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Moghadam AA, Manafzadeh AR, Dajliry K, Ramezan F, Nikoonia MR, Abdolkarimi B, Hamidpour M, Tabibian S. Genotype-phenotype analyses of Iranian patients with hemophilia B (Leyden -) and hemophilia B (Leyden +): A single-center study. Transfus Apher Sci 2024; 63:103962. [PMID: 38964254 DOI: 10.1016/j.transci.2024.103962] [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: 04/16/2024] [Revised: 06/15/2024] [Accepted: 06/19/2024] [Indexed: 07/06/2024]
Abstract
BACKGROUND There is a high prevalence of inherited bleeding disorders in Iran, such as hemophilia A (HA) and hemophilia B (HB). This study aimed to analyze the molecular and clinical profiles of patients with HB. METHODS A single-center study was conducted among patients with severe HB between March 20, 2000, and June 31, 2023. The polymerase chain reaction (PCR) amplification was used for all of the major regions, such as the promoter, the exons, the adjacent intronic regions, and the untranslated regions of the F9 gene. Finally, Sanger sequencing was performed on the PCR products. RESULTS A total of 111 HB patients (17 with HB [Leyden +] and 94 with HB [Leyden -]) were enrolled in this study. Among 94 patients with HB (Leyden -), 59 (62.8 %) had missense, 21 (22.3 %) had nonsense, and 8 (8.5 %) had frameshift mutations. Moreover, the most frequent pathogenic variant in HB (Leyden +) was c.-17 A>G in this study. CONCLUSION The results of this study confirm that HB is caused by a wide range of molecular defects in Iran. Thus, by knowing the genotypes and phenotypes, we would be able to stratify the patients which is important in terms of their management and outcome.
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Affiliation(s)
- Arash Ahmadfard Moghadam
- Department of Hematology and Blood Banking, School of Allied Medical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Amir Reza Manafzadeh
- Department of Internal Medicine, Albert Szent-Györgyi Health Centre, University of Szeged, Szeged 6726, Hungary
| | - Khadijeh Dajliry
- Blood Disease Research Center (BDRC), Iranian Comprehensive Hemophilia Care Center, Iran University of Medical Sciences (IUMS), Tehran, Iran
| | - Farahnaz Ramezan
- Blood Disease Research Center (BDRC), Iranian Comprehensive Hemophilia Care Center, Iran University of Medical Sciences (IUMS), Tehran, Iran
| | - Mohammad Reza Nikoonia
- Blood Disease Research Center (BDRC), Iranian Comprehensive Hemophilia Care Center, Iran University of Medical Sciences (IUMS), Tehran, Iran
| | - Babak Abdolkarimi
- Pediatric Hematology-Oncology, Lorestan University of Medical Sciences, Khorramabad, Iran
| | - Mohsen Hamidpour
- Hematopoietic Stem Cell Research Centre-Department of Hematology and Blood Banking, School of Allied Medical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Shadi Tabibian
- Blood Disease Research Center (BDRC), Iranian Comprehensive Hemophilia Care Center, Iran University of Medical Sciences (IUMS), Tehran, Iran.
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Zhang H, Xin M, Lin L, Chen C, Balestra D, Ding Q. Pleiotropic effects of different exonic nucleotide changes at the same position contribute to hemophilia B phenotypic variation. J Thromb Haemost 2024; 22:975-989. [PMID: 38184202 DOI: 10.1016/j.jtha.2023.12.031] [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: 10/20/2023] [Revised: 12/29/2023] [Accepted: 12/29/2023] [Indexed: 01/08/2024]
Abstract
BACKGROUND The disease-causing effects of genetic variations often depend on their location within a gene. Exonic changes generally lead to alterations in protein production, secretion, activity, or clearance. However, owing to the overlap between proteins and splicing codes, missense variants can also affect messenger RNA splicing, thus adding a layer of complexity and influencing disease phenotypes. OBJECTIVES To extensively characterize a panel of 13 exonic variants in the F9 gene occurring at 6 different factor IX positions and associated with varying severities of hemophilia B (HB). METHODS Computational predictions, splicing analysis, and recombinant factor IX assays were exploited to characterize F9 variants. RESULTS We demonstrated that 5 (38%) of 13 selected F9 exonic variants have pleiotropic effects. Although bioinformatic approaches accurately classified effects, extensive experimental assays were required to elucidate and deepen the molecular mechanisms underlying the pleiotropic effects. Importantly, their characterization was instrumental in developing tailored RNA therapeutics based on engineered U7 small nuclear RNA to mask cryptic splice sites and compensatory U1 small nuclear RNA to enhance exon definition. CONCLUSION Overall, albeit a multitool bioinformatic approach suggested the molecular effects of multiple HB variants, the deep investigation of molecular mechanisms revealed insights into the HB phenotype-genotype relationship, enabling accurate classification of HB variants. Importantly, knowledge of molecular mechanisms allowed the development of tailored RNA therapeutics, which can also be translated to other genetic diseases.
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Affiliation(s)
- Huayang Zhang
- Department of Laboratory Medicine, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China; State Key Laboratory of Medical Genomics, Shanghai Institute of Hematology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Min Xin
- Department of Laboratory Medicine, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China; State Key Laboratory of Medical Genomics, Shanghai Institute of Hematology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Liya Lin
- Department of Laboratory Medicine, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China; State Key Laboratory of Medical Genomics, Shanghai Institute of Hematology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Changming Chen
- Department of Laboratory Medicine, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China; State Key Laboratory of Medical Genomics, Shanghai Institute of Hematology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Dario Balestra
- Department of Life Sciences and Biotechnology, University of Ferrara, Ferrara, Italy.
| | - Qiulan Ding
- Department of Laboratory Medicine, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China; Collaborative Innovation Center of Hematology, Shanghai Jiaotong University School of Medicine, Shanghai, China.
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Dou X, Zhang W, Poon MC, Zhang X, Wu R, Feng X, Yang L, Cheng P, Chen S, Wang Y, Zhou H, Huang M, Song Y, Jin C, Zhang D, Chen L, Liu W, Zhang L, Xue F, Yang R. Factor IX inhibitors in haemophilia B: A report of National Haemophilia Registry in China. Haemophilia 2023; 29:123-134. [PMID: 36163649 DOI: 10.1111/hae.14665] [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: 04/20/2022] [Revised: 08/25/2022] [Accepted: 09/12/2022] [Indexed: 01/27/2023]
Abstract
INTRODUCTION The development of inhibitors against factor FIX (FIX) is the most serious complication of FIX replacement therapy in haemophilia B (HB) patients. Currently, only few cohorts of HB inhibitor patients have been reported worldwide. AIM This Chinese nationwide study of HB inhibitor patients explored their risk factors for FIX inhibitor development and experience on their management. METHODS We retrospectively analysed patient characteristics, F9 genotypes, treatment strategies and outcomes of HB inhibitor patients registered to the Chinese National Registry and Patient Organization Registry. RESULTS Forty-four unique HB inhibitor patients were identified in 4485 unique HB patients registered by year 2021 to the two Registries. Inhibitor diagnosis were usually delayed and the low prevalence (.98%) may suggest some inhibitor patients were not identified. Their median age at inhibitor diagnosis was 7.5 (IQR, 3.0-14.8) years. Most patients (95.5%) had high-titre inhibitors. Allergic/Anaphylactic reactions occurred in 59.1% patients. Large deletions and nonsense mutations were the most common F9 mutation types in our FIX inhibitor patients. Patients with large F9 gene deletions were more likely to develop inhibitors (p = .0002), while those with missense mutations had a low risk (p < .0001). Thirteen (29.5%) patients received immune tolerance induction (ITI) therapy using low-dose prothrombin complex concentrate regimens. Twelve completed ITI with three (25.0%) achieving success. Nephrotic syndrome developed in two (16.7%) patients during ITI. CONCLUSION This study reports the largest Chinese cohort of HB inhibitor patients. Large deletions were most significantly associated with inhibitor development. Low-dose ITI might be feasible for FIX inhibitor eradication.
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Affiliation(s)
- Xueqing Dou
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, China.,National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Wenhui Zhang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, China
| | - Man-Chiu Poon
- Departments of Medicine, Pediatrics and Oncology, Cumming School of Medicine, University of Calgary, and the Southern Alberta Rare Blood and Bleeding Disorders Comprehensive Care Program, Foothills Hospital, Alberta Health Services, Calgary, Alberta, Canada
| | - Xinsheng Zhang
- Shandong Hemophilia Treatment Center, Shandong Blood Center, Jinan, China
| | - Runhui Wu
- Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Xiaoqin Feng
- Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Linhua Yang
- Second Hospital of Shanxi Medical University, Taiyuan, China
| | - Peng Cheng
- Department of Hematology, Guangxi Medical University First Affiliated Hospital, Nanning, China
| | - Shu Chen
- Department of Hematology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Ying Wang
- Shenzhen Children's Hospital, Shenzhen, China
| | - Hu Zhou
- The Affiliated Cancer Hospital of Zhengzhou University/Henan Cancer hospital, Zhengzhou, China
| | - Meijuan Huang
- Fujian Medical University Union Hospital, Fujian Institute of Haematology, Fuzhou, China
| | | | - Chenghao Jin
- Department of Hematology, Jiangxi Provincial People's Hospital, Nanchang, China
| | - Donglei Zhang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, China
| | - Lingling Chen
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, China
| | - Wei Liu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, China
| | - Lei Zhang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, China
| | - Feng Xue
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, China
| | - Renchi Yang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, China
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Astermark J, Holstein K, Abajas YL, Kearney S, Croteau SE, Liesner R, Funding E, Kempton CL, Acharya S, Lethagen S, LeBeau P, Bowen J, Berntorp E, Shapiro AD. The B-Natural study-The outcome of immune tolerance induction therapy in patients with severe haemophilia B. Haemophilia 2021; 27:802-813. [PMID: 34118102 DOI: 10.1111/hae.14357] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 04/14/2021] [Accepted: 05/31/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Inhibitors develop less frequently in haemophilia B (HB) than haemophilia A (HA). However, when present, the success of tolerization by immune tolerance induction (ITI) therapy is lower and the risk of complications higher. AIM To evaluate the use and outcome of ITI in patients with HB and inhibitors. METHODS Subjects include singletons or siblings with a current/history of inhibitors enrolled in B-Natural-an observational study designed to increase understanding of clinical management of patients with HB. Patients were followed for 6 months and information on demographics, medical and social history, and treatment were recorded. RESULTS Twenty-nine patients with severe HB and inhibitors were enrolled in 24 centres. Twenty-two underwent one or more courses of ITI with or without immune suppression. Eight patients (36.4%) were successfully tolerized after the first course of ITI. One of these successes (12.5%) experienced allergic manifestations, whereas the corresponding number for the 10 treatment failures was five (50%). One of seven (14.2%) patients with large deletions and three of eight (37.5%) with nonsense mutations were tolerized at the first attempt, and all patients experiencing nephrosis either failed or were on-going. At study end, 11 (50%) were considered successfully tolerized after one or more ITI courses, three were unsuccessful, and eight were still undergoing treatment. CONCLUSION Our data underscore the possibilities and difficulties of achieving tolerization in patients with HB with inhibitors. The type of mutation and complications appear to correlate with ITI outcome, but more accurate definitions of successful ITI are warranted.
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Affiliation(s)
- Jan Astermark
- Department of Translational Medicine, Lund University, Malmö, Sweden.,Department of Haematology, Oncology and Radiation Physics, Skåne University Hospital, Malmö, Sweden
| | - Katharina Holstein
- Medical Department, Hemophilia Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Yasmina L Abajas
- Hemophilia and Thrombosis Centre, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Susan Kearney
- Children's Minnesota Centre for Bleeding and Clotting Disorders, Minneapolis, Minnesota, USA
| | - Stacy E Croteau
- Boston Children's Hospital, Boston Haemophilia Centre, Boston, Massachusetts, USA
| | - Riana Liesner
- Great Ormond Street Hospital for Children, NHS Trust supported by NIHR, GOSH, BRC, London, UK
| | - Eva Funding
- Department of Haematology, Institute of Clinical Medicine, University Hospital Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Christine L Kempton
- Emory University School of Medicine, Emory University, Atlanta, Georgia, USA
| | - Suchitra Acharya
- Northwell Haemostasis and Thrombosis Centre, New York, New York, USA
| | | | | | - Joel Bowen
- Indiana Haemophilia and Thrombosis Centre, Indianapolis, Indiana, USA
| | - Erik Berntorp
- Department of Translational Medicine, Clinical Coagulation Research, Lund University, Malmö, Sweden
| | - Amy D Shapiro
- Indiana Haemophilia and Thrombosis Centre, Indianapolis, Indiana, USA
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Male C, Andersson NG, Rafowicz A, Liesner R, Kurnik K, Fischer K, Platokouki H, Santagostino E, Chambost H, Nolan B, Königs C, Kenet G, Ljung R, Van den Berg M. Inhibitor incidence in an unselected cohort of previously untreated patients with severe haemophilia B: a PedNet study. Haematologica 2021; 106:123-129. [PMID: 31919092 PMCID: PMC7776246 DOI: 10.3324/haematol.2019.239160] [Citation(s) in RCA: 65] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Accepted: 01/09/2020] [Indexed: 12/20/2022] Open
Abstract
The incidence of factor IX (FIX) inhibitors in severe hemophilia B (SHB) is not well defined. Frequencies of 3-5% have been reported but most studies to date have been small, including patients with different severities, and without prospective follow up for inhibitor incidence. The study objective was to investigate the inhibitor incidence in patients with SHB followed up for to 500 exposure days (ED), the frequency of allergic reactions, and the relationship with genotypes. Consecutive previously untreated patients (PUP) with SHB enrolled into the PedNet cohort were included. Detailed data was collected for the first 50 ED, followed by the annual collection of the inhibitor status and allergic re-actions. The presence of inhibitors was defined by at least two consecutive positive samples. Additionally, data on FIX gene mutation was collected. One hundred and fifty-four PUP with SHB were included; 75% were followed up until 75 ED, and 43% until 500 ED. Inhibitors developed in 14 patients (seven high-titer). The median number of ED at inhibitor manifestation was 11 (interquartile range [IQR]: 6.5-36.5). The cumulative inhibitor incidence was 9.3% (95% Confidence Interval [CI]: 4.4-14.1) at 75 ED, and 10.2% (95% CI: 5.1-15.3) at 500 ED. Allergic reactions occurred in four (28.6%) inhibitor patients. Missense mutations were most frequent (46.8%) overall but not associated with inhibitors. Nonsense mutations and deletions with large structural changes comprised all mutations among inhibitor patients and were associated with an inhibitor risk of 26.9% and 33.3%, respectively. In an unselected, well-defined cohort of PUP with SHB, the cumulative inhibitor incidence was 10.2% at 500 ED. Nonsense mutations and large deletions were strongly associated with the risk of inhibitor development. The ‘PedNet Registry’ is registered at clinicaltrials.gov; identifier: NCT02979119.
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Affiliation(s)
| | - Nadine G Andersson
- Centre for Thrombosis and Hemostasis, Skane University Hospital, Malmö, Sweden
| | | | - Ri Liesner
- Hemophilia Center, Dept. of Hematology, Great Ormond Street Hospital for Children, London
| | - Karin Kurnik
- Dr. V. Haunersches Kinderspital, University of Munich
| | | | - Helen Platokouki
- Haemophilia-Haemostasis Unit, St. Sophia Children Hospital, Athens
| | | | - Hervé Chambost
- APHM, La Timone Children Hospital, Center for Bleeding Disorders, Marseille
| | - Beatrice Nolan
- Department of Paediatric Hematology, Children Health Ireland at Crumlin, Dublin
| | - Christoph Königs
- J.W. Goethe University Hospital, Department of Pediatrics, Frankfurt
| | - Gili Kenet
- National Hemophilia Center, Ministry of Health, Sheba Medical Center, Tel Hashomer, Israel
| | - Rolf Ljung
- Department of Clinical Sciences, Department of Pediatrics, Lund University, Lund, Sweden
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Identification of the Profile of the Patients with Hemophilia B Eligible for Treatment with Nonacog Alfa Once-Weekly. REPORTS 2020. [DOI: 10.3390/reports3010003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
This study aimed to identify the characteristics of patients with hemophilia B eligible for once-weekly treatment with Nonacog alfa. Methods: A survey was conducted in 14 Hemophilia (HCs) of Italy. These centers were given a questionnaire consisting of ten closed multiple-choice questions. The centers were asked: (a) the percentages of their hemophilia B (HB) patients undergoing replacement therapy, “On-demand”, or weekly prophylaxis, (b) the criteria guiding the monitoring of patients, the advantages according to the age of patients, and (c) the obstacles to prophylaxis. The percentage of patients receiving “On-demand” (OD) treatment or continuous prophylaxis (prophy) differed depending on patient age and the severity of the disease. Only 57% of HCs provided “On-demand” therapy to the mild HB patients, about 93% to moderate ones, of whom 43% on prophylaxis. About 78% of patients <6 years old, were on treatment in 9 out of 14 HCs, by prophylaxis 66.7% and 33.3% by On-demand. In the 6–18 age group, 90.1% of HCs treated HB patients with prophylaxis, 42.8% in the 18–30 age range. On-demand treatment was the therapy of choice in 61.5% of HCs for patients aged 30–65 years. In total, 64% of the HCs assigned the maximum score to bleeding frequency, especially in the <6 and 6–18 age groups. Bleeding severity was also taken into significant consideration, particularly in subjects up to 30 years old. The scores regarding venous access were distributed relatively evenly throughout all age groups. The majority of the centers attributed a medium-high score to treatment compliance, especially in the 6–65 age range. In actuality, 55% of HCs attributed pro-thrombotic comorbidity a low score in the 18–30 age group, whereas 81% gave pro-hemorrhagic comorbidity a high rating in patients aged >65 years old. Many centers assigned a medium-high score to the baseline concentration of FIX level at diagnosis in all age groups. Most HCs attributed a medium-high score to type of genetic mutation in the younger age groups. As for socio-cultural barriers and quality of life, the majority of respondents gave a medium-high score in all age groups. For periodic monitoring of patients receiving continuous prophylaxis, 59% of the centers reported using clinical assessment. With regard to prophylaxis administration method, the majority of hemophiliacs were given infusions twice weekly, while as regards to the dose of FIX concentrate delivered, 50% of the centers reported administering prophylaxis once-weekly at a dose ranging from 5–100 IU/kg in 10–50% of HB patients. Thus, 93% of the centers reported using a dose of 25–50 IU/kg for twice-weekly prophylaxis in 6–100% of the patients. The majority of centers (86%) believe that, in a program of early primary prevention, once-weekly treatment with nonacog alfa may represent an alternative strategy to dose escalation. The results show that patients with mild hemophilia, with functional musculoskeletal status and difficulties with venous access, are candidates for once-weekly prophylaxis with nonacog alfa. For such patients, this regimen can improve treatment compliance and quality of life.
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Levy-Mendelovich S, Livnat T, Barg AA, Kidon M, Brutman-Barazani T, Kenet G. Allergy and inhibitors in hemophilia - a rare complication with potential novel solutions. Blood Cells Mol Dis 2019; 80:102370. [PMID: 31669933 DOI: 10.1016/j.bcmd.2019.102370] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Accepted: 09/22/2019] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Hemophilia is a rare bleeding disorder caused by a deficiency of the plasma coagulation factors VIII and IX (hemophilia A [HA] and hemophilia B [HB], respectively). Replacement therapy with clotting factor concentrates is the mainstay of treatment. Unlike in patients with HB, anaphylaxis in patients with HA is extremely rare. METHODS A retrospective study of prospectively collected data on patients with hemophilia who experienced anaphylaxis was conducted in our center. Demographic and clinical data were collected, and laboratory workups that included thrombin generation were conducted. RESULTS Our first patient underwent successful immune tolerance induction (ITI) following the administration of rituximab. The second patient was transitioned to emicizumab. The third patient receives recombinant activated VIIa (rFVIIa) on demand. Thrombin generation was performed following current medical management protocols for supporting hemostasis. DISCUSSION Our case series illustrates the difficulty in managing patients with anaphylaxis to replacement therapy. In the era of novel therapies, such as emicizumab, the management of HA patients who experience anaphylaxis to replacement therapy is becoming easier and may obviate the need for ITI. Current treatment strategies for HB patients with such anaphylaxis, however, are limited to rFVIIa, and it continues to pose a challenge.
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Affiliation(s)
- Sarina Levy-Mendelovich
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; The Israeli National Hemophilia Center and Thrombosis Unit, The Amalia Biron Research Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, Israel.
| | - Tami Livnat
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; The Israeli National Hemophilia Center and Thrombosis Unit, The Amalia Biron Research Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, Israel
| | - Assaf Arie Barg
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; The Israeli National Hemophilia Center and Thrombosis Unit, The Amalia Biron Research Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, Israel
| | - Mona Kidon
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Pediatric Allergy Clinic, Safra Children's Hospital, Sheba Medical Center, Tel Hashomer, Israel
| | - Tami Brutman-Barazani
- The Israeli National Hemophilia Center and Thrombosis Unit, The Amalia Biron Research Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, Israel
| | - Gili Kenet
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; The Israeli National Hemophilia Center and Thrombosis Unit, The Amalia Biron Research Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, Israel
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8
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Bypassing Agents for Bleeding Prophylaxis in Hemophilia B. Am J Ther 2018; 25:e770-e771. [DOI: 10.1097/mjt.0000000000000776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
PURPOSE OF REVIEW Hemophilia is an X-linked blood coagulation genetic disorder, which can cause significant disability. Replacement therapy for coagulation factor VIII (hemophilia A) or factor IX (hemophilia B) may result in the development of high-affinity alloantibodies ('inhibitors') to the replacement therapy, thus making it ineffective. Therefore, there is interest in directing immunological responses towards tolerance to infused factors. RECENT FINDINGS In this review, we will discuss latest advancements in the development of potentially less immunogenic replacement clotting factors, optimization of current tolerance induction protocols (ITI), preclinical and clinical data of pharmacological immune modulation, hepatic gene therapy, and the rapidly advancing field of cell therapies. We will also evaluate publications reporting data from preclinical studies on oral tolerance induction using chloroplast-transgenic (transplastomic) plants. SUMMARY Until now, no clinical prophylactic immune modulatory protocol exists to prevent inhibitor formation to infused clotting factors. Recent innovative technologies provide hope for improved eradication and perhaps even prevention of inhibitors.
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Affiliation(s)
- Alexandra Sherman
- Department Pediatrics, Indiana University, Indianapolis, Indiana, USA
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10
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Kuhn J, Noda C, Massey GV. Successful multi-modal immune tolerance induction for factor IX deficiency with inhibitors and allergic reactions. Haemophilia 2018; 24:e133-e136. [DOI: 10.1111/hae.13457] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- J. Kuhn
- Internal Medicine; Virginia Commonwealth University; Richmond VA USA
| | - C. Noda
- Department of Pharmacy; Virginia Commonwealth University Health System; Richmond VA USA
| | - G. V. Massey
- Internal Medicine; Virginia Commonwealth University; Richmond VA USA
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Erlich‐Hadad T, Hadad R, Feldman A, Greif H, Lictenstein M, Lorberboum‐Galski H. TAT-MTS-MCM fusion proteins reduce MMA levels and improve mitochondrial activity and liver function in MCM-deficient cells. J Cell Mol Med 2018; 22:1601-1613. [PMID: 29265583 PMCID: PMC5824393 DOI: 10.1111/jcmm.13435] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Accepted: 09/25/2017] [Indexed: 12/14/2022] Open
Abstract
Methylmalonic aciduria (MMA) is a disorder of organic acid metabolism resulting from a functional defect of the mitochondrial enzyme, methylmalonyl-CoA mutase (MCM). The main treatments for MMA patients are dietary restriction of propiogenic amino acids and carnitine supplementation. Liver or combined liver/kidney transplantation has been used to treat those with the most severe clinical manifestations. Thus, therapies are necessary to help improve quality of life and prevent liver, renal and neurological complications. Previously, we successfully used the TAT-MTS-Protein approach for replacing a number of mitochondrial-mutated proteins. In this targeted system, TAT, an 11 a.a peptide, which rapidly and efficiently can cross biological membranes, is fused to a mitochondrial targeting sequence (MTS), followed by the mitochondrial mature protein which sends the protein into the mitochondria. In the mitochondria, the TAT-MTS is cleaved off and the native protein integrates into its natural complexes and is fully functional. In this study, we used heterologous MTSs of human, nuclear-encoded mitochondrial proteins, to target the human MCM protein into the mitochondria. All fusion proteins reached the mitochondria and successfully underwent processing. Treatment of MMA patient fibroblasts with these fusion proteins restored mitochondrial activity such as ATP production, mitochondrial membrane potential and oxygen consumption, indicating the importance of mitochondrial function in this disease. Treatment with the fusion proteins enhanced cell viability and most importantly reduced MMA levels. Treatment also enhanced albumin and urea secretion in a CRISPR/Cas9-engineered HepG2 MUT (-/-) liver cell line. Therefore, we suggest using this TAT-MTS-Protein approach for the treatment of MMA.
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Affiliation(s)
- Tal Erlich‐Hadad
- Department of Biochemistry and Molecular BiologyInstitute for Medical Research Israel‐Canada (IMRIC)Faculty of MedicineHebrew University of JerusalemJerusalemIsrael
| | - Rita Hadad
- Department of Biochemistry and Molecular BiologyInstitute for Medical Research Israel‐Canada (IMRIC)Faculty of MedicineHebrew University of JerusalemJerusalemIsrael
| | | | | | - Michal Lictenstein
- Department of Biochemistry and Molecular BiologyInstitute for Medical Research Israel‐Canada (IMRIC)Faculty of MedicineHebrew University of JerusalemJerusalemIsrael
| | - Haya Lorberboum‐Galski
- Department of Biochemistry and Molecular BiologyInstitute for Medical Research Israel‐Canada (IMRIC)Faculty of MedicineHebrew University of JerusalemJerusalemIsrael
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12
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Abstract
Hemophilia B is a hereditary bleeding disorder caused by the deficiency in coagulation factor IX. Understanding coagulation and the role of factor IX as well as patient population and diagnosis are all critical factors in developing treatment strategies and regimens for hemophilia B patients. Current treatment options rely on protein replacement therapy by intravenous injection, which have markedly improved patient lifespan and quality of life. However, issues with current options include lack of patient compliance due to needle-based administration, high expenses, and potential other complications (e.g., surgical procedures, inhibitor formation). As a result, these treatment options are also limited to developed countries. Recent advantages in hemophilia B treatment have focused on addressing these pain points. Emerging commercial products based on modified factor IX aim to reduce injection frequency. Exploratory research efforts have focused on novel drug delivery systems for orally administered treatment and gene therapy as a potential cure. Such alternative treatment methods are promising options for hemophilia B patients worldwide.
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13
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Dolan G, Benson G, Duffy A, Hermans C, Jiménez-Yuste V, Lambert T, Ljung R, Morfini M, Zupančić Šalek S. Haemophilia B: Where are we now and what does the future hold? Blood Rev 2018; 32:52-60. [DOI: 10.1016/j.blre.2017.08.007] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Revised: 08/08/2017] [Accepted: 08/15/2017] [Indexed: 01/19/2023]
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14
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Ding Q, You G, Dai J, Xi X, Wang H, Wu X, Lu Y, Wang X. Characterisation of large F9 deletions in seven unrelated patients with severe haemophilia B. Thromb Haemost 2017; 112:459-65. [DOI: 10.1160/th13-12-1060] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2013] [Accepted: 03/25/2014] [Indexed: 01/05/2023]
Abstract
SummaryLarge deletions in the F9 gene are detected in approximately 5% of patients with severe haemophilia B, but only a few deletion breakpoints have been characterised precisely until now. In this study we identified a total of seven large F9 deletions in the index patients and nine female carriers by the AccuCopy technique. We also successfully characterised the exact breakpoints for each large deletion including four deletions encompassing the entire F9 gene by the genome walking method combined with primer walking strategy. The extents of deletion regions ranged from 11.1 to 884 kb. Microhomologies ranged from 2 to 6 bp were identified in the breakpoint junctions of six deletions. The other deletion occurred between two highly homologous sequences of the same long interspersed nuclear element 1 (LINE/L1). Non-homologous end joining (NHEJ) and microhomology-mediated break-induced replication (MMBIR) may be the main causative mechanisms for the six large deletions with microhomologies. Non-allelic homologous recombination (NAHR) may mediate the deletion occurred between the two tandem LINEs in the other large deletion. Repetitive elements and non-B DNA forming motifs identified in the junction regions may contribute to DNA breakage leading to large deletions.
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15
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Cugno M, Mancuso ME, Tedeschi A, Santagostino E, Lorini M, Carbonelli V, Peyvandi F, Mannucci PM. Involvement of the IgE-basophil system and mild complement activation in haemophilia B with anti-factor IX neutralizing antibodies and anaphylaxis. Haemophilia 2017; 23:e348-e353. [DOI: 10.1111/hae.13282] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/28/2017] [Indexed: 12/20/2022]
Affiliation(s)
- M. Cugno
- Internal Medicine; Department of Pathophysiology and Transplantation; Università degli Studi di Milano; Milan Italy
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center; Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico; Milan Italy
| | - M. E. Mancuso
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center; Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico; Milan Italy
| | - A. Tedeschi
- Internal Medicine; Ospedale Fatebenefratelli e Oftalmico; Milan Italy
| | - E. Santagostino
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center; Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico; Milan Italy
| | - M. Lorini
- Dipartimento di Scienze Cliniche e di Comunità; Università degli Studi di Milano; Milan Italy
| | - V. Carbonelli
- Dipartimento di Scienze Cliniche e di Comunità; Università degli Studi di Milano; Milan Italy
| | - F. Peyvandi
- Internal Medicine; Department of Pathophysiology and Transplantation; Università degli Studi di Milano; Milan Italy
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center; Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico; Milan Italy
| | - P. M. Mannucci
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center; Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico; Milan Italy
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16
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Boylan B, Rice AS, Neff AT, Manco-Johnson MJ, Kempton CL, Miller CH. Survey of the anti-factor IX immunoglobulin profiles in patients with hemophilia B using a fluorescence-based immunoassay. J Thromb Haemost 2016; 14:1931-1940. [PMID: 27501440 PMCID: PMC5083216 DOI: 10.1111/jth.13438] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Indexed: 12/18/2022]
Abstract
Essentials Studies characterizing neutralizing antibodies (inhibitors) in hemophilia B (HB) are lacking. The current study describes anti-factor (F) IX antibody profiles in 37 patients who have HB. Anti-FIX IgG4 levels exhibited a strong positive correlation with Nijmegen-Bethesda results. These data will help to more clearly define, predict, and treat alloantibody formation in HB. SUMMARY Background Hemophilia B (HB) is an inherited bleeding disorder caused by the absence or dysfunction of coagulation factor IX (FIX). A subset of patients who have HB develop neutralizing alloantibodies (inhibitors) against FIX after infusion therapy. HB prevalence and the proportion of patients who develop inhibitors are much lower than those for hemophilia A (HA), which makes studies of inhibitors in patients with HB challenging due to the limited availability of samples. As a result, there is a knowledge gap regarding HB inhibitors. Objective Evaluate the largest group of patients with inhibitor-positive HB studied to date to assess the relationship between anti-FIX antibody profiles and inhibitor formation. Methods A fluorescence immunoassay was used to detect anti-FIX antibodies in plasma samples from 37 patients with HB. Results Assessments of antibody profiles showed that anti-FIX IgG1-4 , IgA, and IgE were detected significantly more often in patients with a positive Nijmegen-Bethesda assay (NBA). All NBA-positive samples were positive for IgG4 . Anti-FIX IgG4 demonstrated a strong correlation with the NBA, while correlations were significant, yet more moderate, for anti-FIX IgG1-2 and IgA. Conclusions The anti-FIX antibody profile in HB patients who develop inhibitors is diverse and correlates well with the NBA across immunoglobulin (sub)class, and anti-FIX IgG4 is particularly relevant to functional inhibition. The anti-FIX fluorescence immunoassay may serve as a useful tool to confirm the presence of antibodies in patients who have low positive NBA results and to more clearly define, predict, and treat alloantibody formation against FIX.
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Affiliation(s)
- B Boylan
- Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, USA.
| | - A S Rice
- Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - A T Neff
- Vanderbilt University Medical Center, Nashville, TN, USA
| | - M J Manco-Johnson
- Hemophilia and Thrombosis Center, University of Colorado and The Children's Hospital, Aurora, CO, USA
| | - C L Kempton
- Department of Hematology/Oncology, Emory University School of Medicine, Atlanta, GA, USA
| | - C H Miller
- Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, USA
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17
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Nakamura Y, Ando Y, Takagi Y, Murata M, Kozuka T, Nakata Y, Hasebe R, Takagi A, Matsushita T, Shima M, Kojima T. Distinct X chromosomal rearrangements in four haemophilia B patients with entire F9 deletion. Haemophilia 2015; 22:433-9. [PMID: 26686734 DOI: 10.1111/hae.12849] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2015] [Revised: 06/09/2015] [Accepted: 09/14/2015] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Haemophilia B is an X-linked bleeding disorder caused by a coagulation factor IX gene (F9) abnormality. Numerous F9 defects have been identified to date; however, only a few with an entire F9 deletion have been reported in detail. AIM To elucidate the cause of severe haemophilia B, we investigated the precise X chromosome abnormalities in four Japanese patients who did not show all amplifications in F9-specific PCR. METHODS We analysed the patient's genomic DNA using Multiplex ligation-dependent probe amplification (MLPA). To assess the extent of any deletions, we further performed mapping PCRs, inverse PCRs or long-range PCRs and direct sequencing analyses of the X chromosome. RESULTS We detected entire F9 deletions in four haemophilia B patients and identified the precise deleted regions of the X chromosome including F9. Patient 1 had a 149-kb deletion with breakpoints 90-kb upstream and 30-kb downstream from F9. Patients 2 and 3 showed 273-kb and 1.19-Mb deletions respectively. Patient 4 had two deleted regions: a 1663-bp deletion 1.34-Mb upstream from F9 and a 7.2-Mb deletion including F9. These distinct breakpoints found in four different patients suggest that the mechanism of X chromosome deletion may be different between individuals. Non-allelic homologous recombination (NAHR), microhomology-mediated break-induced replication (MMBIR) or fork stalling and template switching (FoSTeS) may occur in respective X chromosomes of the four haemophilia B patients analysed. CONCLUSIONS We identified diverse X chromosomal rearrangements in four haemophilia B patients, which might be caused by distinct mechanisms of genomic rearrangement.
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Affiliation(s)
- Y Nakamura
- Department of Pathophysiological Laboratory Sciences, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Y Ando
- Department of Pathophysiological Laboratory Sciences, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Y Takagi
- Department of Pathophysiological Laboratory Sciences, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - M Murata
- Department of Pathophysiological Laboratory Sciences, Nagoya University Graduate School of Medicine, Nagoya, Japan.,Japan Society for the Promotion of Science, Tokyo, Japan
| | - T Kozuka
- Department of Pathophysiological Laboratory Sciences, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Y Nakata
- Department of Pathophysiological Laboratory Sciences, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - R Hasebe
- Department of Pathophysiological Laboratory Sciences, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - A Takagi
- Department of Pathophysiological Laboratory Sciences, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - T Matsushita
- Department of Transfusion Medicine, Nagoya University Hospital, Nagoya, Japan
| | - M Shima
- Department of Paediatric, Nara Medical University, Nara, Japan
| | - T Kojima
- Department of Pathophysiological Laboratory Sciences, Nagoya University Graduate School of Medicine, Nagoya, Japan
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18
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Mårtensson A, Letelier A, Halldén C, Ljung R. Mutation analysis of Swedish haemophilia B families – high frequency of unique mutations. Haemophilia 2015; 22:440-5. [DOI: 10.1111/hae.12854] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/23/2015] [Indexed: 01/19/2023]
Affiliation(s)
- A. Mårtensson
- Department of Clinical Sciences Lund University Malmö Sweden
- Department of Paediatrics and Malmö Centre for Thrombosis and Haemostasis Skåne University Hospital Lund University Malmö Sweden
| | - A. Letelier
- Department of Clinical Sciences Lund University Malmö Sweden
- Department of Paediatrics and Malmö Centre for Thrombosis and Haemostasis Skåne University Hospital Lund University Malmö Sweden
| | - C. Halldén
- Biomedicine Kristianstad University Kristianstad Sweden
| | - R. Ljung
- Department of Clinical Sciences Lund University Malmö Sweden
- Department of Paediatrics and Malmö Centre for Thrombosis and Haemostasis Skåne University Hospital Lund University Malmö Sweden
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19
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Bon A, Morfini M, Dini A, Mori F, Barni S, Gianluca S, de Martino M, Novembre E. Desensitization and immune tolerance induction in children with severe factor IX deficiency; inhibitors and adverse reactions to replacement therapy: a case-report and literature review. Ital J Pediatr 2015; 41:12. [PMID: 25887512 PMCID: PMC4347657 DOI: 10.1186/s13052-015-0116-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Accepted: 02/02/2015] [Indexed: 11/10/2022] Open
Abstract
Hemophilia B is a rare X-linked recessive disorder with plasma factor IX (FIX) deficiency. 1-3% of patients treated with exogenous FIX-containing products develop inhibitors (i.e. polyclonal high affinity immunoglobulins) that neutralize the procoagulant activity of a specific coagulation factor. Although the incidence of inhibitors in hemophilia B patients is low, most are "high titer" and frequently associated with the development of severe allergic or anaphylactic reactions. Immune tolerance induction as a strategy for inhibitor eradication was first described in 1984. Unfortunately, the overall reported success of immune tolerance induction in FIX deficiency with inhibitors is approximately 25-40%.We report the case of a 2-year-old boy with hemophilia B severe FIX deficiency (<1%), inhibitor antibodies to FIX development, and a history of adverse reactions to FIX infusions, who underwent a successful desensitization and immune tolerance induction with a daily FIX infusion. With this regimen the inhibitor titer decreased with effective bleeding prevention.
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Affiliation(s)
- Andrea Bon
- Department of Pediatrics, University of Udine, Udine, Italy.
| | - Massimo Morfini
- Haemophilia Agency, Careggi University Hospital, Florence, Italy.
| | - Alessandro Dini
- Department of Pediatrics, University of Florence, A. Meyer Children's University Hospital, Florence, Italy.
| | - Francesca Mori
- Allergy Unit, Department of Pediatrics, University of Florence, A. Meyer Children's University Hospital, Florence, Italy.
| | - Simona Barni
- Allergy Unit, Department of Pediatrics, University of Florence, A. Meyer Children's University Hospital, Florence, Italy.
| | - Sottilotta Gianluca
- Haemophilia Centre, "Bianchi-Melacrino-Morelli" Hospital, Reggio Calabria, Italy.
| | - Maurizio de Martino
- Department of Health Sciences, University of Florence, A. Meyer Children's University Hospital, Florence, Italy.
| | - Elio Novembre
- Allergy Unit, Department of Pediatrics, University of Florence, A. Meyer Children's University Hospital, Florence, Italy.
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20
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Sack BK, Wang X, Sherman A, Rogers GL, Markusic DM. Immune responses to human factor IX in haemophilia B mice of different genetic backgrounds are distinct and modified by TLR4. Haemophilia 2014; 21:133-9. [PMID: 25417755 PMCID: PMC4309508 DOI: 10.1111/hae.12522] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/21/2014] [Indexed: 12/18/2022]
Abstract
Our laboratory develops protocols to prevent or reverse ongoing anti-hFIX IgG inhibitors in haemophilia B mice with a F9 gene deletion on BALB/c and C3H/HeJ backgrounds. C3H/HeJ F9−/Y mice develop high titre anti-hFIX IgG1 inhibitors and anaphylaxis, whereas most BALB/c F9−/Y mice have mild anti-hFIX IgG1 inhibitors and no anaphylaxis. Our aim was to determine if hFIX-specific B- and T-cell responses in BALB/c and C3H/HeJ F9−/Y mice trigger the difference in anti-hFIX immune responses. BALB/c and C3H/HeJ F9−/Y mice were challenged weekly with recombinant hFIX protein. Humoral immune responses were determined by IgG1 and IgG2a anti-hFIX ELISA, Bethesda assay for inhibitors and B-cell ELISpot on bone marrow and spleen cells. T-cell studies measured the TH1 (IFN-γ) and TH2 (IL-4) cytokine responses in splenocytes at the mRNA and protein level in response to hFIX protein. Antibody responses were also measured in C3H/HeJ/OuJ F9−/Y mice with restored toll-like receptor 4 (TLR4) function. BALB/c F9−/Y mice have a TH2 skewed response and a reduction in anti-hFIX secreting plasma cells in the bone marrow. Independent antigen challenge revealed both strains generated equivalent IgG1 antibody titres to an intravenously delivered antigen. C3H/HeJ F9−/Y mice have a mixed TH1 and TH2 response (mainly TH2). Importantly, TLR4 signalling has a modulatory role in the C3H background on the levels of anti-hFIX IgG1 and incidence of anaphylaxis. The background strain strongly impacts the immune response to hFIX, which can be significantly impacted by mutations in innate immune sensors.
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Affiliation(s)
- B K Sack
- Seattle Biomedical Research Institute, Seattle, WA, USA; Department of Pediatrics, University of Florida, Gainesville, FL, USA
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21
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Shapiro AD, Hedner U. Advances in bypassing agent therapy for hemophilia patients with inhibitors to close care gaps and improve outcomes. Ther Adv Drug Saf 2014; 2:213-25. [PMID: 25083214 DOI: 10.1177/2042098611415566] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
In the past, patients with hemophilia and inhibitors have had less-than-optimal treatment and have experienced more orthopedic complications than patients without inhibitors. Bypassing agents offer the potential to close treatment gaps between inhibitor and noninhibitor patients by helping the former better attain key treatment goals, including: facilitating early initiation of treatment and hemostatic control in hemarthroses; providing effective treatment in serious hemorrhagic episodes; and performance of major surgery. Effective treatment with a bypassing agent minimizes joint and/or muscle damage and potentially can serve as an effective prophylactic agent to minimize the number of hemarthroses experienced per year, thereby mitigating the development of arthropathy. The reported efficacy of the currently available bypassing agents ranges from approximately 50-80% (50-64% in controlled studies) for plasma-derived activated prothrombin complex concentrate (pd-aPCC) and 81-91% (in controlled studies) for recombinant activated factor VII (rFVIIa), including use in major orthopedic surgery. Both bypassing agents have undergone key improvements in their formulation and/or properties in recent years. The nanofiltered, vapor-heated formulation of pd-aPCC has diminished the risk of acquiring blood-borne viral infections and the room temperature stable formulation of rFVIIa allows more convenient storage, increased ease to dissolve and inject, and smaller volumes, thereby increasing overall ease of administration. Use of recommended dosing has been demonstrated to provide effective hemostasis with a minimal number of injections for both agents. In this paper, we review the individual characteristics of pd-aPCC and rFVIIa and discuss clinical data from studies conducted in inhibitor patients that demonstrate the potential benefits of these bypassing agents in this difficult-to-treat population, and underscore the potential opportunities to close the gap in care between inhibitor and noninhibitor hemophilic patients.
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Affiliation(s)
- Amy D Shapiro
- Indiana Hemophilia and Thrombosis Center, 8402 Harcourt Road, Suite 500, Indianapolis, IN 46260, USA
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22
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Li T, Miller CH, Driggers J, Payne AB, Ellingsen D, Hooper WC. Mutation analysis of a cohort of US patients with hemophilia B. Am J Hematol 2014; 89:375-9. [PMID: 24375831 DOI: 10.1002/ajh.23645] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2013] [Revised: 10/22/2013] [Accepted: 11/29/2013] [Indexed: 11/08/2022]
Abstract
Hemophilia B (HB) is a disorder resulting from genetic mutations in the Factor 9 gene (F9). Genotyping of HB patients is important for genetic counseling and patient management. Here we report a study of mutations identified in a large sample of HB patients in the US. Patients were enrolled through an inhibitor surveillance study at 17 hemophilia treatment centers. A total of 87 unique mutations were identified from 225 of the 226 patients, including deletions, insertions, and point mutations. Point mutations were distributed throughout the F9 gene and were found in 86% of the patients. Of these mutations, 24 were recurrent in the population, and 3 of them (c.316G>A, c.1025C>T, and c.1328T>A) accounted for 84 patients (37.1%). Haplotype analysis revealed that the high recurrence arose from a founder effect. The severity of HB was found to correlate with the type of mutation. Inhibitors developed only in severe cases with large deletions and nonsense mutations. None of the mild or moderate patients developed inhibitors. Our results provide a resource describing F9 mutations in US HB patients and confirm previous findings that patients bearing large deletions and nonsense mutations are at high risk of developing inhibitors.
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Affiliation(s)
- Tengguo Li
- Division of Blood Disorders; National Center on Birth Defects and Developmental Disabilities; Centers for Disease Control and Prevention; Atlanta Georgia
| | - Connie H. Miller
- Division of Blood Disorders; National Center on Birth Defects and Developmental Disabilities; Centers for Disease Control and Prevention; Atlanta Georgia
| | - Jennifer Driggers
- Division of Blood Disorders; National Center on Birth Defects and Developmental Disabilities; Centers for Disease Control and Prevention; Atlanta Georgia
| | - Amanda B. Payne
- Division of Blood Disorders; National Center on Birth Defects and Developmental Disabilities; Centers for Disease Control and Prevention; Atlanta Georgia
| | - Dorothy Ellingsen
- Division of Blood Disorders; National Center on Birth Defects and Developmental Disabilities; Centers for Disease Control and Prevention; Atlanta Georgia
| | - W. Craig Hooper
- Division of Blood Disorders; National Center on Birth Defects and Developmental Disabilities; Centers for Disease Control and Prevention; Atlanta Georgia
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23
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Abstract
The genes encoding the coagulation factor proteins were among the first human genes to be characterized over 25 years ago. Since then, significant progress has been made in the translational application of this information for the 2 commonest severe inherited bleeding disorders, hemophilia A and B. For these X-linked disorders, genetic characterization of the disease-causing mutations is now incorporated into the standard of care and genetic information is used for risk stratification of treatment complications. With electronic databases detailing >2100 unique mutations for hemophilia A and >1100 mutations for hemophilia B, these diseases are among the most extensively characterized inherited diseases in humans. Experience with the genetics of the rare bleeding disorders is, as expected, less well advanced. However, here again, electronic mutation databases have been developed and provide excellent guidance for the application of genetic analysis as a confirmatory approach to diagnosis. Most recently, progress has also been made in identifying the mutant loci in a variety of inherited platelet disorders, and these findings are beginning to be applied to the genetic diagnosis of these conditions. Investigation of patients with bleeding phenotypes without a diagnosis, using genome-wide strategies, may identify novel genes not previously recognized as playing a role in hemostasis.
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24
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Markusic DM, Hoffman BE, Perrin GQ, Nayak S, Wang X, LoDuca PA, High KA, Herzog RW. Effective gene therapy for haemophilic mice with pathogenic factor IX antibodies. EMBO Mol Med 2013; 5:1698-709. [PMID: 24106230 PMCID: PMC3840486 DOI: 10.1002/emmm.201302859] [Citation(s) in RCA: 98] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2013] [Revised: 08/15/2013] [Accepted: 08/19/2013] [Indexed: 11/30/2022] Open
Abstract
Formation of pathogenic antibodies is a major problem in replacement therapies for inherited protein deficiencies. For example, antibodies to coagulation factors (‘inhibitors’) seriously complicate treatment of haemophilia. While immune tolerance induction (ITI) protocols have been developed, inhibitors against factor IX (FIX) are difficult to eradicate due to anaphylactic reactions and nephrotic syndrome and thus substantially elevate risks for morbidity and mortality. However, hepatic gene transfer with an adeno-associated virus (AAV) serotype 8 vector expressing FIX (at levels of ≥4% of normal) rapidly reversed pre-existing high-titre inhibitors in haemophilia B mice, eliminated antibody production by B cells, desensitized from anaphylaxis (even if protein therapy was resumed) and provided long-term correction. High levels of FIX protein suppressed memory B cells and increased Treg induction, indicating direct and indirect mechanisms of suppression of inhibitor formation. Persistent presence of Treg was required to prevent relapse of antibodies. Together, these data suggest that hepatic gene transfer-based ITI provides a safe and effective alternative to eradicate inhibitors. This strategy may be broadly applicable to reversal of antibodies in different genetic diseases.
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Affiliation(s)
- David M Markusic
- Department of Pediatrics, University of Florida, Gainesville, FL, USA
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25
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Castaman G, Bonetti E, Messina M, Morfini M, Rocino A, Scaraggi FA, Tagariello G. Inhibitors in haemophilia B: the Italian experience. Haemophilia 2013; 19:686-90. [PMID: 23601006 DOI: 10.1111/hae.12158] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/02/2013] [Indexed: 11/29/2022]
Abstract
The prevalence of inhibitors in haemophilia B is significantly lower than that of patients with haemophilia A. However, the peculiar occurrence of allergic reactions associated with the onset of inhibitor in haemophilia B (HB) may render immune tolerance a risky procedure. We have carried out a detailed survey among all the Italian Hemophilia Centers to analyse all the patients with HB and inhibitors. A total of eight patients were reported among 282 living patients (2.8%) with severe factor IX (FIX) deficiency (FIX < 1 U dL(-1)). In addition, two deceased patients were also identified. Six patients carried nonsense mutations while in four partial or complete gene deletions were detected. Three patients (one deceased) had history of allergic/anaphylactic reaction upon substitutive treatment, which in one case was recurrent and resolved after switching to plasma derived FIX. Immune tolerance was adopted in five patients and in four complete response was achieved while in the remaining it was partial. No nephrotic syndrome was observed. Our data confirm that inhibitors in HB occur in patients with null mutations or complete/partial gene deletion. Immune tolerance can be achieved also in HB patients, without allergic reactions or nephrotic syndrome upon replacement therapy.
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Affiliation(s)
- G Castaman
- Department of Cell Therapy and Hematology, Hemophilia and Thrombosis Center, San Bortolo Hospital, Vicenza, Italy.
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26
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Abstract
The development of alloantibodies against von Willebrand factor (VWF) represents a rare but serious complication of treatment of von Willebrand disease (VWD), occurring in ~5% to 10% of type 3 VWD patients. Affected patients can present with a range of symptoms, including lack or loss of hemostatic response to infused VWF concentrates up to anaphylactic reactions in rare cases. It is classically reported in multitransfused patients and occurs most frequently in patients with partial or complete VWF gene deletions. A positive family history of anti-VWF antibodies also appears to be a risk factor. There is a lack of standardization of laboratory methods for antibody identification and characterization. Issues of variability in laboratory approaches as well as the rarity of the complication act as a barrier to future studies. Recombinant factor VIII as well as bypassing agents and immune tolerance have been reported as effective treatments; however, aside from case reports, little exists in the literature to guide management. The imminent clinical availability of recombinant VWF has prompted a resurgence of interest in this area. Additional study is warranted to address the deficiencies in our understanding of this treatment complication.
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27
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Collins PW, Chalmers E, Hart DP, Liesner R, Rangarajan S, Talks K, Williams M, Hay CR. Diagnosis and treatment of factor VIII and IX inhibitors in congenital haemophilia: (4th edition). Br J Haematol 2012; 160:153-70. [DOI: 10.1111/bjh.12091] [Citation(s) in RCA: 159] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Peter W. Collins
- School of Medicine; Cardiff University; University Hospital of Wales; Wales; UK
| | | | - Daniel P. Hart
- The London School of Medicine and Dentistry; Royal London Hospital; Barts, Queen Mary University; London; UK
| | - Ri Liesner
- Great Ormond Street NHS Trust; London; UK
| | - Savita Rangarajan
- Hampshire Hospital NHS Foundation Trust; Basingstoke & North Hampshire Hospital; Basingstoke; UK
| | - Kate Talks
- Royal Victoria Infirmary; Newcastle upon Tyne; UK
| | - Mike Williams
- Birmingham Childrens' Hospital NHS Foundation Trust; Birmingham; UK
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Pinotti M, Caruso P, Canella A, Campioni M, Tagariello G, Castaman G, Giacomelli S, Belvini D, Bernardi F. Ribosome readthrough accounts for secreted full-length factor IX in hemophilia B patients with nonsense mutations. Hum Mutat 2012; 33:1373-6. [PMID: 22618954 DOI: 10.1002/humu.22120] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2012] [Accepted: 05/07/2012] [Indexed: 01/08/2023]
Abstract
We investigated the spontaneous ribosome readthrough, virtually unexplored in genes encoding secreted proteins, over coagulation F9 nonsense mutations. Expression of recombinant factor IX (FIX) in eukaryotic cells demonstrated appreciable levels of secreted FIX molecules for the mutations p.R162* (5 ± 0.3% of rFIX-wt antigen levels), p.R294* (3.1 ± 1.1%) and p.R298* (2.5 ± 0.7%), but not for the p.L103*. Western blotting revealed a large proportion of truncated molecules, which correlated with small amounts of full-length FIX (rFIX-162*, ∼0.5%; rFIX-294*; and rFIX-298*, ∼0.2%). Western blotting of plasma from FIX deficient (Hemophilia B) patients revealed traces of full-length FIX for the p.R294* and p.R298* mutations, but not for the p.L103* mutation that triggered major FIX mRNA decay. The detection of full-length proteins has clinical implication, particularly for post-therapeutic immunological complications in Hemophilia. Data in patients' plasma and in vitro, obtained in the proper protein context, support a ribosome readthrough gradient, consistent with its predicted determinants of efficiency.
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Affiliation(s)
- Mirko Pinotti
- Dipartimento di Biochimica e Biologia Molecolare and LTTA Centre, Università di Ferrara, Italy.
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29
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Ranta S, Verbruggen B, Wikström A, Mäkipernaa A. Identical but different: haemophilia B in monozygotic twins with inhibitor in one brother and subsequent successful immune tolerance induction. Haemophilia 2012; 18:e349-51. [PMID: 22631443 DOI: 10.1111/j.1365-2516.2012.02865.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/20/2012] [Indexed: 11/29/2022]
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30
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Miller CH, Benson J, Ellingsen D, Driggers J, Payne A, Kelly FM, Soucie JM, Craig Hooper W. F8 and F9 mutations in US haemophilia patients: correlation with history of inhibitor and race/ethnicity. Haemophilia 2011; 18:375-82. [PMID: 22103590 DOI: 10.1111/j.1365-2516.2011.02700.x] [Citation(s) in RCA: 98] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Both genetic and treatment-related risk factors contribute to the development of inhibitors in haemophilia. An inhibitor surveillance system piloted at 12 US sites has the goal of assessing risk factors through prospective data collection. This report examines the relationship of genotype and race/ethnicity to history of inhibitor in a large cohort of US haemophilia patients. Mutation analysis was performed on 676 haemophilia A (HA) and 153 haemophilia B (HB) patients by sequencing, Multiplex Ligation-dependent Probe Amplification, and PCR for inversions in F8 introns 22 (inv22) and 1 (inv1). Two HB patients with deletions had history of inhibitor. In severe HA, frequency of history of inhibitor was: large deletion 57.1%, splice site 35.7%, inv22 26.8%, nonsense 24.5%, frameshift 12.9%, inv1 11.1% and missense 9.5%. In HA, 19.6% of 321 White non-Hispanics (Whites), 37.1% of 35 Black non-Hispanics (Blacks) and 46.9% of 32 Hispanics had history of inhibitor (P = 0.0003). Mutation types and novel mutation rates were similar across ethnicities. When F8 haplotypes were constructed, Whites and Hispanics showed only H1 and H2. Within H1, history of inhibitor was 12.4% in Whites, 40.0% in Blacks (P = 0.009) and 32.4% in Hispanics (P = 0.002). Inhibitor frequency is confirmed to vary by mutation type and race in a large US population. White patients with history of inhibitor did not exhibit rare F8 haplotypes. F8 gene analysis did not reveal a cause for the higher inhibitor frequencies in Black and Hispanic patients.
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Affiliation(s)
- C H Miller
- Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA.
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31
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Berntorp E, Keeling D, Makris M, Tagliaferri A, Male C, Mauser-Bunschoten EP, Musso R, Roca CA, Hassoun A, Kollmer C, Charnigo R, Baumann J, Rendo P. A prospective registry of European haemophilia B patients receiving nonacog alfa, recombinant human factor IX, for usual use. Haemophilia 2011; 18:503-9. [PMID: 22044794 DOI: 10.1111/j.1365-2516.2011.02685.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Nonacog alfa, a recombinant factor IX (FIX) used for the treatment of haemophilia B, was approved in Europe in 1998. In accordance with European Medicines Agency requirements, a registry study was conducted from 2002 to 2009. A reformulated iso-osmotic version was approved for European use in 2007. This study was conducted to evaluate the safety of nonacog alfa in a usual care setting, and provide clinical trial and postmarketing surveillance data support. This open-label, non-interventional, prospective observational cohort study (registry) comprised 52 sites in nine European countries. Patients with haemophilia B receiving nonacog alfa in either formulation for prevention or treatment were followed on a usual care schedule. A total of 218 patients were enrolled, of whom 66 (30.3%) were <18 years of age. Haemophilia severity was evenly distributed, with baseline FIX activity of <1%, 1-5% and >5% in 33.3%, 36.6% and 30.1% of patients, respectively. One hundred thirty-eight patients received the original formulation alone; 80 switched to or received only the new formulation. There was a low incidence of events of special interest (ESIs), with less-than-expected therapeutic effect in five patients (2.2%), inhibitor development in two (0.9%), thrombosis in one (0.5%) and allergic events in eight (3.7%). These accounted for the majority of the 15 serious AEs reported in six patients. Six patients discontinued because of AEs, primarily related to hypersensitivity. Nonacog alfa was shown to be safe for the treatment of haemophilia B, with a low incidence of serious AEs and ESIs.
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Affiliation(s)
- E Berntorp
- Malmö Centre for Thrombosis and Haemostasis, Lund University, Skåne University Hospital, SE-205 02, Malmö, Sweden.
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32
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RECHT M, POLLMANN H, TAGLIAFERRI A, MUSSO R, JANCO R, RICHEY NEUMAN W. A retrospective study to describe the incidence of moderate to severe allergic reactions to factor IX in subjects with haemophilia B. Haemophilia 2011; 17:494-9. [DOI: 10.1111/j.1365-2516.2011.02436.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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33
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Peng K, Siradze K, Quarmby V, Fischer SK. Clinical immunogenicity specificity assessments: A platform evaluation. J Pharm Biomed Anal 2011; 54:629-35. [DOI: 10.1016/j.jpba.2010.09.035] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2010] [Accepted: 09/27/2010] [Indexed: 10/19/2022]
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34
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Monahan PE, Liesner R, Sullivan ST, Ramirez ME, Kelly P, Roth DA. Safety and efficacy of investigator-prescribed BeneFIX prophylaxis in children less than 6 years of age with severe haemophilia B. Haemophilia 2010; 16:460-8. [PMID: 20059559 DOI: 10.1111/j.1365-2516.2009.02162.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Prophylaxis is increasingly prescribed in treatment of haemophilia and its benefit is believed to be most significant for the youngest patients as haemophilic arthropathy may be prevented if prophylaxis is initiated prior to recurrent haemarthroses. While clinical prophylaxis data are readily available for haemophilia A, analogous data for haemophilia B are relatively limited. A prospective clinical study of recombinant factor IX (BeneFIX; rFIX), designed to allow investigator prescribed prophylaxis according to customary practices, was conducted in children <6 years old with severe haemophilia B. Nearly all children were prescribed prophylaxis (22/25; 88%) for all or part of their study participation. Favourable efficacy and safety profiles were reported. Routine prophylaxis with 1 or 2 rFIX infusions per week over an average of greater than 6 months of therapy resulted in near complete prevention of spontaneous breakthrough haemorrhages (<1 per year), with most children (77%) having none, including seven patients (32%) who had no bleeding episodes at all. Haemorrhages in joints were less common than those outside joints (27% vs. 73% of haemorrhages). In a patient population that included children with multiple prior haemarthroses, 68% of children had no joint bleeding. Breakthrough haemorrhages resolved with 1 or 2 infusions in 89% of episodes. The absence of changes in prophylaxis infusion schedules suggests that 1 or 2 rFIX infusion(s) per week were well-tolerated by these young patients, including those with (41%) and without (59%) central venous access devices. Safety was established by the low incidence of treatment-related adverse events.
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Affiliation(s)
- P E Monahan
- Gene Therapy Center, University of North Carolina, Chapel Hill, NC 27599-7352, USA.
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35
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Lissitchkov T, Matysiak M, Zawilska K, Gercheva L, Antonov A, Montañes M, Paez A. An open clinical study assessing the efficacy and safety of Factor IX Grifols®, a high-purity Factor IX concentrate, in patients with severe haemophilia B. Haemophilia 2009; 16:240-6. [PMID: 20015218 DOI: 10.1111/j.1365-2516.2009.02090.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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36
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Abstract
The use of molecular diagnostic techniques in clinical and research hemostasis laboratories is increasing as genetic factors that affect the procoagulant and anticoagulant systems are identified. Many of these molecular alterations are associated with thrombotic tendencies, whereas others tip the hemostatic balance in favor of bleeding. In either scenario, molecular testing may serve as a primary diagnostic modality or may provide information that complements clot-based "functional" assays. The clinical application of DNA-based testing continues to expand since the discoveries of the factor V Leiden and prothrombin G20210A gene mutations. Indications for genetic testing continue to evolve as the underlying causes of hemostatic disorders are better understood. Further development of molecular assays depends on their proved utility in the clinical management and treatment of these complex multifactorial disorders.
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Chitlur M, Warrier I, Rajpurkar M, Lusher JM. Inhibitors in factor IX deficiency a report of the ISTH-SSC international FIX inhibitor registry (1997-2006). Haemophilia 2009; 15:1027-31. [PMID: 19515028 DOI: 10.1111/j.1365-2516.2009.02039.x] [Citation(s) in RCA: 100] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Haemophilia B is an X-linked disorder resulting in coagulation factor IX deficiency. Patients with severe deficiency (<1% factor IX activity) may have significant bleeding complications similar to patients with haemophilia A or factor VIII deficiency. The development of inhibitory antibodies to the missing coagulation factor is a major complication in patients with haemophilia. While the incidence of inhibitors in patients with haemophilia A is higher than that in haemophilia B, the occurrence of allergic and or anaphylactic reactions with the development of inhibitors is unique to haemophilia B patients. Since haemophilia B is a rare bleeding disorder and the incidence of inhibitors is an even rarer entity, a registry was established by Dr Indira Warrier under the auspices of the FVIII/FIX subcommittee of the International Society of Thrombosis and Haemostasis, to gather information on the occurrence and characteristics of patients with inhibitors and also the incidence of allergic and anaphylactic reactions in this group of patients. This is the first report from this registry and helps us to gather some insight on haemophilia B patients with inhibitors and complications related to inhibitor development and difficulties with immune tolerance.
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Affiliation(s)
- M Chitlur
- Carman and Ann Adams Department of Pediatrics, Children's Hospital of Michigan, Detroit Medical Center, Wayne State University, Detroit, MI 48201, USA.
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38
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Anaphylaxis in patients with congenital bleeding disorders and inhibitors. Blood Coagul Fibrinolysis 2009; 20:225-9. [DOI: 10.1097/mbc.0b013e328329f265] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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39
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Dimichele D. The North American Immune Tolerance Registry: contributions to the thirty-year experience with immune tolerance therapy. Haemophilia 2008; 15:320-8. [PMID: 18976249 DOI: 10.1111/j.1365-2516.2008.01880.x] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The North American Immune Tolerance Registry (NAITR) began in 1992 as a project of the ISTH Factor VIII/IX Subcommittee with the goal of further determining immune tolerance induction (ITI) practices in Canada and the United States. This retrospective registry study, published in 2002, was limited in its capacity to provide definitive answers to many unresolved ITI practice issues. Nonetheless, it played a role in developing guidelines for current ITI practice and in generating hypotheses that must now be examined through rigorous prospective data collection efforts. For haemophilia A, the logical next step has been the initiation of international prospective randomized studies of ITI outcome relative to factor VIII (FVIII) dose and purity for subjects with high titre inhibitors. Both trials will additionally provide platforms for translational study of the immunology of tolerance, a prelude to the next generation of safe and effective tolerizing strategies. For the less common problem of FIX inhibitor eradication, prospective randomized studies will not be a feasible way to confirm the NAITR observations. Coordinated international efforts will still be required to prospectively collect data on ITI outcome to document new potentially effective therapeutic strategies for inhibitor eradication. These registries will hopefully also serve to identify potential subjects for scientific studies of immunology of haemophilia B-related allergic phenomena, a devastating complication of FIX antibody development.
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Affiliation(s)
- D Dimichele
- Weill Cornell Medical College, New York, NY, USA.
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40
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Kwon MJ, Yoo KY, Kim HJ, Kim SH. Identification of mutations in theF9gene including exon deletion by multiplex ligation-dependent probe amplification in 33 unrelated Korean patients with haemophilia B. Haemophilia 2008; 14:1069-75. [PMID: 18624698 DOI: 10.1111/j.1365-2516.2008.01796.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- M-J Kwon
- Department of Laboratory Medicine & Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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41
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Wang J, Lozier J, Johnson G, Kirshner S, Verthelyi D, Pariser A, Shores E, Rosenberg A. Neutralizing antibodies to therapeutic enzymes: considerations for testing, prevention and treatment. Nat Biotechnol 2008; 26:901-8. [PMID: 18688246 PMCID: PMC3478093 DOI: 10.1038/nbt.1484] [Citation(s) in RCA: 122] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Lysosomal storage diseases are characterized by deficiencies in lysosomal enzymes, allowing accumulation of target substrate in cells and eventually causing cell death. Enzyme replacement therapy is the principal treatment for most of these diseases. However, these therapies are often complicated by immune responses to the enzymes, blocking efficacy and causing severe adverse outcomes by neutralizing product activity. It is thus crucial to understand the relationships between genetic mutations, endogenous residual enzyme proteins (cross-reactive immunologic material), development of neutralizing antibodies and their impact on clinical outcomes of lysosomal storage diseases. For patients in whom neutralizing antibodies may cause severe adverse clinical outcomes, it is paramount to develop tolerance inducing protocols to preclude, where predictable, or treat such life-threatening responses.
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Affiliation(s)
- Jinhai Wang
- Division of Therapeutic Proteins, Office of Biotechnology Products, Center for Drug Evaluation and Research, Food and Drug Administration, NIH Building 29B, 8800 Rockville Pike, Bethesda, Maryland 20892, USA
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42
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Leader B, Baca QJ, Golan DE. Protein therapeutics: a summary and pharmacological classification. Nat Rev Drug Discov 2008; 7:21-39. [PMID: 18097458 DOI: 10.1038/nrd2399] [Citation(s) in RCA: 1381] [Impact Index Per Article: 86.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Once a rarely used subset of medical treatments, protein therapeutics have increased dramatically in number and frequency of use since the introduction of the first recombinant protein therapeutic--human insulin--25 years ago. Protein therapeutics already have a significant role in almost every field of medicine, but this role is still only in its infancy. This article overviews some of the key characteristics of protein therapeutics, summarizes the more than 130 protein therapeutics used currently and suggests a new classification of these proteins according to their pharmacological action.
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Affiliation(s)
- Benjamin Leader
- Department of Emergency Medicine, Brown Medical School, 593 Eddy Street, Providence, Rhode Island 02093, USA
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43
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Park Y, Yoo KY. A Case of Desensitization for Hemophilia B Inhibitor Patient with Anaphylaxis to FIX Concentrates. THE KOREAN JOURNAL OF HEMATOLOGY 2008. [DOI: 10.5045/kjh.2008.43.3.179] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Youngshil Park
- Department of Pediatrics, Colllege of Medicine, Kyung Hee University, Seoul, Korea
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44
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KLARMANN D, MARTINEZ Saguer I, FUNK MB, KNOEFLER R, VON HENTIG N, HELLER C, KREUZ W. Immune tolerance induction with mycophenolate-mofetil in two children with haemophilia B and inhibitor. Haemophilia 2007; 14:44-9. [DOI: 10.1111/j.1365-2516.2007.01584.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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45
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Abstract
Factor IX (FIX) inhibitors develop in 1.5-3% of haemophilia B patients. Due to its low incidence compared with that in haemophilia A, few comparable data exist on host and treatment-related risk factors, and immunological processes associated with FIX inhibitor development. Moreover, the safety and efficacy of bypass therapy as well as the outcome predictors of successful inhibitor eradication have been poorly characterised. The lack of a useful evidence-based approach to the diagnosis and management of FIX inhibitors complicates their significant morbidity due to the frequency of allergic reactions that often herald antibody development. This review discusses what is currently known about the epidemiology, natural history and immunology of anti-FIX antibody development. It addresses several special considerations in the approach to the treatment of bleeding and inhibitor eradication. A case is made for moving forward with an integrated international collaboration for the further study of the nature and treatment of this problem.
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Affiliation(s)
- Donna DiMichele
- Pediatrics and Public Health, Weill Medical College of Cornell University, New York, NY, USA.
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46
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DiMichele DM, Hoots WK, Pipe SW, Rivard GE, Santagostino E. International workshop on immune tolerance induction: consensus recommendations. Haemophilia 2007; 13 Suppl 1:1-22. [PMID: 17593277 DOI: 10.1111/j.1365-2516.2007.01497.x] [Citation(s) in RCA: 196] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Although immune tolerance induction (ITI) has been used for 30 years to eliminate inhibitors and restore normal factor pharmacokinetics in patients with hemophilia, there is a paucity of scientific evidence to guide therapeutic decision-making. In an effort to provide direction for physicians and hemophilia treatment center staff members, an international panel of hemophilia opinion leaders met to develop consensus recommendations for ITI in patients with severe and mild hemophilia A and hemophilia B. These recommendations draw on the available published literature and the collective clinical experience of the group and are rated based on the level of supporting evidence.
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Affiliation(s)
- D M DiMichele
- Department of Pediatrics, Weill Medical College of Cornell University, New York, NY 10021, USA.
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47
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Cohn EF, Zhuo J, Kelly ME, Chao HJ. Efficient induction of immune tolerance to coagulation factor IX following direct intramuscular gene transfer. J Thromb Haemost 2007; 5:1227-36. [PMID: 17362228 DOI: 10.1111/j.1538-7836.2007.02522.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND The formation of inhibitory anti-factor IX (anti-FIX) antibodies is a major complication of FIX protein replacement-based treatment for hemophilia B. It is difficult to treat patients with anti-FIX antibodies. Gene therapy is emerging as a potentially effective treatment for hemophilia. Direct i.m. injection of adeno-associated virus (AAV) is a safe and efficient procedure for hemophilia B gene therapy. However, the development of anti-FIX antibodies following i.m. of AAV may impede its application to patients. OBJECTIVE We aimed to investigate induction of immune tolerance to human FIX (hFIX) by i.m. of AAV1, further validating i.m. of AAV1 for hemophilia B gene therapy. METHODS AND RESULTS Cohorts of hemostatically normal and hemophilia B mice with diverse genetic and MHC backgrounds received i.m. of AAV-hFIX. Human FIX antigen and anti-hFIX antibodies were examined. I.m. of 1 x 10(11) vector genomes (VG) of AAV2 elicits formation of anti-hFIX antibodies comparable to those by hFIX protein replacement. I.m. of 1 x 10(11) VG of AAV1 results in expression of therapeutic levels of hFIX (up to 950 ng mL(-1), mean = 772 ng mL(-1), SEM +/- 35.7) and hFIX-specific immune tolerance in C57BL/6 mice. CONCLUSIONS A single i.m. of AAV1 can result in efficient expression of therapeutic levels of hFIX and induction of hFIX tolerance in hemostatically normal and hemophilic B mice. Our results substantiate the prospect of i.m. of AAV1 for hemophilia B gene therapy and FIX tolerance induction.
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Affiliation(s)
- E F Cohn
- Division of Hematology/Oncology, Department of Medicine, Mount Sinai School of Medicine, One Gustave L. Levy Place, New York, NY 10029, USA
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48
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Abstract
Hemophilia and von Willebrand disease together account for the large majority of congenital bleeding disorders. Contemporary management, including development of safer clotting factor concentrates and increased emphasis on long-term follow-up in comprehensive hemophilia centers, has improved both quality of life and longevity for patients with congenital bleeding disorders. In addition to facilitating development of recombinant clotting factor concentrates, isolation and characterization of the respective genes have led to increasing availability of a repertoire of genetic tests that, although expensive, are critical for appropriate genetic counseling of affected patients and their family members. This article provides a practical approach to using genetic testing for hemophilia A and B.
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Affiliation(s)
- Rajiv K Pruthi
- Department of Internal Medicine, Division of Hematology, Special Coagulation DNA Diagnostic Laboratory, and Comprehensive Hemophilia Center, Mayo Clinic College of Medicine, Rochester, MN 55905, USA.
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49
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Zineh I, Gerhard T, Aquilante CL, Beitelshees AL, Beasley BN, Hartzema AG. Availability of pharmacogenomics-based prescribing information in drug package inserts for currently approved drugs. THE PHARMACOGENOMICS JOURNAL 2004; 4:354-8. [PMID: 15483659 DOI: 10.1038/sj.tpj.6500284] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- I Zineh
- Department of Pharmacy Practice, University of Florida College of Pharmacy, Gainesville, FL 32610, USA.
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50
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Abstract
The haemophilias are inherited disorders in which one of the coagulation factors is deficient. Although deficiencies of factor VIII (haemophilia A) and factor IX (haemophilia B) are well recognised, von Willebrand's disease is much more common. Rare defects can occur in any of the coagulation factors. In the past, men with haemophilia were likely to die in their youth. With advances in diagnosis, and especially with development of safe and effective treatment, affected individuals can now look forward to a normal life expectancy. Complications of the disorder, particularly the development of antibodies that make treatment ineffective, and of treatment, such as transfusion-transmitted infections, have taken a severe toll on these patients. The future holds the realistic possibility of gene therapy. However, we must not forget that haemophilia is a worldwide disorder that requires significant economic resources not available for the majority.
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