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Vijayakumar VE, Vijayalakshmi MA, Lacroix-Desmazes S, Venkataraman K. The use of Bacillus subtilis as a cost-effective expression system for production of Cholera Toxin B fused factor VIII epitope regions applicable for inducing oral immune tolerance. Folia Microbiol (Praha) 2024:10.1007/s12223-024-01166-z. [PMID: 38683262 DOI: 10.1007/s12223-024-01166-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 04/10/2024] [Indexed: 05/01/2024]
Abstract
Coagulation factor replacement therapy for the X-linked bleeding disorder Haemophilia, characterized by a deficiency of coagulation protein factor VIII (FVIII), is severely complicated by antibody (inhibitors) formation. The development of FVIII inhibitors drastically alters the quality of life of the patients and is associated with a tremendous increase in morbidity as well as treatment costs. The ultimate goal of inhibitor control is antibody elimination. Immune tolerance induction (ITI) is the only clinically established approach for developing antigen-specific tolerance to FVIII. This work aims to establish a novel cost-effective strategy to produce FVIII molecules in fusion with cholera toxin B (CTB) subunit at the N terminus using the Bacillus subtilis expression system for oral tolerance, as the current clinical immune tolerance protocols are expensive. Regions of B-Domain Deleted (BDD)-FVIII that have potential epitopes were identified by employing Bepipred linear epitope prediction; 2 or more epitopes in each domain were combined and cDNA encoding these regions were fused with CTB and cloned in the Bacillus subtilis expression vector pHT43 and expression analysis was carried out. The expressed CTB-fused FVIII epitope domains showed strong binding affinity towards the CTB-receptor GM1 ganglioside. To conclude, Bacillus subtilis expressing FVIII molecules might be a promising candidate for exploring for the induction of oral immune tolerance.
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Affiliation(s)
- Vijay Elakkya Vijayakumar
- Centre for Bio-Separation Technology (CBST), Vellore Institute of Technology (VIT), Tamil Nadu, Vellore, 632014, India
| | | | - Sebastien Lacroix-Desmazes
- Centre de Recherche des Cordeliers, Institut National de la Santé et de la Recherche Médicale, CNRS, Sorbonne Université, Université de Paris, Paris F-75006, France
| | - Krishnan Venkataraman
- Centre for Bio-Separation Technology (CBST), Vellore Institute of Technology (VIT), Tamil Nadu, Vellore, 632014, India.
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Rana J, Muñoz MM, Biswas M. Oral tolerance to prevent anti-drug antibody formation in protein replacement therapies. Cell Immunol 2022; 382:104641. [PMID: 36402002 PMCID: PMC9730862 DOI: 10.1016/j.cellimm.2022.104641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 11/07/2022] [Accepted: 11/09/2022] [Indexed: 11/16/2022]
Abstract
Protein based therapeutics have successfully improved the quality of life for patients of monogenic disorders like hemophilia, Pompe and Fabry disease. However, a significant proportion of patients develop immune responses towards intravenously infused therapeutic protein, which can complicate or neutralize treatment and compromise patient safety. Strategies aimed at circumventing immune responses following therapeutic protein infusion can greatly improve therapeutic efficacy. In recent years, antigen-based oral tolerance induction has shown promising results in the prevention and treatment of autoimmune diseases, food allergies and can prevent anti-drug antibody formation to protein replacement therapies. Oral tolerance exploits regulatory mechanisms that are initiated in the gut associated lymphoid tissue (GALT) to promote active suppression of orally ingested antigen. In this review, we outline general perceptions and current knowledge about the mechanisms of oral tolerance, including tissue specific sites of tolerance induction and the cells involved, with emphasis on antigen presenting cells and regulatory T cells. We define several factors, such as cytokines and metabolites that impact the stability and expansion potential of these immune modulatory cells. We highlight preclinical studies that have been performed to induce oral tolerance to therapeutic proteins or enzymes for single gene disorders, such as hemophilia or Pompe disease. These studies mainly utilize a transgenic plant-based system for oral delivery of antigen in conjugation with fusion protein technology that favors the prevention of antigen degradation in the stomach while enhancing uptake in the small intestine by antigen presenting cells and regulatory T cell induction, thereby promoting antigen specific systemic tolerance.
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Affiliation(s)
- Jyoti Rana
- Herman B Wells Center for Pediatric Research, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Maite Melero Muñoz
- Herman B Wells Center for Pediatric Research, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Moanaro Biswas
- Herman B Wells Center for Pediatric Research, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA.
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3
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Li Z, Liu G, Yao W, Chen Z, Li G, Cheng X, Zhen Y, Ai D, Huang K, Sun J, Poon MC, Wu R. Eradication of FIX inhibitor in haemophilia B children using low-dose immune tolerance induction with rituximab-based immunosuppressive agent(s) in China. Haemophilia 2022; 28:625-632. [PMID: 35503087 DOI: 10.1111/hae.14577] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 04/10/2022] [Accepted: 04/13/2022] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Development of haemophilia B inhibitors (HBI) results in the ineffectiveness of FIX replacement therapy. Inhibitor eradication by immune tolerance induction (ITI) is therefore necessary. In HBI, ITI even at high FIX dose is less effective and has a higher risk of severe complications. AIM To characterize clinical features and outcome of ITI on HBI. METHODS This retrospective study was conducted in Haemophilia Paediatric Comprehensive Care Centre of China. We used low-dose ITI (25-50 FIX IU/kg/three-times-weekly to every-other-day) with domestic prothrombin complex concentrate (PCC), combined with two successive immunosuppressive (IS) regimens. RESULTS Sixteen HBI children, representing 5.7% of all and 14.4% of our severe registered HB patients, were enroled. Seven cases reported allergic reactions (ARs) proximal to inhibitor development. The historic peak inhibitor titre was median 54.2 (range 4.7-512) BU, and 15 (93.8%) had high-titre inhibitors. Twelve patients adherent to ITI were analysable. Of the nine ITI patients who received rituximab/prednisone (IS Regimen-1), four achieved tolerization in 1.4-43.3 months. Two subsequently relapsed but re-tolerized after a second course of IS Regimen-1. During ITI, the median treated bleed was .39/month (82.7% reduction from before ITI), and the incidence of AR and nephrotic syndrome (NS) complications was each at 22% (2/9). Three ITI patients received modified 'Beutel' protocol (IS Regimen-2) using multiple-IS-drugs, and two had rapid tolerization (.8 and 1.8 months). CONCLUSIONS Inhibitor eradication could be achieved by low-dose ITI protocol using PCC combined with IS. Larger studies are needed to confirm if ITI with IS Regimen-2 is more effective with less complications.
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Affiliation(s)
- Zekun Li
- Haemophilia Comprehensive Care Center, Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; Key Laboratory of Major Diseases in Children, Ministry of Education, National Center for Children's Health, National Key Discipline of Pediatrics (Capital Medical University), Beijing Children's Hospital, Capital Medical University, Beijing, China.,Haematologic Disease Laboratory, Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; Key Laboratory of Major Diseases in Children, Ministry of Education; Beijing Pediatric Research Institute, National Center for Children's Health, National Key Discipline of Pediatrics (Capital Medical University), Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Guoqing Liu
- Haemophilia Comprehensive Care Center, Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; Key Laboratory of Major Diseases in Children, Ministry of Education, National Center for Children's Health, National Key Discipline of Pediatrics (Capital Medical University), Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Wanru Yao
- Haemophilia Comprehensive Care Center, Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; Key Laboratory of Major Diseases in Children, Ministry of Education, National Center for Children's Health, National Key Discipline of Pediatrics (Capital Medical University), Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Zhenping Chen
- Haematologic Disease Laboratory, Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; Key Laboratory of Major Diseases in Children, Ministry of Education; Beijing Pediatric Research Institute, National Center for Children's Health, National Key Discipline of Pediatrics (Capital Medical University), Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Gang Li
- Haematologic Disease Laboratory, Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; Key Laboratory of Major Diseases in Children, Ministry of Education; Beijing Pediatric Research Institute, National Center for Children's Health, National Key Discipline of Pediatrics (Capital Medical University), Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Xiaoling Cheng
- Pharmacology Department, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Yingzi Zhen
- Haemophilia Comprehensive Care Center, Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; Key Laboratory of Major Diseases in Children, Ministry of Education, National Center for Children's Health, National Key Discipline of Pediatrics (Capital Medical University), Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Di Ai
- Haemophilia Comprehensive Care Center, Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; Key Laboratory of Major Diseases in Children, Ministry of Education, National Center for Children's Health, National Key Discipline of Pediatrics (Capital Medical University), Beijing Children's Hospital, Capital Medical University, Beijing, China.,Haematologic Disease Laboratory, Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; Key Laboratory of Major Diseases in Children, Ministry of Education; Beijing Pediatric Research Institute, National Center for Children's Health, National Key Discipline of Pediatrics (Capital Medical University), Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Kun Huang
- Haemophilia Comprehensive Care Center, Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; Key Laboratory of Major Diseases in Children, Ministry of Education, National Center for Children's Health, National Key Discipline of Pediatrics (Capital Medical University), Beijing Children's Hospital, Capital Medical University, Beijing, China.,Haematologic Disease Laboratory, Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; Key Laboratory of Major Diseases in Children, Ministry of Education; Beijing Pediatric Research Institute, National Center for Children's Health, National Key Discipline of Pediatrics (Capital Medical University), Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Jie Sun
- Haemophilia Comprehensive Care Center, Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; Key Laboratory of Major Diseases in Children, Ministry of Education, National Center for Children's Health, National Key Discipline of Pediatrics (Capital Medical University), Beijing Children's Hospital, Capital Medical University, Beijing, China.,Haematologic Disease Laboratory, Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; Key Laboratory of Major Diseases in Children, Ministry of Education; Beijing Pediatric Research Institute, National Center for Children's Health, National Key Discipline of Pediatrics (Capital Medical University), Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Man-Chiu Poon
- Department of Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada.,Department of Pediatrics, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada.,Department of Oncology, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada.,Southern Alberta Rare Blood and Bleeding Disorders Comprehensive Care Program, Foothills Hospital, Alberta Health Services, Calgary, Alberta, Canada
| | - Runhui Wu
- Haemophilia Comprehensive Care Center, Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; Key Laboratory of Major Diseases in Children, Ministry of Education, National Center for Children's Health, National Key Discipline of Pediatrics (Capital Medical University), Beijing Children's Hospital, Capital Medical University, Beijing, China
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Dargaud Y, Escuriola‐Ettingshausen C. Recombinant porcine factor VIII: Lessons from the past and place in the management of hemophilia A with inhibitors in 2021. Res Pract Thromb Haemost 2021; 5:e12631. [PMID: 34849451 PMCID: PMC8606027 DOI: 10.1002/rth2.12631] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Revised: 10/25/2021] [Accepted: 10/31/2021] [Indexed: 11/09/2022] Open
Abstract
The most serious complication of factor VIII (FVIII) replacement therapy is the occurrence of anti-FVIII alloantibodies that can strongly reduce or abolish the effect of human FVIII products. Bypassing agents to control bleeding episodes are recommended for these patients, but their efficacy is difficult to predict and monitor. FVIII products derived from porcine plasma had an important role in the treatment of hemophilia A for 50 years, from 1954 to 2004. Indeed, porcine FVIII could achieve hemostasis in patients in whom human FVIII products were ineffective. A recombinant porcine FVIII product is now available. This highly purified protein has the same biochemical and hemostatic properties, but much lower risks of infection and toxicity compared with plasma-derived porcine FVIII. The product is licensed in the United States and Europe for the treatment of acquired hemophilia A. However, this recombinant molecule could also be of clinical interest for people with inherited hemophilia A and inhibitors, particularly for the management of bleeding episodes in people receiving emicizumab as prophylactic treatment in the absence of anti-porcine FVIII antibodies.
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Affiliation(s)
- Yesim Dargaud
- Unite d’Hemostase CliniqueCentre National de Reference de l'HemophilieHôpital Louis PradelLyonFrance
- UR 4609 Hemostase and ThromboseUniversite Claude Bernard Lyon 1LyonFrance
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5
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Samelson-Jones BJ, Arruda VR. Translational Potential of Immune Tolerance Induction by AAV Liver-Directed Factor VIII Gene Therapy for Hemophilia A. Front Immunol 2020; 11:618. [PMID: 32425925 PMCID: PMC7212376 DOI: 10.3389/fimmu.2020.00618] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 03/18/2020] [Indexed: 12/26/2022] Open
Abstract
Hemophilia A (HA) is an X-linked bleeding disorder due to deficiencies in coagulation factor VIII (FVIII). The major complication of current protein-based therapies is the development of neutralizing anti-FVIII antibodies, termed inhibitors, that block the hemostatic effect of therapeutic FVIII. Inhibitors develop in about 20-30% of people with severe HA, but the risk is dependent on the interaction between environmental and genetic factors, including the underlying F8 gene mutation. Recently, multiple clinical trials evaluating adeno-associated viral (AAV) vector liver-directed gene therapy for HA have reported promising results of therapeutically relevant to curative FVIII levels. The inclusion criteria for most trials prevented enrollment of subjects with a history of inhibitors. However, preclinical data from small and large animal models of HA with inhibitors suggests that liver-directed gene therapy can in fact eradicate pre-existing anti-FVIII antibodies, induce immune tolerance, and provide long-term therapeutic FVIII expression to prevent bleeding. Herein, we review the accumulating evidence that continuous uninterrupted expression of FVIII and other transgenes after liver-directed AAV gene therapy can bias the immune system toward immune tolerance induction, discuss the current understanding of the immunological mechanisms of this process, and outline questions that will need to be addressed to translate this strategy to clinical trials.
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Affiliation(s)
- Benjamin J. Samelson-Jones
- The Children’s Hospital of Philadelphia, Philadelphia, PA, United States
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
- Raymond G. Perelman Center for Cellular and Molecular Therapeutics, Philadelphia, PA, United States
| | - Valder R. Arruda
- The Children’s Hospital of Philadelphia, Philadelphia, PA, United States
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
- Raymond G. Perelman Center for Cellular and Molecular Therapeutics, Philadelphia, PA, United States
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6
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De la Corte-Rodriguez H, Rodriguez-Merchan EC, Alvarez-Roman MT, Martin-Salces M, Jimenez-Yuste V. 'Do not Do' Recommendations in Hemophilia. Cardiovasc Hematol Disord Drug Targets 2020; 20:168-174. [PMID: 32133968 DOI: 10.2174/1871529x20666200305111323] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 01/20/2020] [Accepted: 02/17/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND It is important to discard those practices that do not add value. As a result, several initiatives have emerged. All of them try to improve patient safety and the use of health resources. PURPOSE To present a compendium of "do not do recommendations" in the context of hemophilia. METHODS A review of the literature and current clinical guidelines has been made, based on the best evidence available to date. RESULTS The following 13 recommendations stand out: 1) Do not delay the administration of factor after trauma; 2) do not use fresh frozen plasma or cryoprecipitate; 3) do not use desmopressin in case of hematuria; 4) do not change the product in the first 50 prophylaxis exposures; 5) do not interrupt immunotolerance; 6) do not administer aspirin or NSAIDs; 7) do not administer intramuscular injections; 8) do not do routine radiographs of the joint in case of acute hemarthrosis; 9) Do not apply closed casts for fractures; 10) do not discourage the performance of physical activities; 11) do not deny surgery to a patient with an inhibitor; 12) do not perform instrumental deliveries in fetuses with hemophilia; 13) do not use factor IX (FIX) in patients with hemophilia B with inhibitor and a history of anaphylaxis after administration of FIX. CONCLUSION The information mentioned previously can be useful in the management of hemophilia, from different levels of care. As far as we know, this is the first initiative of this type regarding hemophilia.
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7
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Sabatino DE, Pipe SW, Nugent DJ, Soucie JM, Hooper WC, Hoots WK, DiMichele DM. Origins and organization of the NHLBI State of the Science Workshop: Generating a national blueprint for future research on factor VIII inhibitors. Haemophilia 2019; 25:575-580. [PMID: 31329369 DOI: 10.1111/hae.13737] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 02/06/2019] [Accepted: 02/21/2019] [Indexed: 01/05/2023]
Abstract
INTRODUCTION The major complication of protein replacement therapy for haemophilia A is the development of anti-FVIII antibodies or inhibitors that occur in 25%-30% of persons with severe haemophilia A. Alternative therapeutics such as bypassing agents or immune tolerance induction protocols have additional challenges and are not always effective. AIM Assemble a National Heart, Lung and Blood Institute (NHLBI) State of the Science (SOS) Workshop to generate a national blueprint for research on inhibitors to solve the problem of FVIII immunogenicity. METHODS An Executive Steering Committee was formed in October 2017 to establish the scientific focus and Scientific Working Groups for the SOS Workshop in May 2018. Four working groups were assembled to address scientific priorities in basic, translational and clinical research on inhibitors. RESULTS Working Group 1 was charged with determining the scientific priorities for clinical trials to include the integration of non-intravenous, non-factor therapeutics including gene therapy into the standard of care for people with haemophilia A with inhibitors. Working Group 2 established the scientific priorities for 21st-century data science and biospecimen collection for observational inhibitor cohort studies. The scientific priorities for acquiring an actionable understanding of FVIII immunogenicity and the immunology of the host response and FVIII tolerance were developed by Working Group 3. Working Group 4 designed prospective pregnancy/birth cohorts to study FVIII immunogenicity, inhibitor development and eradication. CONCLUSION The NHLBI SOS Workshop generated a focused summary of scientific priorities and implementation strategies to overcome the challenges of eradicating and preventing inhibitors in haemophilia A.
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Affiliation(s)
- Denise E Sabatino
- Perelman School of Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Diane J Nugent
- Children's Hospital of Orange County, University of California at Irvine, Irvine, California
| | - J Michael Soucie
- Division of Blood Disorders, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - W Craig Hooper
- Division of Blood Disorders, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - W Keith Hoots
- Division of Blood Diseases and Resources, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Donna M DiMichele
- Division of Blood Diseases and Resources, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland
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8
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Pyzik M, Sand KMK, Hubbard JJ, Andersen JT, Sandlie I, Blumberg RS. The Neonatal Fc Receptor (FcRn): A Misnomer? Front Immunol 2019; 10:1540. [PMID: 31354709 PMCID: PMC6636548 DOI: 10.3389/fimmu.2019.01540] [Citation(s) in RCA: 253] [Impact Index Per Article: 50.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 06/20/2019] [Indexed: 12/13/2022] Open
Abstract
Antibodies are essential components of an adaptive immune response. Immunoglobulin G (IgG) is the most common type of antibody found in circulation and extracellular fluids. Although IgG alone can directly protect the body from infection through the activities of its antigen binding region, the majority of IgG immune functions are mediated via proteins and receptors expressed by specialized cell subsets that bind to the fragment crystallizable (Fc) region of IgG. Fc gamma (γ) receptors (FcγR) belong to a broad family of proteins that presently include classical membrane-bound surface receptors as well as atypical intracellular receptors and cytoplasmic glycoproteins. Among the atypical FcγRs, the neonatal Fc receptor (FcRn) has increasingly gained notoriety given its intimate influence on IgG biology and its ability to also bind to albumin. FcRn functions as a recycling or transcytosis receptor that is responsible for maintaining IgG and albumin in the circulation, and bidirectionally transporting these two ligands across polarized cellular barriers. More recently, it has been appreciated that FcRn acts as an immune receptor by interacting with and facilitating antigen presentation of peptides derived from IgG immune complexes (IC). Here we review FcRn biology and focus on newer advances including how emerging FcRn-targeted therapies may affect the immune responses to IgG and IgG IC.
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Affiliation(s)
- Michal Pyzik
- Division of Gastroenterology, Hepatology and Endoscopy, Department of Medicine, Harvard Medical School, Brigham and Women's Hospital, Boston, MA, United States
| | - Kine M K Sand
- Division of Gastroenterology, Hepatology and Endoscopy, Department of Medicine, Harvard Medical School, Brigham and Women's Hospital, Boston, MA, United States.,Department of Biosciences, University of Oslo, Oslo, Norway
| | - Jonathan J Hubbard
- Division of Gastroenterology, Hepatology and Endoscopy, Department of Medicine, Harvard Medical School, Brigham and Women's Hospital, Boston, MA, United States.,Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Harvard Medical School, Boston Children's Hospital, Boston, MA, United States
| | - Jan Terje Andersen
- Department of Immunology, Oslo University Hospital Rikshospitalet, Oslo, Norway.,Department of Pharmacology, Institute of Clinical Medicine, University of Oslo and Oslo University Hospital, Oslo, Norway
| | - Inger Sandlie
- Department of Biosciences, University of Oslo, Oslo, Norway
| | - Richard S Blumberg
- Division of Gastroenterology, Hepatology and Endoscopy, Department of Medicine, Harvard Medical School, Brigham and Women's Hospital, Boston, MA, United States.,Harvard Digestive Diseases Center, Boston, MA, United States
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9
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Daniell H, Kulis M, Herzog RW. Plant cell-made protein antigens for induction of Oral tolerance. Biotechnol Adv 2019; 37:107413. [PMID: 31251968 PMCID: PMC6842683 DOI: 10.1016/j.biotechadv.2019.06.012] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 05/21/2019] [Accepted: 06/24/2019] [Indexed: 12/15/2022]
Abstract
The gut associated lymphoid tissue has effective mechanisms in place to maintain tolerance to food antigens. These can be exploited to induce antigen-specific tolerance for the prevention and treatment of autoimmune diseases and severe allergies and to prevent serious immune responses in protein replacement therapies for genetic diseases. An oral tolerance approach for the prevention of peanut allergy in infants proved highly efficacious and advances in treatment of peanut allergy have brought forth an oral immunotherapy drug that is currently awaiting FDA approval. Several other protein antigens made in plant cells are in clinical development. Plant cell-made proteins are protected in the stomach from acids and enzymes after their oral delivery because of bioencapsulation within plant cell wall, but are released to the immune system upon digestion by gut microbes. Utilization of fusion protein technologies facilitates their delivery to the immune system, oral tolerance induction at low antigen doses, resulting in efficient induction of FoxP3+ and latency-associated peptide (LAP)+ regulatory T cells that express immune suppressive cytokines such as IL-10. LAP and IL-10 expression represent potential biomarkers for plant-based oral tolerance. Efficacy studies in hemophilia dogs support clinical development of oral delivery of bioencapsulated antigens to prevent anti-drug antibody formation. Production of clinical grade materials in cGMP facilities, stability of antigens in lyophilized plant cells for several years when stored at ambient temperature, efficacy of oral delivery of human doses in large animal models and lack of toxicity augur well for clinical advancement of this novel drug delivery concept.
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Affiliation(s)
- Henry Daniell
- Department of Biochemistry, School of Dental Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA.
| | - Michael Kulis
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Roland W Herzog
- Department of Pediatrics, Indiana University, Indianapolis, IN 46202, USA.
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10
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Affiliation(s)
- Guy Young
- Hemostasis and Thrombosis Center and Clinical Coagulation Laboratory Children's Hospital Los Angeles Professor of Pediatrics University of Southern California Keck School of Medicine Los Angeles CA USA
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11
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Xue F, Liu W, Cheng YF, Liu XF, Huang YT, Fu RF, Zhang L, Yang RC. [Immune tolerance induction in a case of hemophilia B with inhibitor with prothrombin complex concentrate and rituximab]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2019; 38:749-753. [PMID: 29081190 PMCID: PMC7348358 DOI: 10.3760/cma.j.issn.0253-2727.2017.09.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
目的 探讨血友病B伴抑制物的免疫耐受诱导(ITI)治疗,提高血友病B伴抑制物的诊疗水平。 方法 应用基于APTT标准曲线的一期法测定重型血友病B患者凝血因子Ⅸ(FⅨ)活性,应用Bethesda法进行FⅨ抑制物定量测定;利用凝血酶原复合物(PCC)进行ITI并联合利妥昔单抗清除患者抑制物。 结果 患儿既往PCC暴露日为20 d,抑制物滴度峰值为56 BU/ml。在2015年11月患儿抑制物滴度降至10.4 BU/ml时开始ITI治疗,单用PCC一段时间无效,给予PCC联合利妥昔单抗治疗,17个月后成功清除患者体内FⅨ抑制物,未发生过敏反应及肾病综合征等并发症。ITI过程中患者年化出血率有所改善。 结论 该患者是国内首例报道的采用ITI联合利妥昔单抗成功治疗血友病B伴抑制物的病例。PCC联合利妥昔单抗ITI治疗是目前有希望清除血友病B抑制物的方法。
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Affiliation(s)
- F Xue
- State Key Laboratory of Experimental Hematology, Institute of Hematology & Hospital of Blood Diseases, CAMS & PUMC, Tianjin 300020, China
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12
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Protein-Engineered Coagulation Factors for Hemophilia Gene Therapy. MOLECULAR THERAPY-METHODS & CLINICAL DEVELOPMENT 2018; 12:184-201. [PMID: 30705923 PMCID: PMC6349562 DOI: 10.1016/j.omtm.2018.12.007] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Hemophilia A (HA) and hemophilia B (HB) are X-linked bleeding disorders due to inheritable deficiencies in either coagulation factor VIII (FVIII) or factor IX (FIX), respectively. Recently, gene therapy clinical trials with adeno-associated virus (AAV) vectors and protein-engineered transgenes, B-domain deleted (BDD) FVIII and FIX-Padua, have reported near-phenotypic cures in subjects with HA and HB, respectively. Here, we review the biology and the clinical development of FVIII-BDD and FIX-Padua as transgenes. We also examine alternative bioengineering strategies for FVIII and FIX, as well as the immunological challenges of these approaches. Other engineered proteins and their potential use in gene therapy for hemophilia with inhibitors are also discussed. Continued advancement of gene therapy for HA and HB using protein-engineered transgenes has the potential to alleviate the substantial medical and psychosocial burdens of the disease.
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13
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Sauna ZE, Lagassé D, Pedras-Vasconcelos J, Golding B, Rosenberg AS. Evaluating and Mitigating the Immunogenicity of Therapeutic Proteins. Trends Biotechnol 2018; 36:1068-1084. [DOI: 10.1016/j.tibtech.2018.05.008] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2018] [Revised: 05/18/2018] [Accepted: 05/22/2018] [Indexed: 12/19/2022]
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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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15
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Doshi BS, Arruda VR. Gene therapy for hemophilia: what does the future hold? Ther Adv Hematol 2018; 9:273-293. [PMID: 30210756 DOI: 10.1177/2040620718791933] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Accepted: 07/09/2018] [Indexed: 01/19/2023] Open
Abstract
Recent phase I/II adeno-associated viral vector-mediated gene therapy clinical trials have reported remarkable success in ameliorating disease phenotype in hemophilia A and B. These trials, which highlight the challenges overcome through decades of preclinical and first in human clinical studies, have generated considerable excitement for patients and caregivers alike. Optimization of vector and transgene expression has significantly improved the ability to achieve therapeutic factor levels in these subjects. Long-term follow-up studies will guide standardization of the approach with respect to the combination of serotype, promoter, dose, and manufacturing processes and inform safety for inclusion of young patients. Certain limitations preclude universal applicability of gene therapy, including transient liver transaminase elevations due to the immune responses to vector capsids or as yet undefined mechanisms, underlying liver disease from iatrogenic viral hepatitis, and neutralizing antibodies to clotting factors. Integrating vectors show promising preclinical results, but manufacturing and safety concerns still remain. The prospect of gene editing for correction of the underlying mutation is on the horizon with considerable potential. Herein, we review the advances and limitations that have resulted in these recent successful clinical trials and outline avenues that will allow for broader applicability of gene therapy.
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Affiliation(s)
- Bhavya S Doshi
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Valder R Arruda
- Department of Pediatrics, The Children's Hospital of Philadelphia, 3501 Civic Center Blvd, 5056 Colket Translational Research Center, Philadelphia, PA 19104, USA
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16
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D'Angiolella LS, Cortesi PA, Rocino A, Coppola A, Hassan HJ, Giampaolo A, Solimeno LP, Lafranconi A, Micale M, Mangano S, Crotti G, Pagliarin F, Cesana G, Mantovani LG. The socioeconomic burden of patients affected by hemophilia with inhibitors. Eur J Haematol 2018; 101:435-456. [DOI: 10.1111/ejh.13108] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/02/2018] [Indexed: 01/19/2023]
Affiliation(s)
| | - Paolo A. Cortesi
- Research Centre on Public Health (CESP); University of Milano Bicocca; Monza Italy
| | - Angiola Rocino
- Hemophilia & Thrombosis Centre; San Giovanni Bosco Hospital; Naples Italy
| | - Antonio Coppola
- Regional Reference Center for Inherited Bleeding Disorders; University Hospital of Parma; Parma Italy
| | - Hamisa J. Hassan
- Department of Oncology and Molecular Medicine; Istituto Superiore di Sanità; Rome Italy
| | - Adele Giampaolo
- Department of Oncology and Molecular Medicine; Istituto Superiore di Sanità; Rome Italy
| | - Luigi P. Solimeno
- Division of Orthopaedic Surgery and Traumatology; Fondazione IRCCS Ca’ Granda; Ospedale Maggiore Policlinico; Milan Italy
| | | | - Mariangela Micale
- Research Centre on Public Health (CESP); University of Milano Bicocca; Monza Italy
| | - Sveva Mangano
- Research Centre on Public Health (CESP); University of Milano Bicocca; Monza Italy
| | - Giacomo Crotti
- Research Centre on Public Health (CESP); University of Milano Bicocca; Monza Italy
| | - Federica Pagliarin
- Research Centre on Public Health (CESP); University of Milano Bicocca; Monza Italy
| | - Giancarlo Cesana
- Research Centre on Public Health (CESP); University of Milano Bicocca; Monza Italy
| | - Lorenzo G. Mantovani
- Research Centre on Public Health (CESP); University of Milano Bicocca; Monza Italy
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17
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Tolerogenic properties of the Fc portion of IgG and its relevance to the treatment and management of hemophilia. Blood 2018; 131:2205-2214. [PMID: 29588277 DOI: 10.1182/blood-2017-12-822908] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 03/15/2018] [Indexed: 12/14/2022] Open
Abstract
Hemophilia, or inherited genetic deficiencies in coagulation factors, results in uncontrolled bleeding requiring replacement therapy with recombinant proteins given preventively or on demand. However, a major problem with these approaches is the potential for development of immune responses to the administered proteins due to the underlying genetic deficiency of the factor(s) throughout life. As such, there is great interest in developing strategies that avoid immunogenicity and induce immune tolerance. Recently, recombinant factor VIII (rFVIII) and rFIX fused to the crystallizable fragment (Fc) domain of immunoglobulin G (IgG) have been developed as therapeutic agents for hemophilia A and B, respectively. Although it is well known that the possession of an Fc domain confers IgG's longer-lasting circulating half-life, it is not generally appreciated that the Fc domain also confers immunoregulatory properties that are associated with the induction of tolerance. Here, we review some of the latest advances in our understanding of the tolerogenic abilities of IgG Fc and the impact of Fc-fusion proteins of rFVIII on the treatment of hemophilia.
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18
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The impact of extended half-life versus conventional factor product on hemophilia caregiver burden. Qual Life Res 2018; 27:1335-1345. [PMID: 29392598 PMCID: PMC5891570 DOI: 10.1007/s11136-018-1792-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/20/2018] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Extended half-life factor products have reduced annualized bleeding rates in hemophilia patients. The impact of extended half-life versus conventional factor products on hemophilia caregiver burden has not been investigated. This study aimed to evaluate caregiver burden in extended half-life versus conventional factor products for hemophilia A and B. METHODS This cross-sectional web-based study of caregivers of people with hemophilia A or B was recruited from a panel research company and by word of mouth. Participants completed the Hemophilia Caregiver Impact measure, the PedsQL Family Impact Module (PedsQL), and the Work Productivity and Activity Impairment Questionnaire (WPAI). We also collected demographic, insurance coverage, and medical information related to the hemophilia patient(s). Burden differences were assessed using linear regression and matched cohort analyses. RESULTS The sample (n = 448) included 49 people who were caring for people on extended half-life factor products. Worse caregiver burden was associated with more infusions per week and more bleeds in the past 6 months. Regression analyses suggested that caring for someone who is on a extended half-life factor product is associated with lower emotional impact (β = - 0.11, p < 0.05, Adjusted R2 = 0.06), and shows a trend association with lower practical impact (β = - 0.09, p < 0.10, Adjusted R2 = 0.05). The matched cohort analysis also revealed that people on extended half-life factor product had lower Emotional Impact and Practical Impact scores (t = - 2.95 and - 2.94, respectively, p < 0.05 in both cases). No differences were detected on the PedsQL or the WPAI. CONCLUSION The reduced required frequency of factor product infusions of extended half-life factor products appears to reduce the emotional distress and practical burden of caregiving. Future work should evaluate the longitudinal impact.
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19
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Irigoyen MB, Primiani L, Felippo M, Candela M, de Bracco MME, Galassi NV. IgG subclasses of FVIII inhibitors in an argentine cohort of severe hemophilia A patients: Analysis by flow cytometry. Int J Lab Hematol 2017; 39:569-576. [DOI: 10.1111/ijlh.12696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Accepted: 04/18/2017] [Indexed: 11/28/2022]
Affiliation(s)
- M. B. Irigoyen
- Instituto de Medicina Experimental-Consejo Nacional de Investigaciones Científicas y Técnicas-Academia Nacional de Medicina de Buenos Aires; Buenos Aires Argentina
| | - L. Primiani
- Fundación Argentina de Hemofilia; Buenos Aires Argentina
| | - M. Felippo
- Instituto de Medicina Experimental-Consejo Nacional de Investigaciones Científicas y Técnicas-Academia Nacional de Medicina de Buenos Aires; Buenos Aires Argentina
| | - M. Candela
- Fundación Argentina de Hemofilia; Buenos Aires Argentina
- Instituto de Investigaciones Hematológicas -Academia Nacional de Medicina de Buenos Aires; Buenos Aires Argentina
| | - M. M. E. de Bracco
- Instituto de Medicina Experimental-Consejo Nacional de Investigaciones Científicas y Técnicas-Academia Nacional de Medicina de Buenos Aires; Buenos Aires Argentina
| | - N. V. Galassi
- Instituto de Medicina Experimental-Consejo Nacional de Investigaciones Científicas y Técnicas-Academia Nacional de Medicina de Buenos Aires; Buenos Aires Argentina
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20
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Sherman A, Biswas M, Herzog RW. Innovative Approaches for Immune Tolerance to Factor VIII in the Treatment of Hemophilia A. Front Immunol 2017; 8:1604. [PMID: 29225598 PMCID: PMC5705551 DOI: 10.3389/fimmu.2017.01604] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Accepted: 11/07/2017] [Indexed: 01/19/2023] Open
Abstract
Hemophilia A (coagulation factor VIII deficiency) is a debilitating genetic disorder that is primarily treated with intravenous replacement therapy. Despite a variety of factor VIII protein formulations available, the risk of developing anti-dug antibodies (“inhibitors”) remains. Overall, 20–30% of patients with severe disease develop inhibitors. Current clinical immune tolerance induction protocols to eliminate inhibitors are not effective in all patients, and there are no prophylactic protocols to prevent the immune response. New experimental therapies, such as gene and cell therapies, show promising results in pre-clinical studies in animal models of hemophilia. Examples include hepatic gene transfer with viral vectors, genetically engineered regulatory T cells (Treg), in vivo Treg induction using immune modulatory drugs, and maternal antigen transfer. Furthermore, an oral tolerance protocol is being developed based on transgenic lettuce plants, which suppressed inhibitor formation in hemophilic mice and dogs. Hopefully, some of these innovative approaches will reduce the risk of and/or more effectively eliminate inhibitor formation in future treatment of hemophilia A.
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Affiliation(s)
- Alexandra Sherman
- Department of Pediatrics, University of Florida, Gainesville, FL, United States
| | - Moanaro Biswas
- Department of Pediatrics, University of Florida, Gainesville, FL, United States
| | - Roland W Herzog
- Department of Pediatrics, University of Florida, Gainesville, FL, United States
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21
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Abstract
Although hemophilia has been recognized for centuries as an inherited disorder primarily affecting males, advances in treatments have been very recent. Initial availability of plasma-derived therapies offered significant improvements in morbidity and mortality, but the transmission of viruses quickly negated the benefit of early factor replacement products. After developing successful viral inactivation methods and subsequently developing recombinant technology, the manufacturing of factor concentrates became much safer. Access to safer factor products allowed for a shift from the treatment of bleeds to prevention, called prophylaxis. Although dosing and interval vary, prevention of joint disease is now a realistic goal. Unfortunately, despite advances in the safety of therapy, some patients are unable to use factor replacement products because they develop antibodies, known as inhibitors. Eradication of inhibitors is possible in the majority of patients, but it is expensive and takes time. Management of acute bleeding may require significantly higher doses of factor replacement or the use of a bypassing agent. As a result, patients with inhibitors are at increased risk for sequelae, including joint disease, life-threatening bleeding, infectious complications with central vascular access devices, and thrombotic complications.
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22
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Bertamino M, Riccardi F, Banov L, Svahn J, Molinari AC. Hemophilia Care in the Pediatric Age. J Clin Med 2017; 6:E54. [PMID: 28534860 PMCID: PMC5447945 DOI: 10.3390/jcm6050054] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 05/12/2017] [Accepted: 05/16/2017] [Indexed: 01/19/2023] Open
Abstract
Hemophilia is the most common of the severe bleeding disorders and if not properly managed since early infancy can lead to chronic disease and lifelong disabilities. However, it enjoys the most efficacious and safe treatment among the most prevalent monogenic disorders. Hemophilia should be considered in the neonatal period in the case of unusual bleeding or in the case of positive family history. Later, hemophilia should be suspected mainly in males because of abnormal bruising/bleeding or unusual bleeding following invasive procedures-for example, tonsillectomy or circumcision. Prophylactic treatment that is started early with clotting-factor concentrates has been shown to prevent hemophilic arthropathy and is, therefore, the gold standard of care for hemophilia A and B in most countries with adequate resources. Central venous access catheters and arterovenous fistulas play an important role in the management of hemophilia children requiring repeated and/or urgent administration of coagulation factor concentrates. During childhood and adolescence, personalized treatment strategies that suit the patient and his lifestyle are essential to ensure optimal outcomes. Physical activity is important and can contribute to better coordination, endurance, flexibility and strength. The present article focuses also on questions frequently posed to pediatric hematologists like vaccinations, day-care/school access and dental care.
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Affiliation(s)
- Marta Bertamino
- Thrombosis and Hemostasis Unit, Regional Reference Center for Hemorrhagic Diseases, Giannina Gaslini Children's Hospital, 16147 Genova, Italy.
| | - Francesca Riccardi
- Hematology Unit, Giannina Gaslini Children's Hospital, 16147 Genova, Italy.
| | - Laura Banov
- Thrombosis and Hemostasis Unit, Regional Reference Center for Hemorrhagic Diseases, Giannina Gaslini Children's Hospital, 16147 Genova, Italy.
| | - Johanna Svahn
- Thrombosis and Hemostasis Unit, Regional Reference Center for Hemorrhagic Diseases, Giannina Gaslini Children's Hospital, 16147 Genova, Italy.
| | - Angelo Claudio Molinari
- Thrombosis and Hemostasis Unit, Regional Reference Center for Hemorrhagic Diseases, Giannina Gaslini Children's Hospital, 16147 Genova, Italy.
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23
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Wang X, Herzog RW, Byrne BJ, Kumar SRP, Zhou Q, Buchholz CJ, Biswas M. Immune Modulatory Cell Therapy for Hemophilia B Based on CD20-Targeted Lentiviral Gene Transfer to Primary B Cells. MOLECULAR THERAPY-METHODS & CLINICAL DEVELOPMENT 2017; 5:76-82. [PMID: 28480307 PMCID: PMC5415320 DOI: 10.1016/j.omtm.2017.03.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Accepted: 03/22/2017] [Indexed: 01/06/2023]
Abstract
Gene-modified B cells expressing immunoglobulin G (IgG) fusion proteins have been shown to induce tolerance in several autoimmune and other disease models. However, lack of a vector suitable for gene transfer to human B cells has been an obstacle for translation of this approach. To overcome this hurdle, we developed an IgG-human factor IX (hFIX) lentiviral fusion construct that was targeted to specifically transduce cells expressing human CD20 (hCD20). Receptor-specific retargeting by mutating envelope glycoproteins of measles virus (MV)-lentiviral vector (LV) and addition of a single-chain variable fragment specific for hCD20 resulted in gene delivery into primary human and transgenic hCD20 mouse B cells with high specificity. Notably, this protocol neither required nor induced activation of the B cells, as confirmed by minimal activation of inflammatory cytokines. Using this strategy, we were able to demonstrate induction of humoral tolerance, resulting in suppression of antibody formation against hFIX in a mouse model of hemophilia B (HB). In conclusion, transduction of receptor-specific retargeted LV into resting B cells is a promising method to develop B cell therapies for antigen-specific tolerance induction in human disease.
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Affiliation(s)
- Xiaomei Wang
- Division of Cellular and Molecular Therapy, Department of Pediatrics, University of Florida, Gainesville, FL 32610, USA
| | - Roland W Herzog
- Division of Cellular and Molecular Therapy, Department of Pediatrics, University of Florida, Gainesville, FL 32610, USA
| | - Barry J Byrne
- Powell Gene Therapy Center, Department of Pediatrics, University of Florida, Gainesville, FL 32610, USA
| | - Sandeep R P Kumar
- Division of Cellular and Molecular Therapy, Department of Pediatrics, University of Florida, Gainesville, FL 32610, USA
| | - Qi Zhou
- Molecular Biotechnology and Gene Therapy, Paul-Ehrlich-Institut, 63225 Langen, Germany
| | - Christian J Buchholz
- Molecular Biotechnology and Gene Therapy, Paul-Ehrlich-Institut, 63225 Langen, Germany
| | - Moanaro Biswas
- Division of Cellular and Molecular Therapy, Department of Pediatrics, University of Florida, Gainesville, FL 32610, USA
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24
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Zhang B, Shanmugaraj B, Daniell H. Expression and functional evaluation of biopharmaceuticals made in plant chloroplasts. Curr Opin Chem Biol 2017; 38:17-23. [PMID: 28229907 DOI: 10.1016/j.cbpa.2017.02.007] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Revised: 02/05/2017] [Accepted: 02/06/2017] [Indexed: 12/19/2022]
Abstract
After approval of the first plant-made biopharmaceutical by FDA for human use, many protein drugs are now in clinical development. Within the last decade, significant advances have been made in expression of heterologous complex/large proteins in chloroplasts of edible plants using codon optimized human or viral genes. Furthermore, advances in quantification enable determination of in-planta drug dosage. Oral delivery of plastid-made biopharmaceuticals (PMB) is affordable because it eliminates prohibitively expensive fermentation, purification processes addressing major challenges of short shelf-life after cold storage. In this review, we discuss recent advances in PMBs against metabolic, inherited or infectious diseases, and also mechanisms of post-translational modifications (PTM) in order to increase our understanding of functional PMBs.
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Affiliation(s)
- Bei Zhang
- Department of Biochemistry, School of Dental Medicine, University of Pennsylvania, Philadelphia, PA 19104-6030, USA
| | - Balamurugan Shanmugaraj
- Department of Biochemistry, School of Dental Medicine, University of Pennsylvania, Philadelphia, PA 19104-6030, USA
| | - Henry Daniell
- Department of Biochemistry, School of Dental Medicine, University of Pennsylvania, Philadelphia, PA 19104-6030, USA.
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25
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Hartholt RB, Wroblewska A, Herczenik E, Peyron I, Ten Brinke A, Rispens T, Nolte MA, Slot E, Claassens JW, Nimmerjahn F, Verbeek JS, Voorberg J. Enhanced uptake of blood coagulation factor VIII containing immune complexes by antigen presenting cells. J Thromb Haemost 2017; 15:329-340. [PMID: 27868337 DOI: 10.1111/jth.13570] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Indexed: 02/01/2023]
Abstract
Essentials Anti-factor (F) VIII antibody formation is a major complication in the treatment of hemophilia A. We investigated uptake of FVIII and FVIII immune complex by bone marrow derived dendritic cells. Immune complex formation increased uptake of FVIII 3-4 fold in a Fcγ receptor dependent manner. FVIII immune complex binding to Fcγ receptors may modulate immune tolerance induction. SUMMARY Background A major complication in the treatment of hemophilia A is the development of inhibitory antibodies targeting coagulation factor VIII (FVIII). Eradication of these inhibitors can be established by immune tolerance induction (ITI), which consists of daily administration of high dosages of FVIII. FVIII immune complexes (FVIII-IC) could be formed following FVIII infusion in patients with pre-existing anti-FVIII antibodies. Objectives Here we studied endocytosis of FVIII-IC by bone marrow-derived dendritic cells (BMDCs). Methods BMDCs were pulsed with FVIII/FVIII-IC and uptake was assessed by flow cytometry and confocal imaging. Results BMDCs were able to efficiently internalize FVIII-IC in a dose-dependent manner, 3-4-fold more efficiently when compared with equimolar concentrations of non-complexed FVIII. Uptake of FVIII-IC, but not FVIII alone, could be inhibited with anti-Fcγ receptor (FcγR) antibody 2.4G2, indicating functional involvement of FcγR. No internalization of FVIII-IC was observed in BMDCs lacking FcγRI, FcγRIIb, FcγRIII and FcγRIV. Genetic ablation of FcγRIIb, FcγRIII or FcγRIV individually did not affect the ability of anti-FVIII IgG to promote the uptake of FVIII. BMDCs lacking FcγRI showed lower FVIII-IC uptake levels when compared with other single FcγR null BMDCs. Expression of the inhibitory FcγRIIb alone was sufficient to internalize FVIII-IC more efficiently than FVIII. Conclusions FcγR are critical in the internalization of FVIII-IC by BMDCs and multiple FcγR can contribute independently to this process. Our findings provide a basis for future studies to address whether the outcome of ITI is dependent on the interplay between FVIII-IC and inhibitory and activating FcγR.
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Affiliation(s)
- R B Hartholt
- Department of Plasma Proteins, Sanquin-AMC Landsteiner Laboratory, Amsterdam, the Netherlands
| | - A Wroblewska
- Department of Plasma Proteins, Sanquin-AMC Landsteiner Laboratory, Amsterdam, the Netherlands
| | - E Herczenik
- Department of Plasma Proteins, Sanquin-AMC Landsteiner Laboratory, Amsterdam, the Netherlands
| | - I Peyron
- Department of Plasma Proteins, Sanquin-AMC Landsteiner Laboratory, Amsterdam, the Netherlands
| | - A Ten Brinke
- Department of Immunopathology, Sanquin-AMC Landsteiner Laboratory, Amsterdam, the Netherlands
| | - T Rispens
- Department of Immunopathology, Sanquin-AMC Landsteiner Laboratory, Amsterdam, the Netherlands
| | - M A Nolte
- Department of Hematopoiesis, Sanquin-AMC Landsteiner Laboratory, Amsterdam, the Netherlands
| | - E Slot
- Department of Hematopoiesis, Sanquin-AMC Landsteiner Laboratory, Amsterdam, the Netherlands
| | - J W Claassens
- Department of Human Genetics, Leiden University Medical Center, Leiden, the Netherlands
| | - F Nimmerjahn
- Chair of Genetics, Department of Biology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - J S Verbeek
- Department of Human Genetics, Leiden University Medical Center, Leiden, the Netherlands
| | - J Voorberg
- Department of Plasma Proteins, Sanquin-AMC Landsteiner Laboratory, Amsterdam, the Netherlands
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26
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Herzog RW, Nichols TC, Su J, Zhang B, Sherman A, Merricks EP, Raymer R, Perrin GQ, Häger M, Wiinberg B, Daniell H. Oral Tolerance Induction in Hemophilia B Dogs Fed with Transplastomic Lettuce. Mol Ther 2017; 25:512-522. [PMID: 28153098 PMCID: PMC5368425 DOI: 10.1016/j.ymthe.2016.11.009] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Revised: 11/01/2016] [Accepted: 11/07/2016] [Indexed: 12/25/2022] Open
Abstract
Anti-drug antibodies in hemophilia patients substantially complicate treatment. Their elimination through immune tolerance induction (ITI) protocols poses enormous costs, and ITI is often ineffective for factor IX (FIX) inhibitors. Moreover, there is no prophylactic ITI protocol to prevent anti-drug antibody (ADA) formation. Using general immune suppression is problematic. To address this urgent unmet medical need, we delivered antigen bioencapsulated in plant cells to hemophilia B dogs. Commercial-scale production of CTB-FIX fusion expressed in lettuce chloroplasts was done in a hydroponic facility. CTB-FIX (∼1 mg/g) in lyophilized cells was stable with proper folding, disulfide bonds, and pentamer assembly after 30-month storage at ambient temperature. Robust suppression of immunoglobulin G (IgG)/inhibitor and IgE formation against intravenous FIX was observed in three of four hemophilia B dogs fed with lyophilized lettuce cells expressing CTB-FIX. No side effects were detected after feeding CTB-FIX-lyophilized plant cells for >300 days. Coagulation times were markedly shortened by intravenous FIX in orally tolerized treated dogs, in contrast to control dogs that formed high-titer antibodies to FIX. Commercial-scale production, stability, prolonged storage of lyophilized cells, and efficacy in tolerance induction in a large, non-rodent model of human disease offer a novel concept for oral tolerance and low-cost production and delivery of biopharmaceuticals.
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Affiliation(s)
- Roland W Herzog
- Department of Pediatrics, College of Medicine, University of Florida, Gainesville, FL 32610, USA
| | - Timothy C Nichols
- Department of Pathology and Laboratory Medicine, The University of North Carolina, Chapel Hill, Chapel Hill, NC 25716, USA
| | - Jin Su
- Department of Biochemistry, School of Dental Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Bei Zhang
- Department of Biochemistry, School of Dental Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Alexandra Sherman
- Department of Pediatrics, College of Medicine, University of Florida, Gainesville, FL 32610, USA
| | - Elizabeth P Merricks
- Department of Pathology and Laboratory Medicine, The University of North Carolina, Chapel Hill, Chapel Hill, NC 25716, USA
| | - Robin Raymer
- Department of Pathology and Laboratory Medicine, The University of North Carolina, Chapel Hill, Chapel Hill, NC 25716, USA
| | - George Q Perrin
- Department of Pediatrics, College of Medicine, University of Florida, Gainesville, FL 32610, USA
| | - Mattias Häger
- Global Research, Novo Nordisk A/S, Måløv 2760, Denmark
| | - Bo Wiinberg
- Global Research, Novo Nordisk A/S, Måløv 2760, Denmark
| | - Henry Daniell
- Department of Biochemistry, School of Dental Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA.
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27
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Martinet J, Bourdenet G, Meliani A, Jean L, Adriouch S, Cohen JL, Mingozzi F, Boyer O. Induction of Hematopoietic Microchimerism by Gene-Modified BMT Elicits Antigen-Specific B and T Cell Unresponsiveness toward Gene Therapy Products. Front Immunol 2016; 7:360. [PMID: 27695454 PMCID: PMC5023671 DOI: 10.3389/fimmu.2016.00360] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Accepted: 09/02/2016] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Gene therapy is a promising treatment option for hemophilia and other protein deficiencies. However, immune responses against the transgene product represent an obstacle to safe and effective gene therapy, urging for the implementation of tolerization strategies. Induction of a hematopoietic chimerism via bone marrow transplantation (BMT) is a potent means for inducing immunological tolerance in solid organ transplantation. OBJECTIVES We reasoned, here, that the same viral vector could be used, first, to transduce BM cells for inducing chimerism-associated transgene-specific immune tolerance and, second, for correcting protein deficiencies by vector-mediated systemic production of the deficient coagulation factor. METHODS Evaluation of strategies to induce B and T cell tolerance was performed using ex vivo gene transfer with lentiviral (LV) vectors encoding coagulation factor IX (FIX) or the SIINFEKL epitope of ovalbumin. Following induction of microchimerism via BMT, animals were challenged with in vivo gene transfer with LV vectors. RESULTS The experimental approach prevented humoral immune response against FIX, resulting in persistence of therapeutic levels of circulating FIX, after LV-mediated gene transfer in vivo. In an ovalbumin model, we also demonstrated that this approach effectively tolerized the CD8+ T cell compartment in an antigen-specific manner. CONCLUSION These results provide the proof-of-concept that inducing a microchimerism by gene-modified BMT is a powerful tool to provide transgene-specific B and T cell tolerance in a gene therapy setting.
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Affiliation(s)
- Jérémie Martinet
- Normandie University, UNIROUEN, Pathophysiology and Biotherapy of Inflammatory and Autoimmune Diseases, INSERM, CHU Rouen , Rouen , France
| | - Gwladys Bourdenet
- Normandie University, UNIROUEN, Pathophysiology and Biotherapy of Inflammatory and Autoimmune Diseases, INSERM, CHU Rouen , Rouen , France
| | - Amine Meliani
- U974, INSERM, University Pierre and Marie Curie, Paris, France; Genethon, Evry, France
| | - Laetitia Jean
- Normandie University, UNIROUEN, Pathophysiology and Biotherapy of Inflammatory and Autoimmune Diseases, INSERM, CHU Rouen , Rouen , France
| | - Sahil Adriouch
- Normandie University, UNIROUEN, Pathophysiology and Biotherapy of Inflammatory and Autoimmune Diseases, INSERM, CHU Rouen , Rouen , France
| | | | - Federico Mingozzi
- U974, INSERM, University Pierre and Marie Curie, Paris, France; Genethon, Evry, France
| | - Olivier Boyer
- Normandie University, UNIROUEN, Pathophysiology and Biotherapy of Inflammatory and Autoimmune Diseases, INSERM, CHU Rouen , Rouen , France
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Abstract
Hemophilia is the most well-known hereditary bleeding disorder, with an incidence of one in every 5000 to 30,000 males worldwide. The disease is treated by infusion of protein products on demand and as prophylaxis. Although these therapies have been very successful, some challenging and unresolved tasks remain, such as reducing bleeding rates, presence of target joints and/or established joint damage, eliminating the development of inhibitors, and increasing the success rate of immune-tolerance induction (ITI). Many preclinical trials are carried out on animal models for hemophilia generated by the hemophilia research community, which in turn enable prospective clinical trials aiming to tackle these challenges. Suitable animal models are needed for greater advances in treating hemophilia, such as the development of better models for evaluation of the efficacy and safety of long-acting products, more powerful gene therapy vectors than are currently available, and successful ITI strategies. Mice, dogs, and pigs are the most commonly used animal models for hemophilia. With the advent of the nuclease method for genome editing, namely the CRISPR/Cas9 system, it is now possible to create animal models for hemophilia other than mice in a short period of time. This review presents currently available animal models for hemophilia, and discusses the importance of animal models for the development of better treatment options for hemophilia.
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Affiliation(s)
- Ching-Tzu Yen
- Department of Clinical Laboratory Science and Medical Biotechnology, College of Medicine, National Taiwan University, Taipei, Taiwan ; Center of Genomic Medicine, National Taiwan University, Taipei, Taiwan
| | - Meng-Ni Fan
- Department of Clinical Laboratory Science and Medical Biotechnology, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Yung-Li Yang
- Department of Laboratory Medicine, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan ; Department of Pediatrics, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Sheng-Chieh Chou
- Department of Internal Medicine, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - I-Shing Yu
- Laboratory Animal Center, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Shu-Wha Lin
- Department of Clinical Laboratory Science and Medical Biotechnology, College of Medicine, National Taiwan University, Taipei, Taiwan ; Center of Genomic Medicine, National Taiwan University, Taipei, Taiwan ; Department of Laboratory Medicine, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
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Arruda VR, Samelson-Jones BJ. Gene therapy for immune tolerance induction in hemophilia with inhibitors. J Thromb Haemost 2016; 14:1121-34. [PMID: 27061380 PMCID: PMC4907803 DOI: 10.1111/jth.13331] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Indexed: 12/15/2022]
Abstract
The development of inhibitors, i.e. neutralizing alloantibodies against factor (F) VIII or FIX, is the most significant complication of protein replacement therapy for patients with hemophilia, and is associated with both increased mortality and substantial physical, psychosocial and financial morbidity. Current management, including bypassing agents to treat and prevent bleeding, and immune tolerance induction for inhibitor eradication, is suboptimal for many patients. Fortunately, there are several emerging gene therapy approaches aimed at addressing these unmet clinical needs of patients with hemophilia and inhibitors. Herein, we review the mounting evidence from preclinical hemophilia models that the continuous uninterrupted expression of FVIII or FIX delivered as gene therapy can bias the immune system towards tolerance induction, and even promote the eradication of pre-existing inhibitors. We also discuss several gene transfer approaches that directly target immune cells in order to promote immune tolerance. These preclinical findings also shed light on the immunologic mechanisms that underlie tolerance induction.
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Affiliation(s)
- V R Arruda
- The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Perelman Center for Cell and Molecular Therapeutics, Philadelphia, PA, USA
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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Rosenberg A, Pariser A, Diamond B, Yao L, Turka L, Lacana E, Kishnani P. A role for plasma cell targeting agents in immune tolerance induction in autoimmune disease and antibody responses to therapeutic proteins. Clin Immunol 2016; 165:55-9. [DOI: 10.1016/j.clim.2016.02.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Revised: 02/24/2016] [Accepted: 02/25/2016] [Indexed: 10/22/2022]
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Zhang AH, Rossi RJ, Yoon J, Wang H, Scott DW. Tolerogenic nanoparticles to induce immunologic tolerance: Prevention and reversal of FVIII inhibitor formation. Cell Immunol 2015; 301:74-81. [PMID: 26687613 DOI: 10.1016/j.cellimm.2015.11.004] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Revised: 10/27/2015] [Accepted: 11/20/2015] [Indexed: 01/06/2023]
Abstract
The immune response of hemophilia A patients to administered FVIII is a major complication that obviates this very therapy. We have recently described the use of synthetic, biodegradable nanoparticles carrying rapamycin and FVIII peptide antigens, to induce antigen-specific tolerance. Herein we test the tolerogenicity of nanoparticles that contains full length FVIII protein in hemophilia A mice, focusing on anti-FVIII humoral immune response. As expected, recipients of tolerogenic nanoparticles remained unresponsive to FVIII despite multiple challenges for up to 6 months. Furthermore, therapeutic treatments in FVIII-immunized mice with pre-existing anti-FVIII antibodies resulted in diminished antibody titers, albeit efficacy required longer therapy with the tolerogenic nanoparticles. Interestingly, durable FVIII-specific tolerance was also achieved in animals co-administered with FVIII admixed with nanoparticles encapsulating rapamycin alone. These results suggest that nanoparticles carrying rapamycin and FVIII can be employed to induce specific tolerance to prevent and even reverse inhibitor formation.
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Affiliation(s)
- Ai-Hong Zhang
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Robert J Rossi
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Jeongheon Yoon
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Hong Wang
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - David W Scott
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.
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Su J, Zhu L, Sherman A, Wang X, Lin S, Kamesh A, Norikane JH, Streatfield SJ, Herzog RW, Daniell H. Low cost industrial production of coagulation factor IX bioencapsulated in lettuce cells for oral tolerance induction in hemophilia B. Biomaterials 2015; 70:84-93. [PMID: 26302233 PMCID: PMC4562874 DOI: 10.1016/j.biomaterials.2015.08.004] [Citation(s) in RCA: 99] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Revised: 08/01/2015] [Accepted: 08/04/2015] [Indexed: 01/13/2023]
Abstract
Antibodies (inhibitors) developed by hemophilia B patients against coagulation factor IX (FIX) are challenging to eliminate because of anaphylaxis or nephrotic syndrome after continued infusion. To address this urgent unmet medical need, FIX fused with a transmucosal carrier (CTB) was produced in a commercial lettuce (Simpson Elite) cultivar using species specific chloroplast vectors regulated by endogenous psbA sequences. CTB-FIX (∼1 mg/g) in lyophilized cells was stable with proper folding, disulfide bonds and pentamer assembly when stored ∼2 years at ambient temperature. Feeding lettuce cells to hemophilia B mice delivered CTB-FIX efficiently to the gut immune system, induced LAP(+) regulatory T cells and suppressed inhibitor/IgE formation and anaphylaxis against FIX. Lyophilized cells enabled 10-fold dose escalation studies and successful induction of oral tolerance was observed in all tested doses. Induction of tolerance in such a broad dose range should enable oral delivery to patients of different age groups and diverse genetic background. Using Fraunhofer cGMP hydroponic system, ∼870 kg fresh or 43.5 kg dry weight can be harvested per 1000 ft(2) per annum yielding 24,000-36,000 doses for 20-kg pediatric patients, enabling first commercial development of an oral drug, addressing prohibitively expensive purification, cold storage/transportation and short shelf life of current protein drugs.
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Affiliation(s)
- Jin Su
- Department of Biochemistry, School of Dental Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Liqing Zhu
- Department of Pediatrics, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Alexandra Sherman
- Department of Pediatrics, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Xiaomei Wang
- Department of Pediatrics, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Shina Lin
- Department of Biochemistry, School of Dental Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Aditya Kamesh
- Department of Biochemistry, School of Dental Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Joey H Norikane
- Fraunhofer USA, Center for Molecular Biotechnology, Newark, DE, USA
| | | | - Roland W Herzog
- Department of Pediatrics, College of Medicine, University of Florida, Gainesville, FL, USA.
| | - Henry Daniell
- Department of Biochemistry, School of Dental Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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33
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The use of intravenous immunoglobulin in immune tolerance induction in inherited haemophilia A. Blood Coagul Fibrinolysis 2015; 26:604-12. [DOI: 10.1097/mbc.0000000000000304] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Werwitzke S, Vollack N, von Hornung M, Kalippke K, Kutzschbach J, Trummer A, Ganser A, Tiede A. Deletion or inhibition of Fc gamma receptor 2B (CD32) prevents FVIII-specific activation of memory B cells in vitro. Thromb Haemost 2015; 114:1127-35. [PMID: 26245154 DOI: 10.1160/th14-06-0535] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Accepted: 06/19/2015] [Indexed: 01/09/2023]
Abstract
Development of inhibitory antibodies against factor VIII (FVIII) is a severe complication of replacement therapy in haemophilia A. Patients with inhibitors are treated with high FVIII doses in the context of immune tolerance therapy (ITT). Data from haemophilia A mouse model suggest that high FVIII concentrations prevent the formation of antibody secreting cells (ASCs) from memory B cells (MBCs) by inducing apoptosis. Fc gamma receptor 2B (CD32) is an important regulator of B cell function, mediating inhibitory signals after cross-linking with the B cell receptor. Here, the role of CD32 in the regulation of FVIII-specific MBCs was investigated using F8-/- and F8-/-CD32-/- knockout mice and monoclonal antibodies (mAbs). The initial immune response was similar between F8-/- and F8-/-CD32-/- mice, including concentration of anti-FVIII antibodies and number of FVIII-specific ASCs in spleen and bone marrow. In contrast, formation of ASCs from MBCs upon rhFVIII re-stimulation in vitro was abolished in F8-/-CD32-/- mice, whereas FVIII/anti-FVIII immune complexes significantly enhanced ASC formation in F8-/- mice. Inhibition of CD32 by mAbs or F(ab)2 fragments prevented ASC formation in a dose-dependent manner. Transfer of B cell-depleted splenocytes using CD45R (B220) depletion from CD32-competent mice did not restore ASC formation in F8-/-CD32-/- cells confirming that CD32 is required on B cells. We conclude that CD32 is a crucial regulator of FVIII-specific B cells and is required for the differentiation of MBCs into ASCs. Inhibition of CD32 could potentially improve the efficacy of FVIII in the context of ITT.
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Affiliation(s)
- Sonja Werwitzke
- Sonja Werwitzke, MD, PhD, Department of Haematology, Haemostasis,, Oncology and Stem Cell Transplantation, Hannover Medical School, D-30625 Hannover, Germany, Tel.: + 49 511 532 8377, Fax: + 49 511 18524, E-mail:
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35
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Successful treatment of immune tolerance induction with rituximab in a patient with severe hemophilia B and inhibitor. Blood Coagul Fibrinolysis 2015; 26:580-2. [DOI: 10.1097/mbc.0000000000000288] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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36
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A natural choice for hemophilia B. Blood 2015; 125:1509-10. [PMID: 25745178 DOI: 10.1182/blood-2015-01-622506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
In this issue of Blood, Crudele et al describe a novel study of adeno-associated virus (AAV) vector-mediated gene therapy that induced immune tolerance to factor IX (FIX) in a hemophilia B (HB) dog with previously formed anti-FIX inhibitor antibodies (IAs).
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Walsh CE, Soucie JM, Miller CH. Impact of inhibitors on hemophilia A mortality in the United States. Am J Hematol 2015; 90:400-5. [PMID: 25616111 DOI: 10.1002/ajh.23957] [Citation(s) in RCA: 102] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Revised: 01/15/2015] [Accepted: 01/17/2015] [Indexed: 12/12/2022]
Abstract
The previously published mortality studies are limited in hemophilia populations but suggest that there is no increased risk of mortality in factor VIII inhibitor patients. This retrospective study analyzed surveillance data collected on 7,386 males with severe hemophilia A over a 13-year period to assess the association between a current inhibitor and death. During the study period, 432 participants died, among whom 48 were patients with an inhibitor. Clinical characteristics most strongly associated with death were increased number of reported bleeds, signs of liver disease, infection with either HIV or HCV, and the presence of inhibitor. Patients who underwent successful tolerization were not considered inhibitor patients in our analysis. In a multivariable analysis, the odds of death were 70% higher among patients with a current inhibitor compared to those without an inhibitor (P < 0.01). Deaths among patients with inhibitors were much more likely to be attributed to bleeding complications than those among patients without an inhibitor (42 vs. 12%, P < 0.0001). We conclude that males with severe hemophilia A and a current inhibitor are at increased risk of death.
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Affiliation(s)
| | - J. Michael Soucie
- 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
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38
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Wang X, Su J, Sherman A, Rogers GL, Liao G, Hoffman BE, Leong KW, Terhorst C, Daniell H, Herzog RW. Plant-based oral tolerance to hemophilia therapy employs a complex immune regulatory response including LAP+CD4+ T cells. Blood 2015; 125:2418-27. [PMID: 25700434 PMCID: PMC4392010 DOI: 10.1182/blood-2014-08-597070] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2014] [Accepted: 02/14/2015] [Indexed: 12/12/2022] Open
Abstract
Coagulation factor replacement therapy for the X-linked bleeding disorder hemophilia is severely complicated by antibody ("inhibitor") formation. We previously found that oral delivery to hemophilic mice of cholera toxin B subunit-coagulation factor fusion proteins expressed in chloroplasts of transgenic plants suppressed inhibitor formation directed against factors VIII and IX and anaphylaxis against factor IX (FIX). This observation and the relatively high concentration of antigen in the chloroplasts prompted us to evaluate the underlying tolerance mechanisms. The combination of oral delivery of bioencapsulated FIX and intravenous replacement therapy induced a complex, interleukin-10 (IL-10)-dependent, antigen-specific systemic immune suppression of pathogenic antibody formation (immunoglobulin [Ig] 1/inhibitors, IgE) in hemophilia B mice. Tolerance induction was also successful in preimmune mice but required prolonged oral delivery once replacement therapy was resumed. Orally delivered antigen, initially targeted to epithelial cells, was taken up by dendritic cells throughout the small intestine and additionally by F4/80(+) cells in the duodenum. Consistent with the immunomodulatory responses, frequencies of tolerogenic CD103(+) and plasmacytoid dendritic cells were increased. Ultimately, latency-associated peptide expressing CD4(+) regulatory T cells (CD4(+)CD25(-)LAP(+) cells with upregulated IL-10 and transforming growth factor-β (TGF-β) expression) as well as conventional CD4(+)CD25(+) regulatory T cells systemically suppressed anti-FIX responses.
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Affiliation(s)
- Xiaomei Wang
- Department of Pediatrics, College of Medicine, University of Florida, Gainesville, FL
| | - Jin Su
- Departments of Biochemistry and Pathology, School of Dental Medicine, University of Pennsylvania, Philadelphia, PA
| | - Alexandra Sherman
- Department of Pediatrics, College of Medicine, University of Florida, Gainesville, FL
| | - Geoffrey L Rogers
- Department of Pediatrics, College of Medicine, University of Florida, Gainesville, FL
| | - Gongxian Liao
- Division of Immunology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston MA; and
| | - Brad E Hoffman
- Department of Pediatrics, College of Medicine, University of Florida, Gainesville, FL
| | - Kam W Leong
- Department of Biomedical Engineering, Columbia University, New York, NY
| | - Cox Terhorst
- Division of Immunology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston MA; and
| | - Henry Daniell
- Departments of Biochemistry and Pathology, School of Dental Medicine, University of Pennsylvania, Philadelphia, PA
| | - Roland W Herzog
- Department of Pediatrics, College of Medicine, University of Florida, Gainesville, FL
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Farrugia A, Hermans C, Franchini M. Assessing options for treating haemophilia with inhibitors. Haemophilia 2015; 21:307-309. [PMID: 25855015 DOI: 10.1111/hae.12676] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/22/2015] [Indexed: 01/01/2023]
Affiliation(s)
- A Farrugia
- Faculty of Medicine Surgery and Health Sciences, The University of Western Australia, Crawley, Western Australia
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40
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Boylan B, Rice AS, Dunn AL, Tarantino MD, Brettler DB, Barrett JC, Miller CH. Characterization of the anti-factor VIII immunoglobulin profile in patients with hemophilia A by use of a fluorescence-based immunoassay. J Thromb Haemost 2015; 13:47-53. [PMID: 25354263 PMCID: PMC4383171 DOI: 10.1111/jth.12768] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Accepted: 09/19/2014] [Indexed: 11/26/2022]
Abstract
BACKGROUND The development of neutralizing antibodies, referred to as inhibitors, against factor VIII is a major complication associated with FVIII infusion therapy for the treatment of hemophilia A (HA). Previous studies have shown that a subset of HA patients and a low percentage of healthy individuals harbor non-neutralizing anti-FVIII antibodies that do not elicit the clinical manifestations associated with inhibitor development. OBJECTIVE To assess HA patients' anti-FVIII antibody profiles as potential predictors of clinical outcomes. METHODS A fluorescence immunoassay (FLI) was used to detect anti-FVIII antibodies in 491 samples from 371 HA patients. RESULTS Assessments of antibody profiles showed that the presence of anti-FVIII IgG1 , IgG2 or IgG4 correlated qualitatively and quantitatively with the presence of an FVIII inhibitor as determined with the Nijmegen-Bethesda assay (NBA). Forty-eight patients with a negative inhibitor history contributed serial samples to the study, including seven patients who had negative NBA titers initially and later converted to being NBA-positive. The FLI detected anti-FVIII IgG1 in five of those seven patients prior to their conversion to NBA-positive. Five of 15 serial-sample patients who had a negative inhibitor history and had anti-FVIII IgG1 later developed an inhibitor, as compared with two of 33 patients with a negative inhibitor history without anti-FVIII IgG1 . CONCLUSIONS These data provide a rationale for future studies designed both to monitor the dynamics of anti-FVIII antibody profiles in HA patients as a potential predictor of future inhibitor development and to assess the value of the anti-FVIII FLI as a supplement to traditional inhibitor testing.
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Affiliation(s)
- Brian Boylan
- Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Anne S. Rice
- 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
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41
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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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Windyga J, Solano Trujillo MH, Hafeman AE. BAX326 (RIXUBIS): a novel recombinant factor IX for the control and prevention of bleeding episodes in adults and children with hemophilia B. Ther Adv Hematol 2014; 5:168-80. [PMID: 25324957 DOI: 10.1177/2040620714550573] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Hemophilia B management has improved considerably since the introduction of high-purity plasma-derived factor IX (pdFIX) products in the early 1990s. Recombinant FIX (rFIX) was introduced more recently and has potential safety advantages over the older blood-based products. Until recently, only one such product, nonacog alfa (BeneFIX(®), Pfizer, Inc.), has been available. However, a new rFIX product, BAX326 (RIXUBIS, Baxter Healthcare Corp.), has now been approved by the US Food and Drug Administration. BAX326 undergoes rigorous virus elimination and purification steps during manufacture, and has low activated FIX activity, which confers low thrombogenic potential in humans. Preclinical studies showed promising pharmacokinetic and safety profiles, and these early findings have since been expanded in a series of prospective, multicenter, clinical studies. Foremost among these is a pivotal phase I/III study of BAX326 and its use in routine prophylaxis or on-demand treatment in patients aged 12-65 years with severe (FIX level <1%) or moderately severe (FIX level ≤2%) hemophilia B. This study confirmed the pharmacokinetic equivalence of BAX326 and nonacog alfa, and showed a significant reduction in annualized bleeding rate with BAX326 prophylaxis compared with on-demand treatment (79% versus historic controls; p < 0.001). The hemostatic efficacy of BAX326 was rated as 'excellent' or 'good' in 96% of bleeds. BAX326 was also associated with statistically significant and clinically meaningful improvements in physical health-related quality of life. Results are similarly encouraging in a pediatric study in children aged up to 12 years and in a study in hemophilia B patients undergoing surgery. A further study showed safe transition, with no inhibitor formation in any patient, from treatment with a pdFIX product to BAX326. Overall, the safety profile of BAX326 in clinical trials has been strong, with no inhibitor or specific antibody formation, thrombosis, or treatment-related serious adverse events or anaphylaxis.
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Affiliation(s)
- Jerzy Windyga
- Department of Disorders of Hemostasis and Internal Medicine, Institute of Hematology and Transfusion Medicine, 14 I. Gandhi Str., 02-776 Warsaw, Poland
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43
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Athale A, Giguere A, Barbara A, Krassova S, Iorio A. Developing a two-sided intervention to facilitate shared decision-making in haemophilia: decision boxes for clinicians and patient decision aids for patients. Haemophilia 2014; 20:800-6. [PMID: 25273544 DOI: 10.1111/hae.12495] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/09/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND People with haemophilia face many treatment decisions, which are largely informed by evidence from observational studies. Without evidence-based 'best' treatment options, patient preferences play a large role in decisions regarding therapy. The shared decision-making (SDM) process allows patients and health care providers to make decisions collaboratively based on available evidence, and patient preferences. Decision tools can help the SDM process. The objective of this project was to develop two-sided decision tools, decision boxes for physicians and patient decision aids for patients, to facilitate SDM for treatment decisions in haemophilia. METHODS Development of the decision tools comprised three phases: topic selection, prototype development and usability testing with targeted end-users. Topics were selected using a Delphi survey. Tool prototypes were based on a previously validated framework and were informed by systematic literature reviews. Patients, through focus groups, and physicians, through interviews, reviewed the prototypes iteratively for comprehensibility and usability. RESULTS The chosen topics were: (i) prophylactic treatment: when to start and dosing, (ii) choosing factor source and (iii) immunotolerance induction: when to start and dosing. Intended end users (both health care providers and haemophilia patients and caregivers) were engaged in the development process. Overall perception of the decision tools was positive, and the purpose of using the tools was well received. CONCLUSIONS This study demonstrates the feasibility of developing decision tools for haemophilia treatment decisions. It also provides anecdotal evidence of positive perceptions of such tools. Future directions include assessment of the tools' practical value and impact on clinical practice.
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Affiliation(s)
- A Athale
- Department of Clinical Epidemiology and Biostatistics, Health Information Research Unit, McMaster University, Hamilton, Ontario, Canada
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Sherman A, Su J, Lin S, Wang X, Herzog RW, Daniell H. Suppression of inhibitor formation against FVIII in a murine model of hemophilia A by oral delivery of antigens bioencapsulated in plant cells. Blood 2014; 124:1659-68. [PMID: 24825864 PMCID: PMC4155273 DOI: 10.1182/blood-2013-10-528737] [Citation(s) in RCA: 81] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Accepted: 04/29/2014] [Indexed: 11/20/2022] Open
Abstract
Hemophilia A is the X-linked bleeding disorder caused by deficiency of coagulation factor VIII (FVIII). To address serious complications of inhibitory antibody formation in current replacement therapy, we created tobacco transplastomic lines expressing FVIII antigens, heavy chain (HC) and C2, fused with the transmucosal carrier, cholera toxin B subunit. Cholera toxin B-HC and cholera toxin B-C2 fusion proteins expressed up to 80 or 370 µg/g in fresh leaves, assembled into pentameric forms, and bound to GM1 receptors. Protection of FVIII antigen through bioencapsulation in plant cells and oral delivery to the gut immune system was confirmed by immunostaining. Feeding of HC/C2 mixture substantially suppressed T helper cell responses and inhibitor formation against FVIII in mice of 2 different strain backgrounds with hemophilia A. Prolonged oral delivery was required to control inhibitor formation long-term. Substantial reduction of inhibitor titers in preimmune mice demonstrated that the protocol could also reverse inhibitor formation. Gene expression and flow cytometry analyses showed upregulation of immune suppressive cytokines (transforming growth factor β and interleukin 10). Adoptive transfer experiments confirmed an active suppression mechanism and revealed induction of CD4(+)CD25(+) and CD4(+)CD25(-) T cells that potently suppressed anti-FVIII formation. In sum, these data support plant cell-based oral tolerance for suppression of inhibitor formation against FVIII.
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Affiliation(s)
- Alexandra Sherman
- Department of Pediatrics, College of Medicine, University of Florida, Gainesville, FL; and
| | - Jin Su
- Department of Biochemistry and Department of Pathology, School of Dental Medicine, University of Pennsylvania, Philadelphia, PA
| | - Shina Lin
- Department of Biochemistry and Department of Pathology, School of Dental Medicine, University of Pennsylvania, Philadelphia, PA
| | - Xiaomei Wang
- Department of Pediatrics, College of Medicine, University of Florida, Gainesville, FL; and
| | - Roland W Herzog
- Department of Pediatrics, College of Medicine, University of Florida, Gainesville, FL; and
| | - Henry Daniell
- Department of Biochemistry and Department of Pathology, School of Dental Medicine, University of Pennsylvania, Philadelphia, PA
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Soucie JM, Miller CH, Kelly FM, Aschman D, DiMichele D, Konkle BA, Kulkarni R, Monahan PE. National surveillance for hemophilia inhibitors in the United States: Summary report of an expert meeting. Am J Hematol 2014; 89:621-5. [PMID: 24616187 DOI: 10.1002/ajh.23704] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Accepted: 03/06/2014] [Indexed: 11/06/2022]
Abstract
On March 12, 2012, the Centers for Disease Control and Prevention (CDC) held a meeting of its partners in hemophilia treatment, community-based organizations, industry, and government to review data and discuss implementation issues relevant to planned United States (U.S.) national inhibitor surveillance. Issues discussed included the current status of inhibitor surveillance in the United Kingdom (UK) and the US, the results of a US inhibitor surveillance feasibility study, proposed national surveillance schemes, laboratory testing and reporting issues and potential opportunities for future inhibitor-related research. It was concluded that implementation of a national program of inhibitor surveillance using standardized testing through an established public health registry along with patient and care provider education and targeted research provide the best opportunity to inform efforts to develop and evaluate effective prevention strategies.
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Affiliation(s)
- J. Michael Soucie
- National Centers for Birth Defects and Developmental Disabilities; Division of Blood Disorders; Centers for Disease Control and Prevention; Atlanta Georgia
| | - Connie H. Miller
- National Centers for Birth Defects and Developmental Disabilities; Division of Blood Disorders; Centers for Disease Control and Prevention; Atlanta Georgia
| | - Fiona M. Kelly
- National Centers for Birth Defects and Developmental Disabilities; Division of Blood Disorders; Centers for Disease Control and Prevention; Atlanta Georgia
| | - Diane Aschman
- American Thrombosis and Hemostasis Network; Chicago Illinois
| | - Donna DiMichele
- National Heart; Lung and Blood Institute, National Institutes of Health; Bethesda Maryland
| | - Barbara A. Konkle
- Clinical and Translational Research, Puget Sound Blood Center; Seattle Washington
| | - Roshni Kulkarni
- Department of Pediatrics and Human Development; Michigan State University; East Lansing Michigan
| | - Paul E. Monahan
- Department of Pediatrics; Division of Hematology/Oncology; University of North Carolina at Chapel Hill; Chapel Hill North Carolina
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Wang X, Moghimi B, Zolotukhin I, Morel LM, Cao O, Herzog RW. Immune tolerance induction to factor IX through B cell gene transfer: TLR9 signaling delineates between tolerogenic and immunogenic B cells. Mol Ther 2014; 22:1139-1150. [PMID: 24609143 DOI: 10.1038/mt.2014.43] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2013] [Accepted: 03/03/2014] [Indexed: 12/21/2022] Open
Abstract
A subset of patients with severe hemophilia B, the X-linked bleeding disorder resulting from absence of coagulation factor IX (FIX), develop pathogenic antibody responses during replacement therapy. These inhibitors block standard therapy and are often associated with anaphylactic reactions to FIX. Established clinical immune tolerance induction protocols often fail for FIX inhibitors. In a murine model of this immune complication, retrovirally transduced primary B cells expressing FIX antigen fused with immunoglobulin-G heavy chain prevented antibody formation to FIX and was also highly effective in desensitizing animals with preexisting response. In contrast, transplant of B cells that received the identical expression cassette via nucleofection of plasmid vector substantially heightened antibody formation against FIX, a response that could be blocked by toll-like receptor 9 (TLR9) inhibition. While innate responses to TLR4 activation or to retrovirus were minimal in B cells, plasmid DNA activated TLR9, resulting in CpG-dependent NF-κB activation/IL-6 expression and adaptor protein 3 dependent, CpG-independent induction of IFN-I. Neither response was seen in TLR9-deficient B cells. Therefore, TLR9 signaling in B cells, in particular in response to plasmid vector, is highly immunogenic and has to be avoided in design of tolerance protocols.
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Affiliation(s)
- Xiaomei Wang
- Department of Pediatrics, University of Florida, Gainesville, Florida, USA.
| | - Babak Moghimi
- Department of Pediatrics, University of Miami, Miami, Florida, USA
| | - Irene Zolotukhin
- Department of Pediatrics, University of Florida, Gainesville, Florida, USA
| | - Laurence M Morel
- Department of Pathology, Immunology and Laboratory Medicine, University of Florida, Gainesville, Florida, USA
| | - Ou Cao
- Department of Pediatrics, University of Florida, Gainesville, Florida, USA
| | - Roland W Herzog
- Department of Pediatrics, University of Florida, Gainesville, Florida, USA.
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Zollner S, Schuermann D, Raquet E, Mueller-Cohrs J, Weimer T, Pragst I, Dickneite G, Schulte S. Pharmacological characteristics of a novel, recombinant fusion protein linking coagulation factor VIIa with albumin (rVIIa-FP). J Thromb Haemost 2014; 12:220-8. [PMID: 24641308 PMCID: PMC4166693 DOI: 10.1111/jth.12477] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Indexed: 01/20/2023]
Abstract
BACKGROUND Recombinant factor VIIa (rFVIIa) is approved for use in controlling bleeding episodes in people with hemophilia who have developed inhibitors to replacement therapy. Due to its short half-life (t½), frequent injections are required, limiting its use as a prophylactic treatment. A novel, recombinant fusion protein linking coagulation factor VIIa with albumin (rVIIa-FP) has been developed to extend the t(½) of rFVIIa. OBJECTIVES The aim of our studies was to investigate the pharmacokinetic/pharmacodynamic characteristics of rVIIa-FP in preclinical animal species. METHODS Pharmacokinetic (PK) parameters were derived after single intravenous dosing in hemophilia A mice, rats, rabbits and monkeys. PK analysis was based on human FVII plasma levels determined by measuring FVII antigen levels by ELISA in mice and rats, and FVIIa activity using STACLOT® VIIa-rTF in rabbits and monkeys. Induction of thrombin generation was investigated in mice, while hemostatic activity was assessed by thrombus formation in rabbits. RESULTS Compared with rFVIIa, rVIIa-FP displayed a prolonged t(½), enhanced in vivo recovery and reduced clearance in all species investigated. In mice, 16 h after treatment with rVIIa-FP, thrombin levels were quantifiable, indicating prolonged efficacy, whereas values had approached baseline at this time after treatment with rFVIIa. After 12 h, hemostatic efficacy was negligible in rFVIIa-treated rabbits, but sustained in animals receiving rVIIa-FP. CONCLUSIONS These studies indicate that the longer t(½) of rVIIa-FP compared with rFVIIa translates into extended activity. These findings suggest that rVIIa-FP has the potential to be administered less frequently than rFVIIa-containing concentrates in clinical use.
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Successful immune tolerance induction with a plasma-derived FVIII concentrate and intravenous immunoglobulins in a pediatric patient with congenital severe hemophilia A and poor prognostic factors. Blood Coagul Fibrinolysis 2014; 25:77-80. [DOI: 10.1097/mbc.0b013e328364f992] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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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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