Factor IX Deficiency Workup
- Author: Robert A Schwartz, MD, MPH; Chief Editor: Srikanth Nagalla, MBBS, MS, FACP more...
See the list below:
- Preliminary identification of the coagulation disorder - aPTT, PT, platelet counts, and bleeding time testing
- A prolonged aPTT with a normal PT indicate an abnormality in the early part of the intrinsic coagulation pathway. However, a normal aPTT does not exclude hemophilia B, since aPTT may not be sufficiently sensitive to detect slightly reduced levels of FIX in the 20-30% range, as occurs in mild hemophilia or in carriers. If the clinical history warrants, a specific FIX level should be obtained.
- Prolongation of PT alone, or both the PT and aPTT, is not consistent with hemophilia B alone. This kind of coagulopathy may result from superimposition of other causes, such as liver disease, overdose of heparin or warfarin sodium, or disseminated intravascular coagulation (DIC).
- Thrombocytopenia and platelet dysfunction are not consistent with hemophilia B alone.
- Assessment of nature and severity of bleeding – CBC, stools for blood, and urinalysis for hematuria
- Confirmatory tests - Specific coagulation factor assays
- A mixing test is performed in which the patient's plasma is mixed with normal pooled plasma, incubated at 37°C, and then tested for aPTT.
- Correction of the aPTT in this test implies a deficiency, whereas persistence of an abnormally prolonged aPTT suggests the presence of an inhibitor.
- Determination of the specific titer of an inhibitor to FIX - Ideally, a special method termed the Nijmegen modification of the Bethesda inhibitor assay (used to detect presence of an inhibitor if the mixing test is positive)
- Specific antibodies to FIX usually are IgG subclass 4 or a mixture of IgG subclasses 1 and 4.
- An experienced laboratory must perform these tests.
- Identification of carriers
- Using coagulation assays for the plasma level of FIX, only two thirds of carriers can be identified by a reduced FIX level.
- Carriers can be detected by linkage studies using restriction fragment length polymorphism analysis. This test can be used only if the precise genetic defect is known.
- Prenatal diagnosis
- Use of several diagnostic procedures has been well established in the treatment of patients with FVIII and FIX deficiencies. Prior to the availability of molecular diagnostic techniques, cord blood sampling by fetoscopy at approximately 20 weeks of gestation was used to identify a male fetus with hemophilia with reduced in utero FIX levels.
- Currently, many reports exist of antenatal diagnosis using molecular diagnostic techniques. Chorionic villous sampling at approximately 10-12 weeks of gestation or amniocentesis at 16-20 weeks of gestation can be performed to obtain fetal cells for DNA analysis when the mutation in the family is known or for linkage studies.
- In general, these procedures carry a risk ranging from a low of approximately 0.5% for maternal-fetal complications to a high of approximately 1-6% for fetal death for fetoscopy. These procedures should be undertaken only after intense genetic and obstetric counseling of the parents.
- Other laboratory tests
- Other tests include liver function tests, kidney function testing, HIV type 1 and HIV type 2 antigen/antibody tests, and hepatitis A, B, C, D, and E antigen/antibody tests.
- Assess alpha-fetoprotein levels for evidence of hepatocellular carcinoma in patients with chronic longstanding hepatitis.
See the list below:
- MRI, CT scans, and ultrasound have been used to localize and size bleeds and to follow response to therapy.
See the list below:
- An electrocardiogram (ECG), which is a general test for identifying cardiac abnormalities, is performed prior to procedures requiring anesthesia. Patients receiving factor replacement therapy are at risk for thrombotic complications, especially those receiving activated concentrates.
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|Severity||Functional FIX Levels, %||Bleeding and Hemarthroses|
|Severe||≤ 1||Lifelong spontaneous hemorrhages and hemarthroses starting in infancy|
|Moderate||2-5||Hemorrhage secondary to minor trauma or surgery; occasional spontaneous hemarthrosis|
|Mild||6-25||Hemorrhage secondary to trauma, surgery, or precipitated by the use of drugs such as nonsteroidal anti-inflammatory drugs|
|Type of Hemorrhage||Desired FIX Activity, % of Normal||Duration of Therapy, Days|
Hematoma with dissection
Oral/mucosal hemorrhages and epistaxis hematuria*
(2-5 in oral hemorrhages)
GI tract bleeding,
CNS bleeding surgery
|~100 until bleeding is controlled; then taper to minimum required to prevent rebleed||7-10|
|*Concomitant administration of EACA or tranexamic acid (both fibrinolytic inhibitors) can help reduce the dose of clotting factor replacement required to treat such bleeds.|