Lancet Haematology最新文献

The global population is ageing and this demographic shift has profound effects on haemostasis, notably a progressive tilt towards a hypercoagulable state. A major age-associated change in haemostasis is the increase in von Willebrand factor (VWF), a plasma glycoprotein essential for primary and secondary haemostasis. VWF deficiency causes von Willebrand disease, which is the most common inherited bleeding disorder and affects approximately 1% of the population. Conversely, elevated VWF concentrations are linked to increased thrombotic risk; VWF concentrations increase with age by approximately 10-15 IU/dL per decade. Moreover, longitudinal data indicate that VWF concentrations might normalise over time in individuals initially diagnosed with von Willebrand disease. Understanding the mechanisms underlying age-related increases in VWF is crucial for refining the disease classification and optimising management. Given the strong association between VWF, coagulation factor VIII (which is stabilised and transported by VWF), and thrombotic risk, the interplay between ageing and VWF dynamics has clinical implications. This Review examines age-related changes in VWF synthesis, storage, multimeric structure, and clearance. We also discuss the consequences of rising VWF concentrations in older adults on bleeding symptoms, von Willebrand disease diagnosis and management, and the related risks of thrombosis and cardiovascular complications. Finally, we identify essential knowledge gaps and outline priorities for future research and clinical practice.

Background: Anaemia causes widespread health and economic harm. Current international targets for reducing anaemia in women of reproductive age, including the Sustainable Development Goal of halving prevalence by 2030, are unlikely to be met by any signatory country. This outcome suggests that current targets were grounded in aspiration rather than a systematic assessment of what is achievable given current recommended interventions and national health-care priorities. We propose a novel method of target setting for global health goals, with reducing anaemia in women of reproductive age as an example.

Methods: In this modelling study, we developed a country-level health economic model to support feasible and ambitious target-setting for anaemia for women of reproductive age (aged 15-49 years) based on cost-effectiveness analysis and applied it to 191 signatory countries. Our model integrated country-specific data on the current prevalence of anaemia, the effectiveness and current and maximal coverage of recommended interventions available to each country, the local unit costs of these interventions, and country-specific cost-effectiveness threshold estimates, including Global Burden of Disease data and data from the Demographic and Health Survey Program. Interventions were applied to maximise health gains subject to country-level cost-effectiveness thresholds at 1 × gross domestic product per capita. We assessed parameter uncertainty through Monte Carlo simulations and scenarios that considered alternative thresholds, constraints on cost, and coverage.

Findings: Our results indicate that an ambitious, achievable, and cost-effective global target for anaemia reduction in women aged 15-49 years by 2030 is 17% (95% uncertainty interval [UI] 5-34). The maximum achievable target removing all cost constraints is a 22% (11-36) reduction. No scenario approached the current 50% global Sustainable Development Goal reduction target, indicating that this goal is unachievable with existing recommended interventions. Reduction targets for individual countries ranged from 0% to 29%, with substantial variation both between and within regions and income groups.

Interpretation: Our findings suggest that a value-based global target for anaemia reduction will be substantially lower than the existing international commitment. Value-based targets using evidence from available interventions and cost-effectiveness for what is achievable given countries' differing contexts can provide better incentives for progress and offer more realistic forecasts of human development.

Funding: Gates Foundation.