspirin affects platelet function, which can interfere with some of the functional assays used to diagnose bleeding disorders.

This is used for patients with VWF levels between 30 and 50 IU/dL. They have bleeding risk but may not have a specific genetic mutation found in classic VWD.

Not for every case, but it is very helpful for distinguishing between the complicated Type 2 subtypes and for family planning.

Basic screening takes hours, but specialized tests like Multimer Analysis or genetics can take several weeks to return from specialized laboratories.

Yes, but crying and stress during the blood draw can artificially raise levels. Sometimes testing is repeated when the child is older and calmer.

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