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A group of international physicians committed to the unique care of pediatric hemophilia patients form the International Network for Pediatric Hemophilia (INPH). The main objectives of the group center on scientific studies, educational presentations and networking. By joining together on an international level, large hemophilia centers with extensive experience in the clinical care of children with hemophilia perform and publish scientifically valid studies. Annual meetings of the group include invited speakers who present hot topics or new developments in this therapeutic area for the purpose of educating the group on cutting edge research. Furthermore, since members have experience in pediatric treatment from different parts of the world, current practices as well as new trends can be discussed and shared among the group. The Fifth Annual INPH meeting was held in Buenos Aires, Argentina, on July 8–9, 2010 and focused on the topics of prophylaxis treatment and immune tolerance induction in the clinical care of children with hemophilia. The meeting is structured around roundtable discussions on the members’ current research and clinical activities, project reports of INPH study initiatives, followed by invited educational presentations with interactive discussions.

We describe a case of inferior vena cava thrombosis (IVC) leading to bilateral renal vein thrombosis and renal failure in a neonate, which was successfully treated by thrombolysis. A male neonate, born at term by vaginal delivery (Apgar score 9–10–10) and weighing 4210 g at birth after a normal pregnancy, presented at 9 days of age due to failure to thrive and gross haematuria. At admission the child weighed 4200 g and appeared to be dehydrated. He was anuric with a serum creatinine of 222 μmol/L (reference 14–37 μmol/L), severe metabolic acidosis and respiratory difficulties. He had a palpable abdominal mass on the left side of the abdomen. Ultrasound examination showed enlarged hyperechogenic kidneys, especially on the left side. The renal veins and IVC could not be visualised. Magnetic resonance (MR) angiography revealed thrombosis of the IVC from the bifurcation up to the hepatic veins (Fig. 1a, b) and extending into both renal veins. There was no evidence of adrenal haemorrhage. Treatment with warfarin (Waran; Nycomed, Zurich, Switzerland) was initiated (Fig. 1c), and systemic lowmolecular weight heparin (LMWH) (dalteparin sodium, Fragmin; Pfizer, New York, NY). The dose was adjusted by following levels of anti-Factor Xa geared at 0.5–1.0 kIE/L. Because the ultrasound did not show any change in the size of the thrombus, warfarin was discontinued, and local fibrinolysis was initiated [1, 2]. An angio-catheter was inserted into the occluding thrombus in the IVC, and continuous infusion of recombinant tissue plasminogen activator (rt-PA) (Actilyse; Boehringer, Ingelheim, Germany) was administered at 0.1 mg/kg/hour. The rt-PA treatment was monitored by an analysis of plasma fibrinogen levels. Systemic LMWH was continued in order to prevent thromboembolism, and fresh frozen plasma was infused daily. Cranial ultrasound was performed daily due to the risk of intracranial haemorrhage. Three days after the patient had been admitted, systemic LMWH was switched to unfractionated heparin (LEO Pharma, Ballerup, Denmark) infusion because the level of anti-FXa was too low. The dose of unfractionated heparin was monitored by activated clotting time targeted at 180–200 s. Local rt-PA treatment was discontinued due to excessive bleeding from the peritoneal dialysis catheter insertion site. Pediatr Nephrol (2009) 24:2069–2071 DOI 10.1007/s00467-009-1172-3

Mutation rates for X-linked recessive diseases have so far been estimated indirectly by postulating an equilibrium between the loss of defective genes caused by the low reproductive fitness of affected males and the gain resulting from new mutations. Here, for the first time, we directly estimate both the overall and sex-specific mutation rates for haemophilia B by detecting the gene defect of the families registered at the Malmö Haemophilia Centre. These represent a complete sample of the Swedish haemophilia B population (45 out of 77 pedigrees) and contain 23 families with a single affected male. Fifteen of these males had mothers available for study, and of these mothers, 13 had parents available for study. We show that 3 of the above patients and 10 of their mothers carry new mutations, and by extrapolation calculate that 8 males and 98 females should carry new haemophilia B mutations in the Swedish population (8.52 x 10(6) individuals). This leads to the following estimate of the mutation rates: overall mu = 4.1 x 10(-6); male specific nu = 2.1 x 10(-5); and female specific mu = 1.9 x 10(-6). The ratio of such male to female specific mutation rates is thus nu/mu = 11.

Rapid identification of gene defects allows definite carrier and prenatal diagnosis in virtually every family with haemophilia B. We report a study of the family of an isolated patient. Analysis of all the essential regions of the patient's factor IX gene (promoter, exons, transcript processing signals) revealed two mutations: one C----T transition at residue 17762 and another at residue 30890. The former created a translation stop at codon 116, and the latter caused substitution of His 257 by Tyr. The translation stop is an obvious detrimental mutation, while the His 257----Tyr substitution has uncertain functional consequences. From analysis of other family members, it was found that the first mutation had occurred at grandpaternal gametogenesis, in keeping with the negative family history, while the second was of more remote origin and did not reduce the maternal grandfather's factor IX coagulant and antigen level. This neutral mutation (His 257----Tyr) pinpoints a poorly conserved amino acid in factor IX and related serine proteases. Its coexistence with a detrimental mutation stresses the need to examine all essential regions of a gene before attempting to interpret the functional consequences of its sequence changes.