The role of intensive plasma exchange in the prevention and management of haemorrhage in patients with inhibitors to factor VIII

Efficacy of therapeutic plasma exchange in a patient with coagulation inhibitors (acquired haemophilia A) - A case report

Acquired haemophilia A (AHA) is a rare disorder with mostly idiopathic aetiology that leads to factor VIII (FVIII) deficiency due to coagulation inhibitors formation. Treatment protocol includes immunosuppression and Factor VIII bypassing agents including activated Prothrombin Complex Concentrates (PCC). Nevertheless, the role of plasma exchange is not clear in the treatment of AHA. We report a case of 73 year old male who presented with haematuria, prolonged activated partial thromboplastin time (APTT) and a very high titres of Factor VIII inhibitors of 98 Bethesda units (BU) and was diagnosed with acquired haemophilia A. He failed to respond to multiple immunosuppressive therapies including rituximab. Therefore, therapeutic plasma exchange (TPE) therapy was planned due to persistence of haematuria despite immunosuppressive therapies. After five cycles of plasma exchange, APTT became normal, haematuria subsided and Factor VIII inhibitors became negative. Patient was discharged without any bleeding and in a stable condition. In this index case, plasma exchange played a very crucial role, resulting in recovery of the patient. These results advocate that therapeutic plasma exchange is an effective therapy for acquired haemophilia A.

Guidelines on the Use of Therapeutic Apheresis in Clinical Practice - Evidence-Based Approach from the Writing Committee of the American Society for Apheresis: The Eighth Special Issue

The American Society for Apheresis (ASFA) Journal of Clinical Apheresis (JCA) Special Issue Writing Committee is charged with reviewing, updating and categorizing indications for the evidence-based use of therapeutic apheresis (TA) in human disease. Since the 2007 JCA Special Issue (Fourth Edition), the committee has incorporated systematic review and evidence-based approaches in the grading and categorization of apheresis indications. This Eighth Edition of the JCA Special Issue continues to maintain this methodology and rigor in order to make recommendations on the use of apheresis in a wide variety of diseases/conditions. The JCA Eighth Edition, like its predecessor, continues to apply the category and grading system definitions in fact sheets. The general layout and concept of a fact sheet that was introduced in the Fourth Edition, has largely been maintained in this edition. Each fact sheet succinctly summarizes the evidence for the use of TA in a specific disease entity or medical condition. The Eighth Edition comprises 84 fact sheets for relevant diseases and medical conditions, with 157 graded and categorized indications and/or TA modalities. The Eighth Edition of the JCA Special Issue seeks to continue to serve as a key resource that guides the utilization of TA in the treatment of human disease.

Factor VIII inhibitors: a 50-year perspective

Inhibitors of factor VIII (FVIII) have been studied for more than 50 years, but diagnostic and therapeutic challenges remain. To describe the features that distinguish alloantibodies from autoantibodies, list predisposing factors, and review methods for tolerance induction and autoantibody suppression. Review of key articles published during the past half-century that have advanced knowledge in this field. Alloantibodies generally bind to the A2 or C2 domains of FVIII and disrupt the formation of the FVIII-FIX complex. They exhibit type 1 reaction kinetics, are saturable by FVIII, and display anamnesis. In contrast, autoantibodies usually bind to the C2 domain of FVIII, interfering with phospholipid and von Willebrand factor binding. They have type-2 kinetics and are poorly neutralized by FVIII. Repeated exposures to FVIII induce tolerance in 70-80% of haemophiliacs with inhibitors, whereas drugs that deplete B-lymphocytes restore self-tolerance to FVIII in a similar percentage of non-haemophiliacs. Future work should focus on improving assays that detect and quantify inhibitors, examining the pathophysiology of inhibitor formation using contemporary immunologic tools, and investigating new treatment modalities. These should include agents to control bleeding with less thrombotic risk, more specific immunomodulating drugs to curtail antibody formation, and, for haemophilia patients, genetic therapies to provide FVIII resistant to or protected from inactivation by inhibitors.

Acquired haemophilia in a patient with gram-negative urosepsis and bladder cancer

We here report a patient who developed a high titer antibody to factor VIII (FVIII) during gram-negative urosepsis caused by enterobacter cloacae after complete resection of rectal cancer. The patient initially presented with a life threatening spontaneous hematothorax and multiple large haematomas. Coagulation studies revealed a severe FVIII deficiency <1% with a high FVIII antibody titer of 64 BU. The bleeding responded rapidly to infusions of recombinant factor VIIa. After achievement of a partial remission (FVIII activity 28%) by combined immunosuppressive therapy (prednisone, cyclophosphamide, plasmapheresis and immunoadsorption), subsequently, two relapses occurred following steroid tapering. Resumption of prednisone and cyclophosphamide treatment combined with immunoadsorption induced a second and third remission, respectively. After resection of a papillary carcinoma of the bladder 6 months later and continuous immunosuppressive therapy with cyclophosphamide, FVIII levels remained stable within normal ranges. This clinical course suggests that the cause of inhibitor formation against FVIII resulting in severe acquired haemophilia was multifactorial and was initiated by the gram-negative urosepsis and probably by the underlying malignancies.

Control of bleeding in patients with haemophilia A with inhibitors: a systematic review

This paper reports a systematic review of the best available evidence of clinical effectiveness in the treatment of acute bleeding in haemophilia A patients with inhibitors. Because of the lack of randomized controlled trials (RCTs) on this topic, broad inclusion criteria with regard to study design were applied in order to assess the best available evidence for each intervention. Because of the clinical and methodological heterogeneity of the evidence, it was not appropriate to pool data across studies; instead, data were synthesized using tabulation and qualitative narrative assessment. No evidence was found to support the use of high-dose factor VIII (FVIII) in bleeding episodes. However in surgery it was found to be highly successful (100%) for low-titre, low-responding inhibitors although not reliable for high-responding inhibitors. Porcine FVIII (pFVIII) was effective in the control of severe bleeding episodes with high-titre or high-responding inhibitors (100%) and in 60-90% of surgical procedures. Activated prothrombin complex concentrates (APCCs) appear to be more effective than prothrombin complex concentrates (PCCs) in the control of mild to severe bleeding episodes. There was no good evidence for the use of PCCs in surgery. APCCs controlled bleeding in approximately 90% of surgical episodes. Recombinant factor VIIa (rFVIIa) controlled 70-100% of mild to severe bleeding episodes with high-responding inhibitors, and achieved better results when used early. It was effective in 60-100% of surgical episodes. Doses varied from study to study, and side-effects from mild to infrequent but serious adverse events were reported. The quality of the evidence is variable. Limited evidence relating to other treatment options is also included in the review.

Protein A sepharose immunoadsorption: immunological and haemostatic effects in two cases of acquired haemophilia

Acquired haemophilia is a life-threatening disorder caused by circulating auto-antibodies that inhibit factor VIII coagulant activity (FBIII:C). Immunoadsorption on protein A sepharose (IA-PA) was performed in two bleeding patients with acquired haemophilia: we observed a dramatic and quick decrease in the anti-FVIII:C inhibitor titre leading to a normal, albeit transient, haemostatic status. In one case, IA-PA was the only procedure which succeeded in stopping massive haemorrhage. In the second case, IA-PA reinforced the haemostatic effect of recombinant activated factor VII by increasing the endogenous plasma factor VIII level. The efficacy of IA-PA was sustained with immunosuppressive treatment introduced, respectively, 10 and 15 d before the IA-PA procedures. Our experience with IA-PA suggests that this extracorporeal anti-FVIII:C removal procedure is a valuable therapeutic tool for acquired haemophilia and can alleviate life-threatening haemorrhages.

Immune tolerance induction in the treatment of paediatric haemophilia A patients with factor VIII inhibitors

The development of an inhibitor to transfused factor VIII (FVIII) is a serious treatment-related problem in haemophiliac children. The management of patients with high titre FVIII inhibitors is difficult, and immune tolerance induction (ITI) is the only method available for the eradication of these inhibitors. The results of the ITI regimen used at the Children's Hospital of Michigan Haemophilia Treatment Center are described and discussed. ITI was attempted in 14 children with severe haemophilia A (13 high responders, one low responder), with daily doses of FVIII alone. FVIII dosage was chosen according to the patient's historical peak inhibitor titre. ITI included three phases; induction phase, dose reduction phase and maintenance phase. During the first phase, the starting dose was 50 or 100 U kg-1 d-1; during the second phase the FVIII dosage was reduced gradually to 25 U kg-1 every other day according to the inhibitor titre, FVIII recovery and/or half-life study. In the third (maintenance) phase, the children received either prophylactic therapy or episodic therapy for 12 months. The inhibitor elimination was defined as the time taken to achieve a negative inhibitor assay with no anamnestic response and normal FVIII recovery and/or normal half-life. Immune tolerance was achieved in 11 of 14 patients (79%) patients within a median time of 6 months; two children are still on therapy, three failed ITI. We observed either failure or prolongation of immune tolerance if the historical peak titre or the maximum titre during ITI was >200 BU. The success rate of our low dose ITI regimen is not different from that reported by other investigators and the inhibitor elimination time is similar to some of the studies reported previously.

A case of factor VIII inhibitor-positive acquired hemophilia treated by plasmapheresis

We report on a case of factor VIII inhibitor-positive acquired hemophilia in which combined therapy of plasma exchange (PE) and steroids was effective. The patient, a 68-year-old man, had undergone hemodialysis since April 1998, due to chronic renal failure caused by diabetic nephropathy. The hemostasis of blood access sites gradually became difficult after the initiation of dialysis and the prolongation of activated partial thromboplastin time (APTT) (74.5 s), and a decrease in factor VIII (0.02%) and an abnormally high concentration of factor VIII inhibitor (111 U/ml) were found. Under the diagnosis of factor VIII inhibitor-positive acquired hemophilia, 3 consecutive PE were performed, followed by a large dose administration of gamma globulin. However, the effect of this therapy disappeared within 20 days. Then the PE therapy was performed again accompanied by pulse methylprednisolone therapy. After that, factor VIII inhibitor was suppressed and the patient's hemostatic defect continued to improve even after the reduction of the steroid dose. These results suggest that PE is very effective in treating factor VIII inhibitor-positive acquired hemophilia.

Successful treatment of a non-haemophilic patient with inhibitor to factor VIII by double-filtration plasmapheresis

Factor VIII (FVIII) inhibitors appear in 3-20% of haemophilia A patients after injection of FVIII concentrates. However, autoantibodies to FVIII are also reported in non-haemophiliacs. In these patients FVIII inhibitor disappears spontaneously or diminishes in response to immunosuppressive therapy. However, a few patients show resistance to immunosuppressive therapy. We describe a non-haemophilic elderly patient with acquired FVIII inhibitor who failed to respond to prednisolone. He was treated with double-filtration plasmapheresis (DFPP) which resulted in a very rapid reduction in inhibitor levels and resolution of symptoms.

Hemophilia. A new approach to an old disease

The history of hemophilia diagnosis and therapy has been a turbulent one. We are coming full circle, back to the use of genetics as the main diagnostic tool for this disease. Therapeutically, the retroviruses that ravaged one generation of hemophiliac patients now may participate in the cure for the next generation. The hemophilia community hopes that the future of hemophilia care will follow a course guided by this modified quote from James Russell Lowell: "New times demand new measures, and men [and women]. As the world advances and in time outgrows the laws that in our fathers' [and mothers'] days were the best, doubtless after us some purer scheme will be shaped out by wiser man [and women] than we, made wiser by the steady growth of truth."

Indications for emergency apheresis procedures

Therapeutic apheresis has gained tremendous popularity worldwide in the last 2 decades. Emergency procedures can be life saving but should be undertaken for limited indications. Our emergency indications and experiences since the 1970s are critically described.

[Therapeutic plasma exchange 1996]

Therapeutic plasma exchange (TPE) is an extracorporeal blood purification technique to remove large molecular weight substances. Since the late seventies TPE was used in a variety of diseases in which humoral factors may play a part in the pathogenesis. Today, accepted indications only exist for a few entities in defined situations: Anti-glomerular basement membrane antibody mediated disease, TTP/HUS, Guillain-Barré-syndrome, hyperviscosity syndrome, chronic polyneuropathy associated with IgG and IgA gammopathy, chronic inflammatory demyelinating polyneuropathy and myasthenia gravis.

Haemophilia

Although the nature of haemophilia has been understood for thousands of years, knowledge of its molecular genetics is recent. These X-linked bleeding disorders have diverse underlying DNA defects and, in 1992, DNA inversion within the X chromosome was found to explain half of the most serious cases of haemophilia A. The life-span and quality-of-life for patients with haemophilia had improved steadily throughout the early 1980s but the principal cause of death remained intracranial haemorrhage until the epidemic of HIV infection due to contaminated factor concentrates. Infection with hepatitis C virus is almost universal for patients treated with clotting factors before 1985. No curative treatment is available for hepatitis C at present. Knowledge of the transmission of viruses in concentrates has led to important developments in processing techniques to eliminate them. Recombinant technology has produced factor VIII and, more recently, factor IX concentrate which is likely to be very safe. Development of inhibitors to factor concentrates (especially factor VIII) remains one of the most serious complications of haemophilia. The variety of treatments available testifies to the lack of a single universally efficacious one. The use of prophylactic treatment has been conclusively demonstrated to result in a preservation of joint function in severely affected patients who might otherwise develop significant joint problems. The many facets of the care of patients with severe haemophilia, ranging from dental care to genetic counselling, can be advantageously co-ordinated in a haemophilia comprehensive care centre.

Current Practice in the Treatment of Haemophilia

Haematologists are long standing proponents of evidence based practice-well exemplified among professionals who care for patients with haemophilia. The rapidly expanding range of therapeutic products and the numerous accompanying clinical trials are swiftly interpreted and translated into clinical practice. This translation is formalised by frequently updated quidelines issued by the United Kingdom Haemophilia Centre Directors' Organisation (UKHCDO) and relevant to all doctors involved in the care of patients with haemophilia. In the last five years eight sets of guidelines have been issued in the UK alone relating to the treatment of haemophilia and its complications [1-8]. Against this background we aim to review current practice in the treatment of haemophilia.

Acquired inhibitors

Factor VIII auto-antibody inhibitors, though rare, may present significant and often life-threatening haemorrhage. These auto-antibodies, arising predominantly in older individuals, occur in association with autoimmune disorders, lymphoproliferative disorders, solid tumours, medications and the postpartum state. Almost half of the patients develop auto-antibodies spontaneously without an underlying medical condition. Factor VIII auto-antibody inhibitors are characterized as polyclonal IgG immunoglobulins directed against the FVIII procoagulant activity. Laboratory diagnosis is made by performing the aPTT clotting time in conjunction with a mixing study, and subsequently with specific factor assays. Auto-antibodies are quantified most commonly utilizing the Bethesda assay. Acquired inhibitors to other coagulation factors, including factors IX, XI, XIII, vWF protein, and the vitamin K-dependent proteins are extremely rare. The principles of therapy are similar to those which apply to the management of factor VIII auto-antibodies. Treatment of patients with acquired factor VIII auto-antibody inhibitors varies depending upon the underlying medical condition, the titre of the inhibitor, and the clinical presentation. Acutely bleeding patients with high-titre auto-antibodies generally respond well with infusions of porcine factor VIII concentrate, PCCs or rFVIIa. Extracorporeal plasmapheresis with exchange will acutely reduce circulating antibodies and can be used in conjunction with factor infusions and/or IgIV. Haemorrhage in a patient with a low titre auto-antibody will usually respond to high doses of human factor VIII concentrate. DDAVP may also increase factor VIII levels in patients with low-titre inhibitors. Long-term reduction of auto-antibodies can be achieved by immuno-suppressive regimens using steroids and/or cytotoxic agents, IgIV and interferon-alpha. The selection of the appropriate treatment depends upon the associated medical condition, likelihood of spontaneous remission, risk of toxicities of therapy and cost. Determining the efficacy and safety of new treatment modalities for factor VIII auto-antibodies and other coagulation factor inhibitors will require multicentre randomized clinical trials.

Hemophilia 1996. New approach to an old disease

The history of hemophilia diagnosis and therapy has been a turbulent one. We are coming full circle, back to the use of genetics as the main diagnostic tool for this disease. Therapeutically, the retroviruses that ravaged one generation of hemophiliac patients now may participate in the cure for the next generation. The hemophilia community hopes that the future of hemophilia care will follow a course guided by this modified quote from James Russell Lowell: "New times demand new measures, and men [and women]. As the world advances and in time outgrows the laws that in our fathers' [and mothers'] days were the best, doubtless after us some purer scheme will be shaped out by wiser men [and women] than we, made wiser by the steady growth of truth."

The use of polyelectrolyte-fractionated porcine factor VIII in the treatment of a spontaneously acquired inhibitor to factor VIII

Polyelectrolyte-fractionated porcine factor VIII concentrate is a recent addition to the therapeutic choices for treatment of factor VIII inhibitor patients, but cross-reactivity of the inhibitor with porcine factor VIII limits its usefulness in some cases. Hemophilic patients with inhibitor titers greater than or equal to 50 Bethesda units/micromilligrams often demonstrate sufficient cross-reactivity (10-20%) to prevent the achievement of a satisfactory plasma factor VIII level and a therapeutic response with porcine factor VIII. We have studied plasma from five women with high-titer, spontaneously acquired factor VIII inhibitors to determine the degree of cross-reactivity with porcine factor VIII. Four of the five had little or no detectable inhibitor to porcine factor VIII despite high titers to human factor VIII (26-143 Bethesda units/micromilligrams). One of these patients, with a titer of 53 Bethesda units/micromilligrams against human factor VIII, was treated successfully with porcine factor VIII concentrate, given for serious hemorrhagic complications. These studies and other reports support the conclusion that the majority of high-titer spontaneous factor VIII inhibitors exhibit little cross-reactivity with porcine factor VIII and can be treated successfully with this product.

Effect of intravenous immunoglobulin on a spontaneous inhibitor to factor VIII

A 71-year-old woman with a spontaneous anti-factor VIII inhibitor fractured her right wrist and 2 months later her left femur. She received treatment with porcine factor VIII for the first fracture and developed a secondary anti-porcine antibody response (from 10 to 200 Bethesda units). Following the second fracture she received intravenous immunoglobulin (i.v. IgG) (0.4 g/kg day for 5 days) in an attempt to reduce antibody activity. Despite further treatment with porcine factor VIII, the antibody level declined instead of rising as expected and the anti-human antibody activity also declined. We were not able to demonstrate neutralizing activity to her antibody but did demonstrate a reduced helper: suppressor ratio and reduced B-cell numbers and function after treatment with i.v. IgG. These changes were transient and as B-cell function improved over the following 4 months, her anti-human activity returned toward its previous level. Anti-porcine activity remained at its previous low level. We speculate that one of the mechanisms of action of i.v. IgG may be a direct cellular effect influencing both T-suppressor and B-lymphocyte function.

Prostatectomy in patients with bleeding disorders

Urological surgery is becoming increasingly necessary in patients with acquired or congenital bleeding disorders. We reviewed the management of 10 such patients who required prostatectomy. The average age of the patients at operation was 65.7 years. Seven patients underwent transurethral prostatectomy and 3 underwent suprapubic prostatectomy. Postoperative bleeding occurred in 9 patients who required secondary procedures. Bleeding occurred an average of 13 days postoperatively. The mean hospital stay was 24 days. Partial thromboplastin time when determined was uniformly elevated in all patients preoperatively. The amount of factor and blood replacement is presented. Perioperative management of these patients is discussed in detail. A rational approach for the prevention of postoperative bleeding is presented.

A potential new procedure for removing anti-factor VIII antibodies from hemophilic plasma

A new approach for removing the anti-factor VIII antibodies in hemophilic patients by immunoadsorption is proposed. The method is based on the fact that the anti-factor VIII antibodies were predominantly of the IgG4 subclass; anti-human IgG4 antibodies were covalently linked to agarose and large amounts of anti-factor VIII antibodies can be eliminated. A study of 21 blood samples from hemophilic patients with anti-factor VIII antibodies allows us to confirm the large predominance of IgG4 in the anti-factor VIII population. In some samples, the presence of IgG3 related anti-VIII:C was checked by adsorption on an anti-IgG3 column. In a majority of cases, after IgG4 (or IgG4 + IgG3) immunoadsorption, the substitution therapy becomes possible or easier.

Spontaneously acquired anti-factor VIII antibodies: report of a patient with adenocarcinoma of the prostate

Anti-factor VIII antibodies, inherited or acquired inhibitors of the factor VIII molecule, have not been reported previously in the urological literature. Although more common in hemophiliac patients who have received multiple transfusions, this anticoagulant may be the cause of severe hemorrhage in nonhemophiliac patients. We describe a patient with carcinoma of the prostate and an unsuspected anti-factor VIII antibody, who experienced excessive postoperative bleeding and prolonged hospitalization following a vesicolithotomy and bilateral orchiectomy. A prolonged partial thromboplastin time and a significant decrease in measurable factor VIII clotting activity in a patient with no history of bleeding problems are essential clues in making the diagnosis of a factor VIII inhibitor. This coagulation defect is treated best with prothrombin complex concentrates, which contain vitamin K dependent clotting factors.

Therapeutic apheresis. Applications and future directions

The past 10-15 years have been witness to major technological achievements in the field of therapeutic apheresis. Concurrently, a large number of diseases, primarily with an immunological basis, have been treated with apheresis. In this paper, we review the various applications of therapeutic apheresis, adverse reactions associated with the mode of therapy, and future research directions. Several representative diseases are also discussed in detail.

Plasma exchange in autoimmune thrombocytopenic purpura

We present data on 5 cases with autoimmune thrombocytopenic purpura treated with plasma exchange in whom conventional drug therapy had been ineffective. In 3, preparation for splenectomy allowed the operation to be performed without bleeding problems. 1 patient who was unfit for splenectomy underwent successful coronary artery vein grafting following preparation with plasma exchange. 2 patients were maintained for variable periods with intermittent exchanges, 1 prior to splenectomy and 1 post-splenectomy. In summary we had no prolonged response to plasma exchange but found it a useful technique as preparation for or adjunctive to more conventional therapy. It was also helpful in patients unresponsive to other forms of therapy who required a brief increase in platelet count to cover surgery or spontaneous haemorrhage.

Therapeutic apheresis

Therapeutic applications using semiautomated blood cell separators have improved the clinical management of several disorders through cellular or plasma depletion, or by rapid erythrocyte or plasma replacement. Cytapheresis procedures may remove large numbers of platelets or leukocytes in proliferative disorders, or induce and maintain a lymphopenia in "autoimmune" diseases. Rapid reductions in circulating paraproteins, autoantibodies, and immune complexes can be achieved to augment longer-term cytotoxic or immunosuppressive therapy. Therapeutic apheresis is adjunctive or palliative, not curative, and is usually short-term rather than chronic. Familiarity with the evolving indications for intervention with apheresis is essential for maximal benefit and minimal risk to the patients recommended for therapy.

Role of plasma-exchange in the management of patients with factor VIII inhibitors

Plasma-exchange is one of many treatments available for the prevention and management of hemorrhage in patients with factor VIII inhibitors. Details of exchange technique and the frequency of treatment are determined by the clinical situation, venous access and the availability of equipment, staff and blood products. In view of the many difficulties associated with plasma-exchange, other treatment options are likely to be preferred in most circumstances. The technique remains attractive as a means for reducing inhibitory activity before elective surgery and during life-threatening hemorrhage.

Treatment of the Guillain-Barré syndrome by plasma exchange

Twelve consecutive patients with Guillain-Barré syndrome were treated with plasma exchange. Examination two weeks after treatment was commenced showed that three had not improved. Five showed only a minimal improvement, which was considered to be compatible with the natural history of the disease. The remaining four patients showed a more substantial improvement which could have been related to the plasma exchange.