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Levy-Mendelovich S, Lev A, Avishai E, Budnik I, Dardik R, Barg AA, Somech R, Kenet G. Can T-cell and B-cell excision circles predict development of inhibitors in pediatric hemophilia A? Pediatr Res 2023; 93:1546-1550. [PMID: 36045224 DOI: 10.1038/s41390-022-02268-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 07/06/2022] [Accepted: 08/05/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Hemophilia A (HA) therapy requires intravenous replacement infusions of factor (F) VIII concentrate. Inhibitors are high-affinity immunoglobulin G that are directed against FVIII and thereby render replacement therapy ineffective. This complication has significant prognostic implications. We aimed to examine the immune system involvement in inhibitor formation specifically T-cell excision circles (TRECs) and B-cell excision circles (KRECs), markers of new T and B cells, respectively, and examine them as surrogate markers for inhibitor formation. METHODS Blood samples were collected from 35 children with severe HA. Children were divided into two groups: with FVIII inhibitors and without FVIII inhibitors. TRECs and KRECs were measured in peripheral blood. RESULTS A total of 11 patients with inhibitors and 24 without were evaluated. Children with inhibitors had higher levels of TRECs however not statistically significant (p = 0.085). CjKREC levels were higher in the inhibitor patients (p = 0.003). Moreover, the sj/cjKREC ratio was lower in the inhibitor patients (p = 0.015). CONCLUSIONS Our findings may add to the notion that inhibitor formation is attributed to humoral immunity due to peripheral B-cell expansion and loss of peripheral tolerance. Improved knowledge regarding the involvement of the immune system in the formation of FVIII inhibitors will enable better therapy tailoring in the era of non-replacement therapies. IMPACT The etiology of FVIII inhibitor formation is multifactorial, in which the immune system plays a pivotal role. Our findings may add to the notion that inhibitor formation is attributed to humoral immunity due to peripheral B-cell expansion and production of antibodies against FVIII. Improved knowledge regarding the involvement of the immune system in the development of FVIII inhibitors will enable the identification of patients prone to inhibitor development and better therapy tailoring in the new era of non-replacement therapies.
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Affiliation(s)
- Sarina Levy-Mendelovich
- National Hemophilia Center, Sheba Medical Center, Tel Hashomer, Israel.
- Amalia Biron Research Institute of Thrombosis and Hemostasis, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
- The Sheba Talpiot Medical Leadership Program, Tel Hashomer, Israel.
| | - Atar Lev
- Pediatric Department A and the Immunology Service, Jeffrey Modell Foundation canter, Edmond and Lily Safra Children's Hospital, Sheba Medical Center affiliated with Sackler school of medicine, Tel Aviv University, Tel Hashomer, Israel
| | - Einat Avishai
- National Hemophilia Center, Sheba Medical Center, Tel Hashomer, Israel
- Amalia Biron Research Institute of Thrombosis and Hemostasis, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ivan Budnik
- Department of Pathophysiology, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Rima Dardik
- National Hemophilia Center, Sheba Medical Center, Tel Hashomer, Israel
- Amalia Biron Research Institute of Thrombosis and Hemostasis, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Asaaf Arie Barg
- National Hemophilia Center, Sheba Medical Center, Tel Hashomer, Israel
- Amalia Biron Research Institute of Thrombosis and Hemostasis, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Raz Somech
- Pediatric Department A and the Immunology Service, Jeffrey Modell Foundation canter, Edmond and Lily Safra Children's Hospital, Sheba Medical Center affiliated with Sackler school of medicine, Tel Aviv University, Tel Hashomer, Israel
| | - Gili Kenet
- National Hemophilia Center, Sheba Medical Center, Tel Hashomer, Israel
- Amalia Biron Research Institute of Thrombosis and Hemostasis, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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Abdulqader AMR, Mohammed AI, Rachid S. Polymorphisms in the cytotoxic T lymphocyte-associated protein-4 immune regulatory gene and their impact on inhibitor development in patients with hemophilia A. J Int Med Res 2019; 47:4981-4992. [PMID: 31524022 PMCID: PMC6833422 DOI: 10.1177/0300060519860329] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Objective The development of inhibitors against infused factor VIII represents the most severe complication of substitution therapy in hemophilia A (HA) patients. Data on risk factors for inhibitor formation in Iraqi Kurdish patients with HA are unavailable. This study aimed to evaluate the impact of two single nucleotide polymorphisms (SNPs) in an immune regulatory gene in the emergence of inhibitors. Methods We focused on 126 patients with either severe or mild/moderate HA presenting with and without inhibitors. We analyzed the frequency of two polymorphisms in the cytotoxic T lymphocyte-associated protein-4 gene (CTLA-4; CTLA-4-318C > T and CTLA-4 + 49A > G). Genotyping was performed using restriction fragment length polymorphism–PCR and direct sequencing. Results We found no significant correlation between the CTLA-4-318 C > T T allele and inhibitor development among patients with severe or mild/moderate HA. However, a significantly high inhibitor risk was detected for the CTLA-4 + 49 A > G G allele (odds ratio [OR] = 3.1, 95% confidence interval [CI] = 1.383–7.024) and (OR = 4, 95% CI = 1.719–9.437) among patients with severe and mild/moderate HA, respectively. Conclusion We conclude that the CTLA-4 +49 A > G SNP plays a substantial role as a potential risk determinant for inhibitor formation in Iraqi Kurdish patients with HA.
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Affiliation(s)
- Aveen M Raouf Abdulqader
- Department of Pathology, College of Medicine, University of Sulaymaniyah, Sulaymaniyah 46001, Iraq
| | - Ali Ibrahim Mohammed
- Department of Pathology, College of Medicine, University of Sulaymaniyah, Sulaymaniyah 46001, Iraq
| | - Shwan Rachid
- Charmo Center for Research, Training and Consultancy, Charmo University, Chamchamal, Sulaymaniyah 46023, Iraq
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Inflammatory and immune response genes: A genetic analysis of inhibitor development in Iranian hemophilia A patients. Pediatr Hematol Oncol 2019; 36:28-39. [PMID: 30888230 DOI: 10.1080/08880018.2019.1585503] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
A major problem of hemophilia A (HA) treatment is the development of factor VIII (FVIII) inhibitor, which usually occurs shortly after initiating replacement therapy. Several studies showed the correlation between inhibitor development and polymorphisms in inflammatory and immune response genes of HA patients; however, literature data are not available to prove this association in Iranian population. The aim of this study was to investigate a possible association between FVIII inhibitor formation and the polymorphisms of 16 inflammatory and immune response genes in Iranian severe HA patients (FVIII activity < 1%). This case-control study was performed on 55 patients with severe HA inhibitors and 45 samples without inhibitors from Iranian Comprehensive Hemophilia Care center. After extraction of whole genomic DNA from blood samples and design of primers for 16 genes, the genotyping was performed by Tetra primer ARMS PCR, and the validation of single nucleotide polymorphisms was determined by DNA sequencing. The data indicated that there was a significant association between inhibitor development, and F13A1 (TT), DOCK2 (CC& CT), and MAPK9 (TT) genotypes. Moreover, a considerably increased inhibitor risk carrying T, C, and T allele for F13A1, DOCK2, and MAPK9 genes was observed in patients with inhibitors, respectively. In contrast, there was no statistically significant difference between the genotypic and allelic frequencies for other genes in patients with inhibitors compared to patients without inhibitors. These results demonstrate that only polymorphisms in F13A1, DOCK2, and MAPK9 genes are associated with the risk of developing FVIII inhibitors in Iranian HA patients.
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Yunis LK, Linares A, Cabrera E, Yunis JJ. Systematic molecular analysis of hemophilia A patients from Colombia. Genet Mol Biol 2018; 41:750-757. [PMID: 30534853 PMCID: PMC6415612 DOI: 10.1590/1678-4685-gmb-2017-0072] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Accepted: 03/16/2018] [Indexed: 11/27/2022] Open
Abstract
Hemophilia A (HA) is an X-linked recessive disorder and the second most common coagulation disorder with an incidence of 1 in 5,000 live born males. Worldwide, there are 178,500 affected individuals, 60% with the severe form of the disease. Intron 22 and 1 inversions (Inv22 and Inv1) are the most frequent molecular alterations found in severe HA patients with a frequency of 45-50% and 0.5-5%, respectively. We have implemented a systematic cost-effective strategy for the identification of the molecular alteration in HA patients using Inverse shifting-PCR for Inv22 and Inv1, followed by the analysis of the F8 gene coding region by means of high resolution melting (HRM) PCR and Sanger sequencing in Inv22 and Inv1 negative patients. A total of 33 male HA patients and 6 women were analyzed. Inversion 22 was detected in 14/33 male patients (42.4%), 3/33 (9.1%) had Inv1, 3/33 (9.1%) had large structural variants, and 11/33 (33.3%) single nucleotide/ small frameshift variants. No genetic variant was found in 2/33 patients (6%). With this systematic approach we detected pathogenic variants in 31 out of 33 male affected individuals (94%) tested for the first time.in a cohort of patients from Colombia.
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Affiliation(s)
- Luz Karime Yunis
- Grupo de Patología Molecular, Universidad Nacional de Colombia, Bogotá, D.C., Colombia
| | - Adriana Linares
- Fundación Hospital de la Misericordia, Bogotá, D.C., Colombia.,Grupo de Onco-Hematología Pediátrica, Departamento de Pediatría, Facultad de Medicina, Universidad Nacional de Colombia, Bogotá, D.C., Colombia.,Programa de Hemofilia, Clínica Infantil Colsubsidio. Bogotá, D.C., Colombia
| | - Edgar Cabrera
- Fundación Hospital de la Misericordia, Bogotá, D.C., Colombia
| | - Juan J Yunis
- Grupo de Patología Molecular, Universidad Nacional de Colombia, Bogotá, D.C., Colombia.,Departamento de Patología, Facultad de Medicina e Instituto de Genética, Universidad Nacional de Colombia, Bogotá, D.C., Colombia.,Instituto de Genética, Servicios Médicos Yunis Turbay y Cía S.A.S. Bogotá, D.C., Colombia
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5
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Arshad S, Singh A, Awasthi NP, Kumari S, Husain N. Clinicopathological parameters influencing inhibitor development in patients with hemophilia A receiving on-demand therapy. Ther Adv Hematol 2018; 9:213-226. [PMID: 30181842 PMCID: PMC6116755 DOI: 10.1177/2040620718785363] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Accepted: 05/27/2018] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Development of inhibitors to transfused factor VIII in patients with hemophilia A continues to be a challenge for professionals involved in hemophilia care. The majority of patients in India receive 'on-demand' rather than prophylactic therapy. The present study was done to assess the prevalence of factor VIII inhibitors in patients with hemophilia A (PWHA) receiving 'on-demand' therapy in a North Indian population and to study the clinicopathological parameters influencing the development of inhibitors. METHODS The study group comprised of 300 PWHA. Detailed clinical parameters, treatment history, bleeding profile including family history were recorded. Diagnosis of hemophilia A was confirmed by relevant coagulation tests. Inhibitors were screened using mixing based studies followed by quantification by Bethesda assay and Nijmegen modified Bethesda assay. Samples were collected from five cities in North India where a free supply of factor VIII was available and effectively used in three of these cities. RESULTS In the 300 PWHA, disease phenotype was severe in 219 (73%), moderate in 62 (20.67%) and mild in 19 (6.34%), based on the factor VIII bioassay. Inhibitor prevalence was 9.6% (n = 29) and seen only in the severe phenotype. Inhibitor titers ranged from 0.8 to 108.8 BU/ml. A total of 12 PWHA had low and 17 had high titers. Correlation of various clinicopathological parameters in inhibitor-positive versus negative PWHA showed significant correlation with age at onset of disease, severity of disease, age at first exposure to treatment, annual factor intake (IU/kg/year), intense treatment episodes and bleeding manifestations like central nervous system bleed and hematuria. The total study sample had blood group B in 33.34% PWHA, followed by O (27.34%), A (24.34%) and AB (15%), however, in inhibitor-positive samples, significant inhibitor formation was associated with the ABO subtype A (19/29, 65.51%). CONCLUSIONS Factor VIII inhibitor prevalence in PWHA receiving 'on-demand' therapy was 9.6%. Clinicopathological correlates of inhibitor development in such PWHA have been analyzed in this novel study.
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Affiliation(s)
- Sanya Arshad
- Dr. Ram Manohar Lohia Institute of Medical
Sciences, Lucknow, Uttar Pradesh, India
| | - Anshima Singh
- Dr. Ram Manohar Lohia Institute of Medical
Sciences, Lucknow, Uttar Pradesh, India
| | - Namrata Punit Awasthi
- Department of Pathology, Dr. Ram Manohar Lohia
Institute of Medical Sciences, Vibhuti Khand, Gomti Nagar, Lucknow 226010,
India
| | - Swati Kumari
- Dr. Ram Manohar Lohia Institute of Medical
Sciences, Lucknow, Uttar Pradesh, India
| | - Nuzhat Husain
- Dr. Ram Manohar Lohia Institute of Medical
Sciences, Lucknow, Uttar Pradesh, India
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Naderi N, Ebrahimzadeh F, Jazebi M, Namvar A, Hashemi M, Bolhassani A. Polymorphisms in the TGF-β1 (rs1982037) and IL-2 (rs2069762, rs4833248) genes are not associated with inhibitor development in Iranian patients with hemophilia A. Hematology 2018; 23:839-843. [PMID: 29993342 DOI: 10.1080/10245332.2018.1498168] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Objectives Development of neutralizing antibodies against factor VIII is the major complication in hemophilia care which makes replacement therapies ineffective. The reports showed that inflammatory cytokines play an important role in inhibitor production. In the present study, the relationship between inhibitor development and the polymorphisms of two cytokine genes was studied in severe hemophiliac patients from Iran. Methods In this case-control study, three polymorphisms of immune regulatory genes [TGF-β (rs1982037) and IL-2 (rs2069762, rs4833248)] were analyzed in 100 Iranian hemophilia A patients divided into 55 inhibitor positive and 45 inhibitor negative patients using Tetra primer ARMS PCR, and DNA sequencing. Results The analysis of polymorphisms in the TGF-β and IL-2 genes showed no association between the genotypes and the production of inhibitors (p > 0.05). Also, comparison of allele frequencies for TGF-β and IL-2 genes between two groups indicated no significant differences associated with the development of FVIII inhibitors (p > 0.05). Discussion In contrast with some reports involving the correlation between polymorphisms of the TGF-β1 and IL-2 genes and inhibitor development in the world, no statistically significant differences in analysis of the alleles and genotypes for TGF-β and IL-2 genes were found between the inhibitor and non-inhibitor Iranian patients. Thus, other genetic markers influencing the immune response to replacement therapy in patients with hemophilia should be identified. Conclusions Regarding our results in molecular predisposition for inhibitor development, further studies of effective genetic markers are required as a prerequisite for the development of novel immunogenic therapeutic approaches in the future.
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Affiliation(s)
- Niloofar Naderi
- a Iranian Comprehensive Hemophilia Care Center , Tehran , Iran
| | - Fariba Ebrahimzadeh
- b Department of Molecular Genetics, Tehran Medical Sciences Branch , Islamic Azad University , Tehran , Iran
| | - Mohammad Jazebi
- a Iranian Comprehensive Hemophilia Care Center , Tehran , Iran
| | - Ali Namvar
- a Iranian Comprehensive Hemophilia Care Center , Tehran , Iran
| | - Mehrdad Hashemi
- b Department of Molecular Genetics, Tehran Medical Sciences Branch , Islamic Azad University , Tehran , Iran
| | - Azam Bolhassani
- c Department of Hepatitis and AIDS , Pasteur Institute of Iran , Tehran , Iran
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7
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Ibrahim UA, Ahmed SG. Determinants and modifiers of bleeding phenotypes in haemophilia-A: General and tropical perspectives. EGYPTIAN JOURNAL OF MEDICAL HUMAN GENETICS 2018. [DOI: 10.1016/j.ejmhg.2017.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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8
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Life in the shadow of a dominant partner: the FVIII-VWF association and its clinical implications for hemophilia A. Blood 2016; 128:2007-2016. [PMID: 27587878 DOI: 10.1182/blood-2016-04-713289] [Citation(s) in RCA: 130] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Accepted: 08/18/2016] [Indexed: 11/20/2022] Open
Abstract
A normal hemostatic response to vascular injury requires both factor VIII (FVIII) and von Willebrand factor (VWF). In plasma, VWF and FVIII normally circulate as a noncovalent complex, and each has a critical function in the maintenance of hemostasis. Furthermore, the interaction between VWF and FVIII plays a crucial role in FVIII function, immunogenicity, and clearance, with VWF essentially serving as a chaperone for FVIII. Several novel recombinant FVIII (rFVIII) therapies for hemophilia A have been in clinical development, which aim to increase the half-life of FVIII (∼12 hours) and reduce dosing frequency by utilizing bioengineering techniques including PEGylation, Fc fusion, and single-chain design. However, these approaches have achieved only moderate increases in half-life of 1.5- to 2-fold compared with marketed FVIII products. Clearance of PEGylated rFVIII, rFVIIIFc, and rVIII-SingleChain is still regulated to a large extent by interaction with VWF. Therefore, the half-life of VWF (∼15 hours) appears to be the limiting factor that has confounded attempts to extend the half-life of rFVIII. A greater understanding of the interaction between FVIII and VWF is required to drive novel bioengineering strategies for products that either prolong the survival of VWF or limit VWF-mediated clearance of FVIII.
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Wang X, Terhorst C, Herzog RW. In vivo induction of regulatory T cells for immune tolerance in hemophilia. Cell Immunol 2016; 301:18-29. [PMID: 26454643 PMCID: PMC4761281 DOI: 10.1016/j.cellimm.2015.10.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Revised: 10/01/2015] [Accepted: 10/02/2015] [Indexed: 12/22/2022]
Abstract
Current therapy for the X-linked coagulation disorder hemophilia is based on intravenous infusion of the specifically deficient coagulation factor. However, 20-30% of hemophilia A patients (factor VIII, FVIII, deficiency) generate inhibitory antibodies against FVIII. While formation of inhibitors directed against factor IX, FIX, resulting from hemophilia B treatment is comparatively rare, a serious complication that is often associated with additional immunotoxicities, e.g. anaphylaxis, occurs. Current immune tolerance protocols to eradiate inhibitors are lengthy, expensive, not effective in all patients, and there are no prophylactic tolerance regimens to prevent inhibitor formation. The outcomes of recent experiments in animal models of hemophilia demonstrate that regulatory CD4(+) T cells (Treg) are of paramount importance in controlling B cell responses to FVIII and FIX. This article reviews several novel strategies designed to in vivo induce coagulation factor-specific Treg cells and discusses the subsets of Treg that may promote immune tolerance in hemophilia. Among others, drug- and gene transfer-based protocols, lymphocyte transplant, and oral tolerance are reviewed.
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Affiliation(s)
- Xiaomei Wang
- Dept. Pediatrics, University of Florida, Gainesville, FL 32610, USA
| | - Cox Terhorst
- Div. Immunology, Beth Israel Deaconess Medical Center, Boston, MA 02115, USA
| | - Roland W Herzog
- Dept. Pediatrics, University of Florida, Gainesville, FL 32610, USA.
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10
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Pinto P, Ghosh K, Shetty S. F8 gene mutation profile in Indian hemophilia A patients: Identification of 23 novel mutations and factor VIII inhibitor risk association. Mutat Res 2016; 786:27-33. [PMID: 26897466 DOI: 10.1016/j.mrfmmm.2016.02.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Revised: 01/20/2016] [Accepted: 02/07/2016] [Indexed: 10/22/2022]
Abstract
'FVIII inhibitors', especially in severe hemophilia A (HA) patients, is a serious adverse effect that complicates their clinical management. Many genetic and non-genetic risk factors have been proposed for FVIII inhibitor development, diverse in different population groups. This is the first study in Indian hemophiliacs that analyzes inhibitor risk in relation to the complete F8 mutation profile, in a case-control study that included 145 Indian severe HA patients, i.e. 69 inhibitor positive (with 18 inhibitor concordant/discordant family members), and 58 inhibitor negative patients, after informed consent. While 53.54% (68/127) index cases were positive for intron 22 or intron 1 inversions, 55 causative F8 mutations were detected in the 59 inversion negative patients, of which 23 were novel mutations (in 24 patients) and 32 were reported earlier (in 35 patients). A higher incidence of mutations, in the C1 and C2 domains in inhibitor positive patients, and in the A1 domain in inhibitor negative patients was observed, though not significantly different. The study suggests that large F8 rearrangements (significantly higher in the inhibitor positive patients) pose the highest risk, while missense mutations (significantly higher in the inhibitor negative patients) pose the lowest risk of inhibitor development in Indian hemophilia A patients.
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Affiliation(s)
- Patricia Pinto
- National Institute of Immunohaematology (ICMR), 13th Floor, New Multistoreyed Building, KEM Hospital Campus, Parel, Mumbai 400 012, India
| | - Kanjaksha Ghosh
- National Institute of Immunohaematology (ICMR), 13th Floor, New Multistoreyed Building, KEM Hospital Campus, Parel, Mumbai 400 012, India
| | - Shrimati Shetty
- National Institute of Immunohaematology (ICMR), 13th Floor, New Multistoreyed Building, KEM Hospital Campus, Parel, Mumbai 400 012, India.
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11
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Klintman J, Berntorp E. Epidemiological aspects of inhibitor development in hemophilia and strategies of management. Expert Opin Orphan Drugs 2016. [DOI: 10.1517/21678707.2016.1127157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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12
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Pinto P, Shetty S, Lacroix-Desmazes S, Bayry J, Kaveri S, Ghosh K. Antibody profile in Indian severe haemophilia A patients with and without FVIII inhibitors. Immunol Lett 2015; 169:93-7. [PMID: 26433059 DOI: 10.1016/j.imlet.2015.09.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Accepted: 09/27/2015] [Indexed: 11/17/2022]
Abstract
Diagnosis and management of haemophilia patients with inhibitors is often tricky due to the heterogeneous nature of the antibodies with regard to their kinetics, as well as the co-existence of other interfering antibodies. Plasma samples from severe haemophilia A patients from India with and without FVIII inhibitors were analysed for the presence of possible co-existing antibodies such as lupus anticoagulants (LA), anti-cardiolipin antibodies (ACLA), anti-β2-glycoprotein-I (anti-β2-GP-I) antibodies, viral transfusion transmitted disease (HIV, HBsAg, HCV) related antibodies, anti-cyclic citrullinated peptides (anti-CCP), and anti-nuclear antibodies. A high incidence of LA and anti-HCV antibodies was detected in Indian haemophilia A patients similar to earlier reports. More importantly, a relatively high incidence of autoantibodies to nuclear antigens (18.62%) and anti-CCP antibodies (1.38%) associated with autoimmune disorders was also seen in these congenital haemophilia A patients with and without inhibitors. Knowledge on the antibody profile in these haemophilia patients especially in those with FVIII inhibitors along with correlation with the clinical manifestations and other risk factors for inhibitor development could possibly shed more light on the complex immune response in these patients.
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Affiliation(s)
- Patricia Pinto
- National Institute of Immunohaematology (ICMR), 13th Floor, New Multistoreyed Building, KEM Hospital Campus, Parel, Mumbai 400012, India
| | - Shrimati Shetty
- National Institute of Immunohaematology (ICMR), 13th Floor, New Multistoreyed Building, KEM Hospital Campus, Parel, Mumbai 400012, India
| | - Sebastien Lacroix-Desmazes
- INSERM, UMRS 1138, Centre de Recherche des Cordeliers, Paris, France; Université Pierre et Marie Curie-Paris 6, UMRS 1138, Paris, France; Université Paris Descartes, UMRS 1138, Paris, France; Laboratoire International Associé INSERM (France) - ICMR, India
| | - Jagadeesh Bayry
- INSERM, UMRS 1138, Centre de Recherche des Cordeliers, Paris, France; Université Pierre et Marie Curie-Paris 6, UMRS 1138, Paris, France; Université Paris Descartes, UMRS 1138, Paris, France; Laboratoire International Associé INSERM (France) - ICMR, India
| | - Srini Kaveri
- INSERM, UMRS 1138, Centre de Recherche des Cordeliers, Paris, France; Université Pierre et Marie Curie-Paris 6, UMRS 1138, Paris, France; Université Paris Descartes, UMRS 1138, Paris, France; Laboratoire International Associé INSERM (France) - ICMR, India
| | - Kanjaksha Ghosh
- National Institute of Immunohaematology (ICMR), 13th Floor, New Multistoreyed Building, KEM Hospital Campus, Parel, Mumbai 400012, India.
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Factor VIII gene variants and inhibitor risk in African American hemophilia A patients. Blood 2015; 126:895-904. [PMID: 25617427 DOI: 10.1182/blood-2014-09-599365] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Accepted: 01/02/2015] [Indexed: 01/05/2023] Open
Abstract
African American hemophilia A (HA) patients experience a higher incidence of neutralizing anti-factor VIII (FVIII) antibodies ("inhibitors") vis-à-vis white patients. Nonsynonymous single-nucleotide polymorphisms (ns-SNPs) in the F8 gene encoding FVIII-H484, FVIII-E1241, and FVIII-V2238 are more prevalent in African Americans. This study tested the hypothesis that immune responses to these sites provoke inhibitors. Blood samples were obtained from 174 African American and 198 white HA subjects and their F8 gene sequences determined. Major histocompatibility complex class II binding and T-cell recognition of polymorphic sequences were evaluated using quantitative binding assays and HLA-DRB1 tetramers. Peptides corresponding to 4 common ns-SNPs showed limited binding to 11 HLA-DRB1 proteins. CD4 T cells from 22 subjects treated with FVIII products having sequences at residues FVIII-484, 1241, and 2238 differing from those of putative proteins encoded by their F8 genes did not show high-avidity tetramer binding, whereas positive-control staining of tetanus-specific CD4 T cells was routinely successful. African Americans with an intron-22 inversion mutation showed a 2-3 times-higher inhibitor incidence than whites with the same mutation (odds ratio = 2.3 [1.1-5.0, P = .04]), but this did not correlate with any of the ns-SNPs. We conclude that immune responses to "sequence-mismatched" FVIII products are unlikely to contribute appreciably to the inhibitor incidence in African Americans.
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The IL-10 polarized cytokine pattern in innate and adaptive immunity cells contribute to the development of FVIII inhibitors. BMC HEMATOLOGY 2015; 15:1. [PMID: 25653866 PMCID: PMC4316397 DOI: 10.1186/s12878-014-0019-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Accepted: 12/08/2014] [Indexed: 11/10/2022]
Abstract
BACKGROUND Hemophilia A (HA) is an X-linked inherited bleeding disorder, resulting from a qualitative or quantitative deficiency of clotting factor VIII (FVIII). Antibodies against FVIII, also called inhibitors, block the procoagulant activity of FVIII; thus, impairing hemostatic activity in patients with HA. The exact mechanism underlying the immunological events behind the development of inhibitors remains unknown. This study aimed to understand immune response to FVIII in patients with HA who were either positive [HAα-FVIII(+)] or negative [HAα-FVIII(-)] for inhibitors. METHODS Cytokine profiles [interferon-γ (IFN - γ), tumor necrosis factor-α (TNF-α), interleukin-4 (IL-4), IL-5, and IL-10] of innate and adaptive immune cells present in the peripheral blood of participants were characterized. RESULTS Presence of inhibitors was significantly associated with decreased frequencies of TNF-α-positive monocytes and neutrophils, IL-5-positive monocytes, IL-4-positive neutrophils, and increased frequencies of IL-10-positive neutrophils and T cells. T cells from HAα-FVIII(-) patients expressed increased levels of almost all cytokines. In contrast, HAα-FVIII(+) patients showed lower levels of all cytokines in CD4(+) and CD8(+) T cells, except IL-10. B cells from HAα-FVIII(-) patients expressed increased levels of IL-4 while those from HAα-FVIII(+) patients expressed increased levels of IL-10. CONCLUSIONS The global cytokine profiles of innate and adaptive immune cells showed an anti-inflammatory/regulatory pattern in HAα-FVIII(+) patients and a mixed pattern, with a bias toward inflammatory cytokine profile, in HAα-FVIII(-) patients. The occurrence of these profiles seems to be associated with presence FVIII inhibitors.
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Hashemi SM, Fischer K, Moons KGM, van den Berg HM. Improved prediction of inhibitor development in previously untreated patients with severe haemophilia A. Haemophilia 2014; 21:227-233. [PMID: 25495680 DOI: 10.1111/hae.12566] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/21/2014] [Indexed: 12/15/2022]
Abstract
Treatment of previously untreated patients (PUPs) with severe haemophilia A is complicated by the formation of inhibitors. Prediction of PUPs with high risk is important to allow altering treatment with the intention to reduce the occurrence of inhibitors. An unselected multicentre cohort of 825 PUPs with severe haemophilia A (FVIII<0.01 IU mL(-1) ) was used. Patients were followed until 50 exposure days (EDs) or inhibitor development. All predictors of the existing prediction model including three new potential predictors were studied using multivariable logistic regression. Model performance was quantified [area under the curve (AUC), calibration plot] and internal validation (bootstrapping) was performed. A nomogram for clinical application was developed. Of the 825 patients, 225 (28%) developed inhibitors. The predictors family history of inhibitors, F8 gene mutation and an interaction variable of dose and number of EDs of intensive treatment were independently associated with inhibitor development. Age and reason for first treatment were not associated with inhibitor development. The AUC was 0.69 (95% CI 0.65-0.72) and calibration was good. An improved prediction model for inhibitor development and a nomogram for clinical use were developed in a cohort of 825 PUPs with severe haemophilia A. Clinical applicability was improved by combining dose and duration of intensive treatment, allowing the assessment of the effects of treatment decisions on inhibitor risk and potentially modify treatment.
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Affiliation(s)
- S M Hashemi
- Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht, The Netherlands
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16
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Kurnik K, Auerswald G, Kreuz W. Inhibitors and prophylaxis in paediatric haemophilia patients: Focus on the German experience. Thromb Res 2014; 134 Suppl 1:S27-32. [DOI: 10.1016/j.thromres.2013.10.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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17
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Pinto P, Parasannanavar D, Ghosh K, Shetty S. The association of HLA-DRB1 and HLA-DQB1 alleles with the development of factor VIII inhibitors in severe haemophilia A patients in India. ACTA ACUST UNITED AC 2014; 84:235-7. [DOI: 10.1111/tan.12364] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2013] [Revised: 03/04/2014] [Accepted: 03/31/2014] [Indexed: 11/26/2022]
Affiliation(s)
- P. Pinto
- Department of Haemostasis & Thrombosis; National Institute of Immunohaematology (ICMR); Mumbai India
| | - D. Parasannanavar
- Department of Haemostasis & Thrombosis; National Institute of Immunohaematology (ICMR); Mumbai India
| | - K. Ghosh
- Department of Haemostasis & Thrombosis; National Institute of Immunohaematology (ICMR); Mumbai India
| | - S. Shetty
- Department of Haemostasis & Thrombosis; National Institute of Immunohaematology (ICMR); Mumbai India
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18
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Pinto P, Shelar T, Nawadkar V, Mirgal D, Mukaddam A, Nair P, Kasatkar P, Gaikwad T, Ali S, Jadli A, Patil R, Parihar A, Shanbhag S, Kulkarni B, Ghosh K, Shetty S. The Epidemiology of FVIII Inhibitors in Indian Haemophilia A Patients. Indian J Hematol Blood Transfus 2014; 30:356-63. [PMID: 25435742 DOI: 10.1007/s12288-014-0342-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2013] [Accepted: 01/15/2014] [Indexed: 11/24/2022] Open
Abstract
A serious complication of replacement therapy in patients with bleeding disorders is the development of 'inhibitors', particularly FVIII inhibitors in haemophilia A patients. This leads to an increase in the management cost, morbidity and mortality, especially post-operatively. The mechanism of FVIII inhibitor development is quite complex and it is difficult to predict inhibitor development, but a prompt and accurate diagnosis is critical as early therapy can save lives. The aim of this study was to screen patients with bleeding disorders in India for inhibitors, and to analyse and compare the prevalence of inhibitors in different regions in India. Patient details were recorded and blood samples were collected in sodium citrate vacutainers from 1,505 patients with bleeding disorders, in different cities in India. Coagulation and inhibitor screening assays were performed, followed by the Bethesda assay in inhibitor positive samples to quantify the FVIII inhibitor titre. Out of the 1,505 samples analysed, 1,285 were Haemophilia A patients, out of which 78 (6.07 %) were positive for 'FVIII Inhibitors'. The highest incidence of FVIII Inhibitors was seen in South India (13.04 %). The highest incidence of 20.99 % was observed in Chennai, followed by Hyderabad (13.33 %), Jammu (9.90 %) and Guwahati (8.51 %), respectively, with respect to the samples analysed. The other regions showed an inhibitor incidence <8 %. The incidence of inhibitors in haemophilia A patients is different in different regions of India; this may be due to the intensity of treatment, type of product or the genetic characteristics of these patients.
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Affiliation(s)
- Patricia Pinto
- Department of Haemostasis & Thrombosis, National Institute of Immunohaematology, Indian Council of Medical Research, 13th Floor, New Multistoreyed Building, KEM Hospital Campus, Parel, Mumbai, 400 012 India
| | - Tejashree Shelar
- Department of Haemostasis & Thrombosis, National Institute of Immunohaematology, Indian Council of Medical Research, 13th Floor, New Multistoreyed Building, KEM Hospital Campus, Parel, Mumbai, 400 012 India
| | - Vidhya Nawadkar
- Department of Haemostasis & Thrombosis, National Institute of Immunohaematology, Indian Council of Medical Research, 13th Floor, New Multistoreyed Building, KEM Hospital Campus, Parel, Mumbai, 400 012 India
| | - Darshana Mirgal
- Department of Haemostasis & Thrombosis, National Institute of Immunohaematology, Indian Council of Medical Research, 13th Floor, New Multistoreyed Building, KEM Hospital Campus, Parel, Mumbai, 400 012 India
| | - Alfiya Mukaddam
- Department of Haemostasis & Thrombosis, National Institute of Immunohaematology, Indian Council of Medical Research, 13th Floor, New Multistoreyed Building, KEM Hospital Campus, Parel, Mumbai, 400 012 India
| | - Preethi Nair
- Department of Haemostasis & Thrombosis, National Institute of Immunohaematology, Indian Council of Medical Research, 13th Floor, New Multistoreyed Building, KEM Hospital Campus, Parel, Mumbai, 400 012 India
| | - Priyanka Kasatkar
- Department of Haemostasis & Thrombosis, National Institute of Immunohaematology, Indian Council of Medical Research, 13th Floor, New Multistoreyed Building, KEM Hospital Campus, Parel, Mumbai, 400 012 India
| | - Tejasvita Gaikwad
- Department of Haemostasis & Thrombosis, National Institute of Immunohaematology, Indian Council of Medical Research, 13th Floor, New Multistoreyed Building, KEM Hospital Campus, Parel, Mumbai, 400 012 India
| | - Shahnaz Ali
- Department of Haemostasis & Thrombosis, National Institute of Immunohaematology, Indian Council of Medical Research, 13th Floor, New Multistoreyed Building, KEM Hospital Campus, Parel, Mumbai, 400 012 India
| | - Anshul Jadli
- Department of Haemostasis & Thrombosis, National Institute of Immunohaematology, Indian Council of Medical Research, 13th Floor, New Multistoreyed Building, KEM Hospital Campus, Parel, Mumbai, 400 012 India
| | - Rucha Patil
- Department of Haemostasis & Thrombosis, National Institute of Immunohaematology, Indian Council of Medical Research, 13th Floor, New Multistoreyed Building, KEM Hospital Campus, Parel, Mumbai, 400 012 India
| | - Anita Parihar
- Department of Haemostasis & Thrombosis, National Institute of Immunohaematology, Indian Council of Medical Research, 13th Floor, New Multistoreyed Building, KEM Hospital Campus, Parel, Mumbai, 400 012 India
| | - Sharda Shanbhag
- Department of Haemostasis & Thrombosis, National Institute of Immunohaematology, Indian Council of Medical Research, 13th Floor, New Multistoreyed Building, KEM Hospital Campus, Parel, Mumbai, 400 012 India
| | - Bipin Kulkarni
- Department of Haemostasis & Thrombosis, National Institute of Immunohaematology, Indian Council of Medical Research, 13th Floor, New Multistoreyed Building, KEM Hospital Campus, Parel, Mumbai, 400 012 India
| | - Kanjaksha Ghosh
- Department of Haemostasis & Thrombosis, National Institute of Immunohaematology, Indian Council of Medical Research, 13th Floor, New Multistoreyed Building, KEM Hospital Campus, Parel, Mumbai, 400 012 India
| | - Shrimati Shetty
- Department of Haemostasis & Thrombosis, National Institute of Immunohaematology, Indian Council of Medical Research, 13th Floor, New Multistoreyed Building, KEM Hospital Campus, Parel, Mumbai, 400 012 India
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Lambing AY. Unexpected hemorrhage: an unusual and potentially catastrophic clinical challenge. J Am Assoc Nurse Pract 2013; 25:342-50. [PMID: 24170617 DOI: 10.1111/j.1745-7599.2012.00807.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
PURPOSE Unexpected bleeding or hemorrhage related to the development of acquired factor VIII inhibitors is an emerging clinical challenge in patients. Symptoms can occur suddenly with bleeding and/or bruising that is excessive relative to the degree of injury or severity of a comorbid condition. Diagnosis is difficult, and bleeding can quickly become life threatening if not treated promptly. This review provides current information, using a patient case scenario, to improve awareness and recognition of patients presenting unexpectedly with excessive bleeding of unknown etiology. DATA SOURCES To complete this review, a search of English-language publications was conducted using Medline and CINAHL databases (1966-2010). CONCLUSIONS Although development of acquired factor VIII inhibitors is rare, its incidence is increasing in many different patient care settings. Improved awareness and recognition is needed to mitigate the significant patient morbidity and mortality that can occur without rapid and timely treatment by experienced hematology specialists. IMPLICATIONS FOR PRACTICE Nurse practitioners, as front-line clinicians treating patients in various therapeutic areas, may be the first healthcare professionals who see patients with this disorder. Increased knowledge and awareness of this rare but potentially catastrophic cause of excessive bleeding can improve prompt treatment and optimize patient outcomes.
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Affiliation(s)
- Angela Y Lambing
- Department of Hematology and Oncology, Hemophilia and Thrombosis Treatment Center, Henry Ford Health System, Detroit, Michigan
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20
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Pinto P, Ghosh K, Shetty S. A specific and sensitive activated partial thromboplastin time (APTT)-based factor VIII inhibitor screening assay. Clin Chem Lab Med 2013; 52:e39-41. [PMID: 24088610 DOI: 10.1515/cclm-2013-0595] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2013] [Accepted: 09/05/2013] [Indexed: 11/15/2022]
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21
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Kwon KC, Verma D, Singh ND, Herzog R, Daniell H. Oral delivery of human biopharmaceuticals, autoantigens and vaccine antigens bioencapsulated in plant cells. Adv Drug Deliv Rev 2013; 65:782-99. [PMID: 23099275 PMCID: PMC3582797 DOI: 10.1016/j.addr.2012.10.005] [Citation(s) in RCA: 94] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2012] [Revised: 09/26/2012] [Accepted: 10/17/2012] [Indexed: 12/19/2022]
Abstract
Among 12billion injections administered annually, unsafe delivery leads to >20million infections and >100million reactions. In an emerging new concept, freeze-dried plant cells (lettuce) expressing vaccine antigens/biopharmaceuticals are protected in the stomach from acids/enzymes but are released to the immune or blood circulatory system when plant cell walls are digested by microbes that colonize the gut. Vaccine antigens bioencapsulated in plant cells upon oral delivery after priming, conferred both mucosal and systemic immunity and protection against bacterial, viral or protozoan pathogens or toxin challenge. Oral delivery of autoantigens was effective against complications of type 1 diabetes and hemophilia, by developing tolerance. Oral delivery of proinsulin or exendin-4 expressed in plant cells regulated blood glucose levels similar to injections. Therefore, this new platform offers a low cost alternative to deliver different therapeutic proteins to combat infectious or inherited diseases by eliminating inactivated pathogens, expensive purification, cold storage/transportation and sterile injections.
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Affiliation(s)
- Kwang-Chul Kwon
- Department of Molecular Biology and Microbiology, College of Medicine, University of Central Florida, Biomolecular Science Building, Orlando, FL 32816-2364, USA
| | - Dheeraj Verma
- Department of Molecular Biology and Microbiology, College of Medicine, University of Central Florida, Biomolecular Science Building, Orlando, FL 32816-2364, USA
| | - Nameirakpam D. Singh
- Department of Molecular Biology and Microbiology, College of Medicine, University of Central Florida, Biomolecular Science Building, Orlando, FL 32816-2364, USA
| | - Roland Herzog
- Department of Pediatrics, College of Medicine, University of Florida, Cancer and Genetics Research Complex, 2033 Mowry Road, Gainesville, FL 32610, USA
| | - Henry Daniell
- Department of Molecular Biology and Microbiology, College of Medicine, University of Central Florida, Biomolecular Science Building, Orlando, FL 32816-2364, USA
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22
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Hausammann S, Vogel M, Kremer Hovinga JA, Lacroix-Desmazes S, Stadler BM, Horn MP. Designed ankyrin repeat proteins: a new approach to mimic complex antigens for diagnostic purposes? PLoS One 2013; 8:e60688. [PMID: 23626669 PMCID: PMC3634029 DOI: 10.1371/journal.pone.0060688] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2012] [Accepted: 03/01/2013] [Indexed: 11/18/2022] Open
Abstract
Inhibitory antibodies directed against coagulation factor VIII (FVIII) can be found in patients with acquired and congenital hemophilia A. Such FVIII-inhibiting antibodies are routinely detected by the functional Bethesda Assay. However, this assay has a low sensitivity and shows a high inter-laboratory variability. Another method to detect antibodies recognizing FVIII is ELISA, but this test does not allow the distinction between inhibitory and non-inhibitory antibodies. Therefore, we aimed at replacing the intricate antigen FVIII by Designed Ankyrin Repeat Proteins (DARPins) mimicking the epitopes of FVIII inhibitors. As a model we used the well-described inhibitory human monoclonal anti-FVIII antibody, Bo2C11, for the selection on DARPin libraries. Two DARPins were selected binding to the antigen-binding site of Bo2C11, which mimic thus a functional epitope on FVIII. These DARPins inhibited the binding of the antibody to its antigen and restored FVIII activity as determined in the Bethesda assay. Furthermore, the specific DARPins were able to recognize the target antibody in human plasma and could therefore be used to test for the presence of Bo2C11-like antibodies in a large set of hemophilia A patients. These data suggest, that our approach might be used to isolate epitopes from different sets of anti-FVIII antibodies in order to develop an ELISA-based screening assay allowing the distinction of inhibitory and non-inhibitory anti-FVIII antibodies according to their antibody signatures.
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Affiliation(s)
- Stefanie Hausammann
- University Institute of Immunology, University of Bern, Inselspital, Bern, Switzerland
| | - Monique Vogel
- University Institute of Immunology, University of Bern, Inselspital, Bern, Switzerland
| | - Johanna A. Kremer Hovinga
- Department of Hematology and Central Hematology Laboratory, University Hospital and University of Bern, Bern, Switzerland
| | - Sebastien Lacroix-Desmazes
- INSERM, UMR S 872, Les Cordeliers, Paris
- Université Pierre et Marie Curie-Paris, UMR S 872, Les Cordeliers, Paris
- Université Paris Descartes, UMR S 872, Les Cordeliers, Paris
| | - Beda M. Stadler
- University Institute of Immunology, University of Bern, Inselspital, Bern, Switzerland
| | - Michael P. Horn
- University Institute of Immunology, University of Bern, Inselspital, Bern, Switzerland
- * E-mail:
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23
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Oliveira CA, Velloso-Rodrigues C, Machado FCJ, Carvalho BN, Gentz SHL, Martins-Filho OA, Chaves DG. Cytokine profile and FVIII inhibitors development in haemophilia A. Haemophilia 2013; 19:e139-42. [DOI: 10.1111/hae.12096] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/03/2012] [Indexed: 11/30/2022]
Affiliation(s)
| | | | | | | | - S. H. L. Gentz
- Laboratório de Biomarcadores de Diagnóstico e Monitoração; Centro de Pesquisa René Rachou/FIOCRUZ
| | - O. A. Martins-Filho
- Laboratório de Biomarcadores de Diagnóstico e Monitoração; Centro de Pesquisa René Rachou/FIOCRUZ
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24
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Pinto P, Ghosh K, Shetty S. Factor VIII haplotypes in severe hemophilia A patients in India. Ann Hematol 2012; 92:999-1000. [PMID: 23262994 DOI: 10.1007/s00277-012-1658-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2012] [Accepted: 12/14/2012] [Indexed: 10/27/2022]
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25
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Grancha S, Ortiz AM, Marañón C, Hampel K, Moret A, Zimmermann B, Jorquera JI, Aznar JA. Kinetics of the interaction between anti-FVIII antibodies and FVIII from therapeutic concentrates, with and without von Willebrand factor, assessed by surface plasmon resonance. Haemophilia 2012; 18:982-9. [DOI: 10.1111/j.1365-2516.2012.02858.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/20/2012] [Indexed: 11/27/2022]
Affiliation(s)
- S. Grancha
- R&D Area; Instituto Grifols S.A; Barcelona; Spain
| | - A. M. Ortiz
- R&D Area; Instituto Grifols S.A; Barcelona; Spain
| | - C. Marañón
- R&D Area; Instituto Grifols S.A; Barcelona; Spain
| | - K. Hampel
- Biaffin GmbH & Co KG; Kassel; Germany
| | - A. Moret
- Hemostasis and Thrombosis Unit; Hospital Universitario La Fe; Valencia; Spain
| | | | | | - J. A. Aznar
- Hemostasis and Thrombosis Unit; Hospital Universitario La Fe; Valencia; Spain
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Pinto P, Ghosh K, Shetty S. Immune regulatory gene polymorphisms as predisposing risk factors for the development of factor VIII inhibitors in Indian severe haemophilia A patients. Haemophilia 2012; 18:794-7. [PMID: 22630053 DOI: 10.1111/j.1365-2516.2012.02845.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/03/2012] [Indexed: 11/28/2022]
Abstract
Development of inhibitors to factor VIII, a serious complication of replacement therapy in haemophilia A patients, leads to increased bleeding, morbidity and mortality. There is no data on the risk factors for inhibitor development in Indian patients with severe haemophilia A. Our aim was to study the role of immune regulatory gene polymorphisms in the development of inhibitors. Fourteen immune regulatory gene polymorphisms (IL1β, IL4, IL10, TNFA and CTLA4) were analysed in 120 patients with severe haemophilia A, i.e. 50 inhibitor positive patients, and 70 inhibitor negative control patients, by PCR-RFLP, DNA sequencing and allele-specific PCRs. The IL10 promoter 'GCC' haplotypes overall (P: 0.002, OR: 3.452, 95% CI: 1.607-7.416), and 'GCC/ATA' (P: 0.011, OR: 3.492, 95% CI: 1.402-8.696) haplotype, associated with high and intermediate IL10 production, respectively, were significantly higher in inhibitor positive patients, whereas the 'non-GCC' haplotypes overall (P: 0.002,OR: 0.290, 95% CI 0.135-0.622) and 'ATA/ATA' haplotype (P: 0.025, OR: 0.278, 95% CI: 0.096-0.802), associated with low IL10 synthesis, were significantly higher among inhibitor negative patients. The TNFA rs1799724 C/T heterozygote prevalence was significantly higher in the inhibitor positive group (P: 0.021, OR: 3.190, 95% CI: 1.273-7.990), whereas the other polymorphisms showed no statistically significant association with the presence of inhibitors. Different immune regulatory gene polymorphisms play a significant role as possible risk factors for the development of inhibitors in severe haemophilia A patients.
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Affiliation(s)
- P Pinto
- National Institute of Immunohaematology, ICMR, KEM Hospital Campus, Parel, Mumbai, India
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27
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Porada CD, Sanada C, Kuo CJ, Colletti E, Mandeville W, Hasenau J, Zanjani ED, Moot R, Doering C, Spencer HT, Almeida-Porada G. Phenotypic correction of hemophilia A in sheep by postnatal intraperitoneal transplantation of FVIII-expressing MSC. Exp Hematol 2011; 39:1124-1135.e4. [PMID: 21906573 DOI: 10.1016/j.exphem.2011.09.001] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2011] [Accepted: 09/30/2011] [Indexed: 11/26/2022]
Abstract
We recently re-established a line of sheep that accurately mimics the clinical symptoms and genetics of severe hemophilia A (HA). Here, we tested a novel, nonablative transplantation therapy in two pediatric HA animals. Paternal mesenchymal stem cells (MSC) were transduced with a porcine FVIII-encoding lentivector and transplanted via the intraperitoneal route without preconditioning. At the time of transplantation, these animals had received multiple human FVIII treatments for various spontaneous bleeds and had developed debilitating hemarthroses, which produced severe defects in posture and gait. Transplantation of transduced MSC resolved all existent hemarthroses, and spontaneous bleeds ceased. Damaged joints recovered fully; the animals regained normal posture and gait and resumed normal activity. Despite achieving factor-independence, a sharp rise in pre-existent Bethesda titers occurred following transplantation, decreasing the effectiveness and duration of therapy. Postmortem examination revealed widespread engraftment, with MSC present within the lung, liver, intestine, and thymus, but particularly within joints affected at the time of transplantation, suggesting MSC homed to sites of ongoing injury/inflammation to release FVIII, explaining the dramatic improvement in hemarthrotic joints. In summary, this novel, nonablative MSC transplantation was straightforward, safe, and converted life-threatening, debilitating HA to a moderate phenotype in a large animal model.
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Moghimi B, Sack BK, Nayak S, Markusic DM, Mah CS, Herzog RW. Induction of tolerance to factor VIII by transient co-administration with rapamycin. J Thromb Haemost 2011; 9:1524-33. [PMID: 21585650 PMCID: PMC3154987 DOI: 10.1111/j.1538-7836.2011.04351.x] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Formation of inhibitory antibodies is a frequent and serious complication of factor (F) VIII replacement therapy for the X-linked bleeding disorder hemophilia A. Similarly, hemophilia A mice develop high-titer inhibitors to recombinant human FVIII after a few intravenous injections. OBJECTIVE Using the murine model, the study sought to develop a short regimen capable of inducing tolerance to FVIII. METHODS A 1-month immunomodulatory protocol, consisting of FVIII administration combined with oral delivery of rapamycin, was developed. RESULTS The protocol effectively prevented formation of inhibitors to FVIII upon subsequent intravenous treatment (weekly for 3.5 months). Control mice formed high-titer inhibitors and had CD4(+) T effector cell responses characterized by expression of IL-2, IL-4 and IL-6. Tolerized mice instead had a CD4(+)CD25(+)FoxP3(+) T cell response to FVIII that suppressed antibody formation upon adoptive transfer, indicating a shift from Th2 to Treg if FVIII antigen was introduced to T cells during inhibition with rapamycin. CD4(+) T cells from tolerized mice also expressed TGF-β1 and CTLA4, but not IL-10. The presence of FVIII antigen during the time of rapamycin administration was required for specific tolerance induction. CONCLUSIONS The study shows that a prophylactic immune tolerance protocol for FVIII can be developed using rapamycin, a drug that is already widely in clinical application. Immune suppression with rapamycin was mild and highly transient, as the mice regained immune competence within a few weeks.
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Affiliation(s)
- Babak Moghimi
- Department of Pediatrics, Division of Cellular and Molecular Therapy University of Florida, Gainesville, FL
| | - Brandon K. Sack
- Department of Pediatrics, Division of Cellular and Molecular Therapy University of Florida, Gainesville, FL
| | - Sushrusha Nayak
- Department of Pediatrics, Division of Cellular and Molecular Therapy University of Florida, Gainesville, FL
| | - David M. Markusic
- Department of Pediatrics, Division of Cellular and Molecular Therapy University of Florida, Gainesville, FL
| | - Cathryn S. Mah
- Department of Pediatrics, Division of Cellular and Molecular Therapy University of Florida, Gainesville, FL
| | - Roland W. Herzog
- Department of Pediatrics, Division of Cellular and Molecular Therapy University of Florida, Gainesville, FL
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Phadke S. Hemophilia care in India: a review and experience from a tertiary care centre in uttar pradesh. Indian J Hematol Blood Transfus 2011; 27:121-6. [PMID: 22942560 DOI: 10.1007/s12288-011-0084-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2010] [Accepted: 05/27/2011] [Indexed: 10/18/2022] Open
Abstract
Approximately 14,000 people with hemophilia are registered at the Hemophilia Federation of India; however, hemophilia remains under-diagnosed and many cases are not registered. In June 2009, the Government of Uttar Pradesh made anti-hemophilic factors available at a few centers, including the Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow. Consequently, the level of hemophilia care has improved considerably in recent times. Amongst the many challenges facing people with hemophilia, the development of inhibitors, which neutralize clotting factors provided by replacement therapy, is the most feared one. Healthcare professionals who treat people with hemophilia should not only be knowledgeable about the condition and committed to bettering the management of hemophilia, but also take responsibility for the judicious allocation of resources for various aspects of managing hemophilia. This manuscript aims to raise awareness regarding the detection and management of inhibitors in hemophilia based on the experience of a tertiary care hemophilia treatment centre in Uttar Pradesh, India.
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Affiliation(s)
- Shubha Phadke
- Department of Medical Genetics, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014 India
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De Barros MF, Herrero JCM, Sell AM, De Melo FC, Braga MA, Pelissari CB, Machado J, De Souza Schiller S, De Souza Hirle L, Visentainer JEL. Influence of class I and II HLA alleles on inhibitor development in severe haemophilia A patients from the south of Brazil. Haemophilia 2011; 18:e236-40. [PMID: 21726358 DOI: 10.1111/j.1365-2516.2011.02604.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Congenital haemophilia A is a chromosome-linked recessive disorder caused by the deficiency or reduction of factor VIII (FVIII) pro-coagulant activity. During treatment, some patients develop alloantibodies (FVIII inhibitors) that neutralize the action of exogenously administered FVIII. Currently, the presence of these inhibitors is the most serious adverse event found in replacement therapy. Some studies have suggested that genetic factors influence the development of the FVIII coagulation inhibitors. To identify the class I and II alleles that may be influencing the formation of inhibitors in severe haemophilic patients. Genotyping of the class I (HLA-A, -B and -C) and class II (HLA-DRB1, -DQA1 and -DQB1) alleles of 122 patients with severe haemophilia A, including 36 who had developed antibodies to factor VIII, was performed. After the comparison of the group without inhibitors and the group with inhibitors, HLA-C*16 [Odds ratio (OR) = 7.73; P = 0.0092] and HLA-DRB1*14 (OR = 4.52; P = 0.0174) were found to be positively associated with the formation of the inhibitors. These results confirm that HLA alleles are involved in inhibitor production and could be used as a tool for recognition of groups at high risk of possible inhibitor development in Southern Brazilian haemophilic patients.
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Affiliation(s)
- M F De Barros
- Departamento de Análises Clínicas, Universidade Estadual de Maringá, Maringá, PR, Brazil
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ABDEL-MESSIH IY, MOHAMED HABASHY DM, MOFTAH SG, EL-ALFY M. Persistent factor VIII inhibitors and orthopaedic complications in children with severe haemophilia A. Haemophilia 2011; 17:490-3. [DOI: 10.1111/j.1365-2516.2010.02447.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Tantawy AA. Molecular genetics of hemophilia A: Clinical perspectives. EGYPTIAN JOURNAL OF MEDICAL HUMAN GENETICS 2010. [DOI: 10.1016/j.ejmhg.2010.10.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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WINDYGA J, RUSEN L, GRUPPO R, O’BRIEN AC, KELLY P, ROTH DA, ARKIN S. BDDrFVIII (Moroctocog alfa [AF-CC]) for surgical haemostasis in patients with haemophilia A: results of a pivotal study. Haemophilia 2010; 16:731-9. [DOI: 10.1111/j.1365-2516.2010.02239.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Verma D, Moghimi B, LoDuca PA, Singh HD, Hoffman BE, Herzog RW, Daniell H. Oral delivery of bioencapsulated coagulation factor IX prevents inhibitor formation and fatal anaphylaxis in hemophilia B mice. Proc Natl Acad Sci U S A 2010; 107:7101-6. [PMID: 20351275 PMCID: PMC2872434 DOI: 10.1073/pnas.0912181107] [Citation(s) in RCA: 118] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
To address complications of pathogenic antibody or life-threatening anaphylactic reactions in protein replacement therapy for patients with hemophilia or other inherited protein deficiencies, we have developed a prophylactic protocol using a murine hemophilia B model. Oral delivery of coagulation factor IX fused with cholera toxin beta-subunit (with or without a furin cleavage site; CTB-FFIX or CTB-FIX), expressed in chloroplasts (up to 3.8% soluble protein or 0.4 mg/g leaf tissue), bioencapsulated in plant cells, effectively blocked formation of inhibitory antibodies (undetectable or up to 100-fold less than controls). Moreover, this treatment eliminated fatal anaphylactic reactions that occurred after four to six exposures to intravenous F.IX. Whereas only 20-25% of control animals survived after six to eight F.IX doses, 90-93% of F.IX-fed mice survived 12 injections without signs of allergy or anaphylaxis. Immunostaining confirmed delivery of F.IX to Peyer's patches in the ileum. Within 2-5 h, feeding of CTB-FFIX additionally resulted in systemic delivery of F.IX antigen. This high-responder strain of hemophilia B mice represents a new animal model to study anaphylactic reactions. The protocol was effective over a range of oral antigen doses (equivalent to 5-80 microg recombinant F.IX/kg), and controlled inhibitor formation and anaphylaxis long-term, up to 7 months (approximately 40% life span of this mouse strain). Oral antigen administration caused a deviant immune response that suppressed formation of IgE and inhibitory antibodies. This cost-effective and efficient approach of antigen delivery to the gut should be applicable to several genetic diseases that are prone to pathogenic antibody responses during treatment.
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Affiliation(s)
- Dheeraj Verma
- Department of Molecular Biology and Microbiology, College of Medicine, University of Central Florida, Orlando, FL 32816-2364; and
| | - Babak Moghimi
- Department of Pediatrics, College of Medicine, University of Florida, Gainesville, FL 32610
| | - Paul A. LoDuca
- Department of Pediatrics, College of Medicine, University of Florida, Gainesville, FL 32610
| | - Harminder D. Singh
- Department of Molecular Biology and Microbiology, College of Medicine, University of Central Florida, Orlando, FL 32816-2364; and
| | - Brad E. Hoffman
- Department of Pediatrics, College of Medicine, University of Florida, Gainesville, FL 32610
| | - Roland W. Herzog
- Department of Pediatrics, College of Medicine, University of Florida, Gainesville, FL 32610
| | - Henry Daniell
- Department of Molecular Biology and Microbiology, College of Medicine, University of Central Florida, Orlando, FL 32816-2364; and
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Waters B, Lillicrap D. The molecular mechanisms of immunomodulation and tolerance induction to factor VIII. J Thromb Haemost 2009; 7:1446-56. [PMID: 19583822 DOI: 10.1111/j.1538-7836.2009.03538.x] [Citation(s) in RCA: 78] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Successful factor (F) VIII replacement therapy in hemophilia A patients is confounded by the generation of inhibitory anti-FVIII antibodies (Ab) in 25-30% of treated patients. These antibodies, termed 'inhibitors', significantly increase morbidity within the hemophilia population and lower the quality of life for these patients. For the past 30 years, immune tolerance induction (ITI) has been the standard therapy to elicit immunological tolerance to FVIII in the clinic. ITI works well in approximately 75% of patients, but it is expensive, can take years to show effect and is in many cases practically challenging. Therefore, new immunological tolerance induction strategies are now being designed and tested in hemophilia A animal models. This review attempts to provide a comprehensive description, at both the cellular and molecular levels, of these novel advances in tolerance induction and immunomodulation of FVIII. We begin by briefly reviewing why and how the immune system generates a protective response against exogenous FVIII. This leads to a discussion of the latest advances in FVIII tolerance/immunomodulation technology. These advances include interesting methodologies to induce B cell specific tolerance in FVIII primed humans and animals, as well as newer T cell-specific therapies that modify and/or block co-stimulation. We also discuss methods to manipulate FVIII loading of antigen-presenting cells.
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Affiliation(s)
- B Waters
- Department of Pathology and Molecular Medicine, Queen's University, Kingston, ON, Canada
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Nayak S, Cao O, Hoffman BE, Cooper M, Zhou S, Atkinson MA, Herzog RW. Prophylactic immune tolerance induced by changing the ratio of antigen-specific effector to regulatory T cells. J Thromb Haemost 2009; 7:1523-32. [PMID: 19583824 PMCID: PMC2981868 DOI: 10.1111/j.1538-7836.2009.03548.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Gene and protein replacement therapies for inherited protein deficiencies such as hemophilia or lysosomal storage disorders are limited by deleterious immune responses directed against their respective therapeutic proteins. Therefore, the development of protocols preventing such responses is key to providing successful long-term therapy. OBJECTIVES We sought to develop a protocol, utilizing a drug/peptide cocktail, that would effectively shift the antigen-specific CD4+ T-cell population, tipping the balance from effector T cells (Teffs) towards regulatory T cells (Tregs). METHODS Treg-deficient (DO11.10-tg Rag2(-/-)) BALB/c mice were used to screen for an optimal protocol addressing the aforementioned goal and to study the mechanisms underlying in vivo changes in T-cell populations. Muscle-directed gene transfer to hemophilia B mice was also performed in order to test the optimal protocol in a therapeutically relevant setting. RESULTS Specific antigen administration (4-week repeated dosing) combined with rapamycin and interleukin-10 led to substantial reductions in Teffs, via activation-induced cell death, and induced CD4+CD25+FoxP3+ Tregs to a large extent in multiple organs. The proportion of apoptotic T cells also increased over time, whereas Teffs and Tregs were differentially affected. When applied to a model of protein deficiency (gene therapy for hemophilia B), the protocol successfully prevented inhibitor formation, whereas non-specific immunosuppression was only marginally effective. CONCLUSIONS It is feasible to provide a short-term, prophylactic protocol allowing for the induction of immune tolerance. This protocol may provide a marked advance in efforts seeking to improve clinical outcomes in disorders involving therapeutic protein replacement.
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Affiliation(s)
- S Nayak
- Department of Pediatrics, University of Florida, Gainesville, FL 32610, USA
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