Inclusion

1

• Inclusion
• Pediatric and adult patients with suspected
  congenital primary and secondary erythrocytosis
• Patients lt 20 years with polycythemia vera
• Exclusion
• Patients with secondary erythrocytosis due to a
  known cardiac, pulmonary, or renal disease
• Observational patients
• Patients with secondary erythrocytosis due to an
  underlying disorder (e.g. renal disorder, Epo-
  producing tumor) which has been identified during
  the diagnostic work-up of apparent idiopathic
  erythrocytosis

2
Before the inclusion of a patient with suspected
congenital erythrocytosis or PV in childhood and
adolescence into the register

• exclude causes for relative or apparent
  erythrocytosis (e.g. dehydration, Smokers
  polycythemia)
• confirm the presence of absolute erythrocytosis
  in an independent analysis
• exclude obvious cardiac and pulmonary causes of
  secondary erythrocytoses (e.g. COPD, cyanotic
  cardiac defects)
• in patients older than 20 years, exclude
  polycythemia vera according to established
  diagnostic criteria (PVSG and/or WHO)

3
Red cell mass ? (gt mean 25) or hemoglobin or
hematocrit ? (gt mean 2 SD)
SaO2 gt92
SaO2 lt92
Cardiac or pulmonary disorder?
? leukocytosis ? thrombocytosis ? splenomegaly
Polycythemia vera ? ? PRV-1, EEC, JAK2, BM
Isolated erythrocytosis, no significant
splenomegaly
PRV-1mRNA expression ? EEC ? JAK2 V617F
Serum erythropoietin ? (or upper normal range)
Serum erythropoietin ? (or lower normal range)
PRV-1mRNA expression nl. ØEEC JAK2 V617F -
Polycythemia vera ? BM biopsy cytogenetics
Diagnostic algorithm for absolute erythrocytoses
? PFCP
Sequencing of EPOR gene exon 78 ? Epo
sensitivity assay
- ? PFCP ? ? ? BM biopsy
VHL gene analysis
Hemoglobin oxygen affinity nl.
Hemoglobin oxygen affinity ?
Chuvash P./other VHL mutation?
Hemoglobin analysis nl
Abnormal hemoglobin
PHD2 gene analysis ( other g.)
Globin gene analysis
2,3-BPG quantification
further endocrinol. nephrol. diagnostics (e.g.
angiography)

• 2,3-BPG deficiency ?
• 2,3-BPG mutase ? ?
• Hereditary PK abnormality ?

hemoglobin variant with hyperaffinity to O2
Exclusion of Epo-producing tumour (CNS-MRI,
sonography)
4
Red cell mass ? (gt mean 25) or hemoglobin or
hematocrit ? (gt mean 2 SD)
SaO2 gt92
SaO2 lt92
Cardiac or pulmonary disorder?
? leukocytosis ? thrombocytosis ? splenomegaly
Polycythemia vera ? ? PRV-1, EEC, JAK2, BM
Isolated erythrocytosis, no significant
splenomegaly
PRV-1mRNA expression ? EEC ? JAK2 V617F
Serum erythropoietin ? (or upper normal range)
Serum erythropoietin ? (or lower normal range)
PRV-1mRNA expression nl. ØEEC JAK2 V617F -
Polycythemia vera ? BM biopsy cytogenetics
Diagnostic algorithm for absolute erythrocytoses
? PFCP
Sequencing of EPOR gene exon 78 ? Epo
sensitivity assay
- ? PFCP ? ? ? BM biopsy
VHL gene analysis
Hemoglobin oxygen affinity nl.
Hemoglobin oxygen affinity ?
Chuvash P./other VHL mutation?
Hemoglobin analysis nl
Abnormal hemoglobin
PHD2 gene analysis ( other g.)
Globin gene analysis
2,3-BPG quantification
further endocrinol. nephrol. diagnostics (e.g.
angiography)

• 2,3-BPG deficiency ?
• 2,3-BPG mutase ? ?
• Hereditary PK abnormality ?

hemoglobin variant with hyperaffinity to O2
Exclusion of Epo-producing tumour (CNS-MRI,
sonography)
5
Red cell mass ? (gt mean 25) or hemoglobin or
hematocrit ? (gt mean 2 SD)
SaO2 gt92
SaO2 lt92
Cardiac or pulmonary disorder?
? leukocytosis ? thrombocytosis ? splenomegaly
Polycythemia vera ? ? PRV-1, EEC, JAK2, BM
Isolated erythrocytosis, no significant
splenomegaly
PRV-1mRNA expression ? EEC ? JAK2 V617F
Serum erythropoietin ? (or upper normal range)
Serum erythropoietin ? (or lower normal range)
PRV-1mRNA expression nl. ØEEC JAK2 V617F -
Polycythemia vera ? BM biopsy cytogenetics
Diagnostic algorithm for absolute erythrocytoses
? PFCP
Sequencing of EPOR gene exon 78 ? Epo
sensitivity assay
- ? PFCP ? ? ? BM biopsy
VHL gene analysis
Hemoglobin oxygen affinity nl.
Hemoglobin oxygen affinity ?
Chuvash P./other VHL mutation?
Hemoglobin analysis nl
Abnormal hemoglobin
PHD2 gene analysis ( other g.)
Globin gene analysis
2,3-BPG quantification
further endocrinol. nephrol. diagnostics (e.g.
angiography)

• 2,3-BPG deficiency ?
• 2,3-BPG mutase ? ?
• Hereditary PK abnormality ?

hemoglobin variant with hyperaffinity to O2
Exclusion of Epo-producing tumour (CNS-MRI,
sonography)
6
Red cell mass ? (gt mean 25) or hemoglobin or
hematocrit ? (gt mean 2 SD)
SaO2 gt92
SaO2 lt92
Cardiac or pulmonary disorder?
? leukocytosis ? thrombocytosis ? splenomegaly
Polycythemia vera ? ? PRV-1, EEC, JAK2, BM
Isolated erythrocytosis, no significant
splenomegaly
PRV-1mRNA expression ? EEC ? JAK2 V617F
Serum erythropoietin ? (or upper normal range)
Serum erythropoietin ? (or lower normal range)
PRV-1mRNA expression nl. ØEEC JAK2 V617F -
Polycythemia vera ? BM biopsy cytogenetics
Diagnostic algorithm for absolute erythrocytoses
? PFCP
Sequencing of EPOR gene exon 78 ? Epo
sensitivity assay
- ? PFCP ? ? ? BM biopsy
VHL gene analysis
Hemoglobin oxygen affinity nl.
Hemoglobin oxygen affinity ?
Chuvash P./other VHL mutation?
Hemoglobin analysis nl
Abnormal hemoglobin
PHD2 gene analysis ( other g.)
Globin gene analysis
2,3-BPG quantification
further endocrinol. nephrol. diagnostics (e.g.
angiography)

• 2,3-BPG deficiency ?
• 2,3-BPG mutase ? ?
• Hereditary PK abnormality ?

hemoglobin variant with hyperaffinity to O2
Exclusion of Epo-producing tumour (CNS-MRI,
sonography)
7
Red cell mass ? (gt mean 25) or hemoglobin or
hematocrit ? (gt mean 2 SD)
SaO2 gt92
SaO2 lt92
Cardiac or pulmonary disorder?
? leukocytosis ? thrombocytosis ? splenomegaly
Polycythemia vera ? ? PRV-1, EEC, JAK2, BM
Isolated erythrocytosis, no significant
splenomegaly
PRV-1mRNA expression ? EEC ? JAK2 V617F
Serum erythropoietin ? (or upper normal range)
Serum erythropoietin ? (or lower normal range)
PRV-1mRNA expression nl. ØEEC JAK2 V617F -
Polycythemia vera ? BM biopsy cytogenetics
Diagnostic algorithm for absolute erythrocytoses
? PFCP
Sequencing of EPOR gene exon 78 ? Epo
sensitivity assay
- ? PFCP ? ? ? BM biopsy
VHL gene analysis
Hemoglobin oxygen affinity nl.
Hemoglobin oxygen affinity ?
Chuvash P./other VHL mutation?
Hemoglobin analysis nl
Abnormal hemoglobin
PHD2 gene analysis ( other g.)
Globin gene analysis
2,3-BPG quantification
further endocrinol. nephrol. diagnostics (e.g.
angiography)

• 2,3-BPG deficiency ?
• 2,3-BPG mutase ? ?
• Hereditary PK abnormality ?

hemoglobin variant with hyperaffinity to O2
Exclusion of Epo-producing tumour (CNS-MRI,
sonography)
8
Red cell mass ? (gt mean 25) or hemoglobin or
hematocrit ? (gt mean 2 SD)
SaO2 gt92
SaO2 lt92
Cardiac or pulmonary disorder?
? leukocytosis ? thrombocytosis ? splenomegaly
Polycythemia vera ? ? PRV-1, EEC, JAK2, BM
Isolated erythrocytosis, no significant
splenomegaly
PRV-1mRNA expression ? EEC ? JAK2 V617F
Serum erythropoietin ? (or upper normal range)
Serum erythropoietin ? (or lower normal range)
PRV-1mRNA expression nl. ØEEC JAK2 V617F -
Polycythemia vera ? BM biopsy cytogenetics
Diagnostic algorithm for absolute erythrocytoses
? PFCP
Sequencing of EPOR gene exon 78 ? Epo
sensitivity assay
- ? PFCP ? ? ? BM biopsy
VHL gene analysis
Hemoglobin oxygen affinity nl.
Hemoglobin oxygen affinity ?
Chuvash P./other VHL mutation?
Hemoglobin analysis nl
Abnormal hemoglobin
PHD2 gene analysis ( other g.)
Globin gene analysis
2,3-BPG quantification
further endocrinol. nephrol. diagnostics (e.g.
angiography)

• 2,3-BPG deficiency ?
• 2,3-BPG mutase ? ?
• Hereditary PK abnormality ?

hemoglobin variant with hyperaffinity to O2
Exclusion of Epo-producing tumour (CNS-MRI,
sonography)
9
Red cell mass ? (gt mean 25) or hemoglobin or
hematocrit ? (gt mean 2 SD)
SaO2 gt92
SaO2 lt92
Cardiac or pulmonary disorder?
? leukocytosis ? thrombocytosis ? splenomegaly
Polycythemia vera ? ? PRV-1, EEC, JAK2, BM
Isolated erythrocytosis, no significant
splenomegaly
PRV-1mRNA expression ? EEC ? JAK2 V617F
Serum erythropoietin ? (or upper normal range)
Serum erythropoietin ? (or lower normal range)
PRV-1mRNA expression nl. ØEEC JAK2 V617F -
Polycythemia vera ? BM biopsy cytogenetics
Diagnostic algorithm for absolute erythrocytoses
? PFCP
Sequencing of EPOR gene exon 78 ? Epo
sensitivity assay
- ? PFCP ? ? ? BM biopsy
VHL gene analysis
Hemoglobin oxygen affinity nl.
Hemoglobin oxygen affinity ?
Chuvash P./other VHL mutation?
Hemoglobin analysis nl
Abnormal hemoglobin
PHD2 gene analysis ( other g.)
Globin gene analysis
2,3-BPG quantification
further endocrinol. nephrol. diagnostics (e.g.
angiography)

• 2,3-BPG deficiency ?
• 2,3-BPG mutase ? ?
• Hereditary PK abnormality ?

hemoglobin variant with hyperaffinity to O2
Exclusion of Epo-producing tumour (CNS-MRI,
sonography)
10
Red cell mass ? (gt mean 25) or hemoglobin or
hematocrit ? (gt mean 2 SD)
SaO2 gt92
SaO2 lt92
Cardiac or pulmonary disorder?
? leukocytosis ? thrombocytosis ? splenomegaly
Polycythemia vera ? ? PRV-1, EEC, JAK2, BM
Isolated erythrocytosis, no significant
splenomegaly
PRV-1mRNA expression ? EEC ? JAK2 V617F
Serum erythropoietin ? (or upper normal range)
Serum erythropoietin ? (or lower normal range)
PRV-1mRNA expression nl. ØEEC JAK2 V617F -
Polycythemia vera ? BM biopsy cytogenetics
Diagnostic algorithm for absolute erythrocytoses
? PFCP
Sequencing of EPOR gene exon 78 ? Epo
sensitivity assay
- ? PFCP ? ? ? BM biopsy
VHL gene analysis
Hemoglobin oxygen affinity nl.
Hemoglobin oxygen affinity ?
Chuvash P./other VHL mutation?
Hemoglobin analysis nl
Abnormal hemoglobin
PHD2 gene analysis ( other g.)
Globin gene analysis
2,3-BPG quantification
further endocrinol. nephrol. diagnostics (e.g.
angiography)

• 2,3-BPG deficiency ?
• 2,3-BPG mutase ? ?
• Hereditary PK abnormality ?

hemoglobin variant with hyperaffinity to O2
Exclusion of Epo-producing tumour (CNS-MRI,
sonography)
11
Red cell mass ? (gt mean 25) or hemoglobin or
hematocrit ? (gt mean 2 SD)
SaO2 gt92
SaO2 lt92
Cardiac or pulmonary disorder?
? leukocytosis ? thrombocytosis ? splenomegaly
Polycythemia vera ? ? PRV-1, EEC, JAK2, BM
Isolated erythrocytosis, no significant
splenomegaly
PRV-1mRNA expression ? EEC ? JAK2 V617F
Serum erythropoietin ? (or upper normal range)
Serum erythropoietin ? (or lower normal range)
PRV-1mRNA expression nl. ØEEC JAK2 V617F -
Polycythemia vera ? BM biopsy cytogenetics
Diagnostic algorithm for absolute erythrocytoses
? PFCP
Sequencing of EPOR gene exon 78 ? Epo
sensitivity assay
- ? PFCP ? ? ? BM biopsy
VHL gene analysis
Hemoglobin oxygen affinity nl.
Hemoglobin oxygen affinity ?
Chuvash P./other VHL mutation?
Hemoglobin analysis nl
Abnormal hemoglobin
PHD2 gene analysis ( other g.)
Globin gene analysis
2,3-BPG quantification
further endocrinol. nephrol. diagnostics (e.g.
angiography)

• 2,3-BPG deficiency ?
• 2,3-BPG mutase ? ?
• Hereditary PK abnormality ?

hemoglobin variant with hyperaffinity to O2
Exclusion of Epo-producing tumour (CNS-MRI,
sonography)
12
Red cell mass ? (gt mean 25) or hemoglobin or
hematocrit ? (gt mean 2 SD)
SaO2 gt92
SaO2 lt92
Cardiac or pulmonary disorder?
? leukocytosis ? thrombocytosis ? splenomegaly
Polycythemia vera ? ? PRV-1, EEC, JAK2, BM
Isolated erythrocytosis, no significant
splenomegaly
PRV-1mRNA expression ? EEC ? JAK2 V617F
Serum erythropoietin ? (or upper normal range)
Serum erythropoietin ? (or lower normal range)
PRV-1mRNA expression nl. ØEEC JAK2 V617F -
Polycythemia vera ? BM biopsy cytogenetics
Diagnostic algorithm for absolute erythrocytoses
? PFCP
Sequencing of EPOR gene exon 78 ? Epo
sensitivity assay
- ? PFCP ? ? ? BM biopsy
VHL gene analysis
Hemoglobin oxygen affinity nl.
Hemoglobin oxygen affinity ?
Chuvash P./other VHL mutation?
Hemoglobin analysis nl
Abnormal hemoglobin
PHD2 gene analysis ( other g.)
Globin gene analysis
2,3-BPG quantification
further endocrinol. nephrol. diagnostics (e.g.
angiography)

• 2,3-BPG deficiency ?
• 2,3-BPG mutase ? ?
• Hereditary PK abnormality ?

hemoglobin variant with hyperaffinity to O2
Exclusion of Epo-producing tumour (CNS-MRI,
sonography)