Topics:
autosomal recessive inheritance, bleeding diathesis, blood coagulation disorders, pakistan

Pakistan has a population of 200 million, and 40% of the people live in rural areas. Autosomal recessive bleeding disorders (ARBDs) are not rare because of consanguinity. Only basic hemostatic testing was available before 2001. The ability to diagnose hemophilia A and B was available in only 2 to 3 tertiary care hospitals, but they did not have the expertise to measure hemophilia inhibitors. Very little literature was published regarding our population because of the lack of expertise and facilities. All congenital bleeders were considered as having hemophilia A or B. The capacity-building project of hemophilia and bleeding disorders was planned on the principles of build, operate, and transfer in 2007.

  1. To produce master trainers to teach local health care providers for the diagnosis of ARBDs.

  2. To provide materials for labelling of actual bleeding disorders rather than hemophilia.

  3. To screen all registered participants according to the planned protocol.

  4. To explore rare congenital bleeding disorders rather than those that are common.

  5. To provide genetic analysis for all inherited bleeding disorders.

  6. To share patient data according to the project regulations.

  7. To determine the prevalence of multiple clotting defects according to the regulations.

  8. To publish and share information and data regarding the project.

  • Collaborative research-based investigations of locally important health conditions are an effective method of capacity building with sustainable goals.

  • The prevalence of von Willebrand disease (VWD) will be higher than that of hemophilia A and B in Pakistan.

  • Rare bleeding disorders will not be so rare in Pakistan.

  • Novel mutations will be identified.

The study was approved by the ethics committee of the National Institute of Blood Diseases and Bone Marrow Transplantation (NIBD), Karachi, Pakistan, in accordance with the Declaration of Helsinki. It was a descriptive study with a cross-sectional time prospect and was conducted from March 2007 to December 2014. The study was divided into 2 phases. In the first phase, only patients from Karachi or Sindh were screened. In phase 2, patients were selected from all areas of Pakistan. A doctor at each corresponding recruitment center filled out a general questionnaire with basic demographic details and clinical and family histories and also completed the Tosetto bleeding score questionnaire for each patient. To identify the prevalence period for various ARBDs, records from the current study were merged with those from all the studies reported in the last 12 years. For this purpose, the common national (PakMedinet) and international (PubMed, Google Scholar, ISI Web of Science, EMBASE, and SCOPUS) databases were searched for studies on ARBDs in the Pakistani population.

Figure 1.
Capacity building for the diagnosis of ARBDs across Pakistan. PCR, polymerase chain reaction.
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Capacity building for the diagnosis of ARBDs across Pakistan. PCR, polymerase chain reaction.

Figure 1.
Capacity building for the diagnosis of ARBDs across Pakistan. PCR, polymerase chain reaction.
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Capacity building for the diagnosis of ARBDs across Pakistan. PCR, polymerase chain reaction.

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Figure 2.
(A) Samples were sent to the central reference laboratory at NIBD where the tests were repeated to establish reliability. (B) The following tertiary health care centers (from left to right) are shown: Hayatabad Medical Complex (HMCP); Lady Reading Hospital (LRHP); Khyber Pakhtunkhwa (KP); Fatimid Foundation Karachi (FFK); National Institute of Blood Diseases (NIBD); Chughtai’s Laboratory (CL); Children’s Hospital Lahore (CHL); and Pakistan Atomic Energy Commission (PAEC). For each tertiary health care center, “N” indicates the number of patients with ARBDs and the number in parentheses indicates the total number of patients initially recruited from each center. Prothrombin time (PT), activated partial thromboplastin time (APTT), bleeding time, and fibrinogen levels were measured. Patients with isolated prolonged APTT were tested for factor VIII (FVIII) and FIX using factor assays This was followed by FXI:C-level assessment for patients with normal FVIII and FIX levels. Samples were reanalyzed except platelet aggregation studies. All rare clotting factor defects such as FII, VII, X, XI , and XIII were tested in a reference laboratory (NIBD) because of the unavailability of testing facilities. Platelet aggregation studies were repeated in PAEC, CL, CHL, and NIBD. Patients with low FVIII levels were screened for VWD. Patients with simultaneous prolongation of PT and APTT were tested for FII, FV, and FX. Peripheral blood film examination and platelet aggregation studies were performed to assess platelet disorders. Urea clot solubility testing was performed to detect FXIII levels if platelet function tests were normal. Sanger sequencing was performed for genetic analysis of patient samples. Descriptive analysis was performed using SPSS version 16 software.
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(A) Samples were sent to the central reference laboratory at NIBD where the tests were repeated to establish reliability. (B) The following tertiary health care centers (from left to right) are shown: Hayatabad Medical Complex (HMCP); Lady Reading Hospital (LRHP); Khyber Pakhtunkhwa (KP); Fatimid Foundation Karachi (FFK); National Institute of Blood Diseases (NIBD); Chughtai’s Laboratory (CL); Children’s Hospital Lahore (CHL); and Pakistan Atomic Energy Commission (PAEC). For each tertiary health care center, “N” indicates the number of patients with ARBDs and the number in parentheses indicates the total number of patients initially recruited from each center. Prothrombin time (PT), activated partial thromboplastin time (APTT), bleeding time, and fibrinogen levels were measured. Patients with isolated prolonged APTT were tested for factor VIII (FVIII) and FIX using factor assays This was followed by FXI:C-level assessment for patients with normal FVIII and FIX levels. Samples were reanalyzed except platelet aggregation studies. All rare clotting factor defects such as FII, VII, X, XI , and XIII were tested in a reference laboratory (NIBD) because of the unavailability of testing facilities. Platelet aggregation studies were repeated in PAEC, CL, CHL, and NIBD. Patients with low FVIII levels were screened for VWD. Patients with simultaneous prolongation of PT and APTT were tested for FII, FV, and FX. Peripheral blood film examination and platelet aggregation studies were performed to assess platelet disorders. Urea clot solubility testing was performed to detect FXIII levels if platelet function tests were normal. Sanger sequencing was performed for genetic analysis of patient samples. Descriptive analysis was performed using SPSS version 16 software.

Figure 2.
(A) Samples were sent to the central reference laboratory at NIBD where the tests were repeated to establish reliability. (B) The following tertiary health care centers (from left to right) are shown: Hayatabad Medical Complex (HMCP); Lady Reading Hospital (LRHP); Khyber Pakhtunkhwa (KP); Fatimid Foundation Karachi (FFK); National Institute of Blood Diseases (NIBD); Chughtai’s Laboratory (CL); Children’s Hospital Lahore (CHL); and Pakistan Atomic Energy Commission (PAEC). For each tertiary health care center, “N” indicates the number of patients with ARBDs and the number in parentheses indicates the total number of patients initially recruited from each center. Prothrombin time (PT), activated partial thromboplastin time (APTT), bleeding time, and fibrinogen levels were measured. Patients with isolated prolonged APTT were tested for factor VIII (FVIII) and FIX using factor assays This was followed by FXI:C-level assessment for patients with normal FVIII and FIX levels. Samples were reanalyzed except platelet aggregation studies. All rare clotting factor defects such as FII, VII, X, XI , and XIII were tested in a reference laboratory (NIBD) because of the unavailability of testing facilities. Platelet aggregation studies were repeated in PAEC, CL, CHL, and NIBD. Patients with low FVIII levels were screened for VWD. Patients with simultaneous prolongation of PT and APTT were tested for FII, FV, and FX. Peripheral blood film examination and platelet aggregation studies were performed to assess platelet disorders. Urea clot solubility testing was performed to detect FXIII levels if platelet function tests were normal. Sanger sequencing was performed for genetic analysis of patient samples. Descriptive analysis was performed using SPSS version 16 software.
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(A) Samples were sent to the central reference laboratory at NIBD where the tests were repeated to establish reliability. (B) The following tertiary health care centers (from left to right) are shown: Hayatabad Medical Complex (HMCP); Lady Reading Hospital (LRHP); Khyber Pakhtunkhwa (KP); Fatimid Foundation Karachi (FFK); National Institute of Blood Diseases (NIBD); Chughtai’s Laboratory (CL); Children’s Hospital Lahore (CHL); and Pakistan Atomic Energy Commission (PAEC). For each tertiary health care center, “N” indicates the number of patients with ARBDs and the number in parentheses indicates the total number of patients initially recruited from each center. Prothrombin time (PT), activated partial thromboplastin time (APTT), bleeding time, and fibrinogen levels were measured. Patients with isolated prolonged APTT were tested for factor VIII (FVIII) and FIX using factor assays This was followed by FXI:C-level assessment for patients with normal FVIII and FIX levels. Samples were reanalyzed except platelet aggregation studies. All rare clotting factor defects such as FII, VII, X, XI , and XIII were tested in a reference laboratory (NIBD) because of the unavailability of testing facilities. Platelet aggregation studies were repeated in PAEC, CL, CHL, and NIBD. Patients with low FVIII levels were screened for VWD. Patients with simultaneous prolongation of PT and APTT were tested for FII, FV, and FX. Peripheral blood film examination and platelet aggregation studies were performed to assess platelet disorders. Urea clot solubility testing was performed to detect FXIII levels if platelet function tests were normal. Sanger sequencing was performed for genetic analysis of patient samples. Descriptive analysis was performed using SPSS version 16 software.

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The study cohort consisted of 429 patients (250 males and 179 females) with a male:female ratio of 1.3:1. The median age of patients was 11 ± 5 years. A history of consanguinity was present in 89% of the patients. The most common symptoms reported by the cohort of patients included gum bleeding (57%) and easy bruising (39%). Spontaneous epistaxis and gum bleeding were found in 6%, and menorrhagia was reported in 19% of the adult female patients. Anemia was found in 48% of the patients. Life-threatening intracranial hemorrhage affected 4% of the patients.

Figure 3.
Comparative studies of patients of different nationalities who have ARBDs. BSS, Bernard-Soulier syndrome; GT, Glanzmann thrombasthenia.
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Comparative studies of patients of different nationalities who have ARBDs. BSS, Bernard-Soulier syndrome; GT, Glanzmann thrombasthenia.

Figure 3.
Comparative studies of patients of different nationalities who have ARBDs. BSS, Bernard-Soulier syndrome; GT, Glanzmann thrombasthenia.
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Comparative studies of patients of different nationalities who have ARBDs. BSS, Bernard-Soulier syndrome; GT, Glanzmann thrombasthenia.

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Table 1.

Frequency of ARBDs in different provinces of Pakistan

ARBDSindhPunjabFederal capitalKPKTotalPercentagePreviously reported cases from Pakistan*TotalLocal prevalence per millionInternational prevalence per million†
Type 3 VWD disorder 05 62 21 7 95 33.8 61 156 1.0 0.5 
Fibrinogen deficiency 11 20 3 0 34 12 9 43 0.3 0.5 
Glanzmann thrombasthenia 18 9 0 0 27 9.6 50 77 0.5 1 
FXIII deficiency 7 2 4 0 13 4.6 29 42 0.3 0.5 
FVII deficiency 4 6 1 1 12 4.3 84 96 0.6 2 
FV deficiency 0 9 0 0 9 3.2 28 37 0.2 1 
Vitamin K–dependent clotting factor deficiency 0 7 0 1 8 2.8 0 8 0.04 1 
Bernard-Soulier syndrome 3 0 4 0 7 2.5 5 12 0.07 1 
FX deficiency 1 1 0 0 2 0.7 41 43 0.3 1 
FII deficiency 0 2 0 0 2 0.7 10 12 0.07 0.5 
FXI deficiency 1 0 0 0 1 0.4 1 2 0.01 ∼1 
Combined FV and FVIII deficiency 1 0 0 0 1 0.4 0 1 0.006 1 
ARBDSindhPunjabFederal capitalKPKTotalPercentagePreviously reported cases from Pakistan*TotalLocal prevalence per millionInternational prevalence per million†
Type 3 VWD disorder 05 62 21 7 95 33.8 61 156 1.0 0.5 
Fibrinogen deficiency 11 20 3 0 34 12 9 43 0.3 0.5 
Glanzmann thrombasthenia 18 9 0 0 27 9.6 50 77 0.5 1 
FXIII deficiency 7 2 4 0 13 4.6 29 42 0.3 0.5 
FVII deficiency 4 6 1 1 12 4.3 84 96 0.6 2 
FV deficiency 0 9 0 0 9 3.2 28 37 0.2 1 
Vitamin K–dependent clotting factor deficiency 0 7 0 1 8 2.8 0 8 0.04 1 
Bernard-Soulier syndrome 3 0 4 0 7 2.5 5 12 0.07 1 
FX deficiency 1 1 0 0 2 0.7 41 43 0.3 1 
FII deficiency 0 2 0 0 2 0.7 10 12 0.07 0.5 
FXI deficiency 1 0 0 0 1 0.4 1 2 0.01 ∼1 
Combined FV and FVIII deficiency 1 0 0 0 1 0.4 0 1 0.006 1 
*

There were no patients from the provinces of Baluchistan, Gilgit-Baltistan, Azad Jammu, and Kashmir because of a lack of health and diagnostic facilities.

†

International prevalence data from world hemophilia database and Orphanet Journal of Rare Diseases.

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Table 2.

Genetic analysis of all clotting factor defects

Clotting factor defectReportedNovelTotal No. of patients screened
FI 15 18 30 
FII 02 02 04 
FV 03 02 05 
FVII 08 07 15 
FVIII 08 02 10 
FX 03 02 05 
FXI 02 --- 02 
VWF type 3 25 23 50 
GT 05 05 20 
BSS 02 03 05 
Clotting factor defectReportedNovelTotal No. of patients screened
FI 15 18 30 
FII 02 02 04 
FV 03 02 05 
FVII 08 07 15 
FVIII 08 02 10 
FX 03 02 05 
FXI 02 --- 02 
VWF type 3 25 23 50 
GT 05 05 20 
BSS 02 03 05 

VWF, von Willibrand factor.

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These data have shown that VWD type 3 has the highest incidence among the ARBDs in this study cohort, followed by fibrinogen deficiency. Glanzmann thrombasthenia (GT) was found to be the third most common disorder. The incidence of ARBDs in this region is higher than previously thought.

The authors thank Shehla Tariq, Nauman Malik, Hafiz Rafiq, Nazish Saqlain, and Salwa Paracha (Lahore); Shahtaj Masood (HMCP), Samina Amanat (Islamabad); and Children’s Hospital (Lahore) for providing patient data and samples; and Abdul Malik Khan and Asif Khan for providing computer data input from NIBD. They extend special thanks to their international collaborators (University of Bonn, Bonn, Germany; Debrecen University, Budapest, Hungary; M. Neerman-Arbez, University of Geneva, Geneva, Switzerland; and Royal Free Hospital, London, United Kingdom) for supporting them unconditionally for the development of genetic analysis in Pakistan.

This work was supported by Novo Nordisk Foundation and the International Society of Thrombosis and Hemostasis.

Conflict-of-interest disclosure: The authors declare no competing financial interests.

Correspondence: Arshi Naz, Department of Pathology, National Institute of Blood Disease and Bone Marrow Transplantation, Karachi, Pakistan; e-mail: labarshi2013@gmail.com or labarshi@yahoo.com.

© 2018 by The American Society of Hematology
2018