Factor VIII concentrate inhibits T helper type 2 cytokine production in vitro: relevance to inhibitor antibody formation

Biological considerations of plasma-derived and recombinant factor VIII immunogenicity

In hemophilia A, the most severe complication of factor VIII (FVIII) replacement therapy involves the formation of FVIII neutralizing antibodies, also known as inhibitors, in 25% to 30% of patients. This adverse event is associated with a significant increase in morbidity and economic burden, thus highlighting the need to identify methods to limit FVIII immunogenicity. Inhibitor development is regulated by a complex balance of genetic factors, such as FVIII genotype, and environmental variables, such as coexistent inflammation. One of the hypothesized risk factors of inhibitor development is the source of the FVIII concentrate, which could be either recombinant or plasma derived. Differential immunogenicity of these concentrates has been documented in several recent epidemiologic studies, thus generating significant debate within the hemophilia treatment community. To date, these discussions have been unable to reach a consensus regarding how these outcomes might be integrated into enhancing clinical care. Moreover, the biological mechanistic explanations for the observed differences are poorly understood. In this article, we complement the existing epidemiologic investigations with an overview of the range of possible biochemical and immunologic mechanisms that may contribute to the different immune outcomes observed with plasma-derived and recombinant FVIII products.

Assessment of in vitro cytokine response in hemophilia A patients with or without factor VIII inhibitory antibody

Factor VIII (FVIII) inhibitor antibodies are produced in a proportion of hemophilia A patients. Development of anti-FVIII inhibitor antibodies is a T cell-dependent response, mediated by FVIII specific CD4(+) T cells. This study was performed to investigate the contribution of T helper (Th) cell-mediated cytokine response in inhibitor production. Peripheral blood mononuclear cells (PBMCs) were obtained from hemophilia A patients with (n = 14) or without inhibitor (n = 14) and from normal individuals (n = 14). Following stimulation of PBMCs with rFVIII and phytohemagglutinin (PHA) mitogen, the secreted cytokines, interferon-gamma (IFN-gamma), interleukin-10 (IL-10), and transforming growth factor-beta1 (TGF-beta1), in culture supernatant and the proliferative response were assessed using sandwich ELISA and (3)H-thymidine incorporation, respectively. No significant proliferative response to FVIII was observed, whereas PHA induced a strong response in all groups. No cytokine secretion was observed in response to FVIII stimulation. Although PHA induced IL-10, TGF-beta1 and IFN-gamma secretion in all groups, the level of IFN-gamma was significantly lower in hemophilia A patients than in normal individuals (p < 0.0001). The levels of TGF-beta1 and IL-10 were similarly higher in patients compared with normal subjects, but the difference was not statistically significant. Lack of FVIII-induced proliferative response and cytokine production together with reduced secretion of PHA-induced IFN-gamma in both groups of patients suggest involvement of nonspecific immunosuppression possibly due to hepatitis C virus (HCV) infection observed in the majority of patients.

Recombinant vs. plasma-derived products, especially those with intact VWF, regarding inhibitor development

The development of inhibitors in previously untreated patients (PUPs) with haemophilia A is correlated with a variety of endogenous and exogenous risk factors. It is still controversial whether recombinant factor VIII (rFVIII) products pose a higher risk for inhibitor development than plasma-derived (pd) FVIII concentrates, particularly with intact von Willebrand factor (VWF). A systematic review on the epidemiology of inhibitors in haemophilia A investigated the influence of different FVIII products on inhibitor formation. Patients treated with a single pd product had a lower cumulative incidence (0-12.4%) than those treated with a single recombinant concentrate (36.0-38.7%) independent of disease severity, study size, or inhibitor testing frequency. However, this analysis does not take into account the heterogeneity of the study populations. A study investigating the effects of different variables on inhibitor development in PUPs was started 13 years ago by the Paediatric Committee of the German, Austrian and Swiss Society on Thrombosis and Haemostasis Research. This prospectively conducted study revealed a slight difference (P = 0.08) in terms of type of concentrate. In the group of severe haemophiliacs treated with pdFVIII concentrate (n = 57), 12 patients developed an inhibitor (21%), whereas 17 of 47 patients receiving rFVIII (36%) were affected by this complication. This observation was substantiated by retrospective Italian and French analyses. These results, as well as hypothetical considerations, indicate that there is a body of evidence that FVIII products with VWF may be less immunogenic in PUPs. However, in order to provide more evidence a well-designed randomized study is needed.

von Willebrand factor and transforming growth factor-beta modulate immune response against coagulation factor VIII in FVIII-deficient mice

In up to 25% haemophilia A patients, the administration of coagulation factor VIII (FVIII) preparations for treatment of haemorrhages results in production of factor VIII specific antibodies. Plasma-derived FVIII preparations contain other plasma proteins, which may modulate the immune response to FVIII. We used FVIII-deficient mice to assess the role of von Willebrand factor (VWF) and cytokine transforming growth factor beta-1 (TGF-beta1) in the immune response against FVIII. Using the FVIII and FVIII in complex with VWF purified from the plasma-derived FVIII preparation, we demonstrated that a lower concentration of FVIII antibody was induced in FVIII-VWF-treated mice compared to FVIII-treated mice (p<0.05). The addition of recombinant latent TGF-beta1 to FVIII decreased the antibody response against FVIII compared to FVIII treatment alone (p<0.01). The obtained results suggest that VWF and latent TGF-beta1 present in plasma-derived FVIII preparations reduce the immune response against FVIII. However, we cannot exlude possible modulatory effects of other plasma proteins.

Effect of factor VIII concentrate on leucocyte cytokine receptor expression in vitro: relevance to inhibitor formation and tolerance induction

Inhibitor formation in haemophilia patients receiving factor VIII (FVIII) concentrate is a serious problem requiring tolerance induction therapy. Inhibitor antibody formation is dependent on interactions between leucocyte cytokines with their corresponding receptors. To investigate this we studied the effect of FVIII on cytokine receptor expression using multiparameter flow cytometry and a whole blood stimulation assay. Upregulation of many cytokine receptors was inhibited by plasma-derived FVIII (pdFVIII) in a dose-dependent manner on T cells, B cells and monocytes although interleukin (IL)-4Ralpha and IL-7Ralpha were upregulated on T cells. The decrease in cytokine receptor upregulation on B cells in the presence of pdFVIII, may result in reduced antibody production. Inhibition of CD132 in the presence of pdFVIII may result in immune tolerance in some recipients of pdFVIII. The immunomodulatory effects of pdFVIII were dose and batch dependent, some being more inhibitory than others. The inhibitory effects of prednisolone with pdFVIII, on cytokine receptor upregulation, were additive. Cytokine receptor expression was not altered in the presence of human recombinant FVIII (rFVIII) concentrate. These findings may explain the reports of less frequent inhibitor antibody formation in some recipients of pdFVIII concentrates. The use of pdFVIII, particularly the more inhibitory batches, may be more suitable than rFVIII for tolerance induction protocols. A clinical study needs to be undertaken to determine the significance of these in vitro findings.

Increased peripheral blood T-cell apoptosis and decreased Bcl-2 in chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is an inflammatory airway disease, usually associated with cigarette smoking. Stimulated peripheral blood T cells from patients with COPD have an increased propensity to undergo apoptosis. The mitochondrial apoptotic pathway is regulated by pro-apoptotic proteins (including p53 and Bax) as well as anti-apoptotic proteins (e.g. Bcl-2) and cytokines (IL-2, IL-4 and IL-7). We hypothesized that alterations in expression of these apoptosis-related proteins, cytokines and cytokine receptors may be important in determining the susceptibility of T cells to undergoing apoptosis in COPD. We further hypothesized that inhaled corticosteroids (GCS) contribute to the increased rates of T-cell apoptosis observed in COPD. The process of apoptosis (assessed by Annexin V and ssDNA staining), as well as Bcl-2, Bax, p53, IL-2, IL-4 and receptors IL-7R, IL-4R and IL-2Rgamma were investigated in PHA-stimulated peripheral blood-derived T cells, using flow cytometry. Fifteen patients with COPD receiving inhaled GCS (four of who received additional prednisolone), eight patients with COPD receiving symptom control medication, and 16 control subjects were studied. T cells (CD4(+) and CD8(+)) from GCS-treated COPD patients showed an increased propensity to undergo apoptosis, associated with significantly decreased Bcl-2 and IL-7 receptor expression. No significant differences were observed for the COPD patients who were receiving symptom control medication. These findings may suggest a negative peripheral effect of inhaled GCS on the immune system in COPD, although the clinical significance of these effects remains uncertain.

Up-regulation of interleukin-8, interleukin-10, monocyte chemotactic protein-1, and monocyte chemotactic protein-3 in peripheral blood monocytes in stable lung transplant recipients: are immunosuppression regimens working?

BACKGROUND

Alveolar macrophages are a major source of inflammatory cytokines and chemokines involved in the pathogenesis of lung transplant rejection and are derived from blood monocytes that migrate to the lung. Levels of monocyte cytokines and chemokines that may be relevant in transplant rejection have not previously been determined in transplant recipients. We hypothesized that production of these inflammatory mediators by blood monocytes may be up-regulated despite the use of potent immunosuppression therapy.

METHOD

To investigate this, whole blood from 9 stable lung transplant recipients and 12 control volunteers was stimulated with lipopolysaccharide in vitro, and intracellular chemokine and cytokine production were determined with multiparameter flow cytometry.

RESULTS

Monocyte production of chemokines interleukin (IL)-8, monocyte chemotactic protein (MCP)-1, and MCP-3, and anti-inflammatory cytokine IL-10 were significantly increased in the lung transplant group, but IL-6, tumor necrosis factor-alpha, IL-1alpha, IL-12, macrophage inflammatory protein-1alpha, macrophage inflammatory protein-1beta, and transforming growth factor-beta levels were unchanged.

CONCLUSIONS

Because MCP-3 is a major chemoattractant for leukocytes to sites of antigenic challenge and is a natural ligand for MCP-1 receptor, this novel finding has important implications for the pathogenesis of lung transplant rejection. We now provide evidence that current immunosuppression protocols have a limited effect on monocyte inflammatory cytokine production and do not adequately suppress monocyte IL-8, MCP-1, and MCP-3 chemokine production. Drugs that modulate the action of these chemokines may improve current protocols for reducing graft rejection. Intracellular chemokine and cytokine analysis with flow cytometry may be a more accurate indicator of immunosuppression than drug levels in these patients.

Intracellular cytokines in blood T cells in lung transplant patients--a more relevant indicator of immunosuppression than drug levels

Allograft rejection remains a major cause of morbidity and mortality following lung transplantation and is associated with an increase in T-cell pro-inflammatory cytokine expression. Systemic levels of immunosuppressive drugs used to reduce pro-inflammatory cytokine expression are closely monitored to their 'therapeutic range'. However, it is currently unknown if levels of these drugs correlate with pro-inflammatory cytokine expression in peripheral blood T cells. To investigate the immunomodulatory effects of currently used immunosuppressive regimes on peripheral blood T-cell cytokine production, whole blood from stable lung transplant patients and control volunteers were stimulated in vitro and cytokine production by CD8+ and CD4+ T-cell subsets determined using multiparameter flow cytometry. T-cell IL-2 and TNFalpha production was significantly reduced from lung transplant patients compared to controls. CD4+ T-cell production of IFNgamma was also significantly reduced from lung transplant patients but production of IFNgamma by CD8+ T cells remained unchanged. There was an excellent correlation between the percentage of CD8+ T cells and the percentage of CD8+ T cells producing IFNgamma from transplant patients. T-cell IL-4 and CD8+ T-cell production of TGFbeta was significantly increased from lung transplant patients. We now provide evidence that current immunosuppression protocols have limited effect on peripheral blood IFNgamma production by CD8+ T-cells but do up-regulate T-cell anti-inflammatory cytokines. Drugs that effectively reduce IFNgamma production by CD8+ T cells may improve current protocols for reducing graft rejection in these patients. Intracellular cytokine analysis using flow cytometry may be a more appropriate indicator of immunosuppression than drug levels in these patients. This technique may prove useful in optimizing therapy for individual patients.

Increased production of TGF-beta and apoptosis of T lymphocytes isolated from peripheral blood in COPD

Chronic obstructive pulmonary disease (COPD) is associated with inflammation of airway epithelium, including an increase in the number of intraepithelial T cells. Increased apoptosis of these T cells has been reported in the airways in COPD, and although this process is critical for clearing excess activated T cells, excessive rates of apoptosis may result in unbalanced cellular homeostasis, defective clearance of apoptotic material by monocytes/macrophages, secondary necrosis, and prolongation of the inflammatory response. Lymphocytes are known to traffic between the airway and the peripheral circulation, thus we hypothesized that in COPD, circulating T cells may show an increased propensity to undergo apoptosis. We analyzed phytohemagglutinin (PHA)-stimulated peripheral blood T cells from COPD patients and controls for apoptosis using flow cytometry and staining with annexin V and 7-aminoactinomycin D. As several pathways are involved in induction of apoptosis of T cells, including transforming growth factor (TGF)-beta/TGF receptor (TGFR), TNF-alpha/TNFR1, and Fas/Fas ligand, these mediators were also investigated in peripheral blood samples from these subject groups. Significantly increased apoptosis of PHA-stimulated T cells was observed in COPD (annexin positive 75.0 +/- 14.7% SD vs. control 50.2 +/- 21.8% SD, P = 0.006), along with upregulation of TNF-alpha/TNFR1, Fas, and TGFR. Monocyte production of TGF-beta was also increased. In conclusion we have demonstrated the novel finding of increased apoptosis of stimulated T cells in COPD and have also shown that the increased T-cell death may be associated with upregulation of apoptotic pathways, TGF-beta, TNF-alpha, and Fas in the peripheral blood in COPD.