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Acquired Von Willebrand Syndrome and Desmopressin Resistance During Venovenous Extracorporeal Membrane Oxygenation in Patients With COVID-19. Crit Care Med 2022; 50:1246-1255. [PMID: 35234414 PMCID: PMC9275806 DOI: 10.1097/ccm.0000000000005467] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Although COVID-19 is associated with high von Willebrand factor (vWF) parameters promoting thrombosis, venovenous extracorporeal membrane oxygenation (vvECMO) is associated with the development of acquired von Willebrand syndrome (AVWS) promoting bleeding. This study was designed to assess both the incidence and severity of AVWS in COVID-19 patients undergoing vvECMO, and the benefit of comprehensive vWF analyses. DESIGN Prospective observational study. SETTING ICU at a tertiary-care center. PATIENTS Twenty-seven consecutive COVID-19 patients with acute respiratory distress syndrome (ARDS) requiring vvECMO. MEASUREMENTS AND MAIN RESULTS Comprehensive vWF analyses (including sodium dodecyl-sulfate polyacrylamide gel electrophoresis) were performed before, during, and after vvECMO. In a subgroup of 12 patients with AVWS, effectiveness of treatment with desmopressin was assessed. The patients' mean age was 53 years (range, 23-73), 70% were male, and all had various comorbidities. Following markedly elevated vwf antigen (vWF: Ag; mean, 546% ( sd , 282]), vWF collagen binding capacity (mean, 469% [ sd , 271]), vWF activity (vWF:A; mean, 383% [ sd , 132]), and factor VIII activity (mean, 302% [ sd , 106]), and only borderline decreases in high-molecular-weight (HMW) vWF multimers before vvECMO, all of these variables decreased and HMW vWF multimers became undetectable within hours following initiation of vvECMO. All variables fully recovered within 3-38 hours after discontinuation of vvECMO. During vvECMO, decreases in the vWF:A/vWF:Ag ratio correlated with absent HMW vWF multimers. Desmopressin did not affect vWF parameters. CONCLUSIONS In patients with COVID-19-associated ARDS, AVWS developed soon after initiation of vvECMO. The vWF:A/vWF:Ag ratio was a suitable screening test for AVWS. As desmopressin was ineffective, bleeding during vvECMO-associated AVWS should preferably be treated with concentrates containing vWF.
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Regling K, Callaghan MU, Sidonio R. Managing Severe Hemophilia A in Children: Pharmacotherapeutic Options. Pediatric Health Med Ther 2022; 13:27-35. [PMID: 35210899 PMCID: PMC8857990 DOI: 10.2147/phmt.s293246] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 12/27/2021] [Indexed: 12/22/2022] Open
Abstract
Hemophilia A is the most common severe inherited bleeding disorder in males. Initial treatment strategies focused on the use of factor concentrates to prevent joint bleeding and the development of long-term crippling arthropathy. The current standard of care has evolved from regular replacement of factor VIII concentrates which has significantly improved the quality of life for those with severe disease to include and consider novel therapies that augment or bypass the hemostatic pathway (ie, emicizumab, Mim8). Other pipeline therapies that suppress specific natural anticoagulant pathways (ie, antithrombin, TFPI) to reestablish hemostatic balance are under Phase 3 trial investigation. These novel therapeutics have allowed providers more variety in dosing regimens and ease of administration while also maintaining effective bleeding prevention. The possibility of "curative" gene therapy is under exploration, with ongoing clinical trials in adult males.
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Affiliation(s)
- Katherine Regling
- Pediatric Hematology Oncology, Children’s Hospital of Michigan, Detroit, MI, USA
- Central Michigan University School of Medicine, Mount Pleasant, MI, USA
| | - Michael U Callaghan
- Pediatric Hematology Oncology, Children’s Hospital of Michigan, Detroit, MI, USA
- Central Michigan University School of Medicine, Mount Pleasant, MI, USA
- Agios Pharmaceuticals, Cambridge, MA, USA
| | - Robert Sidonio
- Emory University and Aflac Cancer and Blood Disorders, Atlanta, GA, USA
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Arsiccio A, Metcalfe C, Pisano R, Raut S, Coxon C. A proximity-based in silico approach to identify redox-labile disulfide bonds: The example of FVIII. PLoS One 2022; 17:e0262409. [PMID: 35130281 PMCID: PMC8820644 DOI: 10.1371/journal.pone.0262409] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 12/27/2021] [Indexed: 01/04/2023] Open
Abstract
Allosteric disulfide bonds permit highly responsive, transient 'switch-like' properties that are ideal for processes like coagulation and inflammation that require rapid and localised responses to damage or injury. Haemophilia A (HA) is a rare bleeding disorder managed with exogenous coagulation factor(F) VIII products. FVIII has eight disulfide bonds and is known to be redox labile, but it is not known how reduction/oxidation affects the structure-function relationship, or its immunogenicity-a serious complication for 30% severe HA patients. Understanding how redox-mediated changes influence FVIII can inform molecular engineering strategies aimed at improving activity and stability, and reducing immunogenicity. FVIII is a challenging molecule to work with owing to its poor expression and instability so, in a proof-of-concept study, we used molecular dynamics (MD) to identify which disulfide bonds were most likely to be reduced and how this would affect structure/function; results were then experimentally verified. MD identified Cys1899-Cys1903 disulfide as the most likely to undergo reduction based on energy and proximity criteria. Further MD suggested this reduction led to a more open conformation. Here we present our findings and highlight the value of MD approaches.
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Affiliation(s)
- Andrea Arsiccio
- Department of Applied Science and Technology, Politecnico di Torino, Torino, Italy
| | - Clive Metcalfe
- National Institute for Biological Standards and Control, Hertfordshire, United Kingdom
| | - Roberto Pisano
- Department of Applied Science and Technology, Politecnico di Torino, Torino, Italy
| | - Sanj Raut
- National Institute for Biological Standards and Control, Hertfordshire, United Kingdom
| | - Carmen Coxon
- National Institute for Biological Standards and Control, Hertfordshire, United Kingdom
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A novel mouse model of type 2N VWD was developed by CRISPR/Cas9 gene editing and recapitulates human type 2N VWD. Blood Adv 2022; 6:2778-2790. [PMID: 35015821 PMCID: PMC9092403 DOI: 10.1182/bloodadvances.2021006353] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 12/21/2021] [Indexed: 11/20/2022] Open
Abstract
A novel type 2N VWD mouse model was established in which VWF is incapable of binding FVIII but is otherwise fully functional. VWF2N/2N mice exhibited a severe bleeding phenotype after tail tip amputation but not in lateral tail vein or ventral artery injury models.
Type 2N von Willebrand disease is caused by mutations in the factor VIII (FVIII) binding site of von Willebrand factor (VWF), resulting in dysfunctional VWF with defective binding capacity for FVIII. We developed a novel type 2N mouse model using CRISPR/Cas9 technology. In homozygous VWF2N/2N mice, plasma VWF levels were normal (1167 ± 257 mU/mL), but the VWF was completely incapable of binding FVIII, resulting in 53 ± 23 mU/mL of plasma FVIII levels that were similar to those in VWF-deficient (VWF−/−) mice. When wild-type human or mouse VWF was infused into VWF2N/2N mice, endogenous plasma FVIII was restored, peaking at 4 to 6 hours post-infusion, demonstrating that FVIII expressed in VWF2N mice is viable but short-lived unprotected in plasma due to dysfunctional 2N VWF. The whole blood clotting time and thrombin generation were impaired in VWF2N/2N but not in VWF−/− mice. Bleeding time and blood loss in VWF2N/2N mice were similar to wild-type mice in the lateral tail vein or ventral artery injury model. However, VWF2N/2N mice, but not VWF−/− mice, lost a significant amount of blood during the primary bleeding phase after a tail tip amputation injury model, indicating that alternative pathways can at least partially restore hemostasis when VWF is absent. In summary, we have developed a novel mouse model by gene editing with both the pathophysiology and clinical phenotype found in severe type 2N patients. This unique model can be used to investigate the biological properties of VWF/FVIII association in hemostasis and beyond.
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55
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Badescu MC, Rezus E, Ciocoiu M, Badulescu OV, Butnariu LI, Popescu D, Bratoiu I, Rezus C. Osteonecrosis of the Jaws in Patients with Hereditary Thrombophilia/Hypofibrinolysis-From Pathophysiology to Therapeutic Implications. Int J Mol Sci 2022; 23:ijms23020640. [PMID: 35054824 PMCID: PMC8776054 DOI: 10.3390/ijms23020640] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 12/29/2021] [Accepted: 01/04/2022] [Indexed: 12/24/2022] Open
Abstract
Osteonecrosis of the jaws (ONJ) usually has a clear etiology. Local infection or trauma, radiotherapy and drugs that disrupt the vascular supply or bone turnover in the jaws are its major contributors. The thrombotic occlusion of the bone’s venous outflow that occurs in individuals with hereditary thrombophilia and/or hypofibrinolysis has a less known impact on jaw health and healing capability. Our research provides the most comprehensive, up-to-date and systematized information on the prevalence and significance of hereditary thrombophilia and/or hypofibrinolysis states in ONJ. We found that hereditary prothrombotic abnormalities are common in patients with ONJ refractory to conventional medical and dental treatments. Thrombophilia traits usually coexist with hypofibrinolysis traits. We also found that frequently acquired prothrombotic abnormalities coexist with hereditary ones and enhance their negative effect on the bone. Therefore, we recommend a personalized therapeutic approach that addresses, in particular, the modifiable risk factors of ONJ. Patients will have clear benefits, as they will be relieved of persistent pain and repeated dental procedures.
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Affiliation(s)
- Minerva Codruta Badescu
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 16 University Street, 700115 Iasi, Romania; (M.C.B.); (D.P.); (C.R.)
- III Internal Medicine Clinic, “St. Spiridon” County Emergency Clinical Hospital, 1 Independence Boulevard, 700111 Iasi, Romania
| | - Elena Rezus
- Department of Rheumatology and Physiotherapy, “Grigore T. Popa” University of Medicine and Pharmacy, 16 University Street, 700115 Iasi, Romania;
- I Rheumatology Clinic, Clinical Rehabilitation Hospital, 14 Pantelimon Halipa Street, 700661 Iasi, Romania
- Correspondence: (E.R.); (O.V.B.)
| | - Manuela Ciocoiu
- Department of Pathophysiology, “Grigore T. Popa” University of Medicine and Pharmacy, 16 University Street, 700115 Iasi, Romania;
| | - Oana Viola Badulescu
- Department of Pathophysiology, “Grigore T. Popa” University of Medicine and Pharmacy, 16 University Street, 700115 Iasi, Romania;
- Hematology Clinic, “St. Spiridon” County Emergency Clinical Hospital, 1 Independence Boulevard, 700111 Iasi, Romania
- Correspondence: (E.R.); (O.V.B.)
| | - Lacramioara Ionela Butnariu
- Department of Mother and Child Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 16 University Street, 700115 Iasi, Romania;
| | - Diana Popescu
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 16 University Street, 700115 Iasi, Romania; (M.C.B.); (D.P.); (C.R.)
- III Internal Medicine Clinic, “St. Spiridon” County Emergency Clinical Hospital, 1 Independence Boulevard, 700111 Iasi, Romania
| | - Ioana Bratoiu
- Department of Rheumatology and Physiotherapy, “Grigore T. Popa” University of Medicine and Pharmacy, 16 University Street, 700115 Iasi, Romania;
- I Rheumatology Clinic, Clinical Rehabilitation Hospital, 14 Pantelimon Halipa Street, 700661 Iasi, Romania
| | - Ciprian Rezus
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 16 University Street, 700115 Iasi, Romania; (M.C.B.); (D.P.); (C.R.)
- III Internal Medicine Clinic, “St. Spiridon” County Emergency Clinical Hospital, 1 Independence Boulevard, 700111 Iasi, Romania
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56
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Xu L, Qiu Y, Li Y, Wei Y, Wan Y, Deng W. Tissue dynamics of von Willebrand factor characterized by a novel fluorescent protein-von Willebrand factor chimera. J Thromb Haemost 2022; 20:208-221. [PMID: 34592034 DOI: 10.1111/jth.15542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 09/23/2021] [Accepted: 09/27/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Tissue dynamics of von Willebrand factor (VWF) that are vital to its biological function have not been fully characterized. OBJECTIVE To develop a new fluorescent protein--VWF chimera (FP-VWF) that has similar hematologic function to wild-type VWF and use it to monitor the tissue dynamics of VWF distribution. METHODS Genotyping, platelet counting, tail bleeding time assay, agarose gels, western blot, platelet aggregation, proteolytic analysis, and ELISA were applied in characterizing the function of FP-VWF; fluorescence spectrometer and confocal fluorescence microscope were used to monitor the plasma and tissue distribution of FP-VWF. RESULTS The transgenic mice that carry the FP-VWF retain hematologic activity of VWF with plasma levels of FP-VWF reduced by 50% and there are reduced high molecular weight FP-VWF multimers compared to the wild-type mice. The GPIb-binding and ADAMTS-13 (A Disintegrin and Metalloprotease with ThrombSpondin type 1 motif, member 13) proteolytic efficiency of FP-VWF are similar to wild-type VWF. The tissue distribution of FP-VWF was probed directly through its intrinsic fluorescence at normal or stimulated status, which indicated that the medicine-stimulated endogenous FP-VWF seems primarily released from the aorta and cleared in the spleen. Similar results were observed in non-fluorescent mice through a standard immunofluorescence approach. The fluorescence signals of FP-VWF were also similar to the standard dye-based approach in detecting the FeCl3 -induced blood clotting in vivo. CONCLUSIONS Together, these results suggest that this novel FP-VWF chimera is valuable in probing the tissue dynamics of VWF in quite a few biological and pharmaceutical applications.
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Affiliation(s)
- Linru Xu
- Cyrus Tang Medical Institute and Collaborative Innovation Center of Hematology, State Key Laboratory of Radiation Medicine and Protection, Soochow University, Suzhou, China
| | - Yanyang Qiu
- Cyrus Tang Medical Institute and Collaborative Innovation Center of Hematology, State Key Laboratory of Radiation Medicine and Protection, Soochow University, Suzhou, China
| | - Yanqing Li
- Cyrus Tang Medical Institute and Collaborative Innovation Center of Hematology, State Key Laboratory of Radiation Medicine and Protection, Soochow University, Suzhou, China
| | - Yaxuan Wei
- Cyrus Tang Medical Institute and Collaborative Innovation Center of Hematology, State Key Laboratory of Radiation Medicine and Protection, Soochow University, Suzhou, China
| | - Yan Wan
- Cyrus Tang Medical Institute and Collaborative Innovation Center of Hematology, State Key Laboratory of Radiation Medicine and Protection, Soochow University, Suzhou, China
| | - Wei Deng
- Cyrus Tang Medical Institute and Collaborative Innovation Center of Hematology, State Key Laboratory of Radiation Medicine and Protection, Soochow University, Suzhou, China
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57
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Harris NS, Pelletier JP, Marin MJ, Winter WE. Von Willebrand factor and disease: a review for laboratory professionals. Crit Rev Clin Lab Sci 2021; 59:241-256. [DOI: 10.1080/10408363.2021.2014781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Neil S. Harris
- Department of Pathology, Immunology & Laboratory Medicine, University of Florida, Gainesville, FL, USA
| | - J. Peter Pelletier
- Department of Pathology, Immunology & Laboratory Medicine, University of Florida, Gainesville, FL, USA
| | - Maximo J. Marin
- Department of Pathology, Immunology & Laboratory Medicine, University of Florida, Gainesville, FL, USA
| | - William E. Winter
- Department of Pathology, Immunology & Laboratory Medicine, University of Florida, Gainesville, FL, USA
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58
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Mikesell L, Eriyagama DNAM, Yin Y, Lu BY, Fang S. Stepwise PEG synthesis featuring deprotection and coupling in one pot. Beilstein J Org Chem 2021; 17:2976-2982. [PMID: 35079293 PMCID: PMC8722398 DOI: 10.3762/bjoc.17.207] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 12/17/2021] [Indexed: 12/16/2022] Open
Abstract
The stepwise synthesis of monodisperse polyethylene glycols (PEGs) and their derivatives usually involves using an acid-labile protecting group such as DMTr and coupling the two PEG moieties together under basic Williamson ether formation conditions. Using this approach, each elongation of PEG is achieved in three steps - deprotection, deprotonation and coupling - in two pots. Here, we report a more convenient approach for PEG synthesis featuring the use of a base-labile protecting group such as the phenethyl group. Using this approach, each elongation of PEG can be achieved in two steps - deprotection and coupling - in only one pot. The deprotonation step, and the isolation and purification of the intermediate product after deprotection using existing approaches are no longer needed when the one-pot approach is used. Because the stepwise PEG synthesis usually requires multiple PEG elongation cycles, the new PEG synthesis method is expected to significantly lower PEG synthesis cost.
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Affiliation(s)
- Logan Mikesell
- Department of Chemistry, Michigan Technological University, 1400 Townsend Drive, Houghton, MI 49931, USA
| | - Dhananjani N A M Eriyagama
- Department of Chemistry, Michigan Technological University, 1400 Townsend Drive, Houghton, MI 49931, USA
| | - Yipeng Yin
- Department of Chemistry, Michigan Technological University, 1400 Townsend Drive, Houghton, MI 49931, USA
| | - Bao-Yuan Lu
- ChampionX, 11177 South Stadium Drive, Sugar Land, TX 77478, USA
| | - Shiyue Fang
- Department of Chemistry, Michigan Technological University, 1400 Townsend Drive, Houghton, MI 49931, USA
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Dargaud Y, Janbain M. Clinical Utility of Subcutaneous Factor VIII Replacement Therapies in Hemophilia A: A Review of the Evidence. J Blood Med 2021; 12:1031-1036. [PMID: 34908888 PMCID: PMC8665845 DOI: 10.2147/jbm.s260923] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 12/02/2021] [Indexed: 01/06/2023] Open
Abstract
Hemophilia therapies have tremendously improved over the last decades with the development of prolonged half-life factor VIII (FVIII) and FIX concentrates, non-factor therapies, such as emicizumab, anti-TFPI antibodies or siRNA antithrombin and gene therapy. All of these new molecules significantly reduced the burden of the disease and improved the quality of life of patients with severe hemophilia. Emicizumab, a non-factor therapy, is currently the only subcutaneous molecule available for prophylactic treatment of severe hemophilia A. Because of the subcutaneous route of delivery and similar efficacy to FVIII replacement therapy, emicizumab has been rapidly adopted by patients and their families. This clinical observation emphasizes the relevance and need for the development of subcutaneous FVIII concentrates. Here, we report evidence-based advantages and interest in the subcutaneous route of administration for the treatment of hemophilia A and review the stages of development of the different subcutaneous FVIII molecules.
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Affiliation(s)
- Yesim Dargaud
- UR4609 Hemostase et Thrombose, Université Claude Bernard Lyon 1, Faculté de Médecine Lyon Est, Lyon, France
- Unité d’Hémostase Clinique, Hôpital Cardiologique Louis Pradel, Hospices Civils de Lyon, Lyon, France
| | - Maissa Janbain
- Hematology Department, Tulane School of Medicine, New Orleans, LA, USA
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Chia J, Pestel S, Glauser I, Emmrich K, Hardy MP, Mischnik M, Raquet E, Tomasetig V, Claar P, Zalewski A, Bass GT, Turnbull V, Chen CG, Wilson MJ, Panousis C, Weimer T, Andrews A, Verhagen AM, Dower SK. Increased potency of recombinant VWF D'D3 albumin fusion proteins engineered for enhanced affinity for coagulation factor VIII. J Thromb Haemost 2021; 19:2710-2725. [PMID: 34333849 DOI: 10.1111/jth.15480] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 07/28/2021] [Accepted: 07/29/2021] [Indexed: 01/22/2023]
Abstract
BACKGROUND We have recently reported on a recombinant von Willebrand factor (VWF) D'D3 albumin fusion protein (rD'D3-FP) developed to extend the half-life of coagulation factor VIII (FVIII) for the treatment of hemophilia A. Based on predictive modelling presented in this study, we hypothesized that modifying rD'D3-FP to improve FVIII interaction would reduce exchange with endogenous VWF and provide additional FVIII half-life benefit. OBJECTIVES The aim of this study was to identify novel rD'D3-FP variants with enhanced therapeutic efficacy in extending FVIII half-life. METHODS Through both directed mutagenesis and random mutagenesis using a novel mammalian display platform, we identified novel rD'D3-FP variants with increased affinity for FVIII (rVIII-SingleChain) under both neutral and acidic conditions and assessed their ability to extend FVIII half-life in vitro and in vivo. RESULTS In rat preclinical studies, rD'D3-FP variants with increased affinity for FVIII displayed enhanced potency, with reduced dose levels required to achieve equivalent rVIII-SingleChain half-life extension. In cell-based imaging studies in vitro, we also demonstrated reduced dissociation of rVIII-SingleChain from the rD'D3-FP variants within acidic endosomes and more efficient co-recycling of the rD'D3-FP/rVIII-SingleChain complex via the FcRn recycling system. CONCLUSIONS In summary, at potential clinical doses, the rD'D3-FP variants provide marked benefits with respect to dose levels and half-life extension of co-administered FVIII, supporting their development for use in the treatment of hemophilia A.
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Affiliation(s)
- Jenny Chia
- CSL Limited, Bio21 Molecular Science and Biotechnology Institute, Parkville, Victoria, Australia
| | | | - Isabelle Glauser
- CSL Limited, Bio21 Molecular Science and Biotechnology Institute, Parkville, Victoria, Australia
| | - Kerstin Emmrich
- CSL Limited, Bio21 Molecular Science and Biotechnology Institute, Parkville, Victoria, Australia
| | - Matthew P Hardy
- CSL Limited, Bio21 Molecular Science and Biotechnology Institute, Parkville, Victoria, Australia
| | | | | | - Vesna Tomasetig
- CSL Limited, Bio21 Molecular Science and Biotechnology Institute, Parkville, Victoria, Australia
| | | | - Anton Zalewski
- CSL Limited, Bio21 Molecular Science and Biotechnology Institute, Parkville, Victoria, Australia
| | - Gregory T Bass
- CSL Limited, Bio21 Molecular Science and Biotechnology Institute, Parkville, Victoria, Australia
| | - Victor Turnbull
- CSL Limited, Bio21 Molecular Science and Biotechnology Institute, Parkville, Victoria, Australia
| | - Chao-Guang Chen
- CSL Limited, Bio21 Molecular Science and Biotechnology Institute, Parkville, Victoria, Australia
| | - Michael J Wilson
- CSL Limited, Bio21 Molecular Science and Biotechnology Institute, Parkville, Victoria, Australia
| | - Con Panousis
- CSL Limited, Bio21 Molecular Science and Biotechnology Institute, Parkville, Victoria, Australia
| | | | - Arna Andrews
- CSL Limited, Bio21 Molecular Science and Biotechnology Institute, Parkville, Victoria, Australia
| | - Anne M Verhagen
- CSL Limited, Bio21 Molecular Science and Biotechnology Institute, Parkville, Victoria, Australia
| | - Steve K Dower
- CSL Limited, Bio21 Molecular Science and Biotechnology Institute, Parkville, Victoria, Australia
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Michels A, Swystun LL, Dwyer CN, Rawley O, Nesbitt K, Notley C, Lillicrap D. Stabilin-2 deficiency increases thrombotic burden and alters the composition of venous thrombi in a mouse model. J Thromb Haemost 2021; 19:2440-2453. [PMID: 34152080 DOI: 10.1111/jth.15429] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 05/17/2021] [Accepted: 06/17/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Stabilin-2 is an endocytic scavenger receptor that mediates the clearance of glycosaminoglycans, phosphatidylserine-expressing cells, and the von Willebrand factor-factor VIII (FVIII) complex. In a genome-wide screening study, pathogenic loss-of-function variants in the human STAB2 gene associated with an increased incidence of unprovoked venous thromboembolism (VTE). However, the specific mechanism(s) by which stabilin-2 deficiency influences the pathogenesis of VTE is unknown. OBJECTIVES The aim of this study was to assess the influence of stabilin-2 on deep vein thrombosis (DVT) and to characterize the underlying prothrombotic phenotype of stabilin-2 deficiency in a mouse model. METHODS DVT was induced using the inferior vena cava (IVC) stenosis model in two independent cohorts (littermates and non-littermates) of wild-type (Stab2+/+ ) and stabilin-2 (Stab2-/- )-deficient mice. Thrombus structure and contents were quantified by immunohistochemistry. Plasma procoagulant activity was assessed and complete blood counts were performed. RESULTS Incidence of thrombus formation was not altered between Stab2+/+ and Stab2-/- mice. When thrombi were formed, Stab2-/- mice developed significantly larger thrombi than Stab2+/+ controls. Thrombi from Stab2-/- mice contained significantly more leukocytes and citrullinated histone H3 than Stab2+/+ thrombi. Stab2-/- mice had increased FVIII activity. Circulating levels of monocytes and granulocytes were significantly elevated in Stab2-/- mice, and Stab2-/- mice had elevated plasma cell-free DNA 24 hours post-IVC stenosis compared to their Stab2+/+ counterparts. CONCLUSIONS These data suggest that stabilin-2 deficiency associates with a prothrombotic phenotype involving elevated levels of neutrophil extracellular trap-releasing leukocytes coupled with endogenous procoagulant activity, resulting in larger and qualitatively distinct venous thrombi.
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Affiliation(s)
- Alison Michels
- Department of Pathology and Molecular Medicine, Queens University, Kingston, Ontario, Canada
| | - Laura L Swystun
- Department of Pathology and Molecular Medicine, Queens University, Kingston, Ontario, Canada
| | - Courtney N Dwyer
- Department of Pathology and Molecular Medicine, Queens University, Kingston, Ontario, Canada
| | - Orla Rawley
- Department of Pathology and Molecular Medicine, Queens University, Kingston, Ontario, Canada
| | - Kate Nesbitt
- Department of Pathology and Molecular Medicine, Queens University, Kingston, Ontario, Canada
| | - Colleen Notley
- Department of Pathology and Molecular Medicine, Queens University, Kingston, Ontario, Canada
| | - David Lillicrap
- Department of Pathology and Molecular Medicine, Queens University, Kingston, Ontario, Canada
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Okaygoun D, Oliveira DD, Soman S, Williams R. Advances in the management of haemophilia: emerging treatments and their mechanisms. J Biomed Sci 2021; 28:64. [PMID: 34521404 PMCID: PMC8442442 DOI: 10.1186/s12929-021-00760-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 09/08/2021] [Indexed: 11/10/2022] Open
Abstract
Mainstay haemophilia treatment, namely intravenous factor replacement, poses several clinical challenges including frequent injections due to the short half-life of recombinant factors, intravenous administration (which is particularly challenging in those with difficult venous access), and the risk of inhibitor development. These impact negatively upon quality of life and treatment compliance, highlighting the need for improved therapies. Several novel pharmacological therapies developed for haemophilia aim to rebalance the clotting cascade and potentially circumvent the aforementioned challenges. These therapies utilise a range of different mechanisms, namely: the extension of the circulating half-life of standard recombinant factors; the mimicking of factor VIII cofactor activity; rebalancing of coagulation through targeting of natural anticoagulants such as antithrombin and tissue factor pathway inhibitor; and inducing the production of endogenous factors with gene therapy. These therapies carry the potential of revolutionising haemophilia treatment by alleviating the current challenges presented by mainstay factor replacement. This review will provide an overview of the key trial findings related to novel therapies based on the mechanisms described above.
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Affiliation(s)
- Dide Okaygoun
- Imperial College London: Faculty of Medicine, Imperial College Road, London, SW7 2DD, UK
| | - Danielle D Oliveira
- Imperial College London: Faculty of Medicine, Imperial College Road, London, SW7 2DD, UK.
| | - Sooriya Soman
- Imperial College London: Faculty of Medicine, Imperial College Road, London, SW7 2DD, UK
| | - Riccardo Williams
- Imperial College London: Faculty of Medicine, Imperial College Road, London, SW7 2DD, UK
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Bonanad S, Núñez R, Poveda JL, Kurnik K, Goldmann G, Andreozzi V, Vandewalle B, Santos S. Matching-Adjusted Indirect Comparison of Efficacy and Consumption of rVIII-SingleChain Versus Two Recombinant FVIII Products Used for Prophylactic Treatment of Adults/Adolescents with Severe Haemophilia A. Adv Ther 2021; 38:4872-4884. [PMID: 34368918 PMCID: PMC8408075 DOI: 10.1007/s12325-021-01853-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 06/30/2021] [Indexed: 12/03/2022]
Abstract
Introduction Given the relatively small number of patients with haemophilia A, head-to-head comparisons between recombinant FVIII (rFVIII) products are difficult to conduct. This study compared the efficacy and consumption of rVIII-SingleChain (lonoctocog alfa, AFSTYLA®) with rAHF-PFM (octocog alfa, Advate®) and rFVIIIFc (efmoroctocog alfa, Elocta®), for the prophylaxis and treatment of bleeding episodes in previously treated adolescents/adults with severe haemophilia A, through a matching-adjusted indirect comparison (MAIC). Methods A systematic literature review identified published clinical trials for rAHF-PFM and rFVIIIFc. Individual patient data for rVIII-SingleChain were used to match baseline patient characteristics to those from published trials, using an approach similar to propensity score weighting. After matching, annualized bleeding rates (ABR), percentage of patients with zero bleeds, and rFVIII consumption were compared across trial populations. Results Published data were identified from two rAHF-PFM trials and one rFVIIIFc trial. rVIII-SingleChain had similar ABR (risk ratio [RR]: 0.74 [0.16; 3.48]; RR: 1.18 [0.85; 1.65]) and percentage of patients with zero bleeds (odds ratio [OR]: 1.34 [0.56; 3.22]; OR: 0.78 [0.47; 1.31]) versus rAHF-PFM and rFVIIIFc, respectively. Annual rVIII-SingleChain consumption was significantly lower than rAHF-PFM (mean difference: − 1507.66 IU/kg/year [− 2011.71; − 1003.61]) and equivalent to rFVIIIFc (RR: 0.96 [0.62; 1.49]). Conclusion Although limited to published information for comparator trials, these results suggest that with an annualized rFVIII consumption comparable to rFVIIIFc, but significantly lower than rAHF-PFM, routine prophylaxis with rVIII-SingleChain is able to maintain a similar ABR and percentage of patients with zero bleeds, attesting to the long-acting nature of rVIII-SingleChain. Supplementary Information The online version contains supplementary material available at 10.1007/s12325-021-01853-0. It is difficult to directly compare different recombinant FVIII products in head-to-head studies because there are few patients with haemophilia A. This study aimed to indirectly compare the efficacy and consumption of different recombinant FVIII products in the prophylactic treatment of haemophilia A using published clinical data. A proven method for performing indirect comparisons of products is referred to as a matching-adjusted indirect comparison. Using this approach, we were able to compare rVIII-SingleChain with two other recombinant FVIII products (rAHF-PFM and rFVIIIFc). Our results suggest that annual FVIII consumption with rVIII-SingleChain is comparable to rFVIIIFc, but is significantly lower than rAHF-PFM, while maintaining a similar bleeding rate. These results highlight the long-acting nature of the product.
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Hotea I, Brinza M, Blag C, Zimta AA, Dirzu N, Burzo C, Rus I, Apostu D, Benea H, Marian M, Mester A, Pasca S, Iluta S, Teodorescu P, Jitaru C, Zdrenghea M, Bojan A, Torok-Vistai T, Niculescu R, Tarniceriu C, Dima D, Truica C, Serban M, Tomuleasa C, Coriu D. Current therapeutic approaches in the management of hemophilia-a consensus view by the Romanian Society of Hematology. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1091. [PMID: 34423003 PMCID: PMC8339806 DOI: 10.21037/atm-21-747] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 05/17/2021] [Indexed: 12/28/2022]
Abstract
Hemophilia A (HA) and hemophilia B (HB) are rare disorders, being caused by the total lack or under-expression of two factors from the coagulation cascade coded by genes of the X chromosome. Thus, in hemophilic patients, the blood does not clot properly. This results in spontaneous bleeding episodes after an injury or surgical intervention. A patient-centered regimen is considered optimal. Age, pharmacokinetics, bleeding phenotype, joint status, adherence, physical activity, personal goals are all factors that should be considered when individualizing therapy. In the past 10 years, many innovations in the diagnostic and treatment options were presented as being either approved or in development, thus helping clinicians to improve the standard-of-care for patients with hemophilia. Recombinant factors still remain the standard of care in hemophilia, however they pose a challenge to treatment adherence because they have short half-life, which where the extended half-life (EHL) factors come with the solution, increasing the half-life to 96 hours. Gene therapies have a promising future with proven beneficial effects in clinical trials. We present and critically analyze in the current manuscript the pros and cons of all the major discoveries in the diagnosis and treatment of HA and HB, as well as identify key areas of hemophilia research where improvements are needed.
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Affiliation(s)
- Ionut Hotea
- Department of Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania.,Department of Hematology, Ion Chiricuta Clinical Cancer Center, Cluj Napoca, Romania.,Medfuture Research Center for Advanced Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania
| | - Melen Brinza
- Department of Hematology, Fundeni Clinical Institute, Bucharest, Romania.,Department of Hematology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Cristina Blag
- Department of Pediatrics, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania.,Department of Hematology, Emergency Clinical Children's Hospital, Cluj Napoca, Romania
| | - Alina-Andreea Zimta
- Medfuture Research Center for Advanced Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania
| | - Noemi Dirzu
- Medfuture Research Center for Advanced Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania
| | - Corina Burzo
- Department of Hematology, Ion Chiricuta Clinical Cancer Center, Cluj Napoca, Romania
| | - Ioana Rus
- Department of Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania
| | - Dragos Apostu
- Department of Orthopedics, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania.,Department of Orthopedics, Emergency Clinical County Hospital, Cluj Napoca, Romania
| | - Horea Benea
- Department of Orthopedics, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania.,Department of Orthopedics, Emergency Clinical County Hospital, Cluj Napoca, Romania
| | - Mirela Marian
- Department of Hematology, Ion Chiricuta Clinical Cancer Center, Cluj Napoca, Romania
| | - Alexandru Mester
- Department of Oral Health, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania
| | - Sergiu Pasca
- Department of Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania
| | - Sabina Iluta
- Department of Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania
| | - Patric Teodorescu
- Department of Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania
| | - Ciprian Jitaru
- Department of Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania
| | - Mihnea Zdrenghea
- Department of Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania.,Department of Hematology, Ion Chiricuta Clinical Cancer Center, Cluj Napoca, Romania
| | - Anca Bojan
- Department of Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania.,Department of Hematology, Ion Chiricuta Clinical Cancer Center, Cluj Napoca, Romania
| | - Tunde Torok-Vistai
- Department of Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania.,Department of Hematology, Ion Chiricuta Clinical Cancer Center, Cluj Napoca, Romania
| | - Radu Niculescu
- Department of Hematology, Fundeni Clinical Institute, Bucharest, Romania
| | - Cristina Tarniceriu
- Department of Anatomy, Grigore T. Popa University of Medicine and Pharmacy, Iasi, Romania.,Department of Hematology, St. Spiridon County Clinical Emergency Hospital, Iasi, Romania
| | - Delia Dima
- Department of Hematology, Ion Chiricuta Clinical Cancer Center, Cluj Napoca, Romania
| | - Cristina Truica
- Department of Hematology, Constantin Opris Emergency Hospital, Baia Mare, Romania
| | - Margit Serban
- Department of Hematology, Victor Babes University of Medicine and Pharmacy, Timisoara, Romania.,European Haemophilia Treatment Center, Timisoara, Romania
| | - Ciprian Tomuleasa
- Department of Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania.,Department of Hematology, Ion Chiricuta Clinical Cancer Center, Cluj Napoca, Romania.,Medfuture Research Center for Advanced Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania
| | - Daniel Coriu
- Department of Hematology, Fundeni Clinical Institute, Bucharest, Romania.,Department of Hematology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
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Lunghi B, Morfini M, Martinelli N, Balestra D, Linari S, Frusconi S, Branchini A, Cervellera CF, Marchetti G, Castaman G, Bernardi F. The Asialoglycoprotein Receptor Minor Subunit Gene Contributes to Pharmacokinetics of Factor VIII Concentrates in Hemophilia A. Thromb Haemost 2021; 122:715-725. [PMID: 34407556 DOI: 10.1055/a-1591-7869] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND The asialoglycoprotein receptor (ASGPR) binds with high affinity factor VIII (FVIII) through its N-linked oligosaccharides. However, its contribution to the wide inter-individual variation of infused FVIII pharmacokinetics (PK) in hemophilia A (HA) is unknown. OBJECTIVE To investigate the variability in FVIII PK outcomes in relation to genetic variation in the ASGR2, encoding the ASGPR2 subunit. METHODS Thirty-two HA patients with FVIII:C ≤2 IU/dL underwent 66 single-dose FVIII PK studies. PK parameters were evaluated in relation to ASGR2 5' untranslated region (5'UTR) polymorphisms, which were investigated by recombinant and white blood cell reverse transcription-polymerase chain reaction approaches. RESULTS The 5'UTR polymorphisms determine a frequent and conserved haplotype (HT1) in a regulatory region. The HT1 homozygotes may differ in the amounts of alternatively spliced mRNA transcripts and thus ASGPR2 isoforms. Compared with the other ASGR2 genotypes, the c.-95TT homozygotes (n = 9), showed threefold longer Alpha HL (3.60 hours, 95% confidence interval: 1.44-5.76, p = 0.006), and the c.-95TC heterozygotes (n = 17) showed 25% shorter mean residence time (MRT; 18.5 hours, 15.0-22.0, p = 0.038) and 32% shorter Beta HL (13.5 hours, 10.9-16.0, p = 0.016). These differences were confirmed in patients (n = 27) undergoing PK studies (n = 54) with full-length FVIII only. In different linear regression models, the contribution of the ASGR2 genotypes remained significant after adjustment by ABO genotypes and von Willebrand factor (VWF) antigen levels, and explained 14% (MRT), 15 to 18% (Beta HL), and 22% (Alpha HL) of parameter variability. CONCLUSIONS Infused FVIII distribution was modulated by frequent ASGR2 genotypes, independently from and together with ABO and VWF antigen levels, which has potential implications for genetically tailored substitutive treatment in HA.
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Affiliation(s)
- Barbara Lunghi
- Department of Life Sciences and Biotechnology, University of Ferrara, Ferrara, Italy
| | - Massimo Morfini
- Italian Association Hemophilia Centers (AICE), Naples, Italy
| | | | - Dario Balestra
- Department of Life Sciences and Biotechnology, University of Ferrara, Ferrara, Italy
| | - Silvia Linari
- Department of Oncology, Center for Bleeding Disorders, Careggi University Hospital, Florence, Italy
| | - Sabrina Frusconi
- Genetic Diagnostics Unit, Laboratory Department, Careggi University Hospital, Florence, Italy
| | - Alessio Branchini
- Department of Life Sciences and Biotechnology, University of Ferrara, Ferrara, Italy
| | | | - Giovanna Marchetti
- Department of Neuroscience and Rehabilitation, University of Ferrara, Ferrara, Italy
| | - Giancarlo Castaman
- Department of Oncology, Center for Bleeding Disorders, Careggi University Hospital, Florence, Italy
| | - Francesco Bernardi
- Department of Life Sciences and Biotechnology, University of Ferrara, Ferrara, Italy
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Cadé M, Muñoz-Garcia J, Babuty A, Fouassier M, Heymann MF, Monahan PE, Heymann D. FVIII at the crossroad of coagulation, bone and immune biology: Emerging evidence of biological activities beyond hemostasis. Drug Discov Today 2021; 27:102-116. [PMID: 34311113 DOI: 10.1016/j.drudis.2021.07.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 04/27/2021] [Accepted: 07/19/2021] [Indexed: 12/19/2022]
Abstract
Hemophilia A is an X-linked hereditary disorder that results from deficient coagulation factor VIII (FVIII) activity, leading to spontaneous bleeding episodes, particularly in joints and muscles. FVIII deficiency has been associated with altered bone remodeling, dysregulated macrophage polarization, and inflammatory processes that are associated with the neoformation of abnormal blood vessels. Treatment based on FVIII replacement can lead to the development of inhibitors that render FVIII concentrate infusion ineffective. In this context, hemophilia has entered a new therapeutic era with the development of new drugs, such as emicizumab, that seek to restore the hemostatic balance by bypassing pathologically acquired antibodies. We discuss the potential extrahemostatic functions of FVIII that may be crucial for defining future therapies in hemophilia.
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Affiliation(s)
- Marie Cadé
- Université de Nantes, INSERM, Institut de Cancérologie de l'Ouest, Saint-Herblain 44805, France
| | - Javier Muñoz-Garcia
- Université de Nantes, INSERM, Institut de Cancérologie de l'Ouest, Saint-Herblain 44805, France
| | - Antoine Babuty
- Université de Nantes, INSERM, Institut de Cancérologie de l'Ouest, Saint-Herblain 44805, France; Department of Haemostasis, CHU de Nantes, France
| | | | - Marie-Francoise Heymann
- Université de Nantes, INSERM, Institut de Cancérologie de l'Ouest, Saint-Herblain 44805, France
| | - Paul E Monahan
- Gene Therapy Center, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, United States
| | - Dominique Heymann
- Université de Nantes, INSERM, Institut de Cancérologie de l'Ouest, Saint-Herblain 44805, France; University of Sheffield, Department of Oncology and Metabolism, Sheffield, UK.
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Lagassé HAD, Hopkins LB, Jankowski W, Jacquemin MG, Sauna ZE, Golding B. Factor VIII-Fc Activates Natural Killer Cells via Fc-Mediated Interactions With CD16. Front Immunol 2021; 12:692157. [PMID: 34262568 PMCID: PMC8273617 DOI: 10.3389/fimmu.2021.692157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 06/16/2021] [Indexed: 11/13/2022] Open
Abstract
The most challenging complication associated with Factor VIII (FVIII) replacement therapy is the development of neutralizing anti-drug antibodies, or inhibitors, which occur in 23-35% of severe (FVIII level <1%) hemophilia A (HA) patients and are a serious hindrance to effective management of HA. Consequently, strategies that can either prevent anti-FVIII inhibitors from developing or "tolerize" individuals who develop such antibodies represent a clinically important unmet need. One intervention for patients with high-titer inhibitors is immune tolerance induction (ITI) therapy. Although ITI therapy is the only clinically proven strategy to eradicate anti-FVIII inhibitors, mechanisms of inhibitor reduction remain unknown. Factor VIII Fc-fusion (rFVIIIFc) is an enhanced half-life antihemophilic factor used in replacement therapy for HA. Fc-fusion is a successful protein bio-engineering platform technology. In addition to enhancement of plasma half-life via neonatal Fc receptor (FcRn) binding, other Fc-mediated interactions, including engagement with Fc gamma receptors (FcγR), may have immunological consequences. Several case reports and retrospective analyses suggest that rFVIIIFc offers superior outcomes with respect to ITI compared to other FVIII products. Previously we and others demonstrated rFVIIIFc interactions with activating FcγRIIIA/CD16. Here, we investigated if rFVIIIFc activates natural killer (NK) cells via CD16. We demonstrated rFVIIIFc signaling via CD16 independent of Von Willebrand Factor (VWF):FVIII complex formation. We established that rFVIIIFc potently activated NK cells in a CD16-dependent fashion resulting in IFNγ secretion and cytolytic perforin and granzyme B release. We also demonstrated an association between rFVIIIFc-mediated NK cell IFNγ secretion levels and the high-affinity (158V) CD16 genotype. Furthermore, we show that rFVIIIFc-activated CD16+ NK cells were able to lyse a B-cell clone (BO2C11) bearing an anti-FVIII B-cell receptor in an antibody-dependent cellular cytotoxicity (ADCC) assay. These in vitro findings provide an underlying molecular mechanism that may help explain clinical case reports and retrospective studies suggesting rFVIIIFc may be more effective in tolerizing HA patients with anti-FVIII inhibitors compared to FVIII not linked to Fc. Our in vitro findings suggest a potential use of Fc-fusion proteins acting via NK cells to target antigen-specific B-cells, in the management of unwanted immune responses directed against immunogenic self-antigens or therapeutic protein products.
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Affiliation(s)
- H A Daniel Lagassé
- Hemostasis Branch, Division of Plasma Protein Therapeutics, Office of Tissues and Advanced Therapies, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring, MD, United States
| | - Louis B Hopkins
- Hemostasis Branch, Division of Plasma Protein Therapeutics, Office of Tissues and Advanced Therapies, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring, MD, United States
| | - Wojciech Jankowski
- Hemostasis Branch, Division of Plasma Protein Therapeutics, Office of Tissues and Advanced Therapies, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring, MD, United States
| | - Marc G Jacquemin
- Department of Cardiovascular Sciences, Center for Molecular and Vascular Biology, University of Leuven, Leuven, Belgium
| | - Zuben E Sauna
- Hemostasis Branch, Division of Plasma Protein Therapeutics, Office of Tissues and Advanced Therapies, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring, MD, United States
| | - Basil Golding
- Hemostasis Branch, Division of Plasma Protein Therapeutics, Office of Tissues and Advanced Therapies, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring, MD, United States
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68
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Population pharmacokinetics of the von Willebrand factor-factor VIII interaction in patients with von Willebrand disease. Blood Adv 2021; 5:1513-1522. [PMID: 33683340 DOI: 10.1182/bloodadvances.2020003891] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 01/21/2021] [Indexed: 01/19/2023] Open
Abstract
Recent studies have reported that patients with von Willebrand disease treated perioperatively with a von Willebrand factor (VWF)/factor VIII (FVIII) concentrate with a ratio of 2.4:1 (Humate P/Haemate P) often present with VWF and/or FVIII levels outside of prespecified target levels necessary to prevent bleeding. Pharmacokinetic (PK)-guided dosing may resolve this problem. As clinical guidelines increasingly recommend aiming for certain target levels of both VWF and FVIII, application of an integrated population PK model describing both VWF activity (VWF:Act) and FVIII levels may improve dosing and quality of care. In total, 695 VWF:Act and 894 FVIII level measurements from 118 patients (174 surgeries) who were treated perioperatively with the VWF/FVIII concentrate were used to develop this population PK model using nonlinear mixed-effects modeling. VWF:Act and FVIII levels were analyzed simultaneously using a turnover model. The protective effect of VWF:Act on FVIII clearance was described with an inhibitory maximum effect function. An average perioperative VWF:Act level of 1.23 IU/mL decreased FVIII clearance from 460 mL/h to 264 mL/h, and increased FVIII half-life from 6.6 to 11.4 hours. Clearly, in the presence of VWF, FVIII clearance decreased with a concomitant increase of FVIII half-life, clarifying the higher FVIII levels observed after repetitive dosing with this concentrate. VWF:Act and FVIII levels during perioperative treatment were described adequately by this newly developed integrated population PK model. Clinical application of this model may facilitate more accurate targeting of VWF:Act and FVIII levels during perioperative treatment with this specific VWF/FVIII concentrate (Humate P/Haemate P).
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FVIII half-life extension by coadministration of a D'D3 albumin fusion protein in mice, rabbits, rats, and monkeys. Blood Adv 2021; 4:1870-1880. [PMID: 32374879 DOI: 10.1182/bloodadvances.2019000999] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 03/29/2020] [Indexed: 02/02/2023] Open
Abstract
A novel mechanism for extending the circulatory half-life of coagulation factor VIII (FVIII) has been established and evaluated preclinically. The FVIII binding domain of von Willebrand factor (D'D3) fused to human albumin (rD'D3-FP) dose dependently improved pharmacokinetics parameters of coadministered FVIII in all animal species tested, from mouse to cynomolgus monkey, after IV injection. At higher doses, the half-life of recombinant FVIII (rVIII-SingleChain) was calculated to be increased 2.6-fold to fivefold compared with rVIII-SingleChain administered alone in rats, rabbits, and cynomolgus monkeys, and it was increased 3.1-fold to 9.1-fold in mice. Sustained pharmacodynamics effects were observed (ie, activated partial thromboplastin time and thrombin generation measured ex vivo). No increased risk of thrombosis was observed with coadministration of rVIII-SingleChain and rD'D3-FP compared with rVIII-SingleChain alone. At concentrations beyond the anticipated therapeutic range, rD'D3-FP reduced the hemostatic efficacy of coadministered rVIII-SingleChain. This finding might be due to scavenging of activated FVIII by the excessive amount of rD'D3-FP which, in turn, might result in a reduced probability of the formation of the tenase complex. This observation underlines the importance of a fine-tuned balance between FVIII and its binding partner, von Willebrand factor, for hemostasis in general.
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Coxon CH, Yu X, Beavis J, Diaz-Saez L, Riches-Duit A, Ball C, Diamond SL, Raut S. Characterisation and application of recombinant FVIII-neutralising antibodies from haemophilia A inhibitor patients. Br J Haematol 2021; 193:976-987. [PMID: 33973229 DOI: 10.1111/bjh.17227] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 10/16/2020] [Indexed: 12/20/2022]
Abstract
The development of anti-drug antibodies (ADAs) is a serious outcome of treatment strategies involving biological medicines. Coagulation factor VIII (FVIII) is used to treat haemophilia A patients, but its immunogenicity precludes a third of severe haemophiliac patients from receiving this treatment. The availability of patient-derived anti-drug antibodies can help us better understand drug immunogenicity and identify ways to overcome it. Thus, there were two aims to this work: (i) to develop and characterise a panel of recombinant, patient-derived, monoclonal antibodies covering a range of FVIII epitopes with varying potencies, kinetics and mechanism of action, and (ii) to demonstrate their applicability to assay development, evaluation of FVIII molecules and basic research. For the first objective we used recombinant antibodies to develop a rapid, sensitive, flexible and reproducible ex vivo assay that recapitulates inhibitor patient blood using blood from healthy volunteers. We also demonstrate how the panel can provide important information about the efficacy of FVIII products and reagents without the need for patient or animal material. These materials can be used as experimental exemplars or controls, as well as tools for rational, hypothesis-driven research and assay development in relation to FVIII immunogenicity and FVIII-related products.
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Affiliation(s)
- Carmen H Coxon
- National Institute for Biological Standards and Control, Hertfordshire, UK
| | - Xinren Yu
- University of Pennsylvania, Philadelphia, PA, USA
| | - James Beavis
- Oxford Haemophilia Centre, Churchill Hospital, Oxford, UK
| | | | - Andrew Riches-Duit
- National Institute for Biological Standards and Control, Hertfordshire, UK
| | - Chris Ball
- National Institute for Biological Standards and Control, Hertfordshire, UK
| | | | - Sanj Raut
- National Institute for Biological Standards and Control, Hertfordshire, UK
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71
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Di Minno A, Spadarella G, Esposito S, Mathew P, Di Minno G, Mannucci PM. Perspective - The case for zero bleeds and drug bioequivalence in the treatment of congenital hemophilia A in 2021. Blood Rev 2021; 50:100849. [PMID: 34024681 DOI: 10.1016/j.blre.2021.100849] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 04/13/2021] [Accepted: 05/04/2021] [Indexed: 01/19/2023]
Abstract
Not all patients with severe hemophilia A (HA) respond optimally to a given dose of a given product. Within-individual variance in cross-over studies makes each patient unique in the response to each standard half-life (SHL) factor VIII (FVIII) product in pharmacokinetic (PK) terms. This hampers the prediction of efficacy when a SHL FVIII product is employed. PK data showing that half-lives of SHL rFVIII are unsatisfactory to achieve zero bleeding in individual HA patients provide the rationale for switching from SHL to extended half-life (EHL) products. However, not all subjects receiving prophylaxis with EHL products achieve zero bleeding, the most cogent objective of personalized prophylaxis. Known determinants of FVIII half-life (age, von Willebrand factor [VWF] levels, blood group) cumulatively account for one third of the total inter-individual variation in FVIII clearance in subjects with severe HA. Investigations into precision, and accuracy of laboratory measurement to be employed; newer pathways for the clearance of both free-FVIII and VWF-bound FVIII, and adequately powered studies on omics and phenotypic heterogeneity, are likely to provide additional information on the remaining two thirds of inter-individual variation in FVIII clearance in HA. Variability in the clinical response has also been documented in patients when FVIII activity is mimicked by fixed subcutaneous doses of the bispecific antibody emicizumab. National registries that collect PK data of available FVIII products and ad hoc information on the individual response to emicizumab should be encouraged, to establish newer standards of care and ease personalized clinical decisions to achieve zero bleeding.
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Affiliation(s)
- Alessandro Di Minno
- Dipartimento di Farmacia, Università degli Studi di Napoli "Federico II", Italy; CEINGE-Biotecnologie Avanzate, Università degli Studi di Napoli "Federico II", Italy.
| | - Gaia Spadarella
- Dipartimento di Scienze Mediche Traslazionali, Università degli Studi di Napoli "Federico II", Italy
| | - Salvatore Esposito
- Dipartimento di Medicina Clinica e Chirurgia and Centro Hub per le Malattie Emorragiche Congenite e le Trombofilie, Università degli Studi di Napoli "Federico II", Italy
| | | | - Giovanni Di Minno
- Dipartimento di Medicina Clinica e Chirurgia and Centro Hub per le Malattie Emorragiche Congenite e le Trombofilie, Università degli Studi di Napoli "Federico II", Italy.
| | - Pier Mannuccio Mannucci
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy..
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Lelas A, Greinix HT, Wolff D, Eissner G, Pavletic SZ, Pulanic D. Von Willebrand Factor, Factor VIII, and Other Acute Phase Reactants as Biomarkers of Inflammation and Endothelial Dysfunction in Chronic Graft-Versus-Host Disease. Front Immunol 2021; 12:676756. [PMID: 33995421 PMCID: PMC8119744 DOI: 10.3389/fimmu.2021.676756] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 04/12/2021] [Indexed: 12/14/2022] Open
Abstract
Chronic graft-versus-host disease (cGvHD) is an immune mediated late complication of allogeneic hematopoietic stem cell transplantation (alloHSCT). Discovery of adequate biomarkers could identify high-risk patients and provide an effective pre-emptive intervention or early modification of therapeutic strategy, thus reducing prevalence and severity of the disease among long-term survivors of alloHSCT. Inflammation, endothelial injury, and endothelial dysfunction are involved in cGvHD development. Altered levels of acute phase reactants have shown a strong correlation with the activity of several immune mediated disorders and are routinely used in clinical practice. Since elevated von Willebrand factor (VWF) and factor VIII (FVIII) levels have been described as acute phase reactants that may indicate endothelial dysfunction and inflammation in different settings, including chronic autoimmune diseases, they could serve as potential candidate biomarkers of cGvHD. In this review we focused on reported data regarding VWF and FVIII as well as other markers of inflammation and endothelial dysfunction, evaluating their potential role in cGvHD.
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Affiliation(s)
- Antonela Lelas
- Division of Hematology, Department of Internal Medicine, University Hospital Centre Zagreb, Zagreb, Croatia
| | | | - Daniel Wolff
- Department of Internal Medicine III, University Hospital Regensburg, Regensburg, Germany
| | - Günther Eissner
- Systems Biology Ireland, School of Medicine, Conway Institute, University College Dublin, Dublin, Ireland
| | - Steven Zivko Pavletic
- Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, United States
| | - Drazen Pulanic
- Division of Hematology, Department of Internal Medicine, University Hospital Centre Zagreb, Zagreb, Croatia.,School of Medicine, University of Zagreb, Zagreb, Croatia
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73
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Seidizadeh O, Peyvandi F, Mannucci PM. Von Willebrand disease type 2N: An update. J Thromb Haemost 2021; 19:909-916. [PMID: 33497541 DOI: 10.1111/jth.15247] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 01/13/2021] [Accepted: 01/14/2021] [Indexed: 12/18/2022]
Abstract
Quantitative or qualitative defects of von Willebrand factor (VWF) are responsible for the most common inherited bleeding disorder, von Willebrand disease (VWD). Type 2N VWD is an uncommon recessive disorder that results from gene mutations located in the region coding for the binding site of VWF for factor VIII (FVIII). This narrative review describes the pathophysiology, diagnostic procedures and treatment as well as the molecular biology of type 2N VWD. Although other VWF-dependent functions like binding to platelets and collagen are preserved, FVIII plasma levels are low due to the rapid clearance of this moiety in the absence or reduction of its binding to VWF. The diagnosis of type 2N should be considered in patients with low FVIII coagulant activity (FVIII:C) and disproportionally higher VWF antigen, especially when they present with an autosomal recessive pattern of inheritance. Because an accurate diagnosis is essential for genetic counseling and optimal treatment, type 2N must be distinguished from mild/moderate hemophilia A and its carrier state. This differential diagnosis can be obtained by using the laboratory assay of the FVIII binding capacity of VWF (VWF:FVIIIB) or analysis of the FVIII binding site on the VWF gene.
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Affiliation(s)
- Omid Seidizadeh
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Milan, Italy
| | - Flora Peyvandi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Pier Mannuccio Mannucci
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Milan, Italy
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74
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Chun H, Pettersson JR, Shestopal SA, Wu WW, Marakasova ES, Olivares P, Surov SS, Ovanesov MV, Shen RF, Sarafanov AG. Characterization of protein unable to bind von Willebrand factor in recombinant factor VIII products. J Thromb Haemost 2021; 19:954-966. [PMID: 33527662 DOI: 10.1111/jth.15257] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 11/26/2020] [Accepted: 12/01/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Therapeutic products with coagulation factor VIII (FVIII) have a wide range of specific activities, implying presence of protein with altered structure. Previous studies showed that recombinant FVIII products (rFVIII) contain a fraction (FVIIIFT ) unable to bind von Willebrand factor (VWF) and reported to lack activity. Because of loss of function(s), FVIIIFT can be defined as a product-related impurity, whose properties and levels in rFVIII products should be investigated. OBJECTIVE To isolate and characterize the FVIIIFT fraction in rFVIII products. METHODS Protein fractions unable (FVIIIFT ) and able (FVIIIEL ) to bind VWF were isolated from rFVIII products using immobilized VWF affinity chromatography (IVAC) and characterized by gel electrophoresis, immunoblotting, FVIII activity test, surface plasmon resonance, mass spectrometry, and for plasma clearance in mice. RESULTS AND CONCLUSIONS A robust IVAC methodology was developed and applied for analysis of 10 rFVIII products marketed in the United States. FVIIIFT was found at various contents (0.4%-21.5%) in all products. Compared with FVIIIEL , FVIIIFT had similar patterns of polypeptide bands by gel electrophoresis, but lower functional activity. In several representative products, FVIIIFT was found to have reduced sulfation at Tyr1680, important for VWF binding, decreased interaction with a low-density lipoprotein receptor-related protein 1 fragment, and faster plasma clearance in mice. These findings provide basic characterization of FVIIIFT and demonstrate a potential for IVAC to control this impurity in rFVIII products to improve their efficacy in therapy of hemophilia A.
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Affiliation(s)
- Haarin Chun
- Center for Biologics Evaluation and Research, U. S. Food and Drug Administration, Silver Spring, MD, USA
| | - John R Pettersson
- Center for Biologics Evaluation and Research, U. S. Food and Drug Administration, Silver Spring, MD, USA
| | - Svetlana A Shestopal
- Center for Biologics Evaluation and Research, U. S. Food and Drug Administration, Silver Spring, MD, USA
| | - Wells W Wu
- Center for Biologics Evaluation and Research, U. S. Food and Drug Administration, Silver Spring, MD, USA
| | - Ekaterina S Marakasova
- Center for Biologics Evaluation and Research, U. S. Food and Drug Administration, Silver Spring, MD, USA
| | - Philip Olivares
- Center for Biologics Evaluation and Research, U. S. Food and Drug Administration, Silver Spring, MD, USA
| | - Stepan S Surov
- Center for Biologics Evaluation and Research, U. S. Food and Drug Administration, Silver Spring, MD, USA
| | - Mikhail V Ovanesov
- Center for Biologics Evaluation and Research, U. S. Food and Drug Administration, Silver Spring, MD, USA
| | - Rong-Fong Shen
- Center for Biologics Evaluation and Research, U. S. Food and Drug Administration, Silver Spring, MD, USA
| | - Andrey G Sarafanov
- Center for Biologics Evaluation and Research, U. S. Food and Drug Administration, Silver Spring, MD, USA
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75
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Trevisan B, Morsi A, Aleman J, Rodriguez M, Shields J, Meares D, Farland AM, Doering CB, Spencer HT, Atala A, Skardal A, Porada CD, Almeida-Porada G. Effects of Shear Stress on Production of FVIII and vWF in a Cell-Based Therapeutic for Hemophilia A. Front Bioeng Biotechnol 2021; 9:639070. [PMID: 33732691 PMCID: PMC7957060 DOI: 10.3389/fbioe.2021.639070] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 01/25/2021] [Indexed: 01/05/2023] Open
Abstract
Microfluidic technology enables recapitulation of organ-level physiology to answer pertinent questions regarding biological systems that otherwise would remain unanswered. We have previously reported on the development of a novel product consisting of human placental cells (PLC) engineered to overexpress a therapeutic factor VIII (FVIII) transgene, mcoET3 (PLC-mcoET3), to treat Hemophilia A (HA). Here, microfluidic devices were manufactured to model the physiological shear stress in liver sinusoids, where infused PLC-mcoET3 are thought to lodge after administration, to help us predict the therapeutic outcome of this novel biological strategy. In addition to the therapeutic transgene, PLC-mcoET3 also constitutively produce endogenous FVIII and von Willebrand factor (vWF), which plays a critical role in FVIII function, immunogenicity, stability, and clearance. While vWF is known to respond to flow by changing conformation, whether and how shear stress affects the production and secretion of vWF and FVIII has not been explored. We demonstrated that exposure of PLC-mcoET3 to physiological levels of shear stress present within the liver sinusoids significantly reduced mRNA levels and secreted FVIII and vWF when compared to static conditions. In contrast, mRNA for the vector-encoded mcoET3 was unaltered by flow. To determine the mechanism responsible for the observed decrease in FVIII and vWF mRNA, PCR arrays were performed to evaluate expression of genes involved in shear mechanosensing pathways. We found that flow conditions led to a significant increase in KLF2, which induces miRNAs that negatively regulate expression of FVIII and vWF, providing a mechanistic explanation for the reduced expression of these proteins in PLC under conditions of flow. In conclusion, microfluidic technology allowed us to unmask novel pathways by which endogenous FVIII and vWF are affected by shear stress, while demonstrating that expression of the therapeutic mcoET3 gene will be maintained in the gene-modified PLCs upon transplantation, irrespective of whether they engraft within sites that expose them to conditions of shear stress.
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Affiliation(s)
- Brady Trevisan
- Fetal Research and Therapy Program, Wake Forest Institute for Regenerative Medicine, Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Alshaimaa Morsi
- Fetal Research and Therapy Program, Wake Forest Institute for Regenerative Medicine, Wake Forest School of Medicine, Winston-Salem, NC, United States.,Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Julio Aleman
- Fetal Research and Therapy Program, Wake Forest Institute for Regenerative Medicine, Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Martin Rodriguez
- Fetal Research and Therapy Program, Wake Forest Institute for Regenerative Medicine, Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Jordan Shields
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta and Department of Pediatrics, Emory University, Atlanta, GA, United States
| | - Diane Meares
- Department of Medicine, Section on Hematology and Oncology, Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Andrew M Farland
- Department of Medicine, Section on Hematology and Oncology, Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Christopher B Doering
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta and Department of Pediatrics, Emory University, Atlanta, GA, United States
| | - H Trent Spencer
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta and Department of Pediatrics, Emory University, Atlanta, GA, United States
| | - Anthony Atala
- Fetal Research and Therapy Program, Wake Forest Institute for Regenerative Medicine, Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Aleks Skardal
- Fetal Research and Therapy Program, Wake Forest Institute for Regenerative Medicine, Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Christopher D Porada
- Fetal Research and Therapy Program, Wake Forest Institute for Regenerative Medicine, Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Graça Almeida-Porada
- Fetal Research and Therapy Program, Wake Forest Institute for Regenerative Medicine, Wake Forest School of Medicine, Winston-Salem, NC, United States
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76
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Von Willebrand Factor Multimer Densitometric Analysis: Validation of the Clinical Accuracy and Clinical Implications in Von Willebrand Disease. Hemasphere 2021; 5:e542. [PMID: 33623884 PMCID: PMC7892298 DOI: 10.1097/hs9.0000000000000542] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 12/16/2020] [Indexed: 11/25/2022] Open
Abstract
Von Willebrand factor (VWF) multimer analysis is important in the classification of von Willebrand disease (VWD). Current visual VWF multimer analysis is time consuming and inaccurate in detecting subtle changes in multimer patterns. Although VWF multimer densitometric analysis may be useful, the accuracy needs further investigation before it can be widely applied. In this study we aimed to validate VWF multimer densitometric analysis in a large cohort of VWD patients and to identify patient characteristics associated with densitometric outcomes. Patients were included from the Willebrand in the Netherlands (WiN) study, in which a bleeding score (BS) was obtained, and blood was drawn. For multimer analysis, citrated blood was separated on an agarose gel and visualized by Western blotting. IMAGEJ was used to generate densitometric images and medium-large VWF multimer index was calculated. We included 560 VWD patients: 328 type 1, 211 type 2, and 21 type 3 patients. Medium-large VWF multimer index performed excellent in distinguishing visually classified normal VWF multimers from reduced high-molecular-weight (HMW) multimers (area under the curve [AUC]: 0.96 [0.94-0.98], P < 0.001), normal multimers from absence of HMW multimers (AUC 1.00 [1.00-1.00], P < 0.001), and type 2A and 2B from type 2M and 2N (AUC: 0.96 [0.94-0.99], P < 0.001). Additionally, higher medium-large VWF multimer index was associated with lower BS in type 1 VWD: β = -7.6 (-13.0 to -2.1), P = 0.007, adjusted for confounders. Densitometric analysis of VWF multimers had an excellent accuracy compared with visual multimer analysis and may contribute to a better understanding of the clinical features such as the bleeding phenotype of VWD patients.
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77
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Singh K, Kwong AC, Madarati H, Kunasekaran S, Sparring T, Fox-Robichaud AE, Liaw PC, Kretz CA. Characterization of ADAMTS13 and von Willebrand factor levels in septic and non-septic ICU patients. PLoS One 2021; 16:e0247017. [PMID: 33606732 PMCID: PMC7894828 DOI: 10.1371/journal.pone.0247017] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 01/30/2021] [Indexed: 12/29/2022] Open
Abstract
Sepsis is a life-threatening disease characterized by excessive host response to infection that can lead to activation of the coagulation system. Von Willebrand Factor (VWF) and ADAMTS13 are important regulators of hemostasis and their dysregulation during sepsis progression is not well understood. Herein we characterize ADAMTS13 and VWF in septic and non-septic patients. ADAMTS13 activity, ADAMTS13 antigen, VWF antigen, myeloperoxidase, and protein C, were measured in plasma collected from 40 septic patients (20 non-survivors and 20 survivors) and 40 non-septic patients on the first and last day of their ICU stay. ADAMTS13 activity and ADAMTS13 antigen were reduced, whereas VWF antigen was elevated among septic patients compared to non-septic patients and healthy controls. Non-septic patients also exhibited elevated VWF antigen and reduced ADAMTS13 activity, but to a lesser extent than septic patients. Non-survivor septic patients exhibited the lowest levels of ADAMTS13 activity. ADAMTS13 activity:antigen ratio was similar across all patient cohorts suggesting that the specific activity of ADAMTS13 remains unchanged. Therefore, reduced ADAMTS13 function in circulation is likely due to a reduction in circulating levels. We suggest that massive release of VWF in response to inflammation consumes limited circulating ADAMTS13, resulting in the imbalance observed between VWF and ADAMTS13 among septic and to a lesser extent in non-septic ICU patients. Changes to ADAMTS13 did not correlate with myeloperoxidase or protein C levels. Reduced ADAMTS13 activity and antigen, and elevated VWF antigen observed among all patient cohorts on admission remained unchanged in survivors at ICU discharge. Prolonged reduction in ADAMTS13 activity and antigen in septic patients coincides with elevated levels of VWF. The persistent abnormalities in ADAMTS13 and VWF in sepsis patients discharged from the ICU may contribute to a sustained prothrombotic state.
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Affiliation(s)
- Kanwal Singh
- Department of Health Sciences, Thrombosis and Atherosclerosis Research Institute (TaARI), McMaster University, Hamilton, Ontario, Canada
| | - Andrew C. Kwong
- Department of Health Sciences, Thrombosis and Atherosclerosis Research Institute (TaARI), McMaster University, Hamilton, Ontario, Canada
| | - Hasam Madarati
- Department of Health Sciences, Thrombosis and Atherosclerosis Research Institute (TaARI), McMaster University, Hamilton, Ontario, Canada
| | - Sharumathy Kunasekaran
- Department of Health Sciences, Thrombosis and Atherosclerosis Research Institute (TaARI), McMaster University, Hamilton, Ontario, Canada
| | - Taylor Sparring
- Department of Health Sciences, Thrombosis and Atherosclerosis Research Institute (TaARI), McMaster University, Hamilton, Ontario, Canada
| | - Alison E. Fox-Robichaud
- Department of Health Sciences, Thrombosis and Atherosclerosis Research Institute (TaARI), McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Patricia C. Liaw
- Department of Health Sciences, Thrombosis and Atherosclerosis Research Institute (TaARI), McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Colin A. Kretz
- Department of Health Sciences, Thrombosis and Atherosclerosis Research Institute (TaARI), McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- * E-mail:
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78
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Mancuso ME, Mahlangu JN, Pipe SW. The changing treatment landscape in haemophilia: from standard half-life clotting factor concentrates to gene editing. Lancet 2021; 397:630-640. [PMID: 33460559 DOI: 10.1016/s0140-6736(20)32722-7] [Citation(s) in RCA: 64] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Accepted: 09/15/2020] [Indexed: 12/13/2022]
Abstract
Congenital haemophilia A (factor VIII deficiency) and B (factor IX deficiency) are X-linked bleeding disorders. Replacement therapy has been the cornerstone of the management of haemophilia, aiming to reduce the mortality and morbidity of chronic crippling arthropathy. Frequent intravenous injections are burdensome and costly for patients, consequently with poor adherence and restricted access to therapy for many patients worldwide. Bioengineered clotting factors with enhanced pharmacokinetic profiles can reduce the burden of treatment. However, replacement therapy is associated with a risk for inhibitor development that adversely affects bleeding prevention and outcomes. Novel molecules that are subcutaneously delivered provide effective prophylaxis in the presence or absence of inhibitors, either substituting for the procoagulant function of clotting factors (eg, emicizumab) or targeting the natural inhibitors of coagulation (ie, antithrombin, tissue factor pathway inhibitor, or activated protein C). The ultimate goal of haemophilia treatment would be a phenotypical cure achievable with gene therapy, currently under late phase clinical investigation.
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Affiliation(s)
- Maria Elisa Mancuso
- Centre for Thrombosis and Hemorrhagic Diseases, Humanitas Clinical and Research Centre, Rozzano, Milan, Italy.
| | - Johnny N Mahlangu
- Faculty of Health Sciences, University of the Witwatersrand, National Health Laboratory Service, Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa
| | - Steven W Pipe
- Pediatrics and Pathology, University of Michigan, Ann Arbor, MI, USA
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79
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Molecular determinants of the factor VIII/von Willebrand factor complex revealed by BIVV001 cryo-electron microscopy. Blood 2021; 137:2970-2980. [PMID: 33569592 DOI: 10.1182/blood.2020009197] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 01/01/2021] [Indexed: 12/15/2022] Open
Abstract
Interaction of factor VIII (FVIII) with von Willebrand factor (VWF) is mediated by the VWF D'D3 domains and thrombin-mediated release is essential for hemostasis after vascular injury. VWF-D'D3 mutations resulting in loss of FVIII binding are the underlying cause of von Willebrand disease (VWD) type 2N. Furthermore, the FVIII-VWF interaction has significant implications for the development of therapeutics for bleeding disorders, particularly hemophilia A, in which endogenous VWF clearance imposes a half-life ceiling on replacement FVIII therapy. To understand the structural basis of FVIII engagement by VWF, we solved the structure of BIVV001 by cryo-electron microscopy to 2.9 Å resolution. BIVV001 is a bioengineered clinical-stage FVIII molecule for the treatment of hemophilia A. In BIVV001, VWF-D'D3 is covalently linked to an Fc domain of a B domain-deleted recombinant FVIII (rFVIII) Fc fusion protein, resulting in a stabilized rFVIII/VWF-D'D3 complex. Our rFVIII/VWF structure resolves BIVV001 architecture and provides a detailed spatial understanding of previous biochemical and clinical observations related to FVIII-VWF engagement. Notably, the FVIII acidic a3 peptide region (FVIII-a3), established as a critical determinant of FVIII/VWF complex formation, inserts into a basic groove formed at the VWF-D'/rFVIII interface. Our structure shows direct interaction of sulfated Y1680 in FVIII-a3 and VWF-R816 that, when mutated, leads to severe hemophilia A or VWD type 2N, respectively. These results provide insight on this key coagulation complex, explain the structural basis of many hemophilia A and VWD type 2N mutations, and inform studies to further elucidate how VWF dissociates rapidly from FVIII upon activation.
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80
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Uhler R, Popa-Wagner R, Kröning M, Brehm A, Rennert P, Seifried A, Peschke M, Krieger M, Kohla G, Kannicht C, Wiedemann P, Hafner M, Rosenlöcher J. Glyco-engineered HEK 293-F cell lines for the production of therapeutic glycoproteins with human N-glycosylation and improved pharmacokinetics. Glycobiology 2021; 31:859-872. [PMID: 33403396 DOI: 10.1093/glycob/cwaa119] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 11/25/2020] [Accepted: 12/18/2020] [Indexed: 12/15/2022] Open
Abstract
N-glycosylated proteins produced in human embryonic kidney 293 (HEK 293) cells often carry terminal N-acetylgalactosamine (GalNAc) and only low levels of sialylation. On therapeutic proteins, such N-glycans often trigger rapid clearance from the patient bloodstream via efficient binding to asialoglycoprotein receptor (ASGP-R) and mannose receptor (MR). This currently limits the use of HEK 293 cells for therapeutic protein production. To eliminate terminal GalNAc, we knocked-out GalNAc transferases B4GALNT3 and B4GALNT4 by CRISPR/Cas9 in FreeStyle 293-F cells. The resulting cell line produced a coagulation factor VII-albumin fusion protein without GalNAc but with increased sialylation. This glyco-engineered protein bound less efficiently to both the ASGP-R and MR in vitro and it showed improved recovery, terminal half-life and area under the curve in pharmacokinetic rat experiments. By overexpressing sialyltransferases ST6GAL1 and ST3GAL6 in B4GALNT3 and B4GALNT4 knock-out cells, we further increased factor VII-albumin sialylation; for ST6GAL1 even to the level of human plasma-derived factor VII. Simultaneous knock-out of B4GALNT3 and B4GALNT4, and overexpression of ST6GAL1 further lowered factor VII-albumin binding to ASGP-R and MR. This novel glyco-engineered cell line is well-suited for the production of factor VII-albumin and presumably other therapeutic proteins with fully human N-glycosylation and superior pharmacokinetic properties.
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Affiliation(s)
- Rico Uhler
- Institute of Molecular and Cell Biology, Mannheim University of Applied Sciences, 68163 Mannheim, Germany.,Octapharma Biopharmaceuticals GmbH, 69120 Heidelberg, Germany
| | | | - Mario Kröning
- Octapharma Biopharmaceuticals GmbH, 12489 Berlin, Germany
| | - Anja Brehm
- Octapharma Biopharmaceuticals GmbH, 12489 Berlin, Germany
| | - Paul Rennert
- Octapharma Biopharmaceuticals GmbH, 12489 Berlin, Germany
| | | | | | - Markus Krieger
- Octapharma Biopharmaceuticals GmbH, 69120 Heidelberg, Germany
| | - Guido Kohla
- Octapharma Biopharmaceuticals GmbH, 12489 Berlin, Germany
| | - Christoph Kannicht
- Octapharma Biopharmaceuticals GmbH, 69120 Heidelberg, Germany.,Octapharma Biopharmaceuticals GmbH, 12489 Berlin, Germany
| | - Philipp Wiedemann
- Institute of Molecular and Cell Biology, Mannheim University of Applied Sciences, 68163 Mannheim, Germany
| | - Mathias Hafner
- Institute of Molecular and Cell Biology, Mannheim University of Applied Sciences, 68163 Mannheim, Germany.,Institute for Medical Technology, University Heidelberg and the Mannheim University of Applied Sciences, 68163 Mannheim, Germany
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81
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Croteau SE, Wang M, Wheeler AP. 2021 clinical trials update: Innovations in hemophilia therapy. Am J Hematol 2021; 96:128-144. [PMID: 33064330 DOI: 10.1002/ajh.26018] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 10/07/2020] [Accepted: 10/12/2020] [Indexed: 01/19/2023]
Abstract
Therapies engineered to prolong clotting factor protein circulation time, manipulate the balance of pro-coagulant and anti-coagulant proteins, or introduce new genetic material to enable endogenous factor protein production dominate the clinical trial landscape of hemophilia. The availability of clotting factor concentrates and the establishment of primary prophylaxis have dramatically improved health outcomes for hemophilia patients. But, the burden of hemostatic therapy remains significant, and many barriers to consistent longitudinal use of prophylaxis exist. Several types of emerging therapeutics including engineered factor concentrates, substitutive therapies, rebalancing therapies, and gene transfer/editing all aim to reduce the challenges of current hemophilia treatment. Emerging treatment options may reduce treatment frequency or need for intravenous administration. They may also introduce new challenges in laboratory assessment of hemostasis. These novel therapies must not introduce significant new health risks and continue to support similar or improved outcomes. The potential ramifications of rebalancing the coagulation cascade, particularly in a stress or inflammatory state, or introduction of new genetic material are not trivial. The focus of this review is to provide an overview of active and recently completed clinical trials as well as emerging preclinical data investigating new therapeutic possibilities for hemophilia patients and potentially other rare bleeding disorders.
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Affiliation(s)
| | - Michael Wang
- University of Colorado Hemophilia and Thrombosis Center Aurora Colorado
| | - Allison P. Wheeler
- Department of Pathology, Microbiology & Immunology Vanderbilt University Medical Center Nashville Tennessee
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82
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BIVV001, a new class of factor VIII replacement for hemophilia A that is independent of von Willebrand factor in primates and mice. Blood 2020; 135:1484-1496. [PMID: 32078672 DOI: 10.1182/blood.2019001292] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 01/29/2020] [Indexed: 01/19/2023] Open
Abstract
Factor VIII (FVIII) replacement products enable comprehensive care in hemophilia A. Treatment goals in severe hemophilia A are expanding beyond low annualized bleed rates to include long-term outcomes associated with high sustained FVIII levels. Endogenous von Willebrand factor (VWF) stabilizes and protects FVIII from degradation and clearance, but it also subjects FVIII to a half-life ceiling of ∼15 to 19 hours. Increasing recombinant FVIII (rFVIII) half-life further is ultimately dependent upon uncoupling rFVIII from endogenous VWF. We have developed a new class of FVIII replacement, rFVIIIFc-VWF-XTEN (BIVV001), that is physically decoupled from endogenous VWF and has enhanced pharmacokinetic properties compared with all previous FVIII products. BIVV001 was bioengineered as a unique fusion protein consisting of a VWF-D'D3 domain fused to rFVIII via immunoglobulin-G1 Fc domains and 2 XTEN polypeptides (Amunix Pharmaceuticals, Inc, Mountain View, CA). Plasma FVIII half-life after BIVV001 administration in mice and monkeys was 25 to 31 hours and 33 to 34 hours, respectively, representing a three- to fourfold increase in FVIII half-life. Our results showed that multifaceted protein engineering, far beyond a few amino acid substitutions, could significantly improve rFVIII pharmacokinetic properties while maintaining hemostatic function. BIVV001 is the first rFVIII with the potential to significantly change the treatment paradigm for severe hemophilia A by providing optimal protection against all bleed types, with less frequent doses. The protein engineering methods described herein can also be applied to other complex proteins.
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83
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Wang X, Fu RY, Li C, Chen CY, Firrman J, Konkle BA, Zhang J, Li L, Xiao W, Poncz M, Miao CH. Enhancing therapeutic efficacy of in vivo platelet-targeted gene therapy in hemophilia A mice. Blood Adv 2020; 4:5722-5734. [PMID: 33216891 PMCID: PMC7686911 DOI: 10.1182/bloodadvances.2020002479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 10/15/2020] [Indexed: 11/20/2022] Open
Abstract
Our previous studies demonstrated that intraosseous (IO) infusion of lentiviral vectors (LVs) carrying a modified B domain-deleted factor VIII (FVIII) transgene driven by a megakaryocyte-specific promoter (GP1Bα promoter; G-F8/N6-LV) successfully transduced hematopoietic stem cells (HSCs) to produce FVIII stored in the platelet α-granules. Platelet FVIII corrected the bleeding phenotype with limited efficacy in hemophilia A (HemA) mice with and without preexisting anti-FVIII inhibitors. The present study sought to further enhance the therapeutic efficacy of this treatment protocol by increasing both the efficiency of LV transduction and the functional activity of platelet FVIII. A combined drug regimen of dexamethasone and anti-CD8α monoclonal antibody enhanced the percentage of transduced bone marrow and HSCs over time. In G-F8/N6-LV-treated HemA mice, significant improvement in phenotypic correction was observed on day 84. To improve platelet FVIII functionality, genes encoding FVIII variant F8X10K12 with increased expression or F8N6K12RH with increased functional activity compared with F8/N6 were incorporated into LVs. Treatment with G-F8X10K12-LV in HemA mice produced a higher level of platelet FVIII but induced anti-FVIII inhibitors. After treatment with combined drugs and IO infusion of G-F8/N6K12RH-LV, HemA mice showed significant phenotypic correction without anti-FVIII inhibitor formation. These results indicate that new human FVIII variant F8/N6K12RH combined with immune suppression could significantly enhance the therapeutic efficacy of in vivo platelet-targeted gene therapy for murine HemA via IO delivery. This protocol provides a safe and effective treatment for hemophilia that may be translatable to and particularly beneficial for patients with preexisting inhibitory antibodies to FVIII.
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Affiliation(s)
- Xuefeng Wang
- Center for Immunity and Immunotherapies, Seattle Children's Research Institute, Seattle, WA
| | - Richard Y Fu
- Center for Immunity and Immunotherapies, Seattle Children's Research Institute, Seattle, WA
| | - Chong Li
- Center for Immunity and Immunotherapies, Seattle Children's Research Institute, Seattle, WA
| | - Chun-Yu Chen
- Center for Immunity and Immunotherapies, Seattle Children's Research Institute, Seattle, WA
| | - Jenni Firrman
- Department of Pediatrics, Indiana University, Indianapolis, IN
| | | | - Junping Zhang
- Department of Pediatrics, Indiana University, Indianapolis, IN
| | - Lei Li
- Department of Chemistry, Georgia State University, Atlanta, GA; and
| | - Weidong Xiao
- Department of Pediatrics, Indiana University, Indianapolis, IN
| | - Mortimer Poncz
- Division of Hematology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Carol H Miao
- Center for Immunity and Immunotherapies, Seattle Children's Research Institute, Seattle, WA
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Hermans C, Dolan G. Pharmacokinetics in routine haemophilia clinical practice: rationale and modalities-a practical review. Ther Adv Hematol 2020; 11:2040620720966888. [PMID: 33194165 PMCID: PMC7594230 DOI: 10.1177/2040620720966888] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Accepted: 09/24/2020] [Indexed: 01/19/2023] Open
Abstract
Prophylactic therapy with exogenous clotting factor concentrates in haemophilia A
and B aims to achieve levels of circulating FVIII or FIX that are adequate for
the prevention or reduction of spontaneous joint bleeding. Historically, a
minimum trough level of at least 1% of the normal levels of circulating clotting
factor has been targeted using standardised protocols. However, clearance of
clotting factor varies between products and patients, and other pharmacokinetic
(PK) parameters such as the frequency and magnitude of peaks may be important
for ensuring optimal coverage. Thus, it is increasingly recognised that an
individualised, PK-based approach to prophylaxis is necessary to achieve optimal
protection. This review focuses on the clinical implications of using PK-guided,
individualised prophylaxis in haemophilia to improve patient outcomes and
considers practical methods of establishing patients’ PK parameters. The most
useful PK parameters will depend on the aim of the specific treatment (e.g.
preventing activity-related and traumatic bleeds or addressing subclinical
bleeding). In clinical practice, lengthy and frequent post-infusion sampling for
PK analysis is costly and a significant burden for patients. However, a Bayesian
analysis allows for the estimation of different PK parameters (e.g. half-life,
factor concentrations over time, etc.) with only a minimum number of samples
(e.g. 4, 24 and 48 h for haemophilia A), by using the patient’s data to adjust a
relevant population PK value towards the actual value. Numerous tools are
available to aid in the practical use of Bayesian PK-guided dosing in the
clinic, including the Web-based Application for the Population Pharmacokinetic
Service hosted by McMaster University, Canada. The PK data can be used to
determine the appropriate prophylaxis regimen for the individual patient, which
can be monitored by assessment of the trough level at each clinic visit. Collection of PK data and subsequent PK-guided dosing should become standard
practice when determining treatment strategies for people with haemophilia.
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Affiliation(s)
- Cedric Hermans
- Haemostasis and Thrombosis Unit, Division of Adult Haematology, St-Luc University Hospital, Université catholique de Louvain (UCLouvain), Avenue Hippocrate 10, Brussels, 1200, Belgium
| | - Gerry Dolan
- Haemophilia and Thrombosis Centre, St Thomas' Hospital, London, UK
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Wang H, Wang L, Liang H, Wei J, Wu Y, Wang X, Xu J. Falsely decreased FVIII activity following pneumatic tube transport. Int J Lab Hematol 2020; 43:305-310. [PMID: 33058454 DOI: 10.1111/ijlh.13363] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 09/04/2020] [Accepted: 09/23/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The pneumatic tube system (PTS) is widely used for sample delivery. We aimed to investigate the impacts of PTS on hemostasis assays. METHODS Triplicate samples from 30 healthy volunteers were delivered to the core laboratory manually by human courier or via the 500 m long-distance PTS or via the 1000 m long-distance PTS. Comparisons of 19 hemostasis tests were conducted. RESULTS Although PT, INR, APTT, FII, FV, FVII FIX, FX, FXII, DD, α2-PI, and PC had statistical significance (all P < .05), all had low average bias remaining within clinical acceptable limits. PTS transportation only resulted in a statistically significant and clinically relevant decrease in FVIII activity. In the 500 m-PTS group, 66.7% (20/30) of samples for FVIII testing had a bias greater than 8.3%. Moreover, in the 1000 m-PTS group, 96.7% (29/30) of samples had a bias of over 8.3%, and the maximal bias achieved 42.1%. CONCLUSIONS Pneumatic tube system in our institution could be used to deliver blood samples for hemostasis tests evaluated in this study except FVIII activity assay.
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Affiliation(s)
- Hong Wang
- Department of Laboratory Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China.,National Key Clinical Department of Laboratory Medicine, Nanjing, China
| | - Lin Wang
- Department of Laboratory Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China.,National Key Clinical Department of Laboratory Medicine, Nanjing, China
| | - Hanyu Liang
- Department of Laboratory Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China.,National Key Clinical Department of Laboratory Medicine, Nanjing, China
| | - Jia Wei
- Department of Laboratory Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yining Wu
- Department of Laboratory Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Xueying Wang
- Department of Laboratory Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Jian Xu
- Department of Laboratory Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China.,National Key Clinical Department of Laboratory Medicine, Nanjing, China
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Bioengineering hemophilia A-specific microvascular grafts for delivery of full-length factor VIII into the bloodstream. Blood Adv 2020; 3:4166-4176. [PMID: 31851760 DOI: 10.1182/bloodadvances.2019000848] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 11/15/2019] [Indexed: 01/19/2023] Open
Abstract
Hemophilia A (HA) is a bleeding disorder caused by mutations in the F8 gene encoding coagulation factor VIII (FVIII). Current treatments are based on regular infusions of FVIII concentrates throughout a patient's life. Alternatively, viral gene therapies that directly deliver F8 in vivo have shown preliminary successes. However, hurdles remain, including lack of infection specificity and the inability to deliver the full-length version of F8 due to restricted viral cargo sizes. Here, we developed an alternative nonviral ex vivo gene-therapy approach that enables the overexpression of full-length F8 in patients' endothelial cells (ECs). We first generated HA patient-specific induced pluripotent stem cells (HA-iPSCs) from urine epithelial cells and genetically modified them using a piggyBac DNA transposon system to insert multiple copies of full-length F8. We subsequently differentiated the modified HA-iPSCs into competent ECs with high efficiency, and demonstrated that the cells (termed HA-FLF8-iECs) were capable of producing high levels of FVIII. Importantly, following subcutaneous implantation into immunodeficient hemophilic (SCID-f8ko) mice, we demonstrated that HA-FLF8-iECs were able to self-assemble into vascular networks, and that the newly formed microvessels had the capacity to deliver functional FVIII directly into the bloodstream of the mice, effectively correcting the clotting deficiency. Moreover, our implant maintains cellular confinement, which reduces potential safety concerns and allows effective monitoring and reversibility. We envision that this proof-of-concept study could become the basis for a novel autologous ex vivo gene-therapy approach to treat HA.
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Konkle BA, Shapiro AD, Quon DV, Staber JM, Kulkarni R, Ragni MV, Chhabra ES, Poloskey S, Rice K, Katragadda S, Fruebis J, Benson CC. BIVV001 Fusion Protein as Factor VIII Replacement Therapy for Hemophilia A. N Engl J Med 2020; 383:1018-1027. [PMID: 32905674 DOI: 10.1056/nejmoa2002699] [Citation(s) in RCA: 66] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Factor VIII replacement products have improved the care of patients with hemophilia A, but the short half-life of these products affects the patients' quality of life. The half-life of recombinant factor VIII ranges from 15 to 19 hours because of the von Willebrand factor chaperone effect. BIVV001 (rFVIIIFc-VWF-XTEN) is a novel fusion protein designed to overcome this half-life ceiling and maintain high sustained factor VIII activity levels. Data are lacking on the safety and pharmacokinetics of single-dose BIVV001. METHODS In this phase 1-2a open-label trial, we consecutively assigned 16 previously treated men (18 to 65 years of age) with severe hemophilia A (factor VIII activity, <1%) to receive a single intravenous injection of recombinant factor VIII at a dose of 25 IU per kilogram of body weight (lower-dose group) or 65 IU per kilogram (higher-dose group). This injection was followed by a washout period of at least 3 days. The patients then received a single intravenous injection of BIVV001 at the same corresponding dose of either 25 IU or 65 IU per kilogram. Adverse events and pharmacokinetic measurements were assessed. RESULTS No inhibitors to factor VIII were detected and no hypersensitivity or anaphylaxis events were reported up to 28 days after the injection of single-dose BIVV001. The geometric mean half-life of BIVV001 was three to four times as long as that of recombinant factor VIII (37.6 hours vs. 9.1 hours in the lower-dose group and 42.5 vs. 13.2 hours in the higher-dose group); the area under the curve (AUC) for product exposure was six to seven times as great in the two dose groups (4470 hours vs. 638 hours × IU per deciliter in the lower-dose group and 12,800 hours vs. 1960 hours × IU per deciliter in the higher-dose group). After the injection of BIVV001 in the higher-dose group, the mean factor VIII level was in the normal range (≥51%) for 4 days and 17% at day 7, which suggested the possibility of a weekly interval between treatments. CONCLUSIONS In a small, early-phase study involving men with severe hemophilia A, a single intravenous injection of BIVV001 resulted in high sustained factor VIII activity levels, with a half-life that was up to four times the half-life associated with recombinant factor VIII, an increase that could signal a new class of factor VIII replacement therapy with a weekly treatment interval. No safety concerns were reported during the 28-day period after administration. (Funded by Sanofi and Sobi; ClinicalTrials.gov number, NCT03205163.).
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Affiliation(s)
- Barbara A Konkle
- From Bloodworks Northwest and the University of Washington, Seattle (B.A.K.); Indiana Hemophilia and Thrombosis Center, Indianapolis (A.D.S.); the Orthopaedic Hemophilia Treatment Center, Los Angeles (D.V.Q.); the University of Iowa, Iowa City (J.M.S.); Michigan State University, East Lansing (R.K.); the Department of Medicine, University of Pittsburgh, and the Hemophilia Center of Western Pennsylvania, Pittsburgh (M.V.R.); and Sanofi (E.S.C., S.P., S.K., C.C.B.) and Bioverativ (K.R., J.F.) - both in Waltham, MA
| | - Amy D Shapiro
- From Bloodworks Northwest and the University of Washington, Seattle (B.A.K.); Indiana Hemophilia and Thrombosis Center, Indianapolis (A.D.S.); the Orthopaedic Hemophilia Treatment Center, Los Angeles (D.V.Q.); the University of Iowa, Iowa City (J.M.S.); Michigan State University, East Lansing (R.K.); the Department of Medicine, University of Pittsburgh, and the Hemophilia Center of Western Pennsylvania, Pittsburgh (M.V.R.); and Sanofi (E.S.C., S.P., S.K., C.C.B.) and Bioverativ (K.R., J.F.) - both in Waltham, MA
| | - Doris V Quon
- From Bloodworks Northwest and the University of Washington, Seattle (B.A.K.); Indiana Hemophilia and Thrombosis Center, Indianapolis (A.D.S.); the Orthopaedic Hemophilia Treatment Center, Los Angeles (D.V.Q.); the University of Iowa, Iowa City (J.M.S.); Michigan State University, East Lansing (R.K.); the Department of Medicine, University of Pittsburgh, and the Hemophilia Center of Western Pennsylvania, Pittsburgh (M.V.R.); and Sanofi (E.S.C., S.P., S.K., C.C.B.) and Bioverativ (K.R., J.F.) - both in Waltham, MA
| | - Janice M Staber
- From Bloodworks Northwest and the University of Washington, Seattle (B.A.K.); Indiana Hemophilia and Thrombosis Center, Indianapolis (A.D.S.); the Orthopaedic Hemophilia Treatment Center, Los Angeles (D.V.Q.); the University of Iowa, Iowa City (J.M.S.); Michigan State University, East Lansing (R.K.); the Department of Medicine, University of Pittsburgh, and the Hemophilia Center of Western Pennsylvania, Pittsburgh (M.V.R.); and Sanofi (E.S.C., S.P., S.K., C.C.B.) and Bioverativ (K.R., J.F.) - both in Waltham, MA
| | - Roshni Kulkarni
- From Bloodworks Northwest and the University of Washington, Seattle (B.A.K.); Indiana Hemophilia and Thrombosis Center, Indianapolis (A.D.S.); the Orthopaedic Hemophilia Treatment Center, Los Angeles (D.V.Q.); the University of Iowa, Iowa City (J.M.S.); Michigan State University, East Lansing (R.K.); the Department of Medicine, University of Pittsburgh, and the Hemophilia Center of Western Pennsylvania, Pittsburgh (M.V.R.); and Sanofi (E.S.C., S.P., S.K., C.C.B.) and Bioverativ (K.R., J.F.) - both in Waltham, MA
| | - Margaret V Ragni
- From Bloodworks Northwest and the University of Washington, Seattle (B.A.K.); Indiana Hemophilia and Thrombosis Center, Indianapolis (A.D.S.); the Orthopaedic Hemophilia Treatment Center, Los Angeles (D.V.Q.); the University of Iowa, Iowa City (J.M.S.); Michigan State University, East Lansing (R.K.); the Department of Medicine, University of Pittsburgh, and the Hemophilia Center of Western Pennsylvania, Pittsburgh (M.V.R.); and Sanofi (E.S.C., S.P., S.K., C.C.B.) and Bioverativ (K.R., J.F.) - both in Waltham, MA
| | - Ekta S Chhabra
- From Bloodworks Northwest and the University of Washington, Seattle (B.A.K.); Indiana Hemophilia and Thrombosis Center, Indianapolis (A.D.S.); the Orthopaedic Hemophilia Treatment Center, Los Angeles (D.V.Q.); the University of Iowa, Iowa City (J.M.S.); Michigan State University, East Lansing (R.K.); the Department of Medicine, University of Pittsburgh, and the Hemophilia Center of Western Pennsylvania, Pittsburgh (M.V.R.); and Sanofi (E.S.C., S.P., S.K., C.C.B.) and Bioverativ (K.R., J.F.) - both in Waltham, MA
| | - Stacey Poloskey
- From Bloodworks Northwest and the University of Washington, Seattle (B.A.K.); Indiana Hemophilia and Thrombosis Center, Indianapolis (A.D.S.); the Orthopaedic Hemophilia Treatment Center, Los Angeles (D.V.Q.); the University of Iowa, Iowa City (J.M.S.); Michigan State University, East Lansing (R.K.); the Department of Medicine, University of Pittsburgh, and the Hemophilia Center of Western Pennsylvania, Pittsburgh (M.V.R.); and Sanofi (E.S.C., S.P., S.K., C.C.B.) and Bioverativ (K.R., J.F.) - both in Waltham, MA
| | - Kara Rice
- From Bloodworks Northwest and the University of Washington, Seattle (B.A.K.); Indiana Hemophilia and Thrombosis Center, Indianapolis (A.D.S.); the Orthopaedic Hemophilia Treatment Center, Los Angeles (D.V.Q.); the University of Iowa, Iowa City (J.M.S.); Michigan State University, East Lansing (R.K.); the Department of Medicine, University of Pittsburgh, and the Hemophilia Center of Western Pennsylvania, Pittsburgh (M.V.R.); and Sanofi (E.S.C., S.P., S.K., C.C.B.) and Bioverativ (K.R., J.F.) - both in Waltham, MA
| | - Suresh Katragadda
- From Bloodworks Northwest and the University of Washington, Seattle (B.A.K.); Indiana Hemophilia and Thrombosis Center, Indianapolis (A.D.S.); the Orthopaedic Hemophilia Treatment Center, Los Angeles (D.V.Q.); the University of Iowa, Iowa City (J.M.S.); Michigan State University, East Lansing (R.K.); the Department of Medicine, University of Pittsburgh, and the Hemophilia Center of Western Pennsylvania, Pittsburgh (M.V.R.); and Sanofi (E.S.C., S.P., S.K., C.C.B.) and Bioverativ (K.R., J.F.) - both in Waltham, MA
| | - Joachim Fruebis
- From Bloodworks Northwest and the University of Washington, Seattle (B.A.K.); Indiana Hemophilia and Thrombosis Center, Indianapolis (A.D.S.); the Orthopaedic Hemophilia Treatment Center, Los Angeles (D.V.Q.); the University of Iowa, Iowa City (J.M.S.); Michigan State University, East Lansing (R.K.); the Department of Medicine, University of Pittsburgh, and the Hemophilia Center of Western Pennsylvania, Pittsburgh (M.V.R.); and Sanofi (E.S.C., S.P., S.K., C.C.B.) and Bioverativ (K.R., J.F.) - both in Waltham, MA
| | - Craig C Benson
- From Bloodworks Northwest and the University of Washington, Seattle (B.A.K.); Indiana Hemophilia and Thrombosis Center, Indianapolis (A.D.S.); the Orthopaedic Hemophilia Treatment Center, Los Angeles (D.V.Q.); the University of Iowa, Iowa City (J.M.S.); Michigan State University, East Lansing (R.K.); the Department of Medicine, University of Pittsburgh, and the Hemophilia Center of Western Pennsylvania, Pittsburgh (M.V.R.); and Sanofi (E.S.C., S.P., S.K., C.C.B.) and Bioverativ (K.R., J.F.) - both in Waltham, MA
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Arruda VR, Doshi BS. Gene Therapy for Hemophilia: Facts and Quandaries in the 21st Century. Mediterr J Hematol Infect Dis 2020; 12:e2020069. [PMID: 32952980 PMCID: PMC7485465 DOI: 10.4084/mjhid.2020.069] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 08/19/2020] [Indexed: 01/19/2023] Open
Abstract
Therapy for hemophilia has evolved in the last 40 years from plasma-based concentrates to recombinant proteins and, more recently, to non-factor therapeutics. Along this same timeline, research in adeno-associated viral (AAV) based gene therapy vectors has provided the framework for early phase clinical trials initially for hemophilia B (HB) and now for hemophilia A. Successive lessons learned from early HB trials have paved the way for current advanced phase trials. Nevertheless, questions linger regarding 1) the optimal balance of vector dose to transgene expression, 2) amount and durability of transgene expression required, and 3) long-term safety. Some trials have demonstrated unique findings not seen previously regarding transient elevation of liver enzymes, immunogenicity of the vector capsid, and loss of transgene expression. This review will provide an update on the clinical AAV gene therapy trials in hemophilia and address the questions above. A thoughtful and rationally approached expansion of gene therapy to the clinics would certainly be a welcome addition to the arsenal of options for hemophilia therapy. Further, the global impact of gene therapy could be vastly improved by expanding eligibility to different patient populations and to developing nations. With the advances made to date, it is possible to envision a shift from the early goal of simply increasing life expectancy to a significant improvement in quality of life by reduction in spontaneous bleeding episodes and disease complications.
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Affiliation(s)
- Valder R. Arruda
- Divsion of Hematology, Children’s Hospital of Philadelphia, Philadelphia PA USA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia PA USA
- Raymond G. Perelman Center for Cellular and Molecular Therapeutics, Children’s Hospital of Philadelphia, Philadelphia PA USA
| | - Bhavya S. Doshi
- Divsion of Hematology, Children’s Hospital of Philadelphia, Philadelphia PA USA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia PA USA
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Small AM, Huffman JE, Klarin D, Sabater-Lleal M, Lynch JA, Assimes TL, Sun YV, Miller D, Freiberg MS, Morrison AC, Rader DJ, Wilson PWF, Cho K, Tsao PS, Chang KM, Smith NL, O'Donnell CJ, de Vries PS, Damrauer SM. Mendelian Randomization Analysis of Hemostatic Factors and Their Contribution to Peripheral Artery Disease-Brief Report. Arterioscler Thromb Vasc Biol 2020; 41:380-386. [PMID: 32847391 DOI: 10.1161/atvbaha.119.313847] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND OBJECTIVE Peripheral artery disease (PAD) is the third most common form of atherosclerotic vascular disease and is characterized by significant functional disability and increased cardiovascular mortality. Recent genetic data support a role for a procoagulation protein variant, the factor V Leiden mutation, in PAD. The role of other hemostatic factors in PAD remains unknown. We evaluated the role of hemostatic factors in PAD using Mendelian randomization. Approach and Results: Two-sample Mendelian randomization to evaluate the roles of FVII (factor VII), FVIII (factor VIII), FXI (factor XI), VWF (von Willebrand factor), and fibrinogen in PAD was performed using summary statistics from GWAS for hemostatic factors performed within the Cohorts for Heart and Aging Research in the Genome Epidemiology Consortium and from GWAS performed for PAD within the Million Veteran Program. Genetically determined FVIII and VWF, but not FVII, FXI, or fibrinogen, were associated with PAD in Mendelian randomization experiments (FVIII: odds ratio, 1.41 [95% CI, 1.23-1.62], P=6.0×10-7, VWF: odds ratio, 1.28 [95% CI, 1.07-1.52], P=0.0073). In single variant sensitivity analysis, the ABO locus was the strongest genetic instrument for both FVIII and VWF. CONCLUSIONS Our results suggest a role for hemostasis, and by extension, thrombosis in PAD. Further study is warranted to determine whether VWF and FVIII independently affect the biology of PAD.
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Affiliation(s)
- Aeron M Small
- Corporal Michael J. Crescenz VA Medical Center, PA (A.M.S., K.-M.C., S.M.D.).,Department of Medicine, Yale University School of Medicine, New Haven, CT (A.M.S.)
| | - Jennifer E Huffman
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), Boston VA Healthcare System (J.E.H., D.K., K.C., C.J.O.)
| | - Derek Klarin
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), Boston VA Healthcare System (J.E.H., D.K., K.C., C.J.O.).,Department of Surgery, Massachusetts General Hospital, Boston (D.K.).,Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA (D.K.)
| | - Maria Sabater-Lleal
- Genomics of Complex Diseases, Research Institute of Hospital Sant Pau, IIB Sant Pau, Barcelona, Spain (M.S.-L.).,Cardiovascular Medicine Unit, Department of Medicine, Center for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden (M.S.-L.)
| | - Julie A Lynch
- Department of Veterans Affairs, Salt Lake City Health Care System, UT (J.A.L.).,University of Massachusetts College of Nursing & Health Sciences, Boston (J.A.L.).,Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial VA Hospital, Bedford, MA (J.A.L.)
| | - Themistocles L Assimes
- VA Palo Alto Health Care System, Palo Alto, CA (T.L.A., P.S.T.).,Department of Medicine, Stanford University School of Medicine, CA (T.L.A., P.S.T.)
| | - Yan V Sun
- Atlanta VA Health Care System, Decatur, GA (Y.V.S., P.W.F.W.).,Department of Epidemiology, Emory University Rollins School of Public Health and Department of Biomedical Informatics, Emory University School of Medicine, Atlanta, GA (Y.V.S.)
| | - Donald Miller
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA (D.M.).,Boston University School of Medicine, MA (D.M.)
| | - Matthew S Freiberg
- VA Tennessee Valley Healthcare System, Nashville (M.S.F.).,Vanderbilt University Medical Center, Nashville, TN (M.S.F.)
| | - Alanna C Morrison
- Human Genetics Center, Department of Epidemiology, Human Genetics, and Environmental Sciences, School of Public Health, The University of Texas Health Sciences Center at Houston (A.C.M.)
| | - Daniel J Rader
- Department of Medicine (D.J.R., K.-M.C.), Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Peter W F Wilson
- Atlanta VA Health Care System, Decatur, GA (Y.V.S., P.W.F.W.).,Emory Clinical Cardiovascular Research Institute, Atlanta, Georgia (P.W.F.W.)
| | - Kelly Cho
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), Boston VA Healthcare System (J.E.H., D.K., K.C., C.J.O.)
| | - Philip S Tsao
- VA Palo Alto Health Care System, Palo Alto, CA (T.L.A., P.S.T.).,Department of Medicine, Stanford University School of Medicine, CA (T.L.A., P.S.T.)
| | - Kyong-Mi Chang
- Corporal Michael J. Crescenz VA Medical Center, PA (A.M.S., K.-M.C., S.M.D.).,Department of Medicine (D.J.R., K.-M.C.), Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Nicholas L Smith
- Department of Epidemiology, University of Washington, Seattle (N.L.S.).,Kaiser Permanente Washington Research Institute, Kaiser Permanente Washington, Seattle (N.L.S.).,Department of Veteran Affairs, Office of Research and Development, Seattle Epidemiologic Research and Information Center, WA (N.L.S.)
| | - Christopher J O'Donnell
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), Boston VA Healthcare System (J.E.H., D.K., K.C., C.J.O.).,Cardiovascular Medicine Division, Department of Medicine, Brigham and Women's Hospital (C.J.O.), Harvard Medical School, Boston
| | - Paul S de Vries
- Human Genetics Center, Department of Epidemiology, Human Genetics, and Environmental Sciences, School of Public Health, The University of Texas Health Sciences Center at Houston (P.S.d.V.)
| | - Scott M Damrauer
- Corporal Michael J. Crescenz VA Medical Center, PA (A.M.S., K.-M.C., S.M.D.).,Department of Surgery (S.M.D.), Perelman School of Medicine, University of Pennsylvania, Philadelphia
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Ma C, Liu D, Li D, Zhang J, Xu XQ, Zhu H, Wan XF, Miao CH, Konkle BA, Onigman P, Xiao W, Li L. Comprehensive N- and O-glycosylation mapping of human coagulation factor V. J Thromb Haemost 2020; 18:1884-1892. [PMID: 32310329 PMCID: PMC7732234 DOI: 10.1111/jth.14861] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Revised: 04/08/2020] [Accepted: 04/10/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND/OBJECTIVE Coagulation factor V (FV), a multidomain glycoprotein, is an essential cofactor in the blood clotting cascade. FV deficiency is a rare bleeding disorder that results in poor clotting after an injury or surgery. The only treatment for the disease is infusions of fresh frozen plasma and blood platelets. Glycosylation affects the biological activity, pharmacokinetics, immunogenicity, and in vivo clearance rate of proteins in the plasma. The glycan profile of FV, as well as how it affects the activity, stability, and immunogenicity, remains unknown. METHODS In this study, we comprehensively mapped the glycosylation patterns of human plasma-derived FV by combining multienzyme digestion, hydrophilic interaction chromatography enrichment of glycopeptides, and alternated fragmentation mass spectrometry analysis. RESULTS/CONCLUSION A total of 57 unique N-glycopeptides and 51 O-glycopeptides were identified, which were categorized into 40 N-glycan and 17 O-glycan compositions. Such glycosylation details are fundamental for future functional studies and therapeutics development. In addition, the established methodology can be readily applied to analyze glycosylation patterns of proteins with more than 2000 amino acids.
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Affiliation(s)
- Cheng Ma
- Department of Chemistry, Georgia State University, Atlanta, GA, USA
| | - Ding Liu
- Department of Chemistry, Georgia State University, Atlanta, GA, USA
| | - Dong Li
- Department of Clinical Laboratory, Shanghai Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Junping Zhang
- Department of Microbiology and Immunology, Sol Sherry Thrombosis Research Center, Cardiovascular Research Center, Temple University, Philadelphia, PA, USA
| | - Xiao-Qian Xu
- Department of Hematology, Shanghai Jiaotong University Affiliated Shanghai General Hospital, Shanghai, China
| | - He Zhu
- Department of Chemistry, Georgia State University, Atlanta, GA, USA
| | - Xiu-Feng Wan
- Missouri University Center for Research on Influenza Systems Biology (CRISB), University of Missouri, Columbia, MO, USA
- Department of Molecular Microbiology and Immunology, School of Medicine, University of Missouri, Columbia, MO, USA
- Department of Electrical Engineering & Computer Science, College of Engineering, University of Missouri, Columbia, MO, USA
- Bond Life Sciences Center, University of Missouri, Columbia, MO, USA
- MU Informatics Institute, University of Missouri, Columbia, MO, USA
- Department of Pathobiology, College of Veterinary Medicine, University of Missouri, Columbia, MO, USA
| | - Carol H. Miao
- Center for Immunity and Immunotherapies, Seattle Children’s Research Institute, Seattle, WA, USA
- University of Washington, Seattle, WA, USA
| | - Barbara A. Konkle
- University of Washington, Seattle, WA, USA
- Bloodworks Northwest, Seattle, WA, USA
| | | | - Weidong Xiao
- Department of Microbiology and Immunology, Sol Sherry Thrombosis Research Center, Cardiovascular Research Center, Temple University, Philadelphia, PA, USA
| | - Lei Li
- Department of Chemistry, Georgia State University, Atlanta, GA, USA
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91
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Turecek PL, Johnsen JM, Pipe SW, O'Donnell JS. Biological mechanisms underlying inter-individual variation in factor VIII clearance in haemophilia. Haemophilia 2020; 26:575-583. [PMID: 32596930 PMCID: PMC7496649 DOI: 10.1111/hae.14078] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 05/26/2020] [Indexed: 12/28/2022]
Abstract
Previous studies have highlighted marked inter‐individual variations in factor VIII (FVIII) clearance between patients with haemophilia (PWH). The half‐life of infused FVIII has been reported to vary from as little as 5.3 hours in some adult PWH, up to as long as 28.8 hours in other individuals. These differences in clearance kinetics have been consistently observed using a number of different plasma‐derived and recombinant FVIII products. Furthermore, recent studies have demonstrated that half‐life for extended half‐life (EHL‐) FVIII products also demonstrates significant inter‐patient variation. Since time spent with FVIII trough levels <1% has been shown to be associated with increased bleeding risk in PWH on prophylaxis therapy, this variability in FVIII clearance clearly has major clinical significance. Recent studies have provided significant novel insights into the cellular basis underlying FVIII clearance pathways. In addition, accumulating data have shown that endogenous plasma VWF levels, ABO blood group and age, all play important roles in regulating FVIII half‐life in PWH. Indeed, multiple regression analysis suggests that together these factors account for approximately 34% of the total inter‐individual variation in FVIII clearance observed between subjects with severe haemophilia A. In this review, we consider these and other putative modulators of FVIII half‐life, and discuss the biological mechanisms through which these factors impact upon FVIII clearance in vivo.
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Affiliation(s)
- Peter L Turecek
- Baxalta Innovations GmbH, A Member of the Takeda Group of Companies, Vienna, Austria
| | - Jill M Johnsen
- Bloodworks Northwest Research Institute, Seattle, WA, USA.,Department of Medicine, University of Washington, Seattle, WA, USA
| | - Steven W Pipe
- Departments of Pediatrics and Pathology, University of Michigan, Ann Arbor, MI, USA
| | - James S O'Donnell
- Haemostasis Research Group, Irish Centre for Vascular Biology, Royal College of Surgeons in Ireland, Dublin, Ireland.,National Children's Research Centre, Our Lady's Children's Hospital, Dublin, Ireland.,National Coagulation Centre, St James's Hospital, Dublin, Ireland
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92
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Karim AF, Soltis AR, Sukumar G, Königs C, Ewing NP, Dalgard CL, Wilkerson MD, Pratt KP. Hemophilia A Inhibitor Subjects Show Unique PBMC Gene Expression Profiles That Include Up-Regulated Innate Immune Modulators. Front Immunol 2020; 11:1219. [PMID: 32595650 PMCID: PMC7303277 DOI: 10.3389/fimmu.2020.01219] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 05/15/2020] [Indexed: 12/18/2022] Open
Abstract
Formation of pathological anti-FVIII antibodies, or "inhibitors," is the most serious complication of therapeutic FVIII infusions, affecting up to 1/3 of severe Hemophilia A (HA) patients. Inhibitor formation is a classical T-cell dependent adaptive immune response. As such, it requires help from the innate immune system. However, the roles of innate immune cells and mechanisms of inhibitor development vs. immune tolerance, achieved with or without Immune Tolerance Induction (ITI) therapy, are not well-understood. To address these questions, temporal transcriptomics profiling of FVIII-stimulated peripheral blood mononuclear cells (PBMCs) was carried out for HA subjects with and without a current or historic inhibitor using RNA-Seq. PBMCs were isolated from 40 subjects in the following groups: HA with an inhibitor that resolved either following ITI or spontaneously; HA with a current inhibitor; HA with no inhibitor history and non-HA controls. PBMCs were stimulated with 5 nM FVIII and RNA was isolated 4, 16, 24, and 48 h following stimulation. Time-series differential expression analysis was performed and distinct transcriptional signatures were identified for each group, providing clues as to cellular mechanisms leading to or accompanying their disparate anti-FVIII antibody responses. Subjects with a current inhibitor showed differential expression of 56 genes and a clustering analysis identified three major temporal profiles. Interestingly, gene ontology enrichments featured innate immune modulators, including NLRP3, TLR8, IL32, CLEC10A, and COLEC12. NLRP3 and TLR8 are associated with enhanced secretion of the pro-inflammatory cytokines IL-1β and TNFα, while IL32, which has several isoforms, has been associated with both inflammatory and regulatory immune processes. RNA-Seq results were validated by RT-qPCR, ELISAs, multiplex cytokine analysis, and flow cytometry. The inflammatory status of HA patients suffering from an ongoing inhibitor includes up-regulated innate immune modulators, which may act as ongoing danger signals that influence the responses to, and eventual outcomes of, ITI therapy.
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Affiliation(s)
- Ahmad Faisal Karim
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, United States.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, United States
| | - Anthony R Soltis
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, United States.,Collaborative Health Initiative Research Program, Henry Jackson Foundation for the Advancement of Military Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, United States.,The American Genome Center, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | - Gauthaman Sukumar
- Collaborative Health Initiative Research Program, Henry Jackson Foundation for the Advancement of Military Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, United States.,The American Genome Center, Uniformed Services University of the Health Sciences, Bethesda, MD, United States.,Department of Anatomy, Physiology & Genetics, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | | | - Nadia P Ewing
- City of Hope National Medical Center, Duarte, CA, United States
| | - Clifton L Dalgard
- Collaborative Health Initiative Research Program, Henry Jackson Foundation for the Advancement of Military Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, United States.,The American Genome Center, Uniformed Services University of the Health Sciences, Bethesda, MD, United States.,Department of Anatomy, Physiology & Genetics, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | - Matthew D Wilkerson
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, United States.,Collaborative Health Initiative Research Program, Henry Jackson Foundation for the Advancement of Military Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, United States.,The American Genome Center, Uniformed Services University of the Health Sciences, Bethesda, MD, United States.,Department of Anatomy, Physiology & Genetics, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | - Kathleen P Pratt
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
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93
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Escobar M, Santagostino E, Mancuso ME, Coppens M, Balasa V, Taylor JA, Iorio A, Negrier C. Switching patients in the age of long-acting recombinant products? Expert Rev Hematol 2020; 12:1-13. [PMID: 31282771 DOI: 10.1080/17474086.2018.1564032] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Introduction: Prophylaxis with factor replacement therapy is the gold standard for the treatment of hemophilia, but this often requires frequent infusions. A number of long-acting factor products have been developed to reduce the burden on patients. Areas covered: This is an overview of information presented at two symposia held at the World Federation of Hemophilia and International Society on Thrombosis and Haemostasis - Scientific and Standardization Committee annual meetings. The pharmacokinetic, safety and efficacy data for long-acting recombinant products are reviewed, with a focus on recombinant factor IX albumin fusion protein (rIX-FP) and rVIII-SingleChain. This overview also provides a guide for managing a patient's switch to long-acting products. Expert opinion: Long-acting products may allow patients to maintain or decrease bleeding rates whilst increasing their dosing interval, which may in turn reduce the burden on patients and caregivers. When switching patients to long-acting products health-care professionals should provide balanced and thorough education to the patient, whilst supporting their emotional well-being. Regimens should address patients' needs and goals but should also be guided by clinical phenotype and pharmacokinetic assessment. Follow-up should assess safety concerns, bleeding rates, joint health and the impact of the regimen on patients' lifestyle.
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Affiliation(s)
- Miguel Escobar
- a Department of Internal Medicine and Pediatrics, Division of Hematology , University of Texas Health Science Center and the Gulf States Hemophilia and Thrombophilia Center , Houston , TX , USA
| | - Elena Santagostino
- b Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico , Angelo Bianchi Bonomi Hemophilia and Thrombosis Centre , Milan , Italy
| | - Maria Elisa Mancuso
- b Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico , Angelo Bianchi Bonomi Hemophilia and Thrombosis Centre , Milan , Italy
| | - Michiel Coppens
- c Department of Vascular Medicine , Amsterdam Cardiovascular Sciences, Amsterdam UMC , Amsterdam , the Netherlands
| | - Vinod Balasa
- d Division Chief and Medical Director, Hematology/Oncology , Valley Children's Hospital , Madera , CA , USA
| | - Jason A Taylor
- e Division of Hematology and Medical Oncology , The Hemophilia Center, Knight Cancer Institute, Oregon Health & Science University and Portland VA Medical Center , Portland , OR , USA
| | - Alfonso Iorio
- f Department of Health Research Methods, Evidence and Impact , McMaster University , Hamilton , ON , Canada
| | - Claude Negrier
- g National Reference Centre for Haemophilia, Louis Pradel Hospital , University Claude Bernard Lyon I , Lyon , France
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94
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Plautz WE, Matthay ZA, Rollins-Raval MA, Raval JS, Kornblith LZ, Neal MD. Von Willebrand factor as a thrombotic and inflammatory mediator in critical illness. Transfusion 2020; 60 Suppl 3:S158-S166. [PMID: 32478907 DOI: 10.1111/trf.15667] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 12/26/2019] [Accepted: 12/26/2019] [Indexed: 12/11/2022]
Abstract
The endothelial exocytosis of high-molecular-weight multimeric von Willebrand factor (vWF) may occur in critical illness states, including trauma and sepsis, leading to the sustained elevation and altered composition of plasma vWF. These critical illnesses involve the common process of sympathoadrenal activation and loss of the endothelial glycocalyx. As a prothrombotic and proinflammatory molecule that interacts with the endothelium, the alterations exhibited by vWF in critical illness have been implicated in the development and damaging effects of downstream pathologies, such as disseminated intravascular coagulation and systemic inflammatory response syndrome. Given the role of vWF in these pathologies, there has been a recent push to further understand how the molecule may be involved in the pathophysiology of related diseases, such as trauma-induced coagulopathy and acute renal injury, which are also known to develop secondarily to critical illness states. Elucidation of the role of vWF across the broader spectrum of generalized pathologies may provide a basis for the development of novel preventative and restorative measures, while also bolstering the scaffold of more widely used treatments, such as the administration of plasma-containing blood products.
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Affiliation(s)
- William E Plautz
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Zachary A Matthay
- Department of Surgery, University of California, San Francisco, San Francisco, California.,Department of Surgery, Zuckerberg San Francisco General Hospital, San Francisco, California
| | | | - Jay S Raval
- Department of Pathology, University of New Mexico, Albuquerque, New Mexico
| | - Lucy Z Kornblith
- Department of Surgery, University of California, San Francisco, San Francisco, California.,Department of Surgery, Zuckerberg San Francisco General Hospital, San Francisco, California
| | - Matthew D Neal
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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95
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Lalezari S, Acquadro M, de Bock E, Lambert J, Simpson ML. Comparing Physician and Patient Perspectives on Prophylactic Treatment with BAY 94-9027 for Severe Haemophilia A: A Post Hoc Analysis. Adv Ther 2020; 37:2763-2776. [PMID: 32410165 PMCID: PMC7467448 DOI: 10.1007/s12325-020-01374-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Indexed: 12/02/2022]
Abstract
Introduction BAY 94-9027 is a newly developed extended half-life product to treat haemophilia, allowing for fewer injections than with standard products. This post hoc analysis aimed to compare physicians’ and patients’ opinions on BAY 94-9027 prophylaxis, and explore how qualitative interview data is aligned with the data from the Haemophilia-specific Quality of Life questionnaire for Adults (Haemo-QoL-A). Methods Exploratory qualitative interviews were conducted with physicians and patients by phone upon the exit of patients from the PROTECT VIII extension phase following a semi-directed guide. In this post hoc analysis, all transcripts were reviewed and reported concepts were compared to assess the level of concordance between physicians and patients. These qualitative data were compared with the Haemo-QoL-A mean global and subscale scores at baseline and end of main phase (36 weeks later). Results Ten physicians and 16 patients (mean age 47 years) from Israel, the Netherlands and the USA were interviewed. Significant improvements were reported by all physicians from baseline [e.g. lower frequency of bleeds (80%), improvement in emotional functioning (90%)], which is in concordance with patients’ reports. The improved confidence reported by physicians cascaded to greater participation in various activities, resulting in a better perceived emotional state and a significant improvement on the Haemo-QoL-A emotional impact subscale score (p = 0.04) between baseline and end of main phase. Most physicians (80%) reported improvement in bleed frequency, as patients did (88%). Improvement in physical functioning or mobility was not consistently reported in this 8-month study. Conclusion Interviewed physicians and patients generally agreed on the beneficial impact of BAY 94-9027, specifically regarding the increased level of self-confidence in patients and its subsequent positive impact on patients’ lives. These findings supported the observed improvement on the Haemo-QoL-A emotional impact subscale. Overall, this study highlights the concordance between physician and patient perspective on the positive experience with BAY 94-9027.
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Affiliation(s)
- Shadan Lalezari
- National Hemophilia Center, Sheba Medical Center, Tel Hashomer, and Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | | | | | | | - Mindy L Simpson
- Rush Hemophilia and Thrombophilia Center, Rush University Medical Center, Chicago, IL, USA.
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96
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Peptides identified on monocyte-derived dendritic cells: a marker for clinical immunogenicity to FVIII products. Blood Adv 2020; 3:1429-1440. [PMID: 31053570 DOI: 10.1182/bloodadvances.2018030452] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Accepted: 03/18/2019] [Indexed: 12/14/2022] Open
Abstract
The immunogenicity of protein therapeutics is an important safety and efficacy concern during drug development and regulation. Strategies to identify individuals and subpopulations at risk for an undesirable immune response represent an important unmet need. The major histocompatibility complex (MHC)-associated peptide proteomics (MAPPs) assay directly identifies the presence of peptides derived from a specific protein therapeutic on a donor's MHC class II (MHC-II) proteins. We applied this technique to address several questions related to the use of factor VIII (FVIII) replacement therapy in the treatment of hemophilia A (HA). Although >12 FVIII therapeutics are marketed, most fall into 3 categories: (i) human plasma-derived FVIII (pdFVIII), (ii) full-length (FL)-recombinant FVIII (rFVIII; FL-rFVIII), and (iii) B-domain-deleted rFVIII. Here, we investigated whether there are differences between the FVIII peptides found on the MHC-II proteins of the same individual when incubated with these 3 classes. Based on several observational studies and a prospective, randomized, clinical trial showing that the originally approved rFVIII products may be more immunogenic than the pdFVIII products containing von Willebrand factor (VWF) in molar excess, it has been hypothesized that the pdFVIII molecules yield/present fewer peptides (ie, potential T-cell epitopes). We have experimentally tested this hypothesis and found that dendritic cells from HA patients and healthy donors present fewer FVIII peptides when administered pdFVIII vs FL-rFVIII, despite both containing the same molar VWF excess. Our results support the hypothesis that synthesis of pdFVIII under physiological conditions could result in reduced heterogeneity and/or subtle differences in structure/conformation which, in turn, may result in reduced FVIII proteolytic processing relative to FL-rFVIII.
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97
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Hemophilia A and von Willebrand deficiency: therapeutic implications. Blood Coagul Fibrinolysis 2020; 31:397-401. [PMID: 32255574 DOI: 10.1097/mbc.0000000000000908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
: Hemophilia A is an X-linked bleeding disorder caused by a deficiency of factor VIII. Depending on the factor VIII activity in patient's plasma, we can have three different forms of hemophilia A: mild (5-40 IU/dl), moderate (1-5 IU/dl) and severe (<1 IU/dl). The most common symptoms include recurrent bleeding episodes of soft tissues and joints. The treatment is based on the prophylactic use of clotting factor concentrates to prevent bleeding episodes. We describe three cases of patients with initially diagnosis of hemophilia A that show different clinical severity, undergoing prophylactic therapies with low benefit. In these patients, the dosage of von Willebrand antigen revealed either low level or absence of this factor, which in one case was caused by the occurrence of a type III form of von Willebrand disease.
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98
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Sacco M, Ranalli P, Lancellotti S, Petrucci G, Dragani A, Rocca B, De Cristofaro R. Increased von Willebrand factor levels in polycythemia vera and phenotypic differences with essential thrombocythemia. Res Pract Thromb Haemost 2020; 4:413-421. [PMID: 32211575 PMCID: PMC7086469 DOI: 10.1002/rth2.12315] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 01/13/2020] [Accepted: 01/17/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Acquired von Willebrand factor (VWF) deficiency was described in Philadelphia-negative myeloproliferative neoplasms, especially in essential thrombocythemia (ET). VWF phenotype in contemporary patients with polycythemia vera (PV) remains less explored. OBJECTIVES To characterize the VWF phenotype in PV and to compare VWF phenotype in PV with matched healthy subjects and ET patients. PATIENTS/METHODS We studied 48 PV patients, treated according to current recommendations (hematocrit ≤ 45%, on low-dose aspirin prophylaxis); 48 healthy and 41 subjects with ET, all sex, age, and blood group matched. We measured VWF antigen, activity, multimeric pattern, ADAMTS-13, and factor VIII (FVIII) antigen. RESULTS In patients with PV, VWF antigen and activity were significantly higher than in healthy subjects (antigen: 119[96-137] vs 93[79-107] IU/dL; activity: 114[95-128] vs 90[79-107] IU/dL, respectively, medians and interquartile, P < 0.01), with normal multimeric distribution. ADAMTS-13 levels were similar between patients with PV and healthy subjects. FVIII levels were higher in PV than in healthy subjects (141[119-169] versus 98[88-123] IU/dL, respectively, P < 0.01). By multivariable analysis, JAK2-p.V617F allelic burden, erythrocyte count, and male sex significantly predicted VWF antigen and activity levels. As compared to patients with ET, patients with PV showed similar VWF antigen levels but approximately 40% higher activity (79[49-104] vs 112[93-125] IU/dL, respectively, P < 0.01). CONCLUSIONS Patients with PV show increased VWF and FVIII levels, predicted by JAK2-p.V617F burden and erythrocyte count. At variance with ET, acquired VWF defect was not observed in PV. High VWF/FVIII levels may sustain the thrombotic diathesis of PV and may be investigated as biomarkers for risk stratification.
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Affiliation(s)
- Monica Sacco
- Servizio Malattie Emorragiche e TromboticheFondazione Policlinico Universitario “A. Gemelli” IRCCSRomaItaly
| | - Paola Ranalli
- Dipartimento di Medicina Interna e Chirurgia TraslazionaleFacoltà di Medicina e Chirurgia “A. Gemelli”Università Cattolica del Sacro CuoreRomaItaly
| | | | - Giovanna Petrucci
- Istituto di FarmacologiaFacoltà di Medicina e Chirurgia “A. Gemelli”Università Cattolica del S. Cuore and Fondazione Policlinico Universitario “A. Gemelli” IRCCSRomeItaly
| | - Alfredo Dragani
- Dipartimento di Medicina Interna e Chirurgia TraslazionaleFacoltà di Medicina e Chirurgia “A. Gemelli”Università Cattolica del Sacro CuoreRomaItaly
| | - Bianca Rocca
- Istituto di FarmacologiaFacoltà di Medicina e Chirurgia “A. Gemelli”Università Cattolica del S. Cuore and Fondazione Policlinico Universitario “A. Gemelli” IRCCSRomeItaly
| | - Raimondo De Cristofaro
- Servizio Malattie Emorragiche e TromboticheFondazione Policlinico Universitario “A. Gemelli” IRCCSRomaItaly
- Dipartimento di EmatologiaOspedale S. SpiritoPescaraItaly
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99
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Zakas PM, Healey JF, Smith IW, Lillicrap D, Lollar P. Sedimentation Velocity Analytical Ultracentrifugation of Oxidized Recombinant Full-Length Factor VIII. Front Immunol 2020; 11:150. [PMID: 32117290 PMCID: PMC7020254 DOI: 10.3389/fimmu.2020.00150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Accepted: 01/20/2020] [Indexed: 11/17/2022] Open
Abstract
Anti-drug antibodies to coagulation factor VIII (fVIII), often termed inhibitors, present the greatest economical and treatment related obstacle in the management of hemophilia A. Although several genetic and environmental risk factors associated with inhibitor development have been identified, the precise mechanisms responsible for the immune response to exogenous fVIII therapies remain undefined. Clinical trials suggest there is an increased immunogenic potential of recombinant fVIII compared to plasma-derived products. Additional biochemical and immunological studies have demonstrated that changes in recombinant fVIII production and formulation can alter fVIII structure and immunogenicity. Recently, one study demonstrated increased immunogenicity of the recombinant fVIII product Helixate in hemophilia A mice following oxidation with hypochlorite (ClO−). It is widely reported that protein aggregates within drug products can induce adverse immune reactions in patients. Several studies have therefore investigated the prevalence of molecular aggregates in commercial recombinant products with and without use-relevant stress and agitation. To investigate the potential link between oxidation-induced immunogenicity and molecular aggregation, we analyzed the recombinant fVIII product, Helixate, via sedimentation velocity analytical ultracentrifugation following oxidation with ClO−. At 80 μM ClO−, a concentration that reduced the specific-activity by 67%, no detectable increase in large molecular aggregates (s > 12 S) was observed when compared to non-oxidized fVIII. This lack of aggregates was demonstrated both in commercial excipient as well as a HEPES buffered saline formulation. These data suggest that oxidation induced immunogenicity is independent of aggregate-mediated immune response. Therefore, our data support multiple, independent mechanisms underlying fVIII immunogenicity.
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Affiliation(s)
- Philip M Zakas
- Department of Pathology and Molecular Medicine, Queen's University, Kingston, ON, Canada
| | - John F Healey
- Department of Pediatrics, Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Emory University, Atlanta, GA, United States
| | - Ian W Smith
- Department of Pediatrics, Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Emory University, Atlanta, GA, United States
| | - David Lillicrap
- Department of Pathology and Molecular Medicine, Queen's University, Kingston, ON, Canada
| | - Pete Lollar
- Department of Pediatrics, Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Emory University, Atlanta, GA, United States
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100
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Przeradzka MA, Freato N, Boon-Spijker M, van Galen J, van der Zwaan C, Mertens K, van den Biggelaar M, Meijer AB. Unique surface-exposed hydrophobic residues in the C1 domain of factor VIII contribute to cofactor function and von Willebrand factor binding. J Thromb Haemost 2020; 18:364-372. [PMID: 31675465 DOI: 10.1111/jth.14668] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 10/29/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND The identity of the amino acid regions of factor VIII (FVIII) that contribute to factor IXa (FIXa) and von Willebrand factor (VWF) binding has not been fully resolved. Previously, we observed that replacing the FVIII C1 domain for the one of factor V (FV) markedly reduces VWF binding and cofactor function. Compared to the FV C1 domain, this implies that the FVIII C1 domain comprises unique surface-exposed elements involved in VWF and FIXa interaction. OBJECTIVE The aim of this study is to identify residues in the FVIII C1 domain that contribute to VWF and FIXa binding. METHODS Structures and primary sequences of FVIII and FV were compared to identify surface-exposed residues unique to the FVIII C1 domain. The identified residues were replaced with alanine residues to identify their role in FIXa and VWF interaction. This role was assessed employing surface plasmon resonance analysis studies and enzyme kinetic assays. RESULTS Five surface-exposed hydrophobic residues unique to the FVIII C1 domain, ie, F2035, F2068, F2127, V2130, I2139 were identified. Functional analysis indicated that residues F2068, V2130, and especially F2127 contribute to VWF and/or FIXa interaction. Substitution into alanine of the also surface-exposed V2125, which is spatially next to F2127, affected only VWF binding. CONCLUSION The surface-exposed hydrophobic residues in C1 domain contribute to cofactor function and VWF binding. These findings provide novel information on the fundamental role of the C1 domain in FVIII life cycle.
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Affiliation(s)
- Małgorzata A Przeradzka
- Department of Molecular and Cellular Hemostasis, Sanquin Research, Amsterdam, the Netherlands
| | - Nadia Freato
- Department of Molecular and Cellular Hemostasis, Sanquin Research, Amsterdam, the Netherlands
| | - Mariëtte Boon-Spijker
- Department of Molecular and Cellular Hemostasis, Sanquin Research, Amsterdam, the Netherlands
| | - Josse van Galen
- Department of Molecular and Cellular Hemostasis, Sanquin Research, Amsterdam, the Netherlands
| | - Carmen van der Zwaan
- Department of Molecular and Cellular Hemostasis, Sanquin Research, Amsterdam, the Netherlands
| | - Koen Mertens
- Department of Molecular and Cellular Hemostasis, Sanquin Research, Amsterdam, the Netherlands
- Department of Pharmaceutics, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, the Netherlands
| | | | - Alexander B Meijer
- Department of Molecular and Cellular Hemostasis, Sanquin Research, Amsterdam, the Netherlands
- Department of Biomolecular Mass Spectrometry and Proteomics, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, the Netherlands
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