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Souri M, Osaki T, Shimura Y, Ichikawa S, Mori M, Ogawa Y, Ichinose A. Identification of non-neutralizing anti-factor X autoantibodies in three Japanese cases of autoimmune acquired factor X deficiency. Haemophilia 2023; 29:555-563. [PMID: 36478471 DOI: 10.1111/hae.14711] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 11/21/2022] [Accepted: 11/22/2022] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Autoimmune factor X (FX or F10) deficiency (AiF10D) is an extremely rare acquired haemorrhagic disorder characterized by a severe reduction in FX activity due to autoantibodies against FX. AIM Anti-FX autoantibodies were investigated in four patients with suspected AiF10D, and their properties were analysed. METHODS AND RESULTS Anti-FX auto antibodies in plasma were detected by ELISA with three of four cases. One case of anti-FX autoantibody negativity was later diagnosed as AL-amyloidosis. IgG1 and IgG3 coexisted in all anti-FX autoantibodies of the three patients with AiF10D (cases X1, X2, and X3). Western blot analysis showed that the antibodies were bound to the FX light chain for cases X2 and X3, but the binding was weak for case X1. When the fusion proteins of a secretory luciferase with full-length FX or its γ-carboxylated glutamic acid (Gla) domain were added to the plasma of the three patients, both fusion proteins were immunoprecipitated as antigen-antibody complexes. Contrarily, the latter fusion protein produced in the presence of warfarin demonstrated a decrease in the collection rate, suggesting that their autoantibodies recognized the light chain and regions containing Gla residues. Since all three patients were essentially negative for FX inhibitors, it was concluded that the anti-FX autoantibodies for these cases were predominantly non-neutralizing. The concentration of the FX antigen also significantly reduced in these patients, suggesting that anti-FX autoantibodies promote the clearance of FX. CONCLUSION Immunological anti-FX autoantibody detection is highly recommended to ensure that AiF10D cases are not overlooked, and to start necessary immunosuppressive therapies.
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Affiliation(s)
- Masayoshi Souri
- Department of Molecular Patho-Biochemistry and Patho-Biology, Yamagata University School of Medicine, Yamagata, Japan.,Japanese Collaborative Research Group on Autoimmune Coagulation Factor Deficiency supported by the Japanese Ministry of Health, Labor and Welfare, Yamagata, Japan.,Department of Public Health and Hygiene, Yamagata University School of Medicine, Yamagata, Japan
| | - Tsukasa Osaki
- Department of Molecular Patho-Biochemistry and Patho-Biology, Yamagata University School of Medicine, Yamagata, Japan.,Japanese Collaborative Research Group on Autoimmune Coagulation Factor Deficiency supported by the Japanese Ministry of Health, Labor and Welfare, Yamagata, Japan.,Department of Public Health and Hygiene, Yamagata University School of Medicine, Yamagata, Japan
| | - Yuji Shimura
- Division of Hematology and Oncology, Department of Medicine, Kyoto Prefectural University of Medicine, Kyoto, Kyoto, Japan
| | | | - Makiko Mori
- Department of Clinical Laboratory, Toyama Prefectural Central Hospital, Toyama, Japan
| | - Yoshiyuki Ogawa
- Japanese Collaborative Research Group on Autoimmune Coagulation Factor Deficiency supported by the Japanese Ministry of Health, Labor and Welfare, Yamagata, Japan.,Department of Hematology, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Akitada Ichinose
- Department of Molecular Patho-Biochemistry and Patho-Biology, Yamagata University School of Medicine, Yamagata, Japan.,Japanese Collaborative Research Group on Autoimmune Coagulation Factor Deficiency supported by the Japanese Ministry of Health, Labor and Welfare, Yamagata, Japan
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Seth T. Experience of Immune Tolerance Induction Therapy for Hemophilia A Patients with Inhibitors from a Single Center in India. Indian J Hematol Blood Transfus 2019; 36:458-463. [PMID: 32647418 DOI: 10.1007/s12288-019-01218-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 10/14/2019] [Indexed: 01/06/2023] Open
Abstract
The availability of clotting factor concentrates of both factor VIII and factor IX have improved hemophilia treatment to a great extent. Many more improvements like physiotherapy, and comprehensive care are needed to give better care. One important complication that occurs, but is often set aside is the development of inhibitors. When an inhibitor develops in a patient of severe hemophilia then the care becomes more difficult and expensive. Eradication of the inhibitor is possible by Immune tolerance induction (ITI), this paper explains some important essential factors and practical issues during my experience with ITI.
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Affiliation(s)
- Tulika Seth
- Room 5017, Teaching Block, AIIMS, Ansari Nagar, New Delhi, 110029 India
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Rampersad AG, Boylan B, Miller CH, Shapiro A. Distinguishing lupus anticoagulants from factor VIII inhibitors in haemophilic and non-haemophilic patients. Haemophilia 2018; 24:807-814. [PMID: 30004159 PMCID: PMC6345165 DOI: 10.1111/hae.13565] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/04/2018] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Accurate diagnosis of an inhibitor, a neutralizing antibody to infused factor VIII (FVIII), is essential for appropriate management of haemophilia A (HA). Low-titre inhibitors may be difficult to diagnose due to high rates of false-positive inhibitor results in that range. Transient low-titre inhibitors and false-positive inhibitors may be due to the presence of a lupus anticoagulant (LA) or other non-specific antibodies. Fluorescence immunoassay (FLI) to detect antibodies to FVIII is a sensitive method to identify inhibitors in HA. Evaluations of antibody profiles by various groups have demonstrated that haemophilic inhibitors detected by Nijmegen-Bethesda (NBA) and chromogenic Bethesda (CBA) assays correlate with positivity for anti-FVIII immunoglobulin (Ig) G1 and G4. AIM This study sought to determine whether FLI could distinguish false-positive FVIII inhibitor results related to LAs from clinically relevant FVIII inhibitors in HA patients. METHODS Samples from haemophilic and non-haemophilic subjects were tested for LA, specific FVIII inhibitors by NBA and CBA, and anti-FVIII immunoglobulin profiles by FLI. RESULTS No samples from LA-positive non-haemophilic subjects were positive by FLI for anti-FVIII IgG4. Conversely, 91% of NBA-positive samples from haemophilia subjects were positive for anti-FVIII IgG4. Two of 11 haemophilia subjects had samples negative for anti-FVIII IgG4 and CBA, which likely represented LA rather than FVIII inhibitor presence. CONCLUSIONS Assessment of anti-FVIII profiles along with the CBA may be useful to distinguish a clinically relevant low-titre FVIII inhibitor from a transient LA in HA patients.
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Affiliation(s)
- A G Rampersad
- Indiana Hemophilia & Thrombosis Center, Indianapolis, IN, USA
| | - B Boylan
- Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - C H Miller
- Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - A Shapiro
- Indiana Hemophilia & Thrombosis Center, Indianapolis, IN, USA
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Schep S, Schutgens R, Fischer K, Boes M. Review of immune tolerance induction in hemophilia A. Blood Rev 2018; 32:326-338. [DOI: 10.1016/j.blre.2018.02.003] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Revised: 02/01/2018] [Accepted: 02/13/2018] [Indexed: 12/22/2022]
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Carcao M, Shapiro A, Staber JM, Hwang N, Druzgal C, Lieuw K, Belletrutti M, Thornburg CD, Ahuja SP, Morales-Arias J, Dumont J, Miyasato G, Tsao E, Jain N, Pipe SW. Recombinant factor VIII Fc fusion protein for immune tolerance induction in patients with severe haemophilia A with inhibitors-A retrospective analysis. Haemophilia 2018; 24:245-252. [PMID: 29436077 DOI: 10.1111/hae.13413] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/04/2018] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Immune tolerance induction (ITI) is the gold standard for eradication of factor VIII inhibitors in severe haemophilia A; however, it usually requires treatment for extended periods with associated high burden on patients and healthcare resources. AIM Review outcomes of ITI with recombinant factor VIII Fc fusion protein (rFVIIIFc) in patients with severe haemophilia A and high-titre inhibitors. METHODS Multicentre retrospective chart review of severe haemophilia A patients treated with rFVIIIFc for ITI. RESULTS Of 19 patients, 7 were first-time ITI and 12 were rescue ITI. Of 7 first-time patients, 6 had at least 1 high-risk feature for ITI failure. Four of 7 first-time patients were tolerized in a median of 7.8 months. The remaining 3 patients continue on rFVIIIFc ITI. Of 12 rescue patients, 7 initially achieved a negative Bethesda titre (≤0.6) in a median of 3.3 months, 1 had a decrease in Bethesda titre and continues on rFVIIIFc ITI and 4 have not demonstrated a decrease in Bethesda titre. Of these 4, 3 continue on rFVIIIFc ITI and 1 switched to bypass therapy alone. Two initially responsive patients transitioned to other factors due to recurrence. Overall, 16 of 19 patients remain on rFVIIIFc (prophylaxis or ITI). For those still undergoing ITI, longer follow-up is needed to determine final outcomes. No adverse events reported. CONCLUSIONS Recombinant factor VIII Fc fusion protein demonstrated rapid time to tolerization in high-risk first-time ITI patients. For rescue ITI, rFVIIIFc showed therapeutic benefit in some patients who previously failed ITI with other products. These findings highlight the need to further evaluate the use of rFVIIIFc for ITI.
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Affiliation(s)
- M Carcao
- Division of Haematology/Oncology, Department of Paediatrics, Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, Toronto, ON, Canada
| | - A Shapiro
- Indiana Hemophilia & Thrombosis Center, Indianapolis, IN, USA
| | - J M Staber
- University of Iowa Stead Family Children's Hospital, Iowa City, IA, USA
| | - N Hwang
- Center for Inherited Blood Disorders, Orange, CA, USA
| | - C Druzgal
- University of Virginia Health System, Charlottesville, VA, USA
| | - K Lieuw
- Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - M Belletrutti
- University of Alberta Stollery Children's Hospital, Edmonton, AB, Canada
| | - C D Thornburg
- Rady Children's Hospital San Diego, San Diego, CA, USA
| | - S P Ahuja
- University Hospitals Rainbow Babies and Children's Hospital, Cleveland, OH, USA
| | | | - J Dumont
- Bioverativ Therapeutics, Inc., Waltham, MA, USA
| | | | - E Tsao
- Bioverativ Therapeutics, Inc., Waltham, MA, USA
| | - N Jain
- Bioverativ Therapeutics, Inc., Waltham, MA, USA
| | - S W Pipe
- University of Michigan, Ann Arbor, MI, USA
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Janbain M, Pipe S. What is the role of an extended half-life product in immune tolerance induction in a patient with severe hemophilia A and high-titer inhibitors? HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2016; 2016:648-649. [PMID: 27913541 PMCID: PMC6142440 DOI: 10.1182/asheducation-2016.1.648] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
A 10-year-old boy presents with a history of severe hemophilia A and high-titer inhibitor that had failed high-dose immune tolerance induction (ITI) with a recombinant factor VIII (rFVIII) product and a plasma-derived FVIII product. You are asked by his mother whether he should be tried on ITI with an extended half-life product, in particular, consideration of a rFVIIIFc concentrate.
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Affiliation(s)
- Maissaa Janbain
- Section of Hematology and Medical Oncology, Department of Internal Medicine, Tulane School of Medicine, New Orleans, LA
| | - Steven Pipe
- Division of Pediatric Hematology and Oncology, University of Michigan, Ann Arbor, MI
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Heat treatment of samples improve the performance of the Nijmegen–Bethesda assay in hemophilia A patients undergoing immune tolerance induction. Thromb Res 2015; 136:1280-4. [DOI: 10.1016/j.thromres.2015.08.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Revised: 07/24/2015] [Accepted: 08/22/2015] [Indexed: 11/18/2022]
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Montalvão SAL, Tucunduva AC, Siqueira LH, Sambo ALA, Medina SS, Ozelo MC. A longitudinal evaluation of anti-FVIII antibodies demonstrated IgG4 subclass is mainly correlated with high-titre inhibitor in haemophilia A patients. Haemophilia 2015; 21:686-92. [PMID: 25708525 DOI: 10.1111/hae.12646] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/12/2015] [Indexed: 12/24/2022]
Abstract
The development of inhibitory antibodies against factor VIII (FVIII) (inhibitor) is the major complication in haemophilia A patients. The FVIII-binding antibodies development comprises a polyclonal immunoglobulin (Ig) G response. Recent studies showed strong correlation between the presence of neutralizing anti-FVIII antibodies (inhibitors) and IgG4 subclass. The aim of this study was to evaluate anti-FVIII IgG subclasses in haemophilia A patients with inhibitor both in a cross-sectional and in a longitudinal analysis. Inhibitors were determined by Nijmegen-Bethesda assay. Anti-FVIII IgG subclasses were performed by ELISA, and samples from 20 healthy individuals were used to validate the test. We studied 25 haemophilia A patients with inhibitor, previously treated exclusively with plasma-derived FVIII concentrates or bypassing agents. The IgG subclasses distributions were evaluated in two groups of patients classified according to inhibitor response. IgG1 and IgG4 antibodies were most prominent in haemophilia A patients with inhibitors when compared with IgG2 and IgG3. This study reports for the first time the behaviour of FVIII-binding IgG1 and IgG4 subclasses in a longitudinal analysis, in a clinical setting, of high-response inhibitor haemophilia A patients, showing the correlation of IgG4 and the inhibitor titres. In spite of being considered a non-pathologic antibody subclass with anti-inflammatory properties in other situations, IgG4 is correlated with the presence of high-titre inhibitor in the haemophilia setting. The comprehension of the IgG4 role in immune response may be crucial to establish the process for designing specific tolerance to FVIII.
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Affiliation(s)
- S A L Montalvão
- Hemophilia Unit 'Cláudio L. P. Corrêa', Centro de Hematologia e Hemoterapia da Unicamp, Instituto Nacional de Ciência e Tecnologia do Sangue, University of Campinas, Campinas, São Paulo, Brazil
| | - A C Tucunduva
- Hemophilia Unit 'Cláudio L. P. Corrêa', Centro de Hematologia e Hemoterapia da Unicamp, Instituto Nacional de Ciência e Tecnologia do Sangue, University of Campinas, Campinas, São Paulo, Brazil
| | - L H Siqueira
- Hemophilia Unit 'Cláudio L. P. Corrêa', Centro de Hematologia e Hemoterapia da Unicamp, Instituto Nacional de Ciência e Tecnologia do Sangue, University of Campinas, Campinas, São Paulo, Brazil
| | - A L A Sambo
- Hemophilia Unit 'Cláudio L. P. Corrêa', Centro de Hematologia e Hemoterapia da Unicamp, Instituto Nacional de Ciência e Tecnologia do Sangue, University of Campinas, Campinas, São Paulo, Brazil
| | - S S Medina
- Hemophilia Unit 'Cláudio L. P. Corrêa', Centro de Hematologia e Hemoterapia da Unicamp, Instituto Nacional de Ciência e Tecnologia do Sangue, University of Campinas, Campinas, São Paulo, Brazil
| | - M C Ozelo
- Hemophilia Unit 'Cláudio L. P. Corrêa', Centro de Hematologia e Hemoterapia da Unicamp, Instituto Nacional de Ciência e Tecnologia do Sangue, University of Campinas, Campinas, São Paulo, Brazil
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