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Zuccherato LW, Souza RP, Camelo RM, Dias MM, Jardim LL, Santana MAP, Oliveira AG, Lorenzato CS, Cerqueira MH, Franco VKB, Ribeiro RDA, Etto LY, Roberti MDRF, Callado FMDA, de Cerqueira MAF, Pinto ISDS, Garcia AA, Anegawa TH, Neves DCF, Tan DM, Tou RP, Chaves DG, van der Bom J, Rezende SM. Large deletions and small insertions and deletions in the factor VIII gene predict unfavorable immune tolerance induction outcome in people with severe hemophilia A and high-responding inhibitors. Thromb Res 2024; 242:109115. [PMID: 39186847 DOI: 10.1016/j.thromres.2024.109115] [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: 05/11/2024] [Revised: 07/09/2024] [Accepted: 08/05/2024] [Indexed: 08/28/2024]
Abstract
INTRODUCTION Hemophilia A is an inherited bleeding disorder caused by pathogenic variants in the factor VIII gene (F8), which leads to factor VIII (FVIII) deficiency. Immune tolerance induction (ITI) is a therapeutic approach to eradicate alloantibodies (inhibitors) against exogenous FVIII in people with inherited hemophilia A. Few studies have evaluated the role of F8 variants on ITI outcome. MATERIAL AND METHODS We included people with severe hemophilia A (FVIII ˂ 1 international units/dL) and high-responding inhibitors (≥ 5 Bethesda units/mL lifelong) who underwent a first course of ITI. Socio-demographic, clinical and laboratory data were collected. ITI outcomes were defined as total, partial successes, and failure. Detection of intron 1 and 22 inversions was performed by polymerase-chain reaction, followed by F8 sequencing. RESULTS We included 168 people with inherited hemophilia A and high-responding inhibitors, median age 6 years at ITI start. Intron 22 inversion was the most prevalent variant (53.6 %), followed by nonsense (16.1 %), small insertion/deletion (11.3 %), and large deletion (10.7 %). In comparison with intron 22 inversion, the odds of ITI failure were 15.5 times higher (odds ratio [OR] 15.50; 95 % confidence interval [95 % CI] 4.59-71.30) and 4.25 times higher (95 % CI, 1.53-12.3) among carriers of F8 large deletions and small insertions and deletions, respectively. CONCLUSION F8 large deletions and small insertions/deletions predicted ITI failure after a first course of ITI in patients with severe hemophilia A and high-responding inhibitors. This is the first study to show F8 large deletions and small insertions/deletions as predictors of ITI failure.
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Affiliation(s)
| | | | | | | | - Letícia Lemos Jardim
- Universidade Federal de Minas Gerais, Belo Horizonte, Brazil; Instituto René Rachou (Fiocruz Minas), Belo Horizonte, Minas Gerais, Brazil
| | | | | | | | | | | | | | - Leina Yukari Etto
- Hemocentro da Paraíba (HEMOÍBA), João Pessoa, Brazil; Universidade Federal da Paraíba, João Pessoa, Brazil
| | | | | | | | - Ieda Solange de Souza Pinto
- Centro de Hematologia e Hemoterapia do Pará (HEMOPA), Belém, Brazil; Universidade Federal do Pará, Belém, Brazil
| | - Andrea Aparecida Garcia
- Hemocentro de São José do Rio Preto, São José do Rio Preto, Brazil; Faculdade Regional de Medicina de São José do Rio Preto, São José do Rio Preto, Brazil
| | - Tania Hissa Anegawa
- Centro de Hematologia Regional de Londrina (HEMEPAR Londrina), Londrina, Brazil; Faculdade de Medicina, Universidade Estadual de Londrina, Londrina, Brazil
| | - Daniele Campos Fontes Neves
- Fundação Hemocentro de Rondônia (FHEMERON), Porto Velho, Brazil; Universidade de Rondônia, Porto Velho, Brazil
| | | | | | | | - Johanna van der Bom
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
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Grigore A, Dragomir M, Călugăru OT, Jardan D, Jardan C, Brînză M, Bălănescu P, Coriu D. Mutational Profile in Romanian Patients with Hemophilia A. Int J Mol Sci 2024; 25:8366. [PMID: 39125936 PMCID: PMC11312815 DOI: 10.3390/ijms25158366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2024] [Revised: 07/25/2024] [Accepted: 07/30/2024] [Indexed: 08/12/2024] Open
Abstract
Hemophilia A (HA) is an X-linked recessive bleeding disorder caused by mutations in the F8 gene, resulting in deficient or dysfunctional factor VIII (FVIII). This study aimed to characterize the mutational profile of HA in Romanian patients using next-generation sequencing (NGS) and multiplex ligation-dependent probe amplification (MLPA). A total of 107 patients were analyzed, revealing pathogenic or likely pathogenic variants in 96.3% of cases. The identified mutations included missense (30.5%), nonsense (9.1%), small deletions (6.4%), small insertions (2.1%), splice-site variants (4.3%), large deletions (1.6%), and large duplications (1.1%). Large intron inversion was previously found in 37.5% of the patients. Novel variants accounted for 21.5% of identified mutations, expanding the spectrum of F8 variants in this population. This study underscores the genetic heterogeneity of HA and provides insights into genotype-phenotype correlations, aiding in clinical management and prenatal diagnosis.
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Affiliation(s)
- Andra Grigore
- Hematology (Clinic and Laboratory) Discipline-Fundeni Clinical Institute, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Department of Hematology and Bone Marrow Transplant, Fundeni Clinical Institute, 022328 Bucharest, Romania
| | - Mihaela Dragomir
- Department of Hematology and Bone Marrow Transplant, Fundeni Clinical Institute, 022328 Bucharest, Romania
| | - Onda-Tabita Călugăru
- Department of Hematology and Bone Marrow Transplant, Fundeni Clinical Institute, 022328 Bucharest, Romania
| | - Dumitru Jardan
- Molecular Biology Laboratory, Medlife, 010093 Bucharest, Romania
| | - Cerasela Jardan
- Department of Hematology and Bone Marrow Transplant, Fundeni Clinical Institute, 022328 Bucharest, Romania
- Pediatrics Discipline-Fundeni Clinical Institute, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Melen Brînză
- Department of Hematology and Bone Marrow Transplant, Fundeni Clinical Institute, 022328 Bucharest, Romania
| | - Paul Bălănescu
- Internal Medicine Discipline-Colentina Clinical Hospital, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Daniel Coriu
- Hematology (Clinic and Laboratory) Discipline-Fundeni Clinical Institute, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Department of Hematology and Bone Marrow Transplant, Fundeni Clinical Institute, 022328 Bucharest, Romania
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3
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Trirut C, Sosothikul D, Ittiwut R, Ittiwut C, Pongsewalak S, Songthawee N, Natesirinilkul R, Banjerdlak P, Na Songkhla P, Komvilaisak P, Moonla C, Suphapeetiporn K. F8 variants and their genotype-phenotype correlations in Thai patients with haemophilia A: a nationwide multicentre study. J Clin Pathol 2024:jcp-2024-209542. [PMID: 38981663 DOI: 10.1136/jcp-2024-209542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Accepted: 06/20/2024] [Indexed: 07/11/2024]
Abstract
AIMS Analysis of the F8 gene helps predict the risk of developing factor VIII (FVIII) inhibitors and the depth of phenotype in haemophilia A (HA) patients. Since data in Southeast Asian countries remain scarce, we aim to study F8 variation correlated with HA phenotypes in Thailand. METHODS Thai patients with HA were enrolled from seven haemophilia treatment centres during 2022-2023. Using peripheral blood DNA, inverse shifting-polymerase chain reaction (IS-PCR) for F8-intron 22 inversion (Inv22) and F8-intron 1 inversion (Inv1) was performed. Whole exome sequencing (WES) was explored in cases without Inv22/Inv1. RESULTS Of 124 patients with HA, 91.9% were detected with a causative F8 variant, including Inv22 (30.6%), Inv1 (1.6%), missense (23.4%), nonsense (16.9%) and small insertion/deletion (16.1%) mutations. Inv22, small insertion/deletion and nonsense were associated with severe HA, compared with missense variants, by the ORs of 13.9 (95% CI, 4.2 to 56.7), 14.7 (95% CI, 3.4 to 104.7) and 15.6 (95% CI, 3.6 to 110.2), respectively. While nonsense variants affecting the light chain increased the risk of developing FVIII inhibitors (OR, 6.8; 95% CI, 1.5 to 32.6) compared with the low-risk (small insertion/deletion, missense and splice-site) variants. Twelve patients (9.7%) harboured novel F8 variants, comprising five missense (p.Pro540Leu, p.Ser564Pro, p.Leu668Pro, p.Ala1721Glu, p.His2024Pro), five small insertion/deletion (p.Val502SerfsTer13, p.Ile522PhefsTer13, p.Phe992LysfsTer11, p.Leu1223PhefsTer18, c.6427_6429+3delATGGTA) and one nonsense mutations (p.Glu1292Ter). CONCLUSIONS IS-PCR followed by WES successfully assesses F8 alterations in most HA cases. With several unique variants, severe HA in Thailand is considerably caused by Inv22, small insertion/deletion and nonsense, whereas missense variants are more responsible for nonsevere HA phenotypes.
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Affiliation(s)
- Chayanit Trirut
- Department of Pediatrics, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Darintr Sosothikul
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
- Integrative and Innovative Hematology/Oncology Research Unit, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Rungnapa Ittiwut
- Department of Pediatrics, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
- Excellence Center for Genomics and Precision Medicine, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Chupong Ittiwut
- Department of Pediatrics, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
- Excellence Center for Genomics and Precision Medicine, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Sureeporn Pongsewalak
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Chonburi Hospital, Chonburi, Thailand
| | - Natsaruth Songthawee
- Department of Pediatrics, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | | | - Pallapa Banjerdlak
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Hatyai Hospital, Songkhla, Thailand
| | - Pokpong Na Songkhla
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Prapokklao Hospital, Chanthaburi, Thailand
| | - Patcharee Komvilaisak
- Department of Pediatrics, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Chatphatai Moonla
- Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
- Center of Excellence in Translational Hematology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Kanya Suphapeetiporn
- Excellence Center for Genomics and Precision Medicine, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
- Division of Medical Genetics and Metabolism, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
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4
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Jones D. Characterization of the F8 gene: a silver lining in a dark cloud. Nat Rev Cardiol 2024:10.1038/s41569-024-01050-w. [PMID: 38839880 DOI: 10.1038/s41569-024-01050-w] [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: 06/07/2024]
Affiliation(s)
- Daisy Jones
- National Heart and Lung Institute, Imperial College London, London, UK.
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5
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Pierce GF, Fong S, Long BR, Kaczmarek R. Deciphering conundrums of adeno-associated virus liver-directed gene therapy: focus on hemophilia. J Thromb Haemost 2024; 22:1263-1289. [PMID: 38103734 DOI: 10.1016/j.jtha.2023.12.005] [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: 09/15/2023] [Revised: 11/07/2023] [Accepted: 12/01/2023] [Indexed: 12/19/2023]
Abstract
Adeno-associated virus gene therapy has been the subject of intensive investigation for monogenic disease gene addition therapy for more than 25 years, yet few therapies have been approved by regulatory agencies. Most have not progressed beyond phase 1/2 due to toxicity, lack of efficacy, or both. The liver is a natural target for adeno-associated virus since most serotypes have a high degree of tropism for hepatocytes due to cell surface receptors for the virus and the unique liver sinusoidal geometry facilitating high volumes of blood contact with hepatocyte cell surfaces. Recessive monogenic diseases such as hemophilia represent promising targets since the defective proteins are often synthesized in the liver and secreted into the circulation, making them easy to measure, and many do not require precise regulation. Yet, despite initiation of many disease-specific clinical trials, therapeutic windows are often nonexistent, resulting in excess toxicity and insufficient efficacy. Iterative progress built on these attempts is best illustrated by hemophilia, with the first regulatory approvals for factor IX and factor VIII gene therapies eventually achieved 25 years after the first gene therapy studies in humans. Although successful gene transfer may result in the production of sufficient transgenic protein to modify the disease, many emerging questions on durability, predictability, reliability, and variability of response have not been answered. The underlying biology accounting for these heterogeneous responses and the interplay between host and virus is the subject of intense investigation and the subject of this review.
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Affiliation(s)
- Glenn F Pierce
- World Federation of Hemophilia, Montreal, Quebec, Canada.
| | - Sylvia Fong
- BioMarin Pharmaceutical Inc, Research and Early Development, Novato, California, USA
| | - Brian R Long
- BioMarin Pharmaceutical Inc, Research and Early Development, Novato, California, USA
| | - Radoslaw Kaczmarek
- Department of Pediatrics, Indiana University School of Medicine, Wells Center for Pediatric Research, Indiana, USA; Laboratory of Glycobiology, Hirszfeld Institute of Immunology and Experimental Therapy, Wroclaw, Poland
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Bala NS, Thornburg CD. Gene Therapy in Hemophilia A: Achievements, Challenges, and Perspectives. Semin Thromb Hemost 2024. [PMID: 38588706 DOI: 10.1055/s-0044-1785483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/10/2024]
Abstract
Strides in advancements of care of persons with hemophilia include development of long-acting factor replacement therapies, novel substitution and hemostatic rebalancing agents, and most recently approved gene therapy. Several decades of preclinical and clinical trials have led to development of adeno-associated viral (AAV) vector-mediated gene transfer for endogenous production of factor VIII (FVIII) in hemophilia A (HA). Only one gene therapy product for HA (valoctocogene roxaparvovec) has been approved by regulatory authorities. Results of valoctocogene roxaparvovec trial show significant improvement in bleeding rates and use of factor replacement therapy; however, sustainability and duration of response show variability with overall decline in FVIII expression over time. Further challenges include untoward adverse effects involving liver toxicity requiring immunosuppression and development of neutralizing antibodies to AAV vector rendering future doses ineffective. Real-life applicability of gene therapy for HA will require appropriate patient screening, infrastructure setup, long-term monitoring including data collection of patient-reported outcomes and innovative payment schemes. This review article highlights the success and development of HA gene therapy trials, challenges including adverse outcomes and variability of response, and perspectives on approach to gene therapy including shared decision-making and need for future strategies to overcome the several unmet needs.
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Affiliation(s)
- Natasha S Bala
- Rady Children's Hospital San Diego, Hemophilia and Thrombosis Treatment Center, San Diego, California
- Department of Pediatrics, UC San Diego School of Medicine, La Jolla, California
| | - Courtney D Thornburg
- Rady Children's Hospital San Diego, Hemophilia and Thrombosis Treatment Center, San Diego, California
- Department of Pediatrics, UC San Diego School of Medicine, La Jolla, California
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7
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Chen M, Shen MC, Chang SP, Ma GC, Lee DJ, Yan A. De Novo Noninversion Variants Implicated in Sporadic Hemophilia A: A Variant Origin and Timing Study. Int J Mol Sci 2024; 25:1763. [PMID: 38339041 PMCID: PMC10855912 DOI: 10.3390/ijms25031763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 01/26/2024] [Accepted: 01/26/2024] [Indexed: 02/12/2024] Open
Abstract
Sporadic hemophilia A (HA) enables the persistence of HA in the population. F8 gene inversion originates mainly in male germ cells during meiosis. To date, no studies have shown the origin and timing of HA sporadic noninversion variants (NIVs); herein, we assume that HA-sporadic NIVs are generated as a de novo variant. Of the 125 registered families with HA, 22 were eligible for inclusion. We conducted a linkage analysis using F8 gene markers and amplification refractory mutation system-quantitative polymerase chain reaction to confirm the origin of the sporadic NIVs (~0% mutant cells) or the presence of a mosaic variant, which requires further confirmation of the origin in the parent. Nine mothers, four maternal grandmothers, and six maternal grandfathers were confirmed to be the origin of sporadic NIVs, which most likely occurred in the zygote within the first few cell divisions and in single sperm cells, respectively. Three mothers had mosaic variants, which most likely occurred early in postzygotic embryogenesis. All maternal grandparents were free from sporadic NIV. In conclusion, F8 NIVs in sporadic HA were found to be caused primarily by de novo variants. Our studies are essential for understanding the genetic pathogenesis of HA and improving current genetic counseling.
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Affiliation(s)
- Ming Chen
- Department of Genomic Medicine, Changhua Christian Hospital, Changhua 500, Taiwan; (M.C.); (S.-P.C.); (G.-C.M.); (D.-J.L.); (A.Y.)
- Department of Obstetrics and Gynecology, Changhua Christian Hospital, Changhua 500, Taiwan
- Department of Medical Genetics National Taiwan University Hospital, Taipei 100, Taiwan
- Department of Obstetrics and Gynecology, National Taiwan University Hospital, Taipei 100, Taiwan
| | - Ming-Ching Shen
- Department of Laboratory Medicine, National Taiwan University Hospital, Taipei 100, Taiwan
- Department of Internal Medicine, National Taiwan University Hospital, Taipei 100, Taiwan
- Hemophilia Treatment and Thrombosis Center, Department of Internal Medicine, Changhua Christian Hospital, Changhua 500, Taiwan
| | - Shun-Ping Chang
- Department of Genomic Medicine, Changhua Christian Hospital, Changhua 500, Taiwan; (M.C.); (S.-P.C.); (G.-C.M.); (D.-J.L.); (A.Y.)
| | - Gwo-Chin Ma
- Department of Genomic Medicine, Changhua Christian Hospital, Changhua 500, Taiwan; (M.C.); (S.-P.C.); (G.-C.M.); (D.-J.L.); (A.Y.)
| | - Dong-Jay Lee
- Department of Genomic Medicine, Changhua Christian Hospital, Changhua 500, Taiwan; (M.C.); (S.-P.C.); (G.-C.M.); (D.-J.L.); (A.Y.)
| | - Adeline Yan
- Department of Genomic Medicine, Changhua Christian Hospital, Changhua 500, Taiwan; (M.C.); (S.-P.C.); (G.-C.M.); (D.-J.L.); (A.Y.)
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Hiramoto T, Inaba H, Baatartsogt N, Kashiwakura Y, Hayakawa M, Kamoshita N, Nishimasu H, Nureki O, Kinai E, Ohmori T. Genome editing of patient-derived iPSCs identifies a deep intronic variant causing aberrant splicing in hemophilia A. Blood Adv 2023; 7:7017-7027. [PMID: 37792826 PMCID: PMC10690555 DOI: 10.1182/bloodadvances.2023010838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 08/25/2023] [Accepted: 09/08/2023] [Indexed: 10/06/2023] Open
Abstract
The importance of genetic diagnosis for patients with hemophilia has been recently demonstrated. However, the pathological variant cannot be identified in some patients. Here, we aimed to identify the pathogenic intronic variant causing hemophilia A using induced pluripotent stem cells (iPSCs) from patients and genome editing. We analyzed siblings with moderate hemophilia A and without abnormalities in the F8 exon. Next-generation sequencing of the entire F8 revealed 23 common intron variants. Variant effect predictor software indicated that the deep intronic variant at c.5220-8563A>G (intron 14) might act as a splicing acceptor. We developed iPSCs from patients and used genome editing to insert the elongation factor 1α promoter to express F8 messenger RNA (mRNA). Then, we confirmed the existence of abnormal F8 mRNA derived from aberrant splicing, resulting in a premature terminal codon as well as a significant reduction in F8 mRNA in iPSCs due to nonsense-mediated RNA decay. Gene repair by genome editing recovered whole F8 mRNA expression. Introduction of the intron variant into human B-domain-deleted F8 complementary DNA suppressed factor VIII (FVIII) activity and produced abnormal FVIII lacking the light chain in HEK293 cells. Furthermore, genome editing of the intron variant restored FVIII production. In summary, we have directly proven that the deep intronic variant in F8 results in aberrant splicing, leading to abnormal mRNA and nonsense-mediated RNA decay. Additionally, genome editing targeting the variant restored F8 mRNA and FVIII production. Our approach could be useful not only for identifying causal variants but also for verifying the therapeutic effect of personalized genome editing.
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Affiliation(s)
- Takafumi Hiramoto
- Department of Biochemistry, Jichi Medical University School of Medicine, Shimotsuke, Tochigi, Japan
| | - Hiroshi Inaba
- Department of Laboratory Medicine, Tokyo Medical University, Tokyo, Japan
| | - Nemekhbayar Baatartsogt
- Department of Biochemistry, Jichi Medical University School of Medicine, Shimotsuke, Tochigi, Japan
| | - Yuji Kashiwakura
- Department of Biochemistry, Jichi Medical University School of Medicine, Shimotsuke, Tochigi, Japan
| | - Morisada Hayakawa
- Department of Biochemistry, Jichi Medical University School of Medicine, Shimotsuke, Tochigi, Japan
- Center for Gene Therapy Research, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Nobuhiko Kamoshita
- Department of Biochemistry, Jichi Medical University School of Medicine, Shimotsuke, Tochigi, Japan
- Center for Gene Therapy Research, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Hiroshi Nishimasu
- Structural Biology Division, Research Center for Advanced Science and Technology, The University of Tokyo, Tokyo, Japan
| | - Osamu Nureki
- Department of Biological Sciences, Graduate School of Science, The University of Tokyo, Tokyo, Japan
| | - Ei Kinai
- Department of Laboratory Medicine, Tokyo Medical University, Tokyo, Japan
| | - Tsukasa Ohmori
- Department of Biochemistry, Jichi Medical University School of Medicine, Shimotsuke, Tochigi, Japan
- Center for Gene Therapy Research, Jichi Medical University, Shimotsuke, Tochigi, Japan
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Dardik R, Janczar S, Lalezari S, Avishai E, Levy-Mendelovich S, Barg AA, Martinowitz U, Babol-Pokora K, Mlynarski W, Kenet G. Four Decades of Carrier Detection and Prenatal Diagnosis in Hemophilia A: Historical Overview, State of the Art and Future Directions. Int J Mol Sci 2023; 24:11846. [PMID: 37511607 PMCID: PMC10380558 DOI: 10.3390/ijms241411846] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 07/09/2023] [Accepted: 07/21/2023] [Indexed: 07/30/2023] Open
Abstract
Hemophilia A (HA), a rare recessive X-linked bleeding disorder, is caused by either deficiency or dysfunction of coagulation factor VIII (FVIII) resulting from deleterious mutations in the F8 gene encoding FVIII. Over the last 4 decades, the methods aimed at determining the HA carrier status in female relatives of HA patients have evolved from phenotypic studies based on coagulation tests providing merely probabilistic results, via genetic linkage studies based on polymorphic markers providing more accurate results, to next generation sequencing studies enabling highly precise identification of the causative F8 mutation. In parallel, the options for prenatal diagnosis of HA have progressed from examination of FVIII levels in fetal blood samples at weeks 20-22 of pregnancy to genetic analysis of fetal DNA extracted from chorionic villus tissue at weeks 11-14 of pregnancy. In some countries, in vitro fertilization (IVF) combined with preimplantation genetic diagnosis (PGD) has gradually become the procedure of choice for HA carriers who wish to prevent further transmission of HA without the need to undergo termination of pregnancies diagnosed with affected fetuses. In rare cases, genetic analysis of a HA carrier might be complicated by skewed X chromosome inactivation (XCI) of her non-hemophilic X chromosome, thus leading to the phenotypic manifestation of moderate to severe HA. Such skewed XCI may be associated with deleterious mutations in X-linked genes located on the non-hemophilic X chromosome, which should be considered in the process of genetic counseling and PGD planning for the symptomatic HA carrier. Therefore, whole exome sequencing, combined with X-chromosome targeted bioinformatic analysis, is highly recommended for symptomatic HA carriers diagnosed with skewed XCI in order to identify additional deleterious mutations potentially involved in XCI skewing. Identification of such mutations, which may profoundly impact the reproductive choices of HA carriers with skewed XCI, is extremely important.
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Affiliation(s)
- Rima Dardik
- National Hemophilia Center, Sheba Medical Center, Ramat Gan 52621, Israel
- Amalia Biron Research Institute of Thrombosis and Hemostasis, Sackler School of Medicine, Tel Aviv University, Tel Aviv 52621, Israel
| | - Szymon Janczar
- Department of Pediatrics, Oncology and Hematology, Medical University of Lodz, 90-419 Lodz, Poland
| | - Shadan Lalezari
- National Hemophilia Center, Sheba Medical Center, Ramat Gan 52621, Israel
- Amalia Biron Research Institute of Thrombosis and Hemostasis, Sackler School of Medicine, Tel Aviv University, Tel Aviv 52621, Israel
| | - Einat Avishai
- National Hemophilia Center, Sheba Medical Center, Ramat Gan 52621, Israel
- Amalia Biron Research Institute of Thrombosis and Hemostasis, Sackler School of Medicine, Tel Aviv University, Tel Aviv 52621, Israel
| | - Sarina Levy-Mendelovich
- National Hemophilia Center, Sheba Medical Center, Ramat Gan 52621, Israel
- Amalia Biron Research Institute of Thrombosis and Hemostasis, Sackler School of Medicine, Tel Aviv University, Tel Aviv 52621, Israel
| | - Assaf Arie Barg
- National Hemophilia Center, Sheba Medical Center, Ramat Gan 52621, Israel
- Amalia Biron Research Institute of Thrombosis and Hemostasis, Sackler School of Medicine, Tel Aviv University, Tel Aviv 52621, Israel
| | - Uri Martinowitz
- National Hemophilia Center, Sheba Medical Center, Ramat Gan 52621, Israel
| | - Katarzyna Babol-Pokora
- Department of Pediatrics, Oncology and Hematology, Medical University of Lodz, 90-419 Lodz, Poland
| | - Wojciech Mlynarski
- Department of Pediatrics, Oncology and Hematology, Medical University of Lodz, 90-419 Lodz, Poland
| | - Gili Kenet
- National Hemophilia Center, Sheba Medical Center, Ramat Gan 52621, Israel
- Amalia Biron Research Institute of Thrombosis and Hemostasis, Sackler School of Medicine, Tel Aviv University, Tel Aviv 52621, Israel
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Konkle BA. Efanesoctocog alfa for the prevention and treatment of bleeding in patients with hemophilia A. Expert Rev Hematol 2023; 16:567-573. [PMID: 37289594 DOI: 10.1080/17474086.2023.2223925] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 06/06/2023] [Indexed: 06/10/2023]
Abstract
INTRODUCTION Hemophilia A is an inherited bleeding disorder due to a deficiency of coagulation factor VIII (FVIII). Prevention and treatment of bleeding is traditionally through intravenous infusion of a FVIII concentrate. Modifications of recombinant FVIII (rFVIII) with an aim to prolong the half-life have been modest, thought because FVIII is dependent on plasma von Willebrand factor (VWF) for its half-life. Efanesoctocog alfa (ALTUVIIIO), approved by the Federal Drug Administration (FDA) in February 2023, was made independent of endogenous VWF by linking of the FVIII-binding D'D3 domain of VWF to B-domain deleted single chain FVIII. AREAS COVERED This review will outline the development of efanesoctocog alfa and the pharmacokinetic and safety data from clinical trials, as well as efficacy data from the phase 3 trials. These data formed the basis for the FDA approval. EXPERT OPINION Efanesoctocog alfa is a new type of FVIII replacement with an extended half-life allowing once weekly dosing to achieve hemostasis and FVIII trough levels of 13-15 IU/dL. This provides a highly effective option for treatment and prevention of bleeding in hemophilia A, where FVIII levels are easily measured. It also provides an option for treatment of bleeding and coverage for surgery with few infusions.
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Affiliation(s)
- Barbara A Konkle
- Washington Center for Bleeding Disorders, Division of Hematology, University of Washington, Seattle, WA, USA
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11
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Li S, He J, Chu L, Ren S, He W, Ma X, Wang Y, Zhang M, Kong L, Liang B, Li Q. F8 gene inversion and duplication cause no obvious hemophilia A phenotype. Front Genet 2023; 14:1098795. [PMID: 36845383 PMCID: PMC9947239 DOI: 10.3389/fgene.2023.1098795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 01/23/2023] [Indexed: 02/11/2023] Open
Abstract
Hemophilia A (HA, OMIM#306700) is an X-linked recessive bleeding disorder caused by the defects in the F8 gene, which encodes coagulation factor VIII (FVIII). Intron 22 inversion (Inv22) is found in about 45% of patients with severe hemophilia A. Here, we reported a male without obvious hemophilia A phenotype but bearing an inherited segmental variant duplication encompassing F8 as well as Inv22. The duplication was approximately 0.16 Mb and involved from exon 1 to intron 22 of F8. This partial duplication and Inv22 in F8 was first found in the abortion tissue of his older sister with recurrent miscarriage. The genetic testing of his family revealed that his phenotypically normal older sister and mother also had this heterozygous Inv22 and a 0.16 Mb partial duplication of F8, while his father was genotypically normal. The integrity of the F8 gene transcript was verified by sequencing of the adjacent exons at the inversion breakpoint, which explained why this male had no phenotype for hemophilia A. Interestingly, although he had no significant hemophilia A phenotype, the expression of C1QA in his mother, sister, and the male subject was only about half of that in his father and normal population. Our report broadens the mutation spectrum of F8 inversion and duplication and its pathogenicity in hemophilia A.
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Affiliation(s)
- Shaoying Li
- Department of Obstetrics and Gynecology, Experimental Department of Institute of Obstetrics and Gynecology, The Third Affiliated Hospital of Guangzhou Medical University, Key Laboratory for Major Obstetric Diseases of Guangdong Province, Guangzhou, China
| | - Jianchun He
- Department of Obstetrics and Gynecology, Experimental Department of Institute of Obstetrics and Gynecology, The Third Affiliated Hospital of Guangzhou Medical University, Key Laboratory for Major Obstetric Diseases of Guangdong Province, Guangzhou, China
| | - Liming Chu
- Basecare Medical Device Co., Ltd, Suzhou, China
| | - Shuai Ren
- Basecare Medical Device Co., Ltd, Suzhou, China
| | - Wenzhi He
- Department of Obstetrics and Gynecology, Experimental Department of Institute of Obstetrics and Gynecology, The Third Affiliated Hospital of Guangzhou Medical University, Key Laboratory for Major Obstetric Diseases of Guangdong Province, Guangzhou, China
| | - Xiaoyan Ma
- Department of Obstetrics and Gynecology, Experimental Department of Institute of Obstetrics and Gynecology, The Third Affiliated Hospital of Guangzhou Medical University, Key Laboratory for Major Obstetric Diseases of Guangdong Province, Guangzhou, China
| | - Yanchao Wang
- Department of Obstetrics and Gynecology, Experimental Department of Institute of Obstetrics and Gynecology, The Third Affiliated Hospital of Guangzhou Medical University, Key Laboratory for Major Obstetric Diseases of Guangdong Province, Guangzhou, China
| | - Mincong Zhang
- Department of Obstetrics and Gynecology, Experimental Department of Institute of Obstetrics and Gynecology, The Third Affiliated Hospital of Guangzhou Medical University, Key Laboratory for Major Obstetric Diseases of Guangdong Province, Guangzhou, China
| | | | - Bo Liang
- State Key Laboratory of Microbial Metabolism, Joint International Research Laboratory of Metabolic and Developmental Sciences, School of Life Sciences and Biotechnology, Shanghai Jiao Tong University, Shanghai, China,*Correspondence: Qing Li, ; Bo Liang,
| | - Qing Li
- Department of Obstetrics and Gynecology, Experimental Department of Institute of Obstetrics and Gynecology, The Third Affiliated Hospital of Guangzhou Medical University, Key Laboratory for Major Obstetric Diseases of Guangdong Province, Guangzhou, China,*Correspondence: Qing Li, ; Bo Liang,
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12
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Spectrum of Causative Mutations in Patients with Hemophilia A in Russia. Genes (Basel) 2023; 14:genes14020260. [PMID: 36833187 PMCID: PMC9957479 DOI: 10.3390/genes14020260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Revised: 01/09/2023] [Accepted: 01/17/2023] [Indexed: 01/20/2023] Open
Abstract
Hemophilia A (HA) is one of the most widespread, X-linked, inherited bleeding disorders, which results from defects in the F8 gene. Nowadays, more than 3500 different pathogenic variants leading to HA have been described. Mutation analysis in HA is essential for accurate genetic counseling of patients and their relatives. We analyzed patients from 273 unrelated families with different forms of HA. The analysis consisted of testing for intron inversion (inv22 and inv1), and then sequencing all functionally important F8 gene fragments. We identified 101 different pathogenic variants in 267 patients, among which 35 variants had never been previously reported in international databases. We found inv22 in 136 cases and inv1 in 12 patients. Large deletions (1-8 exons) were found in 5 patients, and we identified a large insertion in 1 patient. The remaining 113 patients carried point variants involving either single nucleotide or several consecutive nucleotides. We report herein the largest genetic analysis of HA patients issued in Russia.
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Labarque V, Mancuso ME, Kartal-Kaess M, Ljung R, Mikkelsen TS, Andersson NG. F8/F9 variants in the population-based PedNet Registry cohort compared with locus-specific genetic databases of the European Association for Haemophilia and Allied Disorders and the Centers for Disease Control and Prevention Hemophilia A or Hemophilia B Mutation Project. Res Pract Thromb Haemost 2023; 7:100036. [PMID: 36798899 PMCID: PMC9926204 DOI: 10.1016/j.rpth.2023.100036] [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: 08/31/2022] [Revised: 11/11/2022] [Accepted: 12/17/2022] [Indexed: 01/11/2023] Open
Abstract
Background Hemophilia A and B are caused by variants in the factor (F) VIII or FIX gene. Selective reporting may influence the distribution of variants reported in genetic databases. Objectives To compare the spectrum of F8 and F9 variants in an international population-based pediatric cohort (PedNet Registry) with the spectrum found in the European Association for Haemophilia and Allied Disorders (EAHAD) and the Centers for Disease Control and Prevention Hemophilia A or Hemophilia B Mutation Project (CHAMP/CHBMP) databases. Methods All patients registered in the PedNet Registry on January 1, 2021 were included in this study. As comparators, data from patients with severe hemophilia included in the CHAMP/CHBMP registry (US center data) and EAHAD were used. Results Genetic information was available for 1941 patients. Intron 22 inversion was present in 52% of patients with severe hemophilia A; frameshift (36%), missense (28%), and nonsense (20%) were the most frequent variants in patients with severe hemophilia A who were inversion-negative. The most frequent variants in severe hemophilia B were missense (48%). In nonsevere disease, most variants were missense variants (moderate hemophilia A: 91%; mild hemophilia A: 95%, moderate and mild hemophilia B: 86% each). Comparison with the databases demonstrated a higher proportion of missense variants associated with severe hemophilia B in EAHAD (68%) than in PedNet (48%) and CHBMP (46%). Conclusion The PedNet population-based cohort provides an alternative to the established databases, which collect data by selective reporting, as it is a well-maintained database covering the full spectrum of pathogenic F8 and F9 variants, and indicates the number of patients affected by each particular variant.
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Affiliation(s)
- Veerle Labarque
- Department of Paediatrics, Paediatric Haematology and Oncology, University Hospitals Leuven, Leuven, Belgium,Correspondence Veerle Labarque, Department of Paediatrics, Paediatric Haematology and Oncology, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium.
| | - Maria Elisa Mancuso
- Center for Thrombosis and Hemorrhagic Diseases, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy,Humanitas University, Rozzano, Milan, Italy
| | - Mutlu Kartal-Kaess
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Inselspital, University Hospital, University of Bern, Bern, Switzerland
| | - Rolf Ljung
- Department of Clinical Sciences and Paediatrics, Lund University, Lund, Sweden
| | - Torben S. Mikkelsen
- Department of Paediatric Oncology and Haematology, University Hospital, Aarhus, Denmark
| | - Nadine G. Andersson
- Department of Clinical Sciences and Paediatrics, Lund University, Lund, Sweden,Centre for Thrombosis and Haemostasis, Skåne University Hospital, Lund, Sweden
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14
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Pipe SW, Arruda VR, Lange C, Kitchen S, Eichler H, Wadsworth S. Characteristics of BAY 2599023 in the Current Treatment Landscape of Hemophilia A Gene Therapy. Curr Gene Ther 2023; 23:81-95. [PMID: 36111754 DOI: 10.2174/1566523222666220914105729] [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: 03/08/2022] [Revised: 08/12/2022] [Accepted: 08/13/2022] [Indexed: 11/22/2022]
Abstract
Hemophilia A, a single gene disorder leading to deficient Factor VIII (FVIII), is a suitable candidate for gene therapy. The aspiration is for single administration of a genetic therapy that would allow the production of endogenous FVIII sufficient to restore hemostasis and other biological processes. This would potentially result in reliable protection from bleeding and its associated physical and emotional impacts. Gene therapy offers the possibility of a clinically relevant improvement in disease phenotype and transformational improvement in quality of life, including an opportunity to engage in physical activities more confidently. Gene therapy products for hemophilia A in advanced clinical development use adeno-associated viral (AAV) vectors and a codon-optimized B-domain deleted FVIII transgene. However, the different AAV-based gene therapies have distinct design features, such as choice of vector capsid, enhancer and promoter regions, FVIII transgene sequence and manufacturing processes. These, in turn, impact patient eligibility, safety and efficacy. Ideally, gene therapy technology for hemophilia A should offer bleed protection, durable FVIII expression, broad eligibility and limited response variability between patients, and long-term safety. However, several limitations and challenges must be overcome. Here, we introduce the characteristics of the BAY 2599023 (AAVhu37.hFVIIIco, DTX 201) gene therapy product, including the low prevalence in the general population of anti-AAV-hu37 antibodies, as well as other gene therapy AAV products and approaches. We will examine how these can potentially meet the challenges of gene therapy, with the ultimate aim of improving the lives of patients with hemophilia A.
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Affiliation(s)
- Steven W Pipe
- Departments of Pediatrics and Pathology, University of Michigan, Ann Arbor, MI, USA
| | - Valder R Arruda
- Division of Hematology, Department of Pediatrics, Center for Cell and Molecular Therapeutics at Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | - Stephen Kitchen
- Sheffield Haemophilia and Thrombosis Centre, Sheffield Teaching Hospitals, Sheffield, UK
| | - Hermann Eichler
- Institute of Clinical Hemostaseology and Transfusion Medicine, Saarland University and University Hospital, Homburg/Saar, Germany
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15
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Gunasekera D, Vir P, Karim AF, Ragni MV, Pratt KP. Hemophilia A subjects with an intron-22 gene inversion mutation show CD4 + T-effector responses to multiple epitopes in FVIII. Front Immunol 2023; 14:1128641. [PMID: 36936969 PMCID: PMC10015889 DOI: 10.3389/fimmu.2023.1128641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 02/20/2023] [Indexed: 03/06/2023] Open
Abstract
Background Almost half of severe hemophilia A (HA) is caused by an intron 22 inversion mutation (Int22Inv), which disrupts the 26-exon F8 gene. Inverted F8 mRNA exons 1-22 are transcribed, while F8B mRNA, containing F8 exons 23-26, is transcribed from a promoter within intron 22. Neither FVIII activity nor FVIII antigen (cross-reacting material, CRM) are detectable in plasma of patients with an intron-22 inversion. Objectives To test the hypothesis that (putative) intracellular synthesis of FVIII proteins encoded by inverted F8 and F8B mRNAs confers T-cell tolerance to almost the entire FVIII sequence, and to evaluate the immunogenicity of the region encoded by the F8 exon 22-23 junction sequence. Patients/Methods Peripheral blood mononuclear cells (PBMCs) from 30 severe or moderate HA subjects (17 with an Int22Inv mutation) were tested by ELISPOT assays to detect cytokine secretion in response to FVIII proteins and peptides and to map immunodominant T-cell epitopes. Potential immunogenicity of FVIII sequences encoded by the F8 exon 22-23 junction region was also tested using peptide-MHCII binding assays. Results Eight of the Int22Inv subjects showed robust cytokine secretion from PBMCs stimulated with FVIII proteins and/or peptides, consistent with earlier publications from the Conti-Fine group. Peptide ELISPOT assays identified immunogenic regions of FVIII. Specificity for sequences encoded within F8 mRNA exons 1-22 and F8B mRNA was confirmed by staining Int22Inv CD4+ T cells with peptide-loaded HLA-Class II tetramers. FVIII peptides spanning the F8 exon 22-23 junction (encoding M2124-V2125) showed limited binding to MHCII proteins and low immunogenicity, with cytokine secretion from only one Int22Inv subject. Conclusions PBMCs from multiple subjects with an Int22Inv mutation, with and without a current FVIII inhibitor, responded to FVIII epitopes. Furthermore, the FVIII region encoded by the exon 22-23 junction sequence was not remarkably immunoreactive and is therefore unlikely to contain an immunodominant, promiscuous CD4+ T-cell epitope. Our results indicate that putative intracellular expression of partial FVIII proteins does not confer T-cell tolerance to FVIII regions encoded by inverted F8 mRNA or F8B mRNA.
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Affiliation(s)
- Devi Gunasekera
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
- Henry Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, United States
| | - Pooja Vir
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
- Henry Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, United States
| | - Ahmad Faisal Karim
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
- Henry Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, United States
| | - Margaret V. Ragni
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Kathleen P. Pratt
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
- *Correspondence: Kathleen P. Pratt,
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Long-term follow-up of liver-directed, adeno-associated vector-mediated gene therapy in the canine model of hemophilia A. Blood 2022; 140:2672-2683. [PMID: 35405003 DOI: 10.1182/blood.2021014735] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 03/01/2022] [Accepted: 03/15/2022] [Indexed: 12/30/2022] Open
Abstract
Questions remain concerning the long-term efficacy, safety, and site(s) of transgene expression following adeno-associated vector (AAV) therapy. We report a long-term follow-up of 8 (male = 4, hemizygous, and female = 4, homozygous) dogs with severe hemophilia A treated with a single portal vein infusion of a B-domain-deleted (BDD)-canine FVIII (cFVIII) AAV vector (median dose = 1.25 × 1013 vg/kg, AAV2 = 4, AAV6 = 3, and AAV8 = 1). After a median follow-up of 10.8 years (8.2-12.0 years), persistent FVIII:C (median one-stage = 12.7%, chromogenic = 7.2%) was seen in all responding dogs (n = 6), with improvement in annualized bleed rates (pre = 3.9 vs post = 0.3 event per year; P = .003). Anti-AAV capsid neutralizing antibodies (nAbs) toward the dosed capsid were detected throughout the study, with limited cross-reactivity to other capsids. nAb titers for all capsid serotypes declined with time, although they remained at levels precluding redosing with the same capsid. AAV-BDD-cFVIII DNA was detected in the liver of all dogs (median = 0.15 vg per diploid genome), with lower levels in the spleen in 4 dogs (median = 0.005 vg per diploid genome). Consistent with the liver-specific promoter, BDD-cFVIII mRNA was only detected in the liver. Postmortem examination demonstrated no evidence of chronic liver disease or liver malignancy. Persistent FVIII expression and an improved bleeding phenotype was seen for more than a decade after vector delivery. This is the longest follow-up reported in a preclinical model supporting long-term efficacy and safety of AAV-mediated gene therapy.
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Pezeshkpoor B, Oldenburg J, Pavlova A. Insights into the Molecular Genetic of Hemophilia A and Hemophilia B: The Relevance of Genetic Testing in Routine Clinical Practice. Hamostaseologie 2022; 42:390-399. [PMID: 36549291 PMCID: PMC9779947 DOI: 10.1055/a-1945-9429] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Hemophilia A and hemophilia B are rare congenital, recessive X-linked disorders caused by lack or deficiency of clotting factor VIII (FVIII) or IX (FIX), respectively. The severity of the disease depends on the reduction of coagulation FVIII or FIX activity levels, which is determined by the type of the pathogenic variants in the genes encoding the two factors (F8 and F9, respectively). Molecular genetic analysis is widely applied in inherited bleeding disorders. The outcome of genetic analysis allows genetic counseling of affected families and helps find a link between the genotype and the phenotype. Genetic analysis in hemophilia has tremendously improved in the last decades. Many new techniques and modifications as well as analysis softwares became available, which made the genetic analysis and interpretation of the data faster and more accurate. Advances in genetic variant detection strategies facilitate identification of the causal variants in up to 97% of patients. In this review, we discuss the milestones in genetic analysis of hemophilia and highlight the importance of identification of the causative genetic variants for genetic counseling and particularly for the interpretation of the clinical presentation of hemophilia patients.
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Affiliation(s)
- Behnaz Pezeshkpoor
- Institute of Experimental Hematology and Transfusion Medicine, Medical Faculty, University of Bonn, University Hospital Bonn, Bonn, Germany,Center for Rare Diseases Bonn (ZSEB), University Clinic Bonn, Bonn, Germany
| | - Johannes Oldenburg
- Institute of Experimental Hematology and Transfusion Medicine, Medical Faculty, University of Bonn, University Hospital Bonn, Bonn, Germany,Center for Rare Diseases Bonn (ZSEB), University Clinic Bonn, Bonn, Germany
| | - Anna Pavlova
- Institute of Experimental Hematology and Transfusion Medicine, Medical Faculty, University of Bonn, University Hospital Bonn, Bonn, Germany,Center for Rare Diseases Bonn (ZSEB), University Clinic Bonn, Bonn, Germany,Address for correspondence Anna Pavlova, MD, PhD Institute of Experimental Hematology and Transfusion Medicine, University of BonnVenusberg Campus 1, 53127, BonnGermany
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Bui TMP, Tran VK, Nguyen TTH, Le TP, Nguyen TM, Tran HA, Luu VD, Nguyen MH, Bui TH, Van Ta T, Tran TH. Preimplantation genetic testing (PGT) for hemophilia A: Experience from one center. Taiwan J Obstet Gynecol 2022; 61:1009-1014. [DOI: 10.1016/j.tjog.2021.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/23/2021] [Indexed: 11/24/2022] Open
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Kavaklı K, Antmen B, Okan V, Şahin F, Aytaç S, Balkan C, Berber E, Kaya Z, Küpesiz A, Zülfikar B. Gene therapy in haemophilia: literature review and regional perspectives for Turkey. Ther Adv Hematol 2022; 13:20406207221104591. [PMID: 35898436 PMCID: PMC9310332 DOI: 10.1177/20406207221104591] [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: 01/17/2022] [Accepted: 05/16/2022] [Indexed: 01/19/2023] Open
Abstract
Haemophilia is an X-linked lifelong congenital bleeding disorder that is caused by insufficient levels of factor VIII (FVIII; haemophilia A) or factor IX (FIX; haemophilia B) and characterized by spontaneous and trauma-related bleeding episodes. The cornerstone of the treatment, factor replacement, constitutes several difficulties, including frequent injections due to the short half-life of recombinant factors, intravenous administration and the risk of inhibitor development. While extended half-life factors and subcutaneous novel molecules enhanced the quality of life, initial successes with gene therapy offer a significant hope for cure. Although adeno-associated viral (AAV)-based gene therapy is one of the most emerging approaches for treatment of haemophilia, there are still challenges in vector immunogenicity, potency and efficacy, genotoxicity and persistence. As the approval for the first gene therapy product is coming closer, eligibility criteria for patient selection, multidisciplinary approach for optimal delivery and follow-up and development of new pricing policies and reimbursement models should be concerned. Therefore, this review addresses the unmet needs of current haemophilia treatment and explains the rationale and principles of gene therapy. Limitations and challenges are discussed from a global and national perspective and recommendations are provided to adopt the gene therapies faster and more sufficient for the haemophilia patients in developing countries like Turkey.
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Affiliation(s)
- Kaan Kavaklı
- Division of Hematology, Department of Pediatrics, Ege University Faculty of Medicine, Bornova, 35100 İzmir, Turkey
| | - Bülent Antmen
- Division of Hematology, Department of Pediatrics, Acıbadem Adana Hospital, Adana, Turkey
| | - Vahap Okan
- Division of Hematology, Department of Internal Diseases, Gaziantep University Faculty of Medicine, Gaziantep, Turkey
| | - Fahri Şahin
- Division of Hematology, Department of Internal Diseases, Ege Adult Hemophilia and Thrombosis Center, Ege University Faculty of Medicine, İzmir, Turkey
| | - Selin Aytaç
- Division of Hematology, Department of Pediatrics, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Can Balkan
- Division of Hematology, Department of Pediatrics, Ege University Faculty of Medicine, İzmir, Turkey
| | - Ergül Berber
- Department of Molecular Biology and Genetics, İstanbul Arel University, İstanbul, Turkey
| | - Zühre Kaya
- Division of Hematology, Department of Pediatrics, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Alphan Küpesiz
- Division of Hematology, Department of Pediatrics, Akdeniz University Faculty of Medicine, Antalya, Turkey
| | - Bülent Zülfikar
- Division of Hematology, Department of Pediatrics, İstanbul University Faculty of Medicine, İstanbul, Turkey
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Meireles MR, Stelmach LH, Bandinelli E, Vieira GF. Unveiling the influence of factor VIII physicochemical properties on hemophilia A phenotype through an in silico methodology. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2022; 219:106768. [PMID: 35367915 DOI: 10.1016/j.cmpb.2022.106768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 01/24/2022] [Accepted: 03/19/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND AND OBJECTIVES Hemophilia A (HA) is an X-linked blood disorder. It is caused by pathogenic F8 gene variants, among which missense mutations are the most prevalent. The resulting amino acid substitutions may have different impacts on physicochemical properties and, consequently, on protein functionality. Regular prediction tools do not include structural elements and their physiological significance, which hampers our ability to functionally link variants to disease phenotype, opening an ample field for investigation. The present study aims to elucidate how physicochemical changes generated by substitutions in different protein domains relate to HA, and which of these features are more consequential to protein function and its impact on HA phenotype. METHODS An in silico evaluation of 71 F8 variants found in patients with different HA phenotypes (mild, moderate, severe) was performed to understand protein modifications and functional impact. Homology modeling was used for the structural analysis of physicochemical changes including electrostatic potential, hydrophobicity, solvent-accessible/excluded surface areas, disulfide disruptions, and substitutions indexes. These variants and properties were analyzed by hierarchical clustering analysis (HCA) and principal component analysis (PCA), independently and in combination, to investigate their relative contribution. RESULTS About 69% of variants show electrostatic changes, and almost all show hydrophobicity and surface area modifications. HCA combining all physicochemical properties analyzed was better in reflecting the impact of different variants in disease severity, more so than the single feature analysis. On the other hand, PCA led to the identification of prominent properties involved in the clustering results for variants of different domains. CONCLUSIONS The methodology developed here enables the assessment of structural features not available in other prediction tools (e.g., surface distribution of electrostatic potential), evaluating what kind of physicochemical changes are involved in FVIII functional disruption. HCA results allow distinguishing substitutions according to their properties, and yielded clusters which were more homogeneous in phenotype. All evaluated properties are involved in determining disease severity. The nature, as well as the position of the variants in the protein, were shown to be relevant for physicochemical changes, demonstrating that all these aspects must be collectively considered to fine-tune an approach to predict HA severity.
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Affiliation(s)
- Mariana R Meireles
- Departamento de Genética, Instituto de Biociências, Universidade Federal do Rio Grande do Sul, Caixa Postal 15053, Porto Alegre 91501-970, RS, Brasil
| | - Lara H Stelmach
- Departamento de Genética, Instituto de Biociências, Universidade Federal do Rio Grande do Sul, Caixa Postal 15053, Porto Alegre 91501-970, RS, Brasil
| | - Eliane Bandinelli
- Departamento de Genética, Instituto de Biociências, Universidade Federal do Rio Grande do Sul, Caixa Postal 15053, Porto Alegre 91501-970, RS, Brasil
| | - Gustavo F Vieira
- Departamento de Genética, Instituto de Biociências, Universidade Federal do Rio Grande do Sul, Caixa Postal 15053, Porto Alegre 91501-970, RS, Brasil; Universidade La Salle, Canoas, RS, Brasil.
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21
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Farrugia A, Smit C, Buzzi A. The legacy of haemophilia: Memories and reflections from three survivors. Haemophilia 2022; 28:872-884. [PMID: 35588502 PMCID: PMC9542818 DOI: 10.1111/hae.14587] [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: 01/26/2022] [Revised: 04/04/2022] [Accepted: 05/01/2022] [Indexed: 11/28/2022]
Abstract
Following the publication of a book of personal memories by one of us (CS1,2), we have attempted to synthesis our joint memories of three ageing men, born in the era preceding universal access to treatment, in an attempt to describe our experience, our challenges and our reflections on the development of therapies, which have ensured that our experience of growing up with haemophilia in the 1950s and 1960s has not been mirrored by the current generation of patients. We describe our upbringing in different parts of Europe in health care systems which, while of varying standards, were all unable to offer the kind of care which developed after the development of specific therapies. We assess the effect of the contamination of these therapies by blood‐borne pathogens on our own development, and the development of our communities around us. In addition, we reflect on the lessons learnt, sometimes painfully, by our generation of people with haemophilia and how some of these enabled us to overcome substantial hurdles, survive and build productive lives. Finally, we survey the development of therapies in the past 20 years, and offer some reflections on how our experience can be integrated in a realistic expectation of what the future holds for our community, in our own affluent societies and in countries less advantaged economically. We hope that our thoughts may contribute to continued progress in the field of haemophilia care.
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Affiliation(s)
- Albert Farrugia
- Faculty of Medicine and Medical Sciences, University of Western Australia, Perth, Australia
| | - Cees Smit
- Department of Epidemiology, Leiden University Medical Center (LUMC), Hoofddorp, The Netherlands
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22
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Gomez K. Advances in the diagnosis of heritable platelet disorders. Blood Rev 2022; 56:100972. [PMID: 35595614 DOI: 10.1016/j.blre.2022.100972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 05/09/2022] [Accepted: 05/10/2022] [Indexed: 11/02/2022]
Abstract
The last decade has seen large increases in the number of patients registered with heritable platelet disorders in national databases of bleeding disorders. Although individually rare, collectively they are a relatively common cause of heritable bleeding. This revolution has come about through the application of high-throughput sequencing strategies and efforts to standardize diagnostic testing. There is renewed interest in established parameters such as platelet volume and utilising simple tools such as blood smears. The diagnostic yield from peripheral blood smears can be improved with new microscopy techniques that could potentially assist in determining which patients need to be referred to tertiary centres for specialist testing. A better understanding of the other clinical features that can accompany abnormalities of platelet number or function, can lead to better clinical management and prevention of serious complications. There are challenges for clinicians who need to be aware of these developments, understand the limitations of new diagnostic techniques and keep abreast of strategies for incorporation into clinical practice. This review discusses some of these approaches, the limitations that clinicians need to be aware of and techniques that may enter clinical use in the future.
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Affiliation(s)
- Keith Gomez
- Haemophilia Centre and Thrombosis Unit, Royal Free London NHS Foundation Trust, London, UK.
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23
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Kaczmarek R. Gene therapy - are we ready now? Haemophilia 2022; 28 Suppl 4:35-43. [PMID: 35521736 PMCID: PMC9325484 DOI: 10.1111/hae.14530] [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: 12/16/2021] [Revised: 02/20/2022] [Accepted: 02/21/2022] [Indexed: 01/19/2023]
Abstract
Introduction Haemophilia therapy has evolved from rudimentary transfusion‐based approaches to an unprecedented level of innovation with glimmers of functional cure brought by gene therapy. After decades of misfires, gene therapy has normalized factor (F)VIII and factor (F)IX levels in some individuals in the long term. Several clinical programmes testing adeno‐associated viral (AAV) vector gene therapy are approaching completion with imminent regulatory approvals. Discussion Phase 3 studies along with multiyear follow‐up in earlier phase investigations raised questions about efficacy as well as short‐ and long‐term safety, prompting a reappraisal of AAV vector gene therapy. Liver toxicities, albeit mostly low‐grade, occur in the first year in at least some individuals in all haemophilia A and B trials and are poorly understood. Extreme variability and unpredictability of outcome, as well as a slow decline in factor expression (seemingly unique to FVIII gene therapy), are vexing because immune responses to AAV vectors preclude repeat dosing, which could increase suboptimal or restore declining expression, while overexpression may result in phenotoxicity. The long‐term safety will need lifelong monitoring because AAV vectors, contrary to conventional wisdom, integrate into chromosomes at the rate that calls for vigilance. Conclusions AAV transduction and transgene expression engage the host immune system, cellular DNA processing, transcription and translation machineries in ways that have been only cursorily studied in the clinic. Delineating those mechanisms will be key to finding mitigants and solutions to the remaining problems, and including individuals who cannot avail of gene therapy at this time.
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Affiliation(s)
- Radoslaw Kaczmarek
- Coagulation Products Safety Supply and Access Committee, World Federation of Hemophilia, Montreal, Quebec, Canada.,Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, Indiana, USA
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24
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Meijer K, van Heerde W, Gomez K. Diagnosis of rare bleeding disorders. Haemophilia 2022; 28 Suppl 4:119-124. [PMID: 35521730 DOI: 10.1111/hae.14561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 05/07/2020] [Accepted: 05/11/2020] [Indexed: 11/30/2022]
Abstract
Rare bleeding disorders result in significant morbidity but are globally underdiagnosed. Advances in genomic testing and specialist laboratory assays have greatly increased the diagnostic armamentarium. This has resulted in the discovery of new genetic causes for rare diseases and a better understanding of the underlying molecular pathology.
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Affiliation(s)
- Karina Meijer
- Division of Thrombosis and Haemostasis, Department of Haematology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Waander van Heerde
- Radboud University Medical Center, Hemophilia Treatment Centre, Nijmegen-Eindhoven-Maastricht, Nijmegen, The Netherlands.,Enzyre, Nijmegen, The Netherlands
| | - Keith Gomez
- Haemophilia Centre and Thrombosis Unit, Royal Free London NHS Foundation Trust, London, UK
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25
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Abstract
INTRODUCTION Hemophilia A (HA) or B (HB) is an X-linked recessive disorder caused by a defect in the factor VIII (FVIII) or factor IX (FIX) gene which leads to the dysfunction of blood coagulation. Protein replacement therapy (PRT) uses recombinant proteins and plasma-derived products, which incurs high cost and inconvenience requiring routine intravenous infusions and life-time treatment. Understanding of detailed molecular mechanisms on FVIII gene function could provide innovative solutions to amend this disorder. In recent decades, gene therapeutics have advanced rapidly and a one-time cure solution has been proposed. AREAS COVERED This review summarizes current understanding of molecular pathways involved in blood coagulation, with emphasis on FVIII's functional role. The existing knowledge and challenges on FVIII gene expression, from transcription, translation, post-translational modification including glycosylation to protein processing and secretion, and co-factor interactions are deciphered and potential molecular interventions discussed. EXPERT OPINION This article reviews the potential treatment targets for HA and HB, including antibodies, small molecules and gene therapeutics, based on molecular mechanisms of FVIII biosynthesis, and further, assessing the pros and cons of these various treatment strategies. Understanding detailed FVIII protein synthesis and secretory pathways could provide exciting opportunities in identifying novel therapeutics to ameliorate hemophilia state.
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Affiliation(s)
- Jie Gong
- School of Medicine, University of Electronic Science and Technology of China, Sichuan, China
| | - Hao-Lin Wang
- School of Medicine, University of Electronic Science and Technology of China, Sichuan, China
| | - Lung-Ji Chang
- School of Medicine, University of Electronic Science and Technology of China, Sichuan, China.,Geno-Immune Medical Institute, Shenzhen, China
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26
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Genetic Characterization of the Factor VIII Gene in a Cohort of Colombian Patients with Severe Hemophilia A with Inhibitors. Hematol Rep 2022; 14:149-154. [PMID: 35645303 PMCID: PMC9149853 DOI: 10.3390/hematolrep14020022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 04/20/2022] [Accepted: 04/28/2022] [Indexed: 11/17/2022] Open
Abstract
Hemophilia A is an X-linked bleeding disorder caused by mutations in the FVIII gene. Genetic factors have been shown to be a risk factor for the development of inhibitors. We aimed to identify the specific variations of the FVIII gene of patients with hemophilia A with inhibitors and their association with the inhibitor titer. Methods: Cross-sectional descriptive study. We included 12 Colombian patients from a health care provider, “Integral Solutions SD”, who underwent analysis of genetic material (DNA), which was reported by the Molecular Hemostasis Laboratory in Bonn, Germany. Results: All of these patients were diagnosed with severe hemophilia A with inhibitors; ages ranged between 6 and 48 years, with a median age of 13.5 years. Molecular analysis showed the inversion of intron 22 in six patients (50.0%), a small duplication in two patients (16.7%), the inversion of intron 1 in one patient (8.3%), a large deletion (8.3%), a nonsense mutation (8.3%) and a splice-site (8.3%), findings similar to those of other studies. A total of 58.3% of the patients presented inversion mutations with a high risk of developing inhibitors A total of 83.3% of the evaluated patients presented null mutations; however the presence of high inhibitor titers was 66.7%. The most frequent mutation was the inversion intron 22. Knowing the type of mutation and its association as a risk factor for generating inhibitors invites us to delve into other outcomes such as residual values of coagulation FVIII as well as its impact on the half-life of the exogenous factor applied in prophylaxis.
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27
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Abstract
The utility of mouse models to dissect the molecular basis of hemostasis and thrombosis is now well established. The anucleate properties of circulating blood platelet and their specialized release from mature megakaryocytes makes the use of in vivo models all the more informative and powerful. Indeed, they are powerful but there do exist limitations. Here, we review the contributions of mouse models to the pathogenesis of the Bernard-Soulier syndrome, their use in platelet-specific gene expression, the recent development of mice expressing both human GPIb-IX and human von Willebrand factor (VWF), and finally the use of GPIb-IX mouse models to examine the impact of platelet biology beyond clotting. The humanization of the receptor and ligand axis is likely to be a major advancement in the characterization of therapeutics in the complex pathogenesis that drives thrombosis. When appropriate, we highlight some limitations of each mouse model, but this is not to minimize the contributions these models to the field. Rather, the limitations are meant to provide context for any direct application to the important mechanisms supporting human primary hemostasis and thrombosis.
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Affiliation(s)
- Jerry Ware
- University of Arkansas for Medical Sciences, Little Rock, AR
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28
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Cortina VR. Evolutional development of the hemostasis laboratory and the treatment of hemophilia. Blood Coagul Fibrinolysis 2022; 33:S22-S23. [PMID: 35088771 DOI: 10.1097/mbc.0000000000001106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Vicente R Cortina
- Department of Hematology, Vall d'Hebron University Hospital, Barcelona, Spain
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29
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Pinki S, Mohan G, Venugopal D, Innah SJ. Surgical management of endometriosis in a severe Hemophilia A female patient and the role of transfusion medicine specialist: A case report with review of literature. Asian J Transfus Sci 2021; 15:237-240. [PMID: 34908762 PMCID: PMC8628223 DOI: 10.4103/ajts.ajts_6_21] [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: 01/20/2021] [Revised: 04/05/2021] [Accepted: 05/26/2021] [Indexed: 11/04/2022] Open
Abstract
Hemophilia A is an X-linked recessive bleeding disorder occurs due to deficiency of factor VIII (FVIII). The disease manifests exclusively in males though it rarely occurs in females due to complex pathophysiological mechanisms. We present a rare case of female hemophilia due to skewed X-inactivation which adversely affected the quality of patient life. She presented with recurrent abdominal pain and was diagnosed with severe endometriosis and underwent total abdominal hysterectomy with left salpingo-oophorectomy and appendicectomy. She was infused recombinant factor VIII both prophylactically and postoperatively as per the World Federation of Hemophilia guidelines. Recombinant Factor VIII was supplemented every 12th hourly and Factor VIII activity levels were monitored daily. She was discharged uneventfully on the postoperative day 21 after screened negative for acquired inhibitors.
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Affiliation(s)
- Sanooja Pinki
- Department of Transfusion Medicine, Kerala institute of Medical Science, Trivandrum, Kerala, India
| | - Ganesh Mohan
- Department of Immunohematology and Blood Transfusion, Kasturba Medical College Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Divya Venugopal
- Department of Transfusion Medicine, District Hospital, Idukki, Kerala, India
| | - Susheela J Innah
- Department of Transfusion Medicine, Jubilee Mission Medical College, Thrissur, Kerala, India
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30
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The role of genetics in the diagnosis and treatment of haemorrhagic diathesis: a historical perspective. Blood Coagul Fibrinolysis 2021; 33:S17-S18. [PMID: 34654014 DOI: 10.1097/mbc.0000000000001096] [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
The rapid development of genetic studies, not only in haemophilia but also in other congenital coagulopathies and platelet-related alterations, has been made possible by massive sequencing (e.g. next-generation sequencing or NGS), which allows a rapid and automatic analysis of the whole gene, simultaneous study of several genes and multiple individuals, detection of genetic variants and the possibility to create personalized panels [16]. The new technologies have also changed the way results are evaluated. Currently, our interest goes beyond the study of carriers, extending to the relationship between the mutation and the risk of developing an inhibitor and the latter's role in the classification of diseases [17]. There is also great interest in understanding the genotype/phenotype relationship, analytical discrepancies and variations in the response to treatment [18].
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31
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Batty P, Lillicrap D. Gene therapy for hemophilia: Current status and laboratory consequences. Int J Lab Hematol 2021; 43 Suppl 1:117-123. [PMID: 34288447 DOI: 10.1111/ijlh.13605] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 04/12/2021] [Accepted: 04/21/2021] [Indexed: 12/19/2022]
Abstract
Since the cloning and characterization of the factor VIII (FVIII) and factor IX genes in the mid-1980s, gene therapy has been perceived as having significant potential for the treatment of severe hemophilia. Now, some 35 years later, these proposals are close to being realized through the licensing of the first clinical gene therapy product. Adeno-associated viral vector-mediated gene therapy for hemophilia A and B has been extensively investigated in preclinical models over the past 20 years, and since 2011, there has been increasing evidence in early phase clinical trials that this therapeutic strategy can provide safe and effective rescue of the hemostatic phenotype in severe hemophilia. As the uptake of hemophilia gene therapy progresses, it is clear that many aspects of the gene therapy process require crucial laboratory support to ensure safe and effective outcomes from his new therapeutic paradigm. These laboratory contributions extend from evaluations of the gene therapy vehicle, assessments of the patient immune status for the vector, and ultimately the performance of assays to determine the hemostatic benefit of the gene therapy and potentially of its long-term safety on the host genome. As with many aspects of past hemophilia care, the safe and effective delivery of gene therapy will require an informed and coordinated contribution from laboratory science.
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Affiliation(s)
- Paul Batty
- Department of Pathology and Molecular Medicine, Queen's University, Kingston, ON, Canada
| | - David Lillicrap
- Department of Pathology and Molecular Medicine, Queen's University, Kingston, ON, Canada
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32
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Antonarakis SE. History of the methodology of disease gene identification. Am J Med Genet A 2021; 185:3266-3275. [PMID: 34159713 PMCID: PMC8596769 DOI: 10.1002/ajmg.a.62400] [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: 04/26/2021] [Revised: 06/10/2021] [Accepted: 06/11/2021] [Indexed: 11/06/2022]
Abstract
The past 45 years have witnessed a triumph in the discovery of genes and genetic variation that cause Mendelian disorders due to high impact variants. Important discoveries and organized projects have provided the necessary tools and infrastructure for the identification of gene defects leading to thousands of monogenic phenotypes. This endeavor can be divided in three phases in which different laboratory strategies were employed for the discovery of disease-related genes: (i) the biochemical phase, (ii) the genetic linkage followed by positional cloning phase, and (iii) the sequence identification phase. However, much more work is needed to identify all the high impact genomic variation that substantially contributes to the phenotypic variation.
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Affiliation(s)
- Stylianos E Antonarakis
- University of Geneva Medical School, Geneva, Switzerland.,Medigenome, Swiss Institute of Genomic Medicine, Geneva, Switzerland
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33
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Famà R, Borroni E, Merlin S, Airoldi C, Pignani S, Cucci A, Corà D, Bruscaggin V, Scardellato S, Faletti S, Pelicci G, Pinotti M, Walker GE, Follenzi A. Deciphering the Ets-1/2-mediated transcriptional regulation of F8 gene identifies a minimal F8 promoter for hemophilia A gene therapy. Haematologica 2021; 106:1624-1635. [PMID: 32467137 PMCID: PMC8168518 DOI: 10.3324/haematol.2019.239202] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Indexed: 11/09/2022] Open
Abstract
Amajor challenge in the development of a gene therapy for hemophilia A is the selection of cell type- or tissue-specific promoters to ensure factor VIII (FVIII) expression without eliciting an immune response. As liver sinusoidal endothelial cells are the major FVIII source, understanding the transcriptional F8 regulation in these cells would help to optimize the minimal F8 promoter (pF8) to efficiently drive FVIII expression. In silico analyses predicted several binding sites (BS) for the E26 transformation-specific (Ets) transcription factors Ets-1 and Ets-2 in the pF8. Reporter assays demonstrated a significant up-regulation of pF8 activity by Ets-1 or Ets- 1/Est-2 combination, while Ets-2 alone was ineffective. Moreover, Ets-1/Ets- 2-DNA binding domain mutants (DBD) abolished promoter activation only when the Ets-1 DBD was removed, suggesting that pF8 up-regulation may occur through Ets-1/Ets-2 interaction with Ets-1 bound to DNA. pF8 carrying Ets-BS deletions unveiled two Ets-BS essential for pF8 activity and response to Ets overexpression. Lentivirus-mediated delivery of green fluorescent protein (GFP) or FVIII cassettes driven by the shortened promoters, led to GFP expression mainly in endothelial cells in the liver and to longterm FVIII activity without inhibitor formation in HA mice. These data strongly support the potential application of these promoters in hemophilia A gene therapy.
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Affiliation(s)
- Rosella Famà
- Department of Health Sciences, Università del Piemonte Orientale, Novara, Italy
| | - Ester Borroni
- Department of Health Sciences, Università del Piemonte Orientale, Novara, Italy
| | - Simone Merlin
- Department of Health Sciences, Università del Piemonte Orientale, Novara, Italy
| | - Chiara Airoldi
- Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
| | - Silvia Pignani
- Department of Health Sciences, Università del Piemonte Orientale, Novara, Italy
| | - Alessia Cucci
- Department of Health Sciences, Università del Piemonte Orientale, Novara, Italy
| | - Davide Corà
- Department of Translational Medicine, Center for Translational Research on Autoimmune and Allergic Disease (CAAD), University of Piemonte Orientale, Novara, Italy
| | | | - Sharon Scardellato
- Department of Health Sciences, Università del Piemonte Orientale, Novara, Italy
| | - Stefania Faletti
- Department of Experimental Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Giuliana Pelicci
- Department of Health Sciences, Università del Piemonte Orientale, Novara, Italy
| | - Mirko Pinotti
- Department of Life Sciences and Biotechnology, Universita' di Ferrara, Italy
| | - Gillian E Walker
- Department of Health Sciences, Università del Piemonte Orientale, Novara, Italy
| | - Antonia Follenzi
- Department of Health Sciences, Università del Piemonte Orientale, Novara, Italy
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34
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Abstract
Introduction: The standard treatment of hemophilia A consists of the prophylactic administration of a coagulation factor concentrate, to be administered intravenously several times a week. Newly approved factor concentrates and non-factor products reduce the frequency of injection and offer better protection against bleeding.Areas covered: New treatment options for hemophilia A are either coagulation factor concentrates based on innovative active principles extending half-life (EHL) or non-factor products allowing subcutaneous application with an extended half-life, so that their broader application only needs to be made every one to four weeks. Other new therapeutic options are still in clinical studies, such as the inhibition of TFPI (tissue factor pathway inhibitor) or small interfering mRNA molecule against antithrombin and gene therapy for hemophilia A.Expert opinion: It can be expected that patients with hemophilia will benefit significantly from the new treatment options and that the protection against bleeding and joint damage as well as the quality of life will increase. The availability of alternatives to classical replacement therapy will require the development of treatment algorithms for patients with hemophilia. It is still unclear to what extent factor substitution will be challenged by the new therapies as first-line therapy.
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Affiliation(s)
- Wolfgang Miesbach
- Institute of Transfusion Medicine, University Hospital Frankfurt, Frankfurt, Germany
| | - Fagr Eladly
- Department of Haemostaseology and Haemophilia Center, Internal Medicine, Frankfurt, Germany
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35
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Hemophilia Gene Therapy: Approaching the First Licensed Product. Hemasphere 2021; 5:e540. [PMID: 33604517 PMCID: PMC7886458 DOI: 10.1097/hs9.0000000000000540] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 12/27/2020] [Indexed: 02/06/2023] Open
Abstract
The clinical potential of hemophilia gene therapy has now been pursued for the past 30 years, and there is a realistic expectation that this goal will be achieved within the next couple of years with the licensing of a gene therapy product. While recent late phase clinical trials of hemophilia gene therapy have shown promising results, there remain a number of issues that require further attention with regard to both efficacy and safety of this therapeutic approach. In this review, we present information relating to the current status of the field and focus attention on the unanswered questions for hemophilia gene therapy and the future challenges that need to be overcome to enable the widespread application of this treatment paradigm.
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36
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Gene therapy for hemophilias: the end of phenotypic testing or the start of a new era? Blood Coagul Fibrinolysis 2021; 31:237-242. [PMID: 32108681 DOI: 10.1097/mbc.0000000000000905] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
: Hemophilia comprises two distinct genetic disorders caused by missing or defective clotting factor VIII (hemophilia A) or clotting factor IX (hemophilia B). The management of these conditions has been for long based on replacement therapies, but emerging evidence garnered from recent landmark studies suggests that a promising avenue toward routine use of gene therapy is clearly progressing forward, thus generating unavoidable consequences on laboratory hemostasis, especially as pertaining to phenotypic testing. Although it seems likely that widespread use of gene therapy will be associated with a relative decrease of hemostasis tests requests in this patient population due to the relatively stable effect of transgene delivery and persistent production of endogenous clotting factor, some important aspects persuade us that conventional laboratory diagnostics, especially encompassing activated partial thromboplastin time, as well as one-stage and two-stage clotting factor assays, will not be completely voided in the gene therapy era. In particular, phenotypic testing will remain essential for excluding acquired or sporadic cases of hemophilia, for identifying and titrating factor inhibitors, as well as for defining and monitoring the long-term therapeutic effectiveness of gene transfection in hemophiliacs.
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37
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Chatterjee M, Meeks S, Novakovic VA, Gilbert GE. Discordance between platelet-supported and vesicle-supported factor VIII activity in the presence of anti-C2 domain inhibitory antibodies. J Thromb Haemost 2020; 18:3184-3193. [PMID: 32558078 DOI: 10.1111/jth.14961] [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: 03/25/2020] [Revised: 05/14/2020] [Accepted: 06/05/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND We recently reported that factor VIII (FVIII) binds to a macromolecular complex including fibrin on thrombin-stimulated platelets and that two antibodies against FVIII diminish platelet-supported FVIII activity more than vesicle-supported activity. The C2 domain of FVIII is known to bind to phospholipid membrane and also binds fibrin. OBJECTIVES We asked whether the degree of inhibition by anti-C2 antibodies would show differences between platelet-supported and the standard activated partial thromboplastin time (aPTT) assay. METHODS We evaluated the inhibition by a well-defined panel of monoclonal anti-C2 domain antibodies encompassing the major epitopes of the C2 domain. Activity was measured in an activated platelet time (aPT) assay containing fresh, density gradient-purified human platelets. RESULTS The aPT exhibited a log-linear relationship between FVIII and time to fibrin formation over a 4-log range, encompassing 0.01% to 100% plasma FVIII. Nine of 10 mAbs inhibited 89% to 96% of FVIII activity, whereas mAb F85 did not. There was no correlation between the degree of inhibition in the aPTT-based assay and the platelet assay. In particular, four mAbs did not inhibit the aPTT assay, yet inhibited 90% of platelet-based activity. Residual FVIII activity in purified-protein assays, relying on platelets, correlated with the aPT assay. CONCLUSIONS The degree of FVIII impairment by some inhibitor antibodies is substantially different on platelet membranes vs synthetic vesicles. Thus, current inhibitor assays may underestimate the frequency of significant inhibitors, and a platelet-based assay may more accurately assess bleeding risk.
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Affiliation(s)
- Madhumouli Chatterjee
- Departments of Medicine & Research, VA Boston Healthcare System, Boston, Massachusetts, USA
| | - Shannon Meeks
- Department of Pediatrics, Children's Healthcare Atlanta/Aflac Cancer and Blood Disorder Center, Emory University, Atlanta, Georgia, USA
| | - Valerie A Novakovic
- Departments of Medicine & Research, VA Boston Healthcare System, Boston, Massachusetts, USA
| | - Gary E Gilbert
- Departments of Medicine & Research, VA Boston Healthcare System, Boston, Massachusetts, USA
- Departments of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
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38
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Feng Y, Li Q, Shi P, Liu N, Kong X, Guo R. Mutation analysis in the F8 gene in 485 families with haemophilia A and prenatal diagnosis in China. Haemophilia 2020; 27:e88-e92. [PMID: 33245802 PMCID: PMC7898705 DOI: 10.1111/hae.14206] [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: 06/01/2020] [Revised: 10/14/2020] [Accepted: 11/03/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND Haemophilia A (HA) is an X-linked bleeding disorder caused by mutations in the coagulation factor Ⅷ (F8) gene. Its incidence in men is estimated to be approximately 1/5000. OBJECTIVE This study aimed to characterize the mutation spectrum of the F8 gene in 485 Chinese families, encompassing all HA phenotypic classes. Additionally, we evaluated the accuracy of prenatal diagnosis of foetuses at risk of having HA. METHODS Long-Distance PCR (LD-PCR) and Multiplex PCR were used to detect inversions, next-generation sequencing (NGS) was used for point mutations, and multiplex ligation-dependent probe amplification (MLPA) was used for large deletions or duplications. RESULTS A mutation spectrum of 478 HA families was produced. Throughout 26 exons and 15 introns, a total of 237 different alterations of mutations were detected, of which 146 are known mutations (64.5%) and 91 are novel mutations (35.5%). Prenatal diagnosis revealed 97 normal males (35.79%), 103 HA males (38.01%), 36 normal females (13.28%), and 38 HA carrier females (14.02%). CONCLUSION Using a systematic approach comprised of three steps, 237 pathogenic variants in 478 out of 485 patient samples (98.6%) were detected, including the identification of a heterogeneous mutation spectrum of 91 novel mutations. In addition, prenatal diagnosis of HA in pregnant carriers allowed for accurate determination of the foetal F8 gene state.
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Affiliation(s)
- Yin Feng
- The Department of Obstetrics and Gynecology, The Genetics and Prenatal Diagnosis Center, The First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Qianqian Li
- The Department of Obstetrics and Gynecology, The Genetics and Prenatal Diagnosis Center, The First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Panlai Shi
- The Department of Obstetrics and Gynecology, The Genetics and Prenatal Diagnosis Center, The First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Ning Liu
- The Department of Obstetrics and Gynecology, The Genetics and Prenatal Diagnosis Center, The First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Xiangdong Kong
- The Department of Obstetrics and Gynecology, The Genetics and Prenatal Diagnosis Center, The First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Ruixia Guo
- The Department of Obstetrics and Gynecology, The First Affiliated Hospital of Zhengzhou University, Henan, China
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Sherief LM, Gaber OA, Youssef HM, Sherbiny HS, Mokhtar WA, Ali AAA, Kamal NM, Abdel Maksoud YH. Factor VIII inhibitor development in Egyptian hemophilia patients: does intron 22 inversion mutation play a role? Ital J Pediatr 2020; 46:129. [PMID: 32928254 PMCID: PMC7488666 DOI: 10.1186/s13052-020-00878-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 07/29/2020] [Indexed: 11/30/2022] Open
Abstract
Background Hemophilia A (HA) is an X-linked recessive bleeding disorder characterized by qualitative and quantitative deficiency of factor VIII (FVIII). The development of inhibitor antibodies against FVIII is the most challenging complication of treatment. Mutations in the FVIII gene is one of the genetic factors that leads to development of FVIII inhibitors especially intron 22 inversion (Inv22). Objectives This study was carried out to assess the frequency of Inv22 of FVIII gene in Egyptian patients with hemophilia A and its role as a risk factor for developing inhibitors. Patients and methods Seventy-two patients with severe HA and 48 patients with moderate HA were enrolled in the current study. All patients were treated on demand with either plasma-derived factor VIII or recombinant factor VIII concentrates. Genotyping of FVIII Inv22 was performed by LD-PCR while the presence and magnitude of inhibitor activity in blood was determined by the Bethesda assay. Results Around 23% of all hemophilia cases had positive Inv22. Intron 22 inversion mutation was detected in 6 and 33% of patients with moderate and severe HA respectively. Twenty-one cases (18%) of all hemophilic patients developed inhibitors. Thirty-7% of patients with Inv22 had inhibitor in their blood, almost all, but one, had severe HA. The risk of an inhibitor development during replacement therapy was four folds higher among Inv22 positive cases as compared with mutation negative peers (OR 4.3, 95% CI 1.6–11.9, P = 0.003). Conclusions The prevalence of Inv22 of F VIII in Egyptian hemophiliacs is nearly like that of other population. This mutation was more frequently detected among severe hemophilic patients as compared with moderately affected peers. The presence of Inv22 mutation significantly predispose to FVIII inhibitor development.
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Affiliation(s)
- Laila M Sherief
- Pediatric Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Osama A Gaber
- Biochemistry Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Hala Mosaad Youssef
- Biochemistry Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Hanan S Sherbiny
- Pediatric Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt.,Pediatric Department, Collage of Medicine, University of Bisha (UB), Bisha, Kingdom of Saudi Arabia
| | - Wesam A Mokhtar
- Pediatric Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Asmaa A A Ali
- Biochemistry Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Naglaa M Kamal
- Pediatric Department, Faculty of Medicine, Cairo University, Cairo, Egypt.
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40
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Singh VK, Maurya NS, Mani A, Yadav RS. Machine learning method using position-specific mutation based classification outperforms one hot coding for disease severity prediction in haemophilia 'A'. Genomics 2020; 112:5122-5128. [PMID: 32927010 DOI: 10.1016/j.ygeno.2020.09.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 08/10/2020] [Accepted: 09/08/2020] [Indexed: 01/20/2023]
Abstract
Haemophilia is an X-linked genetic disorder in which A and B types are the most common that occur due to absence or lack of protein factors VIII and IX, respectively. Severity of the disease depends on mutation. Available Machine Learning (ML) methods that predict the mutational severity by using traditional encoding approaches, generally have high time complexity and compromised accuracy. In this study, Haemophilia 'A' patient mutation dataset containing 7784 mutations was processed by the proposed Position-Specific Mutation (PSM) and One-Hot Encoding (OHE) technique to predict the disease severity. The dataset processed by PSM and OHE methods was analyzed and trained for classification of mutation severity level using various ML algorithms. Surprisingly, PSM outperformed OHE, both in terms of time efficiency and accuracy, with training and prediction time improvement in the range of approximately 91 to 98% and 80 to 99% respectively. The severity prediction accuracy also improved by using PSM with different ML algorithms.
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Affiliation(s)
- Vikalp Kumar Singh
- Department of Computer Science and Engineering, Motilal Nehru National Institute of Technology Allahabad, UP 211004, India
| | - Neha Shree Maurya
- Department of Biotechnology, Motilal Nehru National Institute of Technology Allahabad, UP 211004, India
| | - Ashutosh Mani
- Department of Biotechnology, Motilal Nehru National Institute of Technology Allahabad, UP 211004, India.
| | - Rama Shankar Yadav
- Department of Computer Science and Engineering, Motilal Nehru National Institute of Technology Allahabad, UP 211004, India
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41
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A novel splicing mutation in F8 causes various aberrant transcripts in a hemophilia A patient and identifies a new transcript from healthy individuals. Blood Coagul Fibrinolysis 2020; 31:506-510. [PMID: 32852327 DOI: 10.1097/mbc.0000000000000952] [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 hemorrhagic disorder caused by deficiency or dysfunction of the coagulation factor VIII (FVIII), and a great variety of mutations in the factor VIII gene (F8) are identified. We aimed to identify the genetic defects of the F8 gene in a Chinese patient with moderate hemophilia A. We have identified a novel intronic variant in the hemophilia A patient by DNA sequence analysis, cDNA sequencing, and TA clone sequencing. An intronic variant, c.5816-1G>A, was identified and the cDNA sequencing confirmed the pathogenicity of the transition. TA clone sequencing showed that the splicing mutation produced two aberrant premRNA skipping exons (18 and exon 18 + 19, respectively). These aberrant mRNA forms maintain the reading frame and are predicted to code for deleted FVIII isoforms and the shorter abnormal transcript accounted for one-eighth of the total mRNA. There was a new unreported transcript with E22 spliced out in healthy individuals and our patient, whose specific functions need to be determined in further studies. Our study widens the mutation spectrum of the F8 gene. In addition, the study findings could provide the opportunity to reveal alternative splicing patterns.
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42
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Abdulqader AMR, Mohammed AI, Rachid S, Ghoraishizadeh P, Mahmood SN. Identification of the Intron 22 and Intron 1 Inversions of the Factor VIII Gene in Iraqi Kurdish Patients With Hemophilia A. Clin Appl Thromb Hemost 2020; 26:1076029619888293. [PMID: 31994403 PMCID: PMC7098248 DOI: 10.1177/1076029619888293] [Citation(s) in RCA: 3] [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
Hemophilia A (HA) is a severe coagulation disorder affecting 1 in 5000 to 10 000 male births. In severe cases, the most deleterious large DNA rearrangements are inversions of intron 22 (Inv22) and intron 1 (Inv1) of the factor VIII (FVIII) gene. These account for 40% to 50% and 1% to 5% of all causative mutations, respectively. Nevertheless, no genetic analysis to identify the actual causative mutation of FVIII, particularly Inv22 and Inv1, among Iraqi Kurdish hemophiliacs has been performed. In this study, we aimed to genotype Inv22 and Inv1 of the FVIII gene in our patients with HA and reveal the genotype/phenotype correlation with the inversion mutations and their role as a risk factor for the development of inhibitors. Analyses of the Inv22 and Inv1 mutations in 80 Iraqi Kurdish patients with HA (60 severe, 18 moderate, and 2 mild) were performed using the inverse shifting–polymerase chain reaction (IS-PCR) method. In severe cases, 46.7% (28/60) had Inv22 and 3.3% (2/60) had Inv1. The genotype/phenotype relation of Inv22 and Inv1 illustrated a statistically significant association (P = .012) between disease severity and inversion mutations. Slightly more patients with Inv22 (39%) developed inhibitors than those without Inv22 (28%; odds ratio = 1.65, 95% confidence interval = 0.56-4.87, P = .361). Inv22 is a major cause of severe HA in Iraqi Kurdish patients, and IS-PCR is a rapid, robust, and effective method that can be applied for carrier detection and prenatal diagnosis of HA in developing countries.
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Affiliation(s)
| | - Ali Ibrahim Mohammed
- Department of Pathology, College of Medicine, University of Sulaymaniyah, Sulaymaniyah, Iraq
| | - Shwan Rachid
- Charmo Center for Research, Training and Consultancy, Charmo University, Chamchamal, Sulaymaniyah, Iraq
| | | | - Sarwar Noori Mahmood
- Department of Surgery, College of Medicine, University of Sulaymaniyah, Sulaymaniyah, Iraq
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44
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Konkle BA, Coffin D, Pierce GF, Clark C, George L, Iorio A, Mahlangu J, Naccache M, O’Mahony B, Peyvandi F, Pipe S, Quartel A, Sawyer EK, Skinner MW, Tortella B, Watson C, Winburn I. World Federation of Hemophilia Gene Therapy Registry. Haemophilia 2020; 26:563-564. [PMID: 32462720 PMCID: PMC8944922 DOI: 10.1111/hae.14015] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Accepted: 04/07/2020] [Indexed: 01/09/2023]
Affiliation(s)
- Barbara A. Konkle
- Bloodworks NW, Washington Center for Bleeding Disorders, Seattle, WA, USA
| | - Donna Coffin
- World Federation of Hemophilia, Montreal, QC, Canada
| | | | - Cary Clark
- International Society on Thrombosis and Hemostasis, Carrboro, NC, USA
| | - Lindsey George
- The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Univerisity of Pennsylvania, Philadelphia, PA, USA
| | | | - Johnny Mahlangu
- International Society on Thrombosis and Hemostasis, Carrboro, NC, USA
- Haemophilia Comprehensive Care Centre, University of the Witwatersrand, NHLS and Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa
| | | | - Brian O’Mahony
- Irish Haemophilia Society, Dublin, Ireland
- European Hemophilia Consortium, Brussels, Belgium
| | - Flora Peyvandi
- International Society on Thrombosis and Hemostasis, Carrboro, NC, USA
- IRCCS Maggiore Hospital Milan and University of Milan, Milan, Italy
| | - Steve Pipe
- University of Michigan, Pediatrics, Ann Arbor, MI, USA
- National Hemophilia Foundation, New York, NY, USA
| | | | | | | | | | - Crystal Watson
- American Thrombosis and Hemostssasis Network, Chicago, IL, USA
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45
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Jardim LL, Chaves DG, Rezende SM. Development of inhibitors in hemophilia A: An illustrated review. Res Pract Thromb Haemost 2020; 4:752-760. [PMID: 32685884 PMCID: PMC7354390 DOI: 10.1002/rth2.12335] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 01/20/2020] [Accepted: 02/09/2020] [Indexed: 02/02/2023] Open
Abstract
This illustrated review focuses on the development of inhibitors in patients with congenital hemophilia, which is the most serious treatment-related complication in these patients. Hemophilia A (HA) is an inherited X-linked bleeding disorder affecting 1:5000-10 000 newborn males worldwide. It results from the deficiency of coagulation factor VIII (FVIII), due to mutation(s) in its coding gene (F8). Treatment requires administration of FVIII-containing products either on demand or as prophylaxis, which can induce inhibitor development in 20%-35% of patients. Inhibitors are alloantibodies that neutralize the procoagulant activity of exogenous FVIII. During the initial administration of FVIII-containing products, patients with HA can develop a proinflammatory immune response with synthesis of anti-FVIII IgG1, which has no FVIII inhibitory activity. However, in patients with inhibitors, immune response shifts toward an anti-inflammatory/regulatory pattern favoring the synthesis of anti- FVIII IgG4 antibodies. Patients with inhibitors present with bleeding episodes that are difficult to control, and they have reduced response to FVIII replacement. Currently, immune tolerance induction is the available treatment for eradication of persistent high-titer inhibitors. Despite the clinical relevance, the immunological mechanisms for inhibitor development in patients with HA remains unexplained.
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Affiliation(s)
- Letícia Lemos Jardim
- Faculty of MedicineUniversidade Federal de Minas GeraisMinas GeraisBrazil
- Department of Clinical EpidemiologyLeiden University Medical CentreLeidenThe Netherlands
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46
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Meijer K, van Heerde W, Gomez K. Diagnosis of rare bleeding disorders. Haemophilia 2020; 27 Suppl 3:60-65. [PMID: 32578312 DOI: 10.1111/hae.14049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 05/07/2020] [Accepted: 05/11/2020] [Indexed: 11/27/2022]
Abstract
Rare bleeding disorders result in significant morbidity but are globally underdiagnosed. Advances in genomic testing and specialist laboratory assays have greatly increased the diagnostic armamentarium. This has resulted in the discovery of new genetic causes for rare diseases and a better understanding of the underlying molecular pathology.
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Affiliation(s)
- Karina Meijer
- Division of Thrombosis and Haemostasis, Department of Haematology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Waander van Heerde
- Radboud University Medical Center, Hemophilia Treatment Centre, Nijmegen-Eindhoven-Maastricht, Nijmegen, The Netherlands.,Enzyre, Nijmegen, The Netherlands
| | - Keith Gomez
- Haemophilia Centre and Thrombosis Unit, Royal Free London NHS Foundation Trust, London, UK
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47
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Dubé E, Gauthier J, Merlen C, Bonnefoy A, Couture F, Lillicrap D, Rivard GE. The diagnosis of a haemophilia A carrier over 2 decades. Haemophilia 2020; 27:e133-e136. [PMID: 32526814 DOI: 10.1111/hae.14073] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 05/08/2020] [Accepted: 05/20/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Evemie Dubé
- Division of Hematology-Oncology, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montreal, QC, Canada
| | - Julie Gauthier
- Molecular Diagnostic Laboratory, CHU Sainte-Justine, Montreal, QC, Canada.,Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montreal, QC, Canada
| | - Clémence Merlen
- Division of Hematology-Oncology, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montreal, QC, Canada
| | - Arnaud Bonnefoy
- Division of Hematology-Oncology, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montreal, QC, Canada
| | - Francoise Couture
- Molecular Diagnostic Laboratory, CHU Sainte-Justine, Montreal, QC, Canada
| | - David Lillicrap
- Department of Medicine, Department of Pathology and Molecular Medicine, Queen's University, Kingston, ON, Canada
| | - Georges-Etienne Rivard
- Division of Hematology-Oncology, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montreal, QC, Canada
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48
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Pierce GF. Uncertainty in an era of transformative therapy for haemophilia: Addressing the unknowns. Haemophilia 2020; 27 Suppl 3:103-113. [PMID: 32484283 DOI: 10.1111/hae.14023] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 03/24/2020] [Indexed: 12/12/2022]
Abstract
Haemophilia is at the dawn of a new era in therapeutic management, one that can generate greater protection from bleeding and a functional cure in some individuals. Prior advances in protein engineering and monoclonal antibody technology have facilitated therapeutic options to maintain decreased risk of bleeding and less burdensome treatment. The use of gene transfer, first proposed in 1971 for monogenic diseases, is emerging as an effective long-term treatment for a variety of diseases. Transfer of functional factor VIII (FVIII) and factor IX (FIX) genes has witnessed a series of advances and setbacks since the first non-clinical experiments in animals were initiated nearly 30 years ago. More recently, multiyear therapeutic levels of FVIII and FIX activity have been achieved in human clinical trials, translated into meaningful clinical benefit and a functional cure. While clinical progress has been definitive, many questions remain unanswered as prelicensure phase 3 clinical trials are underway. These unanswered questions translate into a state of uncertainty about the known unknowns and unknown unknowns intrinsic to any new therapeutic platform. Accepting this modality as a means to functionally cure haemophilia also means accepting the uncertainty regarding the biology of viral vector-mediated gene transfer, which remains inadequately understood. Gene therapy is a far more complex biological 'drug' than small molecule and protein drugs, where manufacturing processes and the drugs themselves are now well characterized. Extent of community acceptance of uncertainty and acknowledgement of the need for an uncompromising drive for answers to the unknowns will characterize the introduction of this first generation of gene therapy for haemophilia to the wider patient population in both resource-rich and resource-poor countries.
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Abstract
BACKGROUND Haemophilia is a genetic disorder characterized by spontaneous or provoked, often uncontrolled, bleeding into joints, muscles and other soft tissues. Current methods of treatment are expensive, challenging and involve regular administration of clotting factors. Gene therapy for haemophilia is a curative treatment modality currently under investigation. This is an update of a published Cochrane Review. OBJECTIVES To evaluate the safety and efficacy of gene therapy for treating people with haemophilia A or B. SEARCH METHODS We searched the Cochrane Cystic Fibrosis & Genetic Disorders Group's Coagulopathies Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. We also searched the reference lists of relevant articles and reviews. Date of last search: 17 April 2020. SELECTION CRITERIA Eligible trials include randomised or quasi-randomised clinical trials, including controlled clinical trials comparing gene therapy (with or without standard treatment) with standard treatment (factor replacement) or other 'curative' treatment such as stem cell transplantation for individuals with haemophilia A or B of all ages who do not have inhibitors to factor VIII or IX. DATA COLLECTION AND ANALYSIS No trials of gene therapy for haemophilia matching the inclusion criteria were identified. MAIN RESULTS No trials of gene therapy for haemophilia matching the inclusion criteria were identified. AUTHORS' CONCLUSIONS No randomised or quasi-randomised clinical trials of gene therapy for haemophilia were identified. Thus, we are unable to determine the safety and efficacy of gene therapy for haemophilia. Gene therapy for haemophilia is still in clinical investigation and there is a need for well-designed clinical trials to assess the long-term feasibility, success and risks of gene therapy for people with haemophilia.
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Affiliation(s)
- Akshay Sharma
- Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Manu Easow Mathew
- South Asian Cochrane Network & Center, Prof. BV Moses Center for Evidence-Informed Health Care and Health Policy, Christian Medical College, Vellore, India
| | | | - Ulrike M Reiss
- Hematology Department, St Jude Children's Research Hospital, Memphis, Tennessee, USA
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50
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Patel SR, Lundgren TS, Spencer HT, Doering CB. The Immune Response to the fVIII Gene Therapy in Preclinical Models. Front Immunol 2020; 11:494. [PMID: 32351497 PMCID: PMC7174743 DOI: 10.3389/fimmu.2020.00494] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 03/04/2020] [Indexed: 12/14/2022] Open
Abstract
Neutralizing antibodies to factor VIII (fVIII), referred to as "inhibitors," remain the most challenging complication post-fVIII replacement therapy. Preclinical development of novel fVIII products involves studies incorporating hemophilia A (HA) and wild-type animal models. Though immunogenicity is a critical aspect of preclinical pharmacology studies, gene therapy studies tend to focus on fVIII expression levels without major consideration for immunogenicity. Therefore, little clarity exists on whether preclinical testing can be predictive of clinical immunogenicity risk. Despite this, but perhaps due to the potential for transformative benefits, clinical gene therapy trials have progressed rapidly. In more than two decades, no inhibitors have been observed. However, all trials are conducted in previously treated patients without a history of inhibitors. The current review thus focuses on our understanding of preclinical immunogenicity for HA gene therapy candidates and the potential indication for inhibitor treatment, with a focus on product- and platform-specific determinants, including fVIII transgene sequence composition and tissue/vector biodistribution. Currently, the two leading clinical gene therapy vectors are adeno-associated viral (AAV) and lentiviral (LV) vectors. For HA applications, AAV vectors are liver-tropic and employ synthetic, high-expressing, liver-specific promoters. Factors including vector serotype and biodistribution, transcriptional regulatory elements, transgene sequence, dosing, liver immunoprivilege, and host immune status may contribute to tipping the scale between immunogenicity and tolerance. Many of these factors can also be important in delivery of LV-fVIII gene therapy, especially when delivered intravenously for liver-directed fVIII expression. However, ex vivo LV-fVIII targeting and transplantation of hematopoietic stem and progenitor cells (HSPC) has been demonstrated to achieve durable and curative fVIII production without inhibitor development in preclinical models. A critical variable appears to be pre-transplantation conditioning regimens that suppress and/or ablate T cells. Additionally, we and others have demonstrated the potential of LV-fVIII HSPC and liver-directed AAV-fVIII gene therapy to eradicate pre-existing inhibitors in murine and canine models of HA, respectively. Future preclinical studies will be essential to elucidate immune mechanism(s) at play in the context of gene therapy for HA, as well as strategies for preventing adverse immune responses and promoting immune tolerance even in the setting of pre-existing inhibitors.
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Affiliation(s)
- Seema R. Patel
- Hemostasis and Thrombosis Program, Department of Pediatrics, Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta and Emory University, Atlanta, GA, United States
| | - Taran S. Lundgren
- Cell and Gene Therapy Program, Department of Pediatrics, Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta and Emory University, Atlanta, GA, United States
- Graduate Program in Molecular and Systems Pharmacology, Laney Graduate School, Emory University, Atlanta, GA, United States
| | - H. Trent Spencer
- Cell and Gene Therapy Program, Department of Pediatrics, Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta and Emory University, Atlanta, GA, United States
| | - Christopher B. Doering
- Cell and Gene Therapy Program, Department of Pediatrics, Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta and Emory University, Atlanta, GA, United States
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