Thus, VWF:CBA is sometimes used as an alternative to multimeric analysis, and the ratio of VWF:CB to VWF:Ag levels appears to be useful for distinguishing between type 1 and 2 VWD [8]. However, this concept has been recently challenged by the identification of rare VWD mutations located in A3 domain (W1745C and S1783A) characterized by a normal multimeric pattern, but with a discrepant low VWF:CB/VWF:Ag ratio [9]. In some of these patients, the diagnosis of VWD could be missed as VWF:RCo level may be border-line. In general, this test seems not to provide INCB024360 cost substantial advantage compared with VWF:RCo, and furthermore, it is not well standardized yet. Previous studies have shown

that a wide variety of animal sources and collagen types are used in this test and that this significantly affects the results [10]. The ristocetin-induced platelet aggregation (RIPA) using

patient platelets explores the threshold ristocetin concentration, which induces aggregation of the patient platelet-rich plasma. Aggregation occurring at low concentrations identifies type 2B VWD cases, in whom desmopressin may cause thrombocytopenia. This test is critical, especially when multimeric pattern evaluation is not feasible. An additional test typically used in VWD diagnosis is the closure time (CT). The evaluation of CT with PFA-100 (platelet function analyzer) (Dade, Miami, FL, USA) allows rapid and simple determination of VWF-dependent platelet function at Selleck Everolimus high-shear stress. This system was demonstrated to be sensitive and reproducible when screening for severe reduction in VWF, but it is normal in type 2N VWD and it has been questioned as an aid in screening for mild VWF deficiencies [11]. Type 2N VWD is suspected

when the MCE FVIII:C level is disproportionately decreased compared with levels of VWF:Ag and VWF:RCo [12]. Usually, plasma VWF:Ag levels are normal or subnormal depending on the ABO blood group [13] and genotype of the patient (i.e., presence of a silent allele) [14]. As a consequence, the FVIII:C to VWF:Ag ratio is reduced (<0.5) in all the patients with type 2N VWD. The diagnosis relies on the measurement of the affinity of VWF to FVIII (VWF:FVIIIB), which is markedly decreased. The original assay is a solid phase immunoassay, but several modifications have enabled simplification and even automation of the assay [15–18]. Recently, the assay for von Willebrand factor propeptide (VWFpp) has been developed. Even though the assay is based on an ELISA, it provides information on VWF ‘function’ of some VWD variants. The half-life of VWFpp is around 2–3 h, whereas normal VWF has a half-life of 8–12 h. An increased ratio of steady-state plasma VWFpp to VWF:Ag has been demonstrated to identify patients and VWF mutations with increased VWF clearance [reviewed in 20].