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Oleshko O, Vollack-Hesse N, Tiede A, Hegermann J, Curth U, Werwitzke S. von Willebrand factor modulates immune complexes and the recall response against factor VIII in a murine hemophilia A model. Blood Adv 2023; 7:6771-6781. [PMID: 37756521 PMCID: PMC10660012 DOI: 10.1182/bloodadvances.2023010388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 09/13/2023] [Accepted: 09/16/2023] [Indexed: 09/29/2023] Open
Abstract
Achieving tolerance toward factor VIII (FVIII) remains an important goal of hemophilia treatment. Up to 40% of patients with severe hemophilia A (HA) develop neutralizing antibodies against FVIII, and the only proven treatment to achieve tolerance is infusion of FVIII over prolonged periods in the context of immune tolerance induction. Here, we addressed the role of von Willebrand factor (VWF) as a modulator of anti-FVIII antibody effector functions and the FVIII-specific recall response in an HA mouse model. Analytical ultracentrifugation was used to demonstrate formation of FVIII-containing immune complexes (FVIII-ICs). VWF did not fully prevent FVIII-IC formation but was rather incorporated into larger macromolecular complexes. VWF prevented binding of FVIII-ICs to complement C1q, most efficiently when it was preincubated with FVIII before the addition of antibodies. It also prevented binding to immobilized Fc-γ receptor and to bone marrow-derived dendritic cells. An in vitro model of the anti-FVIII recall response demonstrated that addition of VWF to FVIII abolished the proliferation of FVIII-specific antibody-secreting cells. After adoptive transfer of sensitized splenocytes into immunocompetent HA mice, the FVIII recall response was diminished by VWF. In summary, these data indicate that VWF modulates the formation and effector functions of FVIII-ICs and attenuates the secondary immune response to FVIII in HA mice.
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Affiliation(s)
- Olga Oleshko
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Nadine Vollack-Hesse
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Andreas Tiede
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Jan Hegermann
- Research Core Unit Electron Microscopy, Institute of Functional and Applied Anatomy, Hannover Medical School, Hannover, Germany
| | - Ute Curth
- Institute for Biophysical Chemistry, Hannover Medical School, Hannover, Germany
| | - Sonja Werwitzke
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
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2
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Sarmiento Doncel S, Díaz Mosquera GA, Cortes JM, Agudelo Rico C, Meza Cadavid FJ, Peláez RG. Haemophilia A: A Review of Clinical Manifestations, Treatment, Mutations, and the Development of Inhibitors. Hematol Rep 2023; 15:130-150. [PMID: 36810557 PMCID: PMC9944491 DOI: 10.3390/hematolrep15010014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 09/07/2022] [Accepted: 02/10/2023] [Indexed: 02/18/2023] Open
Abstract
The purpose of this narrative review was to provide an overview that allows readers to improve their understanding of hemophilia A, which is considered a genetic disease with a high impact on the quality of life of people who suffer from it is considered one of the diseases with the highest cost for health systems (In Colombia it is part of the five diseases with the greatest economic impact). After this exhaustive review, we can see that the treatment of hemophilia is on the way to precision medicine, which involves genetic variables specific to each race and ethnicity, pharmacokinetics (PK), as well as environmental factors and lifestyle. Knowing the impact of each of these variables and their relationship with the efficacy of treatment (prophylaxis: regular infusion of the missing clotting factor VIII in order to prevent spontaneous bleeding) will allow for individualizing the medical behavior in a cost-effective way. For this is required to build more strong scientific evidence with statistical power that allows us to infer.
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Affiliation(s)
- Samuel Sarmiento Doncel
- Integral Solutions SD SAS, Integral Solutions Research, Bogota 110121, Colombia
- Life Sciences and Health Research Group, Graduates School, CES University, Medellin 050021, Colombia
| | | | | | - Carol Agudelo Rico
- Integral Solutions SD SAS, Integral Solutions Research, Bogota 110121, Colombia
| | - Francisco Javier Meza Cadavid
- Integral Solutions SD SAS, Integral Solutions Research, Bogota 110121, Colombia
- Hospital Universitario San Jorge, Pereira 660002, Colombia
| | - Ronald Guillermo Peláez
- Life Sciences and Health Research Group, Graduates School, CES University, Medellin 050021, Colombia
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3
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Becker-Gotot J, Meissner M, Kotov V, Jurado-Mestre B, Maione A, Pannek A, Albert T, Flores C, Schildberg FA, Gleeson PA, Reipert BM, Oldenburg J, Kurts C. Immune tolerance against infused FVIII in hemophilia A is mediated by PD-L1+ Tregs. J Clin Invest 2022; 132:e159925. [PMID: 36107620 PMCID: PMC9663153 DOI: 10.1172/jci159925] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 09/13/2022] [Indexed: 11/03/2023] Open
Abstract
A major complication of hemophilia A therapy is the development of alloantibodies (inhibitors) that neutralize intravenously administered coagulation factor VIII (FVIII). Immune tolerance induction therapy (ITI) by repetitive FVIII injection can eradicate inhibitors, and thereby reduce morbidity and treatment costs. However, ITI success is difficult to predict and the underlying immunological mechanisms are unknown. Here, we demonstrated that immune tolerance against FVIII under nonhemophilic conditions was maintained by programmed death (PD) ligand 1-expressing (PD-L1-expressing) regulatory T cells (Tregs) that ligated PD-1 on FVIII-specific B cells, causing them to undergo apoptosis. FVIII-deficient mice injected with FVIII lacked such Tregs and developed inhibitors. Using an ITI mouse model, we found that repetitive FVIII injection induced FVIII-specific PD-L1+ Tregs and reengaged removal of inhibitor-forming B cells. We also demonstrated the existence of FVIII-specific Tregs in humans and showed that such Tregs upregulated PD-L1 in patients with hemophilia after successful ITI. Simultaneously, FVIII-specific B cells upregulated PD-1 and became killable by Tregs. In summary, we showed that PD-1-mediated B cell tolerance against FVIII operated in healthy individuals and in patients with hemophilia A without inhibitors, and that ITI reengaged this mechanism. These findings may impact monitoring of ITI success and treatment of patients with hemophilia A.
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Affiliation(s)
- Janine Becker-Gotot
- Institute of Molecular Medicine and Experimental Immunology (IMMEI), Rheinische Friedrich-Wilhelms-Universität, Venusberg Campus 1, Bonn, Germany
| | - Mirjam Meissner
- Institute of Molecular Medicine and Experimental Immunology (IMMEI), Rheinische Friedrich-Wilhelms-Universität, Venusberg Campus 1, Bonn, Germany
| | - Vadim Kotov
- Institute of Molecular Medicine and Experimental Immunology (IMMEI), Rheinische Friedrich-Wilhelms-Universität, Venusberg Campus 1, Bonn, Germany
| | - Blanca Jurado-Mestre
- Institute of Molecular Medicine and Experimental Immunology (IMMEI), Rheinische Friedrich-Wilhelms-Universität, Venusberg Campus 1, Bonn, Germany
| | - Andrea Maione
- Institute of Molecular Medicine and Experimental Immunology (IMMEI), Rheinische Friedrich-Wilhelms-Universität, Venusberg Campus 1, Bonn, Germany
- Department of Biochemistry and Pharmacology, Bio21 Molecular Science and Biotechnology Institute, The University of Melbourne, Parkville, Victoria, Australia
| | - Andreas Pannek
- Institute of Molecular Medicine and Experimental Immunology (IMMEI), Rheinische Friedrich-Wilhelms-Universität, Venusberg Campus 1, Bonn, Germany
- Department of Biochemistry and Pharmacology, Bio21 Molecular Science and Biotechnology Institute, The University of Melbourne, Parkville, Victoria, Australia
| | - Thilo Albert
- Institute for Experimental Hematology and Transfusion Medicine (IHT), Rheinische Friedrich-Wilhelms-Universität, Venusberg Campus 1, Bonn, Germany
| | - Chrystel Flores
- Institute of Molecular Medicine and Experimental Immunology (IMMEI), Rheinische Friedrich-Wilhelms-Universität, Venusberg Campus 1, Bonn, Germany
| | - Frank A. Schildberg
- Clinic for Orthopedics and Trauma Surgery, University Hospital Bonn, Bonn, Germany
| | - Paul A. Gleeson
- Department of Biochemistry and Pharmacology, Bio21 Molecular Science and Biotechnology Institute, The University of Melbourne, Parkville, Victoria, Australia
| | | | - Johannes Oldenburg
- Institute for Experimental Hematology and Transfusion Medicine (IHT), Rheinische Friedrich-Wilhelms-Universität, Venusberg Campus 1, Bonn, Germany
| | - Christian Kurts
- Institute of Molecular Medicine and Experimental Immunology (IMMEI), Rheinische Friedrich-Wilhelms-Universität, Venusberg Campus 1, Bonn, Germany
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4
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Lundgren TS, Denning G, Stowell SR, Spencer HT, Doering CB. Pharmacokinetic analysis identifies a factor VIII immunogenicity threshold after AAV gene therapy in hemophilia A mice. Blood Adv 2022; 6:2628-2645. [PMID: 35286375 PMCID: PMC9043920 DOI: 10.1182/bloodadvances.2021006359] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 02/28/2022] [Indexed: 11/20/2022] Open
Abstract
Advances in the development of novel treatment options for hemophilia A are prevalent. However, the anti-factor VIII (FVIII) neutralizing antibody (inhibitor) response to existing FVIII products remains a major treatment challenge. Although some novel products are designed to function in the presence of inhibitors, they do not specific address the immunogenicity risk or mechanistic causes of inhibitor development, which remain unclear. Furthermore, most preclinical studies supporting clinical gene therapy programs have reported immunogenicity signals in animal models, especially at higher vector doses and sometimes using multiple vector designs. In these settings, immunogenicity risk factor determination, comparative immunogenicity of competing vector designs, and the potential for obtaining meaningful prognostic data remain relatively unexplored. Additionally, there remains the opportunity to investigate clinical gene therapy as an alternative to standard immune tolerance induction therapy. The current study was designed to address these issues through longitudinal dose-response evaluation of 4 adeno-associated viral (AAV) vector candidates encoding 2 different FVIII transgenes in a murine model of hemophilia A. Plasma FVIII activity and anti-FVIII antibody data were used to generate a pharmacokinetic model that (1) identifies initial AAV-FVIII product expression kinetics as the dominant risk factor for inhibitor development, (2) predicts a therapeutic window where immune tolerance is achieved, and (3) demonstrates evidence of gene therapy-based immune tolerance induction. Although there are known limitations to the predictive value of preclinical immunogenicity testing, these studies can uncover or support the development of design principles that can guide the development of safe and effective genetic medicines.
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Affiliation(s)
- Taran S. Lundgren
- Graduate Program in Molecular and Systems Pharmacology, Laney Graduate School, Emory University, Atlanta, GA
| | | | - Sean R. Stowell
- Joint Program in Transfusion Medicine, Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; and
| | - H. Trent Spencer
- Expression Therapeutics, Inc., Tucker, GA
- Aflac Cancer and Blood Disorders Center, Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA
| | - Christopher B. Doering
- Expression Therapeutics, Inc., Tucker, GA
- Aflac Cancer and Blood Disorders Center, Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA
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5
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Kumar SR, Xie J, Hu S, Ko J, Huang Q, Brown HC, Srivastava A, Markusic DM, Doering CB, Spencer HT, Srivastava A, Gao G, Herzog RW. Coagulation factor IX gene transfer to non-human primates using engineered AAV3 capsid and hepatic optimized expression cassette. Mol Ther Methods Clin Dev 2021; 23:98-107. [PMID: 34631930 PMCID: PMC8476648 DOI: 10.1016/j.omtm.2021.08.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 08/10/2021] [Indexed: 11/17/2022]
Abstract
Hepatic gene transfer with adeno-associated viral (AAV) vectors shows much promise for the treatment of the X-linked bleeding disorder hemophilia B in multiple clinical trials. In an effort to further innovate this approach and to introduce alternative vector designs with potentially superior features into clinical development, we recently built a vector platform based on AAV serotype 3 because of its superior tropism for human hepatocytes. A vector genome with serotype-matched inverted terminal repeats expressing hyperactive human coagulation factor IX (FIX)-Padua was designed for clinical use that is optimized for translation using hepatocyte-specific codon-usage bias and is depleted of immune stimulatory CpG motifs. Here, this vector genome was packaged into AAV3 (T492V + S663V) capsid for hepatic gene transfer in non-human primates. FIX activity within or near the normal range was obtained at a low vector dose of 5 × 1011 vector genomes/kg. Pre-existing neutralizing antibodies, however, completely or partially blocked hepatic gene transfer at that dose. No CD8+ T cell response against capsid was observed. Antibodies against the human FIX transgene product formed at a 10-fold higher vector dose, albeit hepatic gene transfer was remarkably consistent, and sustained FIX activity in the normal range was nonetheless achieved in two of three animals for the 3-month duration of the study. These results support the use of this vector at low vector doses for gene therapy of hemophilia B in humans.
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Affiliation(s)
- Sandeep R.P. Kumar
- Department of Pediatrics, Herman B Wells Center for Pediatric Research, Indiana University, Indianapolis, IN, USA
| | - Jun Xie
- Horae Gene Therapy Center, Department of Microbiology and Physiological Systems, University of Massachusetts Medical School, Worcester, MA, USA
| | - Shilang Hu
- Horae Gene Therapy Center, Department of Microbiology and Physiological Systems, University of Massachusetts Medical School, Worcester, MA, USA
| | - Jihye Ko
- Horae Gene Therapy Center, Department of Microbiology and Physiological Systems, University of Massachusetts Medical School, Worcester, MA, USA
| | - Qifeng Huang
- Horae Gene Therapy Center, Department of Microbiology and Physiological Systems, University of Massachusetts Medical School, Worcester, MA, USA
| | | | - Alok Srivastava
- Department of Haematology, Christian Medical College and Centre for Stem Cell Research (a Unit of inStem, Bengaluru), Vellore, Tamil Nadu, India
| | - David M. Markusic
- Department of Pediatrics, Herman B Wells Center for Pediatric Research, Indiana University, Indianapolis, IN, USA
| | - Christopher B. Doering
- Department of Pediatrics, Aflac Cancer and Blood Disorders Center, Emory University School of Medicine, Atlanta, GA, USA
| | - H. Trent Spencer
- Department of Pediatrics, Aflac Cancer and Blood Disorders Center, Emory University School of Medicine, Atlanta, GA, USA
| | - Arun Srivastava
- Division of Cellular and Molecular Therapy, Departments of Pediatrics and Molecular Genetics and Microbiology, Powell Gene Therapy Center, University of Florida College of Medicine, Gainesville, FL, USA
| | - Guangping Gao
- Horae Gene Therapy Center, Department of Microbiology and Physiological Systems, University of Massachusetts Medical School, Worcester, MA, USA
- Li Weibo Institute for Rare Diseases Research, University of Massachusetts Medical School, Worcester, MA, USA
| | - Roland W. Herzog
- Department of Pediatrics, Herman B Wells Center for Pediatric Research, Indiana University, Indianapolis, IN, USA
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6
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Doshi BS, Rana J, Castaman G, Shaheen MA, Kaczmarek R, Butterfield JS, Meeks SL, Leissinger C, Biswas M, Arruda VR. B cell-activating factor modulates the factor VIII immune response in hemophilia A. J Clin Invest 2021; 131:142906. [PMID: 33651716 PMCID: PMC8262462 DOI: 10.1172/jci142906] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 02/23/2021] [Indexed: 01/19/2023] Open
Abstract
Inhibitors of factor VIII (FVIII) remain the most challenging complication of FVIII protein replacement therapy in hemophilia A (HA). Understanding the mechanisms that guide FVIII-specific B cell development could help identify therapeutic targets. The B cell-activating factor (BAFF) cytokine family is a key regulator of B cell differentiation in normal homeostasis and immune disorders. Thus, we used patient samples and mouse models to investigate the potential role of BAFF in modulating FVIII inhibitors. BAFF levels were elevated in pediatric and adult HA inhibitor patients and decreased to levels similar to those of noninhibitor controls after successful immune tolerance induction (ITI). Moreover, elevations in BAFF levels were seen in patients who failed to achieve FVIII tolerance with anti-CD20 antibody-mediated B cell depletion. In naive HA mice, prophylactic anti-BAFF antibody therapy prior to FVIII immunization prevented inhibitor formation and this tolerance was maintained despite FVIII exposure after immune reconstitution. In preimmunized HA mice, combination therapy with anti-CD20 and anti-BAFF antibodies dramatically reduced FVIII inhibitors via inhibition of FVIII-specific plasma cells. Our data suggest that BAFF may regulate the generation and maintenance of FVIII inhibitors and/or anti-FVIII B cells. Finally, anti-CD20/anti-BAFF combination therapy may be clinically useful for ITI.
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Affiliation(s)
- Bhavya S Doshi
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Divison of Hematology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jyoti Rana
- Herman B. Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Giancarlo Castaman
- Center for Bleeding Disorders and Coagulation, Careggi University Hospital, Florence, Italy
| | - Mostafa A Shaheen
- Divison of Hematology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Radoslaw Kaczmarek
- Herman B. Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - John Ss Butterfield
- Herman B. Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Shannon L Meeks
- Department of Pediatrics, Aflac Cancer Center and Blood Disorders Center at Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Cindy Leissinger
- Section of Hematology/Oncology, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Moanaro Biswas
- Herman B. Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Valder R Arruda
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Divison of Hematology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Raymond G. Perelman Center for Cellular and Molecular Therapies, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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7
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Role of Regulatory Cells in Immune Tolerance Induction in Hemophilia A. Hemasphere 2021; 5:e557. [PMID: 33898928 PMCID: PMC8061682 DOI: 10.1097/hs9.0000000000000557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 03/09/2021] [Indexed: 11/26/2022] Open
Abstract
The main complication of hemophilia A treatment is the development of neutralizing antibodies (inhibitors) against factor VIII (FVIII). Immune tolerance induction (ITI) is the prescribed treatment for inhibitor eradication, although its working mechanism remains unresolved. To clarify this mechanism, we compared blood samples of hemophilia A patients with and without inhibitors for presence of immunoregulatory cells and markers, including regulatory B-cells (Bregs), regulatory T-cells (Tregs), myeloid-derived suppressor cells (MDSCs), and expression of regulatory markers on T-cells (programmed cell death protein 1 [PD1], inducable T-cell costimulator, cytotoxic T-lymphocyte-associated protein 4 [CTLA4]), by use of flow cytometry. By cross-sectional analysis inhibitor patients (N = 20) were compared with inhibitor-negative (N = 28) and ex-inhibitor (N = 17) patients. In another longitudinal study, changes in immunoregulatory parameters were evaluated during ITI (N = 12) and compared with inhibitor-negative hemophilia A patients (N = 36). The frequency of Bregs, but not of Tregs nor MDSCs, was significantly reduced in inhibitor patients (3.2%) compared with inhibitor-negative (5.9%) and ex-inhibitor patients (8.9%; P < 0.01). CTLA4 expression on T-cells was also reduced (mean fluorescence intensity 133 in inhibitor versus 537 in inhibitor-negative patients; P < 0.01). Fittingly, in patients followed during ITI, inhibitor eradication associated with increased Bregs, increased Tregs, and increased expression of CTLA4 and PD1 on CD4+ T-cells. In conclusion, inhibitor patients express significantly lower frequency of Bregs and Tregs marker expression, which are restored by successful ITI. Our findings suggest that an existing anti-FVIII immune response is associated with deficits in peripheral tolerance mechanisms and that Bregs and changes in immunoregulatory properties of CD4+ T-cells likely contribute to ITI in hemophilia A patients with inhibitors.
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8
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Boylan B, Niemeyer GP, Werner B, Miller CH. Evaluation of anti-factor VIII antibody levels in patients with haemophilia A receiving immune tolerance induction therapy or bypassing agents. Haemophilia 2020; 27:e40-e50. [PMID: 33216433 DOI: 10.1111/hae.14202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 10/13/2020] [Accepted: 10/26/2020] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Bleeding episodes in patients who have haemophilia A (HA), a hereditary bleeding disorder caused by a deficiency in factor VIII (FVIII), are treated or prophylactically prevented with infusions of exogenous FVIII. Neutralizing antibodies, referred to as inhibitors, against infusion products are a major complication experienced by up to 30% of patients who have severe HA. Bypassing agents (BPA), a class of therapeutics given to patients who have inhibitors, bypass the need for FVIII in the coagulation cascade, and long-term inhibitor eradication is accomplished using immune tolerance induction therapy (ITI). Data examining the antibody levels in patients receiving BPA and ITI are limited. AIM Measure anti-FVIII antibody levels in specimens from patients receiving ITI or BPA in order to evaluate the anti-FVIII antibody response in those patients. METHODS Specimens were tested using the CDC-modified Nijmegen-Bethesda assay (NBA) and the CDC fluorescence immunoassay (FLI) for anti-FVIII IgG1 and IgG4 . RESULTS NBA-negative specimens from patients undergoing ITI or receiving BPAs have a higher frequency of anti-FVIII IgG4 positivity compared with the previously published level for NBA-negative HA patients. Analysis of anti-FVIII antibody levels in serial samples from patients undergoing ITI reveals that antibodies can persist even after the patient's NBA result falls into the negative range. CONCLUSIONS Measurement of anti-FVIII antibodies may be a useful means to better contextualize NBA results in specimens from patients receiving BPA or ITI. In addition, assessment of anti-FVIII antibody levels has the potential to improve inhibitor surveillance and clinical decision-making related to the progress of ITI.
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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, GA, USA
| | - Glenn P Niemeyer
- Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Bonnie Werner
- Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Connie H Miller
- Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, USA
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9
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Biswas M, Palaschak B, Kumar SRP, Rana J, Markusic DM. B Cell Depletion Eliminates FVIII Memory B Cells and Enhances AAV8-coF8 Immune Tolerance Induction When Combined With Rapamycin. Front Immunol 2020; 11:1293. [PMID: 32670285 PMCID: PMC7327091 DOI: 10.3389/fimmu.2020.01293] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 05/21/2020] [Indexed: 01/19/2023] Open
Abstract
Hemophilia A is an inherited coagulation disorder resulting in the loss of functional clotting factor VIII (FVIII). Presently, the most effective treatment is prophylactic protein replacement therapy. However, this requires frequent life-long intravenous infusions of plasma derived or recombinant clotting factors and is not a cure. A major complication is the development of inhibitory antibodies that nullify the replacement factor. Immune tolerance induction (ITI) therapy to reverse inhibitors can last from months to years, requires daily or every other day infusions of supraphysiological levels of FVIII and is effective in only up to 70% of hemophilia A patients. Preclinical and recent clinical studies have shown that gene replacement therapy with AAV vectors can effectively cure hemophilia A patients. However, it is unclear how hemophilia patients with high risk inhibitor F8 mutations or with established inhibitors will respond to gene therapy, as these patients have been excluded from ongoing clinical trials. AAV8-coF8 gene transfer in naïve BALB/c-F8e16−/Y mice (BALB/c-HA) results in anti-FVIII IgG1 inhibitors following gene transfer, which can be prevented by transient immune modulation with anti-mCD20 (18B12) and oral rapamycin. We investigated if we could improve ITI in inhibitor positive mice by combining anti-mCD20 and rapamycin with AAV8-coF8 gene therapy. Our hypothesis was that continuous expression of FVIII protein from gene transfer compared to transient FVIII from weekly protein therapy, would enhance regulatory T cell induction and promote deletion of FVIII reactive B cells, following reconstitution. Mice that received anti-CD20 had a sharp decline in inhibitors, which corresponded to FVIII memory B (Bmem) cell deletion. Importantly, only mice receiving both anti-mCD20 and rapamycin failed to increase inhibitors following rechallenge with intravenous FVIII protein therapy. Our data show that B and T cell immune modulation complements AAV8-coF8 gene therapy in naïve and inhibitor positive hemophilia A mice and suggest that such protocols should be considered for AAV gene therapy in high risk or inhibitor positive hemophilia patients.
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Affiliation(s)
- Moanaro Biswas
- Herman B Wells Center for Pediatric Research, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Brett Palaschak
- Department of Pediatrics, University of Florida, Gainesville, FL, United States
| | - Sandeep R P Kumar
- Herman B Wells Center for Pediatric Research, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Jyoti Rana
- Herman B Wells Center for Pediatric Research, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, United States
| | - David M Markusic
- Herman B Wells Center for Pediatric Research, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, United States
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10
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Pohl ADP, Venkatesha SH, Zhang AH, Scott DW. Suppression of FVIII-Specific Memory B Cells by Chimeric BAR Receptor-Engineered Natural Regulatory T Cells. Front Immunol 2020; 11:693. [PMID: 32373126 PMCID: PMC7186411 DOI: 10.3389/fimmu.2020.00693] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2020] [Accepted: 03/26/2020] [Indexed: 11/18/2022] Open
Abstract
Anti-drug antibody formation poses tremendous obstacles for optimal treatment of hemophilia A (HA). In this study, we sought to utilize chimeric receptor-modified natural regulatory T cells (Tregs) to target FVIII-specific memory B cells, which are responsible for persistent anti-FVIII neutralizing antibodies (inhibitors) in HA patients. Thus, CD4+CD25hiCD304+ natural Tregs were FACS sorted from naïve C57BL/6 mice and retrovirally transduced to express a chimeric B-cell antibody receptor (BAR) containing the immunodominant A2 domain of FVIII. Plasmablast-depleted (CD138neg) splenocytes from FVIII immunized FVIII-knockout HA mice served as the source for FVIII-specific memory B cells, which were specifically stimulated in vitro with FVIII and enumerated in a B-cell ELISPOT assays. Adding A2-BAR Tregs (1 per 150 splenocytes), but not conventional T cells, to the CD138– splenocytes significantly suppressed the formation of anti-FVIII antibody secreting cells (ASC), compared to the non-relevant OVA-BAR Tregs control group. The observation that A2-BAR Tregs can suppress the response to FVIII suggests that bystander suppression can occur in the local milieu in this system. Transwell experiments confirmed that the suppression was contact-dependent. Moreover, even in the presence of antibodies to FVIII (so-called inhibitors), similarly prepared CD4+CD25hiCD127low A2-BAR human natural Tregs completely suppressed polyclonal anti-FVIII ASC formation. In conclusion, we demonstrated in vitro that FVIII domain-expressing BAR Tregs could efficiently target and suppress FVIII-specific memory B cells.
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Affiliation(s)
- Alessandra De Paula Pohl
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | - Shivaprasad H Venkatesha
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | - Ai-Hong Zhang
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | - David W Scott
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
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11
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Atiqi S, Hooijberg F, Loeff FC, Rispens T, Wolbink GJ. Immunogenicity of TNF-Inhibitors. Front Immunol 2020; 11:312. [PMID: 32174918 PMCID: PMC7055461 DOI: 10.3389/fimmu.2020.00312] [Citation(s) in RCA: 85] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Accepted: 02/07/2020] [Indexed: 01/19/2023] Open
Abstract
Tumor necrosis factor inhibitors (TNFi) have significantly improved treatment outcome of rheumatic diseases since their incorporation into treatment protocols two decades ago. Nevertheless, a substantial fraction of patients experiences either primary or secondary failure to TNFi due to ineffectiveness of the drug or adverse reactions. Secondary failure and adverse events can be related to the development of anti-drug antibodies (ADA). The earliest studies that reported ADA toward TNFi mainly used drug-sensitive assays. Retrospectively, we recognize this has led to an underestimation of the amount of ADA produced due to drug interference. Drug-tolerant ADA assays also detect ADA in the presence of drug, which has contributed to the currently reported higher incidence of ADA development. Comprehension and awareness of the assay format used for ADA detection is thus essential to interpret ADA measurements correctly. In addition, a concurrent drug level measurement is informative as it may provide insight in the extent of underestimation of ADA levels and improves understanding the clinical consequences of ADA formation. The clinical effects are dependent on the ratio between the amount of drug that is neutralized by ADA and the amount of unbound drug. Pharmacokinetic modeling might be useful in this context. The ADA response generally gives rise to high affinity IgG antibodies, but this response will differ between patients. Some patients will not reach the phase of affinity maturation while others generate an enduring high titer high affinity IgG response. This response can be transient in some patients, indicating a mechanism of tolerance induction or B-cell anergy. In this review several different aspects of the ADA response toward TNFi will be discussed. It will highlight the ADA assays, characteristics and regulation of the ADA response, impact of immunogenicity on the pharmacokinetics of TNFi, clinical implications of ADA formation, and possible mitigation strategies.
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Affiliation(s)
- Sadaf Atiqi
- Amsterdam Rheumatology and Immunology Center, Department of Rheumatology, Reade, Amsterdam, Netherlands
| | - Femke Hooijberg
- Amsterdam Rheumatology and Immunology Center, Department of Rheumatology, Reade, Amsterdam, Netherlands
| | - Floris C Loeff
- Department of Immunopathology, Sanquin Research and Landsteiner Laboratory Academic Medical Centre, Amsterdam, Netherlands
| | - Theo Rispens
- Department of Immunopathology, Sanquin Research and Landsteiner Laboratory Academic Medical Centre, Amsterdam, Netherlands
| | - Gerrit J Wolbink
- Amsterdam Rheumatology and Immunology Center, Department of Rheumatology, Reade, Amsterdam, Netherlands.,Department of Immunopathology, Sanquin Research and Landsteiner Laboratory Academic Medical Centre, Amsterdam, Netherlands
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12
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Georgescu MT, Moorehead PC, Liu T, Dumont J, Scott DW, Hough C, Lillicrap D. Recombinant Factor VIII Fc Inhibits B Cell Activation via Engagement of the FcγRIIB Receptor. Front Immunol 2020; 11:138. [PMID: 32117285 PMCID: PMC7025534 DOI: 10.3389/fimmu.2020.00138] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 01/20/2020] [Indexed: 01/05/2023] Open
Abstract
The development of neutralizing antibodies (inhibitors) against factor VIII (FVIII) is a major complication of hemophilia A treatment. The sole clinical therapy to restore FVIII tolerance in patients with inhibitors remains immune tolerance induction (ITI) which is expensive, difficult to administer and not always successful. Although not fully understood, the mechanism of ITI is thought to rely on inhibition of FVIII-specific B cells (1). Its efficacy might therefore be improved through more aggressive B cell suppression. FcγRIIB is an inhibitory Fc receptor that down-regulates B cell signaling when cross-linked with the B cell receptor (BCR). We sought to investigate if recombinant FVIII Fc (rFVIIIFc), an Fc fusion molecule composed of FVIII and the Fc region of immunoglobulin G1 (IgG1) (2), is able to inhibit B cell activation more readily than FVIII. rFVIIIFc was able to bind FVIII-exposed and naïve B cells from hemophilia A mice as well as a FVIII-specific murine B cell hybridoma line (413 cells). An anti-FcγRIIB antibody and FVIII inhibited binding, suggesting that rFVIIIFc is able to interact with both FcγRIIB and the BCR. Furthermore, incubation of B cells from FVIII-exposed mice and 413 cells with rFVIIIFc resulted in increased phosphorylation of SH-2 containing inositol 5-phosphatase (SHIP) when compared to FVIII. B cells from FVIII-exposed hemophilia A mice also exhibited decreased extracellular signal-regulated kinase (ERK) phosphorylation when exposed to rFVIIIFc. These differences were absent in B cells from naïve, non-FVIII exposed hemophilic mice suggesting an antigen-dependent effect. Finally, rFVIIIFc was able to inhibit B cell calcium flux induced by anti-Ig F(ab)2. Our results therefore indicate that rFVIIIFc is able to crosslink FcγRIIB and the BCR of FVIII-specific B cells, causing inhibitory signaling in these cells.
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Affiliation(s)
- Maria T Georgescu
- Clinical and Molecular Hemostasis Research Group, Department of Pathology and Molecular Medicine, Queen's University, Kingston, ON, Canada
| | - Paul C Moorehead
- Janeway Children's Health and Rehabilitation Centre, St. John's, NL, Canada.,Faculty of Medicine, Memorial University, St. John's, NL, Canada
| | - Tongyao Liu
- Bioverativ, a Sanofi Company, Cambridge, MA, United States
| | | | - David W Scott
- Department of Medicine, Uniformed Services University, Bethesda, MD, United States
| | - Christine Hough
- Clinical and Molecular Hemostasis Research Group, Department of Pathology and Molecular Medicine, Queen's University, Kingston, ON, Canada
| | - David Lillicrap
- Clinical and Molecular Hemostasis Research Group, Department of Pathology and Molecular Medicine, Queen's University, Kingston, ON, Canada
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13
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Lacroix-Desmazes S, Voorberg J, Lillicrap D, Scott DW, Pratt KP. Tolerating Factor VIII: Recent Progress. Front Immunol 2020; 10:2991. [PMID: 31998296 PMCID: PMC6965068 DOI: 10.3389/fimmu.2019.02991] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Accepted: 12/05/2019] [Indexed: 02/02/2023] Open
Abstract
Development of neutralizing antibodies against biotherapeutic agents administered to prevent or treat various clinical conditions is a longstanding and growing problem faced by patients, medical providers and pharmaceutical companies. The hemophilia A community has deep experience with attempting to manage such deleterious immune responses, as the lifesaving protein drug factor VIII (FVIII) has been in use for decades. Hemophilia A is a bleeding disorder caused by genetic mutations that result in absent or dysfunctional FVIII. Prophylactic treatment consists of regular intravenous FVIII infusions. Unfortunately, 1/4 to 1/3 of patients develop neutralizing anti-FVIII antibodies, referred to clinically as “inhibitors,” which result in a serious bleeding diathesis. Until recently, the only therapeutic option for these patients was “Immune Tolerance Induction,” consisting of intensive FVIII administration, which is extraordinarily expensive and fails in ~30% of cases. There has been tremendous recent progress in developing novel potential clinical alternatives for the treatment of hemophilia A, ranging from encouraging results of gene therapy trials, to use of other hemostatic agents (either promoting coagulation or slowing down anti-coagulant or fibrinolytic pathways) to “bypass” the need for FVIII or supplement FVIII replacement therapy. Although these approaches are promising, there is widespread agreement that preventing or reversing inhibitors remains a high priority. Risk profiles of novel therapies are still unknown or incomplete, and FVIII will likely continue to be considered the optimal hemostatic agent to support surgery and manage trauma, or to combine with other therapies. We describe here recent exciting studies, most still pre-clinical, that address FVIII immunogenicity and suggest novel interventions to prevent or reverse inhibitor development. Studies of FVIII uptake, processing and presentation on antigen-presenting cells, epitope mapping, and the roles of complement, heme, von Willebrand factor, glycans, and the microbiome in FVIII immunogenicity are elucidating mechanisms of primary and secondary immune responses and suggesting additional novel targets. Promising tolerogenic therapies include development of FVIII-Fc fusion proteins, nanoparticle-based therapies, oral tolerance, and engineering of regulatory or cytotoxic T cells to render them FVIII-specific. Importantly, these studies are highly applicable to other scenarios where establishing immune tolerance to a defined antigen is a clinical priority.
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Affiliation(s)
| | - Jan Voorberg
- Sanquin Research and Landsteiner Laboratory, Department of Molecular and Cellular Hemostasis, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - David Lillicrap
- Department of Pathology and Molecular Medicine, Queen's University, Kingston, ON, Canada
| | - David W Scott
- Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | - Kathleen P Pratt
- Uniformed Services University of the Health Sciences, Bethesda, MD, United States
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14
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Molecular Mechanisms of Inhibitor Development in Hemophilia. Mediterr J Hematol Infect Dis 2020; 12:e2020001. [PMID: 31934311 PMCID: PMC6951349 DOI: 10.4084/mjhid.2020.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 11/10/2019] [Indexed: 11/25/2022] Open
Abstract
The development of neutralizing antibodies in hemophilia is a serious complication of factor replacement therapy. These antibodies, also known as “inhibitors”, significantly increase morbidity within the hemophilia population and lower the quality of life for these patients. People with severe hemophilia A have an overall 25–40% lifetime risk of inhibitor development, compared to that of 5–15% lifetime risk in those with moderate/mild hemophilia A. The risk is lower in hemophilia B population (about 1–5%) and occurrence of inhibitors is almost only seen in patients with severe hemophilia B. The understanding of the pathophysiological mechanism leading to the development of inhibitors in patients with hemophilia has improved considerably over the last 2 decades. Identification of early biomarkers which predict inhibitor development in previously untreated patients with hemophilia will assist in risk identification and possible early intervention strategies. In this review, we aim to summarize the molecular mechanisms of inhibitor development in hemophilia and to identify potential areas in need of further investigation.
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15
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Scott DW. Genetic Engineering of T Cells for Immune Tolerance. MOLECULAR THERAPY-METHODS & CLINICAL DEVELOPMENT 2019; 16:103-107. [PMID: 31934598 PMCID: PMC6953701 DOI: 10.1016/j.omtm.2019.11.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Regulatory T cells (Tregs) play a role in the induction and maintenance of tolerance, as well as in modulating aberrant immune responses. While expanded Tregs have been used in clinical trials, they are polyclonal and the frequency of specific Tregs is very low. To overcome this issue, we have endeavored to "specify" Tregs by engineering them to express receptors that can recognize a given antigen and applied this protocol in autoimmunity, hemophilia and allergy. Thus, we have used retroviral transduction of a specific T cell receptor, single-chain variable fragments (Fvs), or antigen domains in Tregs to achieve this goal. This review summarizes our steps to achieve the ultimate goal of modulating human diseases.
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Affiliation(s)
- David W Scott
- Department of Medicine, Uniformed Services University of Health Sciences, Bethesda, MD 20814, USA
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16
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Delignat S, Russick J, Gangadharan B, Rayes J, Ing M, Voorberg J, Kaveri SV, Lacroix-Desmazes S. Prevention of the anti-factor VIII memory B-cell response by inhibition of Bruton tyrosine kinase in experimental hemophilia A. Haematologica 2018; 104:1046-1054. [PMID: 30545924 PMCID: PMC6518880 DOI: 10.3324/haematol.2018.200279] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 11/22/2018] [Indexed: 01/19/2023] Open
Abstract
Hemophilia A is a rare hemorrhagic disorder caused by the lack of functional pro-coagulant factor VIII. Factor VIII replacement therapy in patients with severe hemophilia A results in the development of inhibitory anti-factor VIII IgG in up to 30% of cases. To date, immune tolerance induction, with daily injection of large amounts of factor VIII, is the only strategy to eradicate factor VIII inhibitors. This strategy is, however, efficient in only 60-80% of patients. We investigated whether blocking B-cell receptor signaling upon inhibition of Bruton tyrosine kinase prevents anti-factor VIII immune responses in a mouse model of severe hemophilia A. Factor VIII-naïve and factor VIII-sensitized factor VIII-deficient mice were fed with the selective inhibitor of Bruton tyrosine kinase, (R)-5-amino-1-(1-cyanopiperidin-3-yl)-3-(4-[2,4-difluorophenoxyl] phenyl)-1H pyrazole-4-carboxamide (PF-06250112), to inhibit B-cell receptor signaling prior to challenge with exogenous factor VIII. The consequences on the anti-factor VIII immune response were studied. Inhibition of Bruton tyrosine kinase during the primary anti-factor VIII immune response in factor VIII-naïve mice did not prevent the development of inhibitory anti-factor VIII IgG. In contrast, the anti-factor VIII memory B-cell response was consistently reduced upon treatment of factor VIII-sensitized mice with the Bruton tyrosine kinase inhibitor. The Bruton tyrosine kinase inhibitor reduced the differentiation of memory B cells ex vivo and in vivo following adoptive transfer to factor VIII-naïve animals. Taken together, our data identify inhibition of Bruton tyrosine kinase using PF-06250112 as a strategy to limit the reactivation of factor VIII-specific memory B cells upon re-challenge with therapeutic factor VIII.
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Affiliation(s)
- Sandrine Delignat
- INSERM, UMR S 1138, Centre de Recherche des Cordeliers, Paris, France.,Université Pierre et Marie Curie-Paris 6, UMR S 1138, Centre de Recherche des Cordeliers, Paris, France.,Université Paris Descartes, UMR S 1138, Centre de Recherche des Cordeliers, Paris, France
| | - Jules Russick
- INSERM, UMR S 1138, Centre de Recherche des Cordeliers, Paris, France.,Université Pierre et Marie Curie-Paris 6, UMR S 1138, Centre de Recherche des Cordeliers, Paris, France.,Université Paris Descartes, UMR S 1138, Centre de Recherche des Cordeliers, Paris, France
| | - Bagirath Gangadharan
- INSERM, UMR S 1138, Centre de Recherche des Cordeliers, Paris, France.,Université Pierre et Marie Curie-Paris 6, UMR S 1138, Centre de Recherche des Cordeliers, Paris, France.,Université Paris Descartes, UMR S 1138, Centre de Recherche des Cordeliers, Paris, France
| | - Julie Rayes
- INSERM, UMR S 1138, Centre de Recherche des Cordeliers, Paris, France.,Université Pierre et Marie Curie-Paris 6, UMR S 1138, Centre de Recherche des Cordeliers, Paris, France.,Université Paris Descartes, UMR S 1138, Centre de Recherche des Cordeliers, Paris, France
| | - Mathieu Ing
- INSERM, UMR S 1138, Centre de Recherche des Cordeliers, Paris, France.,Université Pierre et Marie Curie-Paris 6, UMR S 1138, Centre de Recherche des Cordeliers, Paris, France.,Université Paris Descartes, UMR S 1138, Centre de Recherche des Cordeliers, Paris, France
| | - Jan Voorberg
- Department of Plasma Proteins, Sanquin Research and Landsteiner Laboratory, Academic Medical Center, University of Amsterdam, the Netherlands
| | - Srinivas V Kaveri
- INSERM, UMR S 1138, Centre de Recherche des Cordeliers, Paris, France.,Université Pierre et Marie Curie-Paris 6, UMR S 1138, Centre de Recherche des Cordeliers, Paris, France.,Université Paris Descartes, UMR S 1138, Centre de Recherche des Cordeliers, Paris, France
| | - Sébastien Lacroix-Desmazes
- INSERM, UMR S 1138, Centre de Recherche des Cordeliers, Paris, France .,Université Pierre et Marie Curie-Paris 6, UMR S 1138, Centre de Recherche des Cordeliers, Paris, France.,Université Paris Descartes, UMR S 1138, Centre de Recherche des Cordeliers, Paris, France
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17
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Brettschneider K, Schmidt A, Kahle J, Orlowski A, Stichel D, Schwabe D, Königs C. Elimination of factor VIII-specific B cells by immunotoxins composed of a single factor VIII domain fused to Pseudomonas exotoxin A. J Thromb Haemost 2018; 16:2223-2232. [PMID: 30152083 DOI: 10.1111/jth.14273] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Indexed: 01/19/2023]
Abstract
Essentials There is still a need for novel therapeutic approaches for hemophilia A patients with inhibitors. A factor VIII domain was used as the targeting moiety for elimination of FVIII-specific B cells. The immunodominant C2 domain was fused to exotoxin A from Pseudomonas aeruginosa (hC2-ETA). Murine C2 domain-specific B cells were selectively and efficiently eliminated by hC2-ETA ex vivo. SUMMARY: Background Today, the most serious complication for patients with hemophilia A undergoing factor VIII (FVIII) replacement therapy is the development of neutralizing antibodies (inhibitors). Although inhibitors can be eradicated by application of high doses of FVIII, the immune tolerance induction therapy fails in up to 30% of patients. Hence, there is still an urgent need for novel therapeutic approaches for patients with persisting inhibitors. Objectives In the present study, the potential use of immunotoxins containing exotoxin A (ETA) from Pseudomonas aeruginosa for selective elimination of FVIII-specific B cells was explored. Methods The immunodominant C2 domain of human FVIII was used as a targeting moiety instead of the full-length FVIII protein and the resulting human C2 domain-ETA fusion protein (hC2-ETA) was produced in Escherichia coli. Results Binding studies with monoclonal C2 domain-specific antibodies confirmed the conformational integrity of the C2 domain in hC2-ETA. The functionality of hC2-ETA was tested ex vivo by incubation of splenocytes from inhibitor-positive FVIII knockout mice with hC2-ETA and controls. FVIII-specific memory B cells from splenocytes were differentiated by FVIII stimulation in antibody-secreting cells (ASC) and detected by an enzyme-linked immunospot assay. Although the controls showed no effect, incubation of splenocytes with hC2-ETA reduced the number of C2-specific ASC in a dose-dependent fashion, indicating specific and efficient elimination of C2-specific memory B cells. Conclusions Overall, the results of the study support the fact that FVIII domain immunotoxins might be a potential new tool for the elimination of FVIII-specific B cells in patients with hemophilia A and persisting inhibitors.
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Affiliation(s)
- K Brettschneider
- Department of Pediatrics and Adolescent Medicine, University Hospital, Goethe University, Frankfurt am Main, Germany
- Faculty of Biological Science, Goethe University, Frankfurt am Main, Germany
| | - A Schmidt
- Department of Pediatrics and Adolescent Medicine, University Hospital, Goethe University, Frankfurt am Main, Germany
| | - J Kahle
- Department of Pediatrics and Adolescent Medicine, University Hospital, Goethe University, Frankfurt am Main, Germany
| | - A Orlowski
- Department of Pediatrics and Adolescent Medicine, University Hospital, Goethe University, Frankfurt am Main, Germany
| | - D Stichel
- Department of Pediatrics and Adolescent Medicine, University Hospital, Goethe University, Frankfurt am Main, Germany
| | - D Schwabe
- Department of Pediatrics and Adolescent Medicine, University Hospital, Goethe University, Frankfurt am Main, Germany
| | - C Königs
- Department of Pediatrics and Adolescent Medicine, University Hospital, Goethe University, Frankfurt am Main, Germany
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18
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Zhang AH, Yoon J, Kim YC, Scott DW. Targeting Antigen-Specific B Cells Using Antigen-Expressing Transduced Regulatory T Cells. THE JOURNAL OF IMMUNOLOGY 2018; 201:1434-1441. [PMID: 30021767 DOI: 10.4049/jimmunol.1701800] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Accepted: 06/27/2018] [Indexed: 01/23/2023]
Abstract
Controlling immune responses in autoimmunity and to biotherapeutics is an unmet need. In hemophilia, for example, up to one third of patients receiving therapeutic factor VIII (FVIII) infusions develop neutralizing Abs termed "inhibitors." To address this problem in a mouse model of hemophilia A, we used an Ag-specific regulatory T cell (Treg) approach in which we created a novel B cell-targeting chimeric receptor composed of an FVIII Ag domain linked with the CD28-CD3ζ transmembrane and signaling domains. We termed these "BAR" for B cell-targeting Ab receptors. CD4+CD25hiCD127low human Tregs were retrovirally transduced to express a BAR containing the immunodominant FVIII C2 or A2 domains (C2- and A2-BAR). Such BAR-Tregs specifically suppressed the recall Ab response of spleen cultures from FVIII-immunized mice in vitro and completely prevented anti-FVIII Ab development in response to FVIII immunization. Mechanistic studies with purified B cells and T cells from tolerized or control recipients demonstrated that the FVIII-specific B cells were directly suppressed or anergized, whereas the T cell response remained intact. Taken together, we report in this study a successful proof-of-principle strategy using Ag-expressing Tregs to directly target specific B cells, an approach which could be adapted to address other adverse immune responses as well.
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Affiliation(s)
- Ai-Hong Zhang
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814
| | - Jeongheon Yoon
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814
| | - Yong Chan Kim
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814
| | - David W Scott
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814
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19
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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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20
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Georgescu MT, Moorehead PC, van Velzen AS, Nesbitt K, Reipert BM, Steinitz KN, Schuster M, Hough C, Lillicrap D. Dexamethasone promotes durable factor VIII-specific tolerance in hemophilia A mice via thymic mechanisms. Haematologica 2018; 103:1403-1413. [PMID: 29674503 PMCID: PMC6068046 DOI: 10.3324/haematol.2018.189852] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 04/19/2018] [Indexed: 11/12/2022] Open
Abstract
The development of inhibitory antibodies to factor VIII is the most serious complication of replacement therapy in hemophilia A. Activation of the innate immune system during exposure to this protein contributes to inhibitor development. However, avoidance of factor VIII exposure during innate immune system activation by external stimuli (e.g., vaccines) has not been consistently shown to prevent inhibitors. We hypothesized that dexamethasone, a drug with potent anti-inflammatory effects, could prevent inhibitors by promoting immunologic tolerance to factor VIII in hemophilia A mice. Transient dexamethasone treatment during ainitial factor VIII exposure reduced the incidence of anti-factor VIII immunoglobulin G in both a conventional hemophilia A mouse model (E16KO, 77% vs. 100%, P=0.048) and a hemophilia A mouse model with a humanized major histocompatibility complex type II transgene (E17KO/hMHC, 6% vs. 33%, P=0.0048). More importantly, among E17KO/hMHC mice that did not develop anti-factor VIII immunoglobulin G after initial exposure, dexamethasone-treated mice were less likely to develop a response after re-exposure six (7% vs. 52%, P=0.005) and 16 weeks later (7% vs. 50%, P=0.097). Similar results were obtained even when factor VIII re-exposure occurred in the context of lipopolysaccharide (30% vs. 100%, P=0.069). The ability of these mice to develop immunoglobulin G to human von Willebrand factor, a structurally unrelated antigen, remained unaffected by treatment. Transient dexamethasone administration therefore promotes antigen-specific immunologic tolerance to factor VIII. This effect is associated with an increase in the percentage of thymic regulatory T cells (12.06% vs. 4.73%, P<0.001) and changes in the thymic messenger ribonucleic acid transcription profile.
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Affiliation(s)
- Maria T Georgescu
- Department of Pathology and Molecular Medicine, Queen's University, Kingston, ON, Canada
| | - Paul C Moorehead
- Janeway Children's Health and Rehabilitation Centre, St. John's, NL, Canada.,Faculty of Medicine, Memorial University, St. John's, NL, Canada
| | - Alice S van Velzen
- Department of Pediatric Hematology, Immunology and Infectious Diseases, Emma Children's Hospital, Amsterdam, the Netherlands
| | - Kate Nesbitt
- Department of Pathology and Molecular Medicine, Queen's University, Kingston, ON, Canada
| | | | | | | | - Christine Hough
- Department of Pathology and Molecular Medicine, Queen's University, Kingston, ON, Canada
| | - David Lillicrap
- Department of Pathology and Molecular Medicine, Queen's University, Kingston, ON, Canada
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21
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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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22
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Brackmann HH, White G, Berntorp E, Andersen T, Escuriola-Ettingshausen C. Immune tolerance induction: What have we learned over time? Haemophilia 2018. [DOI: 10.1111/hae.13445] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- H.-H. Brackmann
- Institute of Experimental Haematology and Blood Transfusion; University of Bonn; Bonn Germany
| | - G.C. White
- Blood Center of Wisconsin & Medical College of Wisconsin; Milwaukee WI USA
| | - E. Berntorp
- Clinical Coagulation Research Unit; Skåne University Hospital; Lund University; Malmö Sweden
| | - T. Andersen
- Danish Haemophilia Society; Copenhagen Denmark
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23
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Platokouki H, Fischer K, Gouw SC, Rafowicz A, Carcao M, Kenet G, Liesner R, Kurnik K, Rivard GE, van den Berg HM. Vaccinations are not associated with inhibitor development in boys with severe haemophilia A. Haemophilia 2017; 24:283-290. [DOI: 10.1111/hae.13387] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/19/2017] [Indexed: 01/22/2023]
Affiliation(s)
- H. Platokouki
- Haemophilia-Haemostasis Unit; St. Sophia Children's Hospital; Athens Greece
| | - K. Fischer
- Van Creveldkliniek; University Medical Centre Utrecht; Utrecht The Netherlands
| | - S. C. Gouw
- Department of Paediatric Haematology; Academic Medical Centre Amsterdam; Emma Children's Hospital; Amsterdam The Netherlands
| | - A. Rafowicz
- Centre de Référence pour le Traitement des Maladies Hémorragiques (CRTH); Hôpital Bicêtre; Paris France
| | - M. Carcao
- Division of Haematology/Oncology; Department of Paediatrics and Child Health Evaluative Sciences; Research Institute; Hospital for Sick Children; Toronto ON Canada
| | - G. Kenet
- National Haemophilia Centre; Ministry of Health; Sheba Medical Center; Tel Hashomer Israel
| | - R. Liesner
- Department of Haematology; Haemophilia Centre; Great Ormond Street Hospital for Children; London UK
| | - K. Kurnik
- Dr. v. Haunersches Kinderspital; University of Munich; Munich Germany
| | - G. E. Rivard
- Division of Haematology/Oncology; Hôpital St. Justine; Montréal QC Canada
| | - H. M. van den Berg
- PedNet Haemophilia Research Foundation; Mollerusstraat1 3743BW Baarn The Netherlands
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24
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Scott DW. From IgG Fusion Proteins to Engineered-Specific Human Regulatory T Cells: A Life of Tolerance. Front Immunol 2017; 8:1576. [PMID: 29181011 PMCID: PMC5693857 DOI: 10.3389/fimmu.2017.01576] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Accepted: 11/02/2017] [Indexed: 01/23/2023] Open
Abstract
Recent efforts have concentrated on approaches to expand and “specify” human regulatory T cells (Tregs) and to apply them to modulate adverse immune responses in autoimmunity and hemophilia. We have used retroviral transduction of specific T-cell receptor, single chain Fv, or antigen domains in Tregs to achieve this goal. Each of these approaches have advantages and disadvantages. Results with these engineered T cells and evolution of the research developments and paths that led to the development of specific regulatory approaches for tolerance are summarized.
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Affiliation(s)
- David W Scott
- Department of Medicine, Uniformed Services University, Bethesda, MD, United States
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Chen Y, Luo X, Schroeder JA, Chen J, Baumgartner CK, Hu J, Shi Q. Immune tolerance induced by platelet-targeted factor VIII gene therapy in hemophilia A mice is CD4 T cell mediated. J Thromb Haemost 2017; 15:1994-2004. [PMID: 28799202 PMCID: PMC5630523 DOI: 10.1111/jth.13800] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Indexed: 02/03/2023]
Abstract
Essentials The immune response is a significant concern in gene therapy. Platelet-targeted gene therapy can restore hemostasis and induce immune tolerance. CD4 T cell compartment is tolerized after platelet gene therapy. Preconditioning regimen affects immune tolerance induction in platelet gene therapy. SUMMARY Background Immune responses are a major concern in gene therapy. Our previous studies demonstrated that platelet-targeted factor VIII (FVIII) (2bF8) gene therapy together with in vivo drug selection of transduced cells can rescue the bleeding diathesis and induce immune tolerance in FVIIInull mice. Objective To investigate whether non-selectable 2bF8 lentiviral vector (LV) for the induction of platelet-FVIII expression is sufficient to induce immune tolerance and how immune tolerance is induced after 2bF8LV gene therapy. Methods Platelet-FVIII expression was introduced by 2bF8LV transduction and transplantation. FVIII assays and tail bleeding tests were used to confirm the success of platelet gene therapy. Animals were challenged with rhF8 to explore if immune tolerance was induced after gene therapy. Treg cell analysis, T-cell proliferation assay and memory B-cell-mediated ELISPOT assay were used to investigate the potential mechanisms of immune tolerance. Results We showed that platelet-FVIII expression was sustained and the bleeding diathesis was restored in FVIIInull mice after 2bF8LV gene therapy. None of the transduced recipients developed anti-FVIII inhibitory antibodies in the groups preconditioned with 660 cGy irradiation or busulfan plus ATG treatment even after rhF8 challenge. Treg cells significantly increased in 2bF8LV-transduced recipients and the immune tolerance developed was transferable. CD4+ T cells from treated animals failed to proliferate in response to rhF8 re-stimulation, but memory B cells could differentiate into antibody secreting cells in 2bF8LV-transduced recipients. Conclusion 2bF8LV gene transfer without in vivo selection of manipulated cells can introduce immune tolerance in hemophilia A mice and this immune tolerance is CD4+ T cell mediated.
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Affiliation(s)
- Y Chen
- Blood Research Institute, Blood Center of Wisconsin, Milwaukee, WI, USA
- Fujian Institute of Hematology, Fujian Medical University Union Hospital, Fuzhou, China
| | - X Luo
- Blood Research Institute, Blood Center of Wisconsin, Milwaukee, WI, USA
- Fujian Institute of Hematology, Fujian Medical University Union Hospital, Fuzhou, China
| | - J A Schroeder
- Blood Research Institute, Blood Center of Wisconsin, Milwaukee, WI, USA
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - J Chen
- Blood Research Institute, Blood Center of Wisconsin, Milwaukee, WI, USA
| | - C K Baumgartner
- Blood Research Institute, Blood Center of Wisconsin, Milwaukee, WI, USA
| | - J Hu
- Fujian Institute of Hematology, Fujian Medical University Union Hospital, Fuzhou, China
| | - Q Shi
- Blood Research Institute, Blood Center of Wisconsin, Milwaukee, WI, USA
- Fujian Institute of Hematology, Fujian Medical University Union Hospital, Fuzhou, China
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
- Children's Research Institute, Children's Hospital of Wisconsin, Milwaukee, WI, USA
- MACC Fund Research Center, Milwaukee, WI, USA
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Abstract
Immune tolerance induction (ITI) with aggressive infusion of factor VIII (FVIII) is the current strategy used to eradicate FVIII inhibitors and restore normal FVIII pharmacokinetics in inhibitor patients. Whether the use of FVIII products containing von Willebrand factor (VWF) will affect the efficacy of ITI is still controversial. In this study, we explored the impact of VWF on FVIII memory immune responses in hemophilia A (HA) mice. A T-cell proliferation assay and cytokine profile analysis were used to study FVIII-primed CD4+ T cells. When CD4+ T cells from primed FVIIInull mice were restimulated with recombinant human FVIII (rhF8) plus recombinant human VWF (rhVWF) in vitro, the percentages of daughter CD4+ T cells were significantly decreased compared with the groups cultured with rhF8 only. Levels of interferon-γ and interleukin 10 were significantly lower in the rhF8 plus rhVWF groups than in the rhF8 groups. When memory B-cell pools from primed FVIIInull mice were cultured with rhF8 with or without rhVWF to induce differentiation of memory B cells into antibody-secreting cells (ASCs), the number of ASCs was significantly lower in the rhF8 plus VWF group than in the rhF8 group. When memory B-cell pools were transferred into NSGF8KO mice followed by rhF8 immunization with or without rhVWF, the titers of anti-F8 inhibitors and total immunoglobulin G were significantly higher in the rhF8 group than in the rhF8 plus rhVWF group, with an average difference of 2.23- and 2.04-fold. Together, our data demonstrate that VWF attenuates FVIII memory immune responses in HA mice.
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27
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Vollack N, Friese J, Bergmann S, Tiede A, Werwitzke S. CD32 inhibition and high dose of rhFVIII suppress murine FVIII-specific recall response by distinct mechanisms in vitro. Thromb Haemost 2017; 117:1679-1687. [PMID: 28492697 DOI: 10.1160/th17-03-0201] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Accepted: 04/18/2017] [Indexed: 12/24/2022]
Abstract
Development of neutralising antibodies (inhibitors) against factor VIII (FVIII) is a frequent and severe complication of replacement therapy in haemophilia A. Previous data from haemophilia A mouse model demonstrates that both CD32 inhibition and high doses of rhFVIII prevent the differentiation of FVIII-specific memory B cells (MBCs) into antibody secreting cells (ASCs). Here, cellular targets responsible for the suppression of ASC formation by means of CD32 inhibition and high dose of rhFVIII were analysed. We investigated apoptosis on FVIII-specific MBCs using a pan caspases inhibitor, and screened for defects in rhFVIII presentation by analysing T cell release of Th1- and Th2-cytokines in vitro. Although high dose of rhFVIII suppressed ASC formation, cytokine response was not affected. Upon re-stimulation of splenocytes with high dose of rhFVIII, prevention of apoptosis fully restored the FVIII-specific recall response. In contrast, genetic deletion or inhibition of CD32 significantly altered Th1- and Th2-response. CD32 blockade and inhibition of apoptosis resulted in a partial rescue of FVIII-specific ASCs. Normal cytokine secretion could not be restored. In conclusion, suppression of FVIII-specific recall response by CD32 and high doses of rhFVIII is mediated by distinct mechanisms. High dose of rhFVIII induces apoptosis in FVIII-specific MBCs but does not influence FVIII-specific T cell response. CD32 blockade, however, may suppress the FVIII-specific recall response by two ways: i) increasing apoptosis of FVIII-specific MBCs and ii) disturbing FVIII-specific T cell response by modulating presentation of rhFVIII to CD4+ T cells in vitro.
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Affiliation(s)
| | | | | | | | - Sonja Werwitzke
- Sonja Werwitzke, MD, PhD, Department of Haematology, Haemostasis, Oncology and Stem Cell Transplantation, Hanover Medical School, Carl-Neuberg-Straße 1, 30625 Hanover, Germany, Tel.: +49 511 532 8377, Fax: +49 511 532 18524, E-mail:
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28
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Lai JD, Lillicrap D. Factor VIII inhibitors: Advances in basic and translational science. Int J Lab Hematol 2017; 39 Suppl 1:6-13. [DOI: 10.1111/ijlh.12659] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Accepted: 02/18/2017] [Indexed: 11/27/2022]
Affiliation(s)
- J. D. Lai
- Department of Pathology & Molecular Medicine; Queen's University; Kingston ON Canada
| | - D. Lillicrap
- Department of Pathology & Molecular Medicine; Queen's University; Kingston ON Canada
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29
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Shima M, Lillicrap D, Kruse-Jarres R. Alternative therapies for the management of inhibitors. Haemophilia 2017; 22 Suppl 5:36-41. [PMID: 27405674 DOI: 10.1111/hae.13005] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/04/2016] [Indexed: 12/21/2022]
Abstract
The development of inhibitors to factor VIII (FVIII) or factor IX (FIX) remains a major treatment complication encountered in the treatment of haemophilia. Not all patients with even the same severity and genotype develop inhibitors suggesting an underlying mechanism of tolerance against FVIII- or FIX-related immunity. One mechanism may be central tolerance observed in patients in whom the FVIII mutation enables some production of the protein. The other is a peripheral tolerance mechanism which may be evident in patients with null mutation. Recently, recombinant porcine FVIII (rpFVIII, Obixur, OBI-1, BAX801) has been developed for the haemostatic treatment of both congenital haemophilia with inhibitor (CHAWI) and acquired haemophilia A (AHA). In 28 subjects with AHA with life-/limb-threatening bleeding, rpFVIII reduced or stopped bleeding in all patients within 24 h. The cross-reactivity of anti-human FVIII antibodies to rpFVIII remains around 30-50%. Recently, new therapeutics based on the quite novel concepts have been developed and clinical studies are ongoing. These are humanized asymmetric antibody mimicking FVIIIa function by maintaining a suitable interaction between FIXa and FX (Emicizumab, ACE910), and small interfering RNAs (siRNA, ALN-AT3) suppress liver production of AT through post-transcriptional gene silencing and a humanized anti-TFPI monoclonal antibody (Concizumab). Their main advantages are longer half-life, subcutaneous applicability and efficacy irrespective of the presence of inhibitors which will make it easier to initiate more effective treatment especially early childhood.
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Affiliation(s)
- M Shima
- Department of Pediatrics, Nara Medical University, Kashihara, Japan
| | - D Lillicrap
- Department of Pathology and Molecular Medicine, Queen's University, Kingston, ON, Canada
| | - R Kruse-Jarres
- Washington Center for Bleeding Disorders at Bloodworks NW, University of Washington, Seattle, WA, USA
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30
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Diaz I, Bolloré K, Tuaillon E, Lapalud P, Giansily-Blaizot M, Vendrell JP, Schved JF, Lavigne-Lissalde G. Circulating FVIII-specific IgG, IgA and IgM memory B cells from haemophilia A patients. Haemophilia 2016; 22:799-805. [DOI: 10.1111/hae.12958] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2016] [Indexed: 01/02/2023]
Affiliation(s)
- I. Diaz
- Laboratory of Hematology; University Hospital of Montpellier; Montpellier France
- Institute of Research in Biotherapy; Montpellier France
| | - K. Bolloré
- Institute of Research in Biotherapy; Montpellier France
- INSERM U1058; Montpellier 1 University; Montpellier France
| | - E. Tuaillon
- Institute of Research in Biotherapy; Montpellier France
- INSERM U1058; Montpellier 1 University; Montpellier France
| | - P. Lapalud
- UMR 3145 SysDiag CNRS/Biorad; Montpellier France
| | | | - J. P. Vendrell
- INSERM U1058; Montpellier 1 University; Montpellier France
| | - J. F. Schved
- Laboratory of Hematology; University Hospital of Montpellier; Montpellier France
- Regional Hemophilia Treatment Center; Montpellier France
| | - G. Lavigne-Lissalde
- UMR 3145 SysDiag CNRS/Biorad; Montpellier France
- Regional Hemophilia Treatment Center; Montpellier France
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31
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Concurrent influenza vaccination reduces anti-FVIII antibody responses in murine hemophilia A. Blood 2016; 127:3439-49. [DOI: 10.1182/blood-2015-11-679282] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Accepted: 03/28/2016] [Indexed: 12/23/2022] Open
Abstract
Key Points
Vaccination against influenza, with and without the adjuvant MF59, decreases the risk of inhibitor development in HA mice. Decreased FVIII immunogenicity may be attributed to antigenic competition via T-cell chemotaxis toward the site of vaccination.
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32
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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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33
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Reipert BM. B-cell memory against factor VIII. Cell Immunol 2016; 301:49-58. [DOI: 10.1016/j.cellimm.2016.01.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Revised: 01/05/2016] [Accepted: 01/06/2016] [Indexed: 10/22/2022]
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34
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War and peace: Factor VIII and the adaptive immune response. Cell Immunol 2016; 301:2-7. [DOI: 10.1016/j.cellimm.2015.11.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Revised: 11/27/2015] [Accepted: 11/28/2015] [Indexed: 12/31/2022]
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35
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Effects of FVIII immunity on hepatocyte and hematopoietic stem cell-directed gene therapy of murine hemophilia A. MOLECULAR THERAPY-METHODS & CLINICAL DEVELOPMENT 2016; 3:15056. [PMID: 26909355 PMCID: PMC4750467 DOI: 10.1038/mtm.2015.56] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/26/2015] [Revised: 12/10/2015] [Accepted: 12/11/2015] [Indexed: 02/08/2023]
Abstract
Immune responses to coagulation factors VIII (FVIII) and IX (FIX) represent primary obstacles to hemophilia treatment. Previously, we showed that hematopoietic stem cell (HSC) retroviral gene therapy induces immune nonresponsiveness to FVIII in both naive and preimmunized murine hemophilia A settings. Liver-directed adeno-associated viral (AAV)-FIX vector gene transfer achieved similar results in preclinical hemophilia B models. However, as clinical immune responses to FVIII and FIX differ, we investigated the ability of liver-directed AAV-FVIII gene therapy to affect FVIII immunity in hemophilia A mice. Both FVIII naive and preimmunized mice were administered recombinant AAV8 encoding a liver-directed bioengineered FVIII expression cassette. Naive animals receiving high or mid-doses subsequently achieved near normal FVIII activity levels. However, challenge with adjuvant-free recombinant FVIII induced loss of FVIII activity and anti-FVIII antibodies in mid-dose, but not high-dose AAV or HSC lentiviral (LV) vector gene therapy cohorts. Furthermore, unlike what was shown previously for FIX gene transfer, AAV-FVIII administration to hemophilia A inhibitor mice conferred no effect on anti-FVIII antibody or inhibitory titers. These data suggest that functional differences exist in the immune modulation achieved to FVIII or FIX in hemophilia mice by gene therapy approaches incorporating liver-directed AAV vectors or HSC-directed LV.
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36
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The immunogenicity of platelet-derived FVIII in hemophilia A mice with or without preexisting anti-FVIII immunity. Blood 2015; 127:1346-54. [PMID: 26668132 DOI: 10.1182/blood-2015-08-662916] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 12/09/2015] [Indexed: 01/04/2023] Open
Abstract
Evidence shows that factor VIII (FVIII) ectopically expressed in platelets (2bF8) is therapeutic in FVIII(null) mice even with anti-FVIII inhibitory antibodies (inhibitors). If current efforts to generate platelets in vitro succeed, genetically manipulated platelets containing FVIII may be used therapeutically in hemophilia A patients with inhibitors. One important concern is the immunogenicity of platelet-derived FVIII. To address this concern, we infused 2bF8 transgenic (2bF8(Tg)) platelets into naïve FVIII(null) mice weekly for 8 weeks. No anti-FVIII antibodies were detected in the infused animals during the study course. We then explored whether platelet-derived FVIII is immunogenic in FVIII(null) mice with inhibitors. The 2bF8(Tg) platelets were transfused into rhF8-primed FVIII(null) mice, resulting in no augmentation of anti-FVIII antibodies. To investigate whether preconditioning affects the immune response, animals were sublethally irradiated and subsequently transfused with 2bF8(Tg) platelets. No anti-FVIII antibodies were detected in the recipients after platelet infusions. Following further challenge with rhF8, the inhibitor titer in this group was significantly lower than in naïve FVIII(null) mice utilizing the same immunization protocol. Thus, our data demonstrate that infusion of platelets containing FVIII triggers neither primary nor memory anti-FVIII immune response in FVIII(null) mice and that sublethal irradiation plus 2bF8(Tg) platelet infusion suppresses anti-FVIII immune response in FVIII(null) mice.
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37
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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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38
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Fogdell-Hahn A. Antidrug Antibodies: B Cell Immunity Against Therapy. Scand J Immunol 2015; 82:184-90. [DOI: 10.1111/sji.12327] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Accepted: 06/18/2015] [Indexed: 01/19/2023]
Affiliation(s)
- A. Fogdell-Hahn
- Karolinska Institutet; Department of Clinical Neuroscience; Clinical Neuroimmunology; Center for Molecular Medicine (CMM); Karolinska University Hospital; Solna Stockholm Sweden
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39
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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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40
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Hegen H, Guger M, Harrer A, Hoelzl M, Kraus J, Skrobal A, Schautzer F, Schmidegg S, Schocke M, Deisenhammer F. High-dose intravenous interferon-beta in multiple sclerosis patients with high-titer neutralizing antibodies (HINABS II) - A pilot study. Mult Scler Relat Disord 2015; 3:220-6. [PMID: 25878009 DOI: 10.1016/j.msard.2013.09.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2013] [Revised: 07/25/2013] [Accepted: 09/03/2013] [Indexed: 12/28/2022]
Abstract
BACKGROUND Neutralizing antibodies (NAb) against interferon-beta (IFNβ) affect its treatment efficacy. So far, there are no anti-NAb strategies available. OBJECTIVES To investigate if the repeated administration of high-dose IFNβ-1b intravenous in NAb positive multiple sclerosis (MS) patients induces tolerance and establishes IFNβ bioavailability as measured by the induction of myxovirus protein A (MxA). METHODS Nine MS patients with NAb titers >500 10-fold reduction units (TRU) received 1500μg IFNβ-1b intravenously once weekly over three months. Blood samples were collected at screening, monthly during the treatment period (before and four hours after IFNβ administration), and at follow-up after 6 months for determination of NAbs and MxA expression. RESULTS Median NAb titer at baseline was 1429TRU. NAb titers determined before each infusion did not significantly change over the treatment period and were not different at follow-up compared to baseline. However, NAb titers were significantly decreased four hours after IFNβ infusions (by roughly 50%) and MxA mRNA levels were significantly elevated reaching a median value of 206. CONCLUSIONS Weekly intravenous administration of IFNβ in patients with high NAb titers established its bioavailability, but failed to induce tolerance towards IFNβ.
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Affiliation(s)
- H Hegen
- Innsbruck Medical University, Department of Neurology, Anichstraße 35, 6020 Innsbruck, Austria.
| | - M Guger
- Allgemeines Krankenhaus Linz, Department of Neurology, Krankenhausstraße 9, 4021 Linz, Austria
| | - A Harrer
- Paracelsus Medical University, Department of Neurology, Ignaz-Harrer-Straße 79, 5020 Salzburg, Austria
| | - M Hoelzl
- Innsbruck Medical University, Department of Neurology, Anichstraße 35, 6020 Innsbruck, Austria
| | - J Kraus
- Paracelsus Medical University, Department of Neurology, Ignaz-Harrer-Straße 79, 5020 Salzburg, Austria
| | - A Skrobal
- Landesklinikum Horn, Department of Neurology, Spitalgase 10, 3580 Horn, Austria
| | - F Schautzer
- Landeskrankenhaus Villach, Department of Neurology, Nikolaigasse 43, 9500 Villach, Austria
| | - S Schmidegg
- Allgemeines Krankenhaus Linz, Department of Neurology, Krankenhausstraße 9, 4021 Linz, Austria
| | - M Schocke
- Innsbruck Medical University, Department of Radiology, Anichstraße 35, 6020 Innsbruck, Austria
| | - F Deisenhammer
- Innsbruck Medical University, Department of Neurology, Anichstraße 35, 6020 Innsbruck, Austria
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41
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Badami KG. Induction of immune tolerance to RBC, platelet, and neutrophil antigens and IgA. Med Hypotheses 2015; 84:586-8. [PMID: 25795096 DOI: 10.1016/j.mehy.2015.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Revised: 02/22/2015] [Accepted: 03/04/2015] [Indexed: 10/23/2022]
Abstract
Antibodies to red blood cell (RBC), platelet, and neutrophil antigens, and IgA may cause serious clinical problems. With a few exceptions, preventing these conditions is a matter of limiting exposure to the foreign antigen while treatment consists of managing the consequences. Might immune tolerance induction (ITI) be possible and beneficial in these situations? Neonatal exposure to antigens is known to induce central tolerance. However central tolerance may not be absolute. Factors that determine whether an antibody will be produced in response to an antigen are not well understood but include the appropriate expression of major histocompatibility complex-class II and/or co-stimulatory molecules on dendritic cells, the presence or absence of adjuvants and whether or not the antigen is presented together with agonists for the toll-like receptor. Modifying these may prevent alloimmunization. Peripheral tolerance, in sensitized individuals, as routinely used in patients with allergic/anaphylactic reactions, those with haemophilia A or B with inhibitors and acquired haemophilia, may also be possible. Briefly, monitored, graded, increasing exposure to the antigen of interest with or without additional immunosuppression is used. Neither central nor peripheral ITI has been tried or suggested for individuals sensitizable or sensitised to RBC, platelet, and neutrophil antigens, or IgA. Theoretically, this is possible and may be of benefit.
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Affiliation(s)
- K G Badami
- New Zealand Blood Service, 15, Lester Lane, Addington, Christchurch, New Zealand.
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42
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Abstract
The pathogenesis of inhibitory antibodies has been the focus of major scientific interest over the last decades, and several studies on underlying immune mechanisms and risk factors for formation of these antibodies have been performed with the aim of improving the ability to both predict and prevent their appearance. It seems clear that the decisive factors for the immune response to the deficient factor are multiple and involve components of both a constitutional and therapy-related nature. A scientific concern and obstacle for research in the area of hemophilia is the relatively small cohorts available for studies and the resulting risk of confounded and biased results. Careful interpretation of data is recommended to avoid treatment decisions based on a weak scientific platform. This review will summarize current concepts of the underlying immunological mechanisms and risk factors for development of inhibitory antibodies in patients with hemophilia A and discuss how these findings may be interpreted and influence our clinical management of patients.
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Minno GD, Santagostino E, Pratt K, Königs C. New predictive approaches for ITI treatment. Haemophilia 2015; 20 Suppl 6:27-43. [PMID: 24975702 DOI: 10.1111/hae.12467] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Immune tolerance induction (ITI) therapy in patients with haemophilia A and inhibitors constitutes a huge burden for affected patients and families and poses a large economic burden for a chronic disease. Concerted research efforts are attempting to optimize the therapeutic approach to the prevention and eradication of inhibitors. The Italian ITI Registry has provided data on 110 patients who completed ITI therapy as at July 2013. Analysis of independent predictors of success showed that, together with previously recognized factors - namely inhibitor titre prior to ITI, historical peak titre and peak titre on ITI - the type of causative FVIII gene mutation also contributes to the identification of patients with good prognosis and may be useful to optimize candidate selection and treatment regimens. Numerous studies have demonstrated that inhibitor reactivity against different FVIII products varies and is lower against concentrates containing von Willebrand factor (VWF). An Italian study compared inhibitor titres against a panel of FVIII concentrates in vitro and correlated titres with the capacity to inhibit maximum thrombin generation as measured by the thrombin generation assay (TGA). Observations led to the design of the PredictTGA study which aims to correlate TGA results with epitope specificity, inhibitor reactivity against different FVIII concentrates and clinical data in inhibitor patients receiving FVIII in the context of ITI or as prophylactic/on demand treatment. At the immunological level, it is known that T cells drive inhibitor development and that B cells secrete FVIII-specific antibodies. As understanding increases about the immunological response in ITI, it is becoming apparent that modulation of T-cell- and B-cell-mediated responses offers a range of potential new and specific approaches to prevent and eliminate inhibitors as well as individualize ITI therapy.
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Affiliation(s)
- G D Minno
- Regional Reference Centre for Coagulation Disorders, Department of Clinical and Experimental Medicine, Federico II University, Naples, Italy
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Engineered antigen-specific human regulatory T cells: immunosuppression of FVIII-specific T- and B-cell responses. Blood 2014; 125:1107-15. [PMID: 25498909 DOI: 10.1182/blood-2014-04-566786] [Citation(s) in RCA: 120] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Expansion of human regulatory T cells (Tregs) for clinical applications offers great promise for the treatment of undesirable immune responses in autoimmunity, transplantation, allergy, and antidrug antibody responses, including inhibitor responses in hemophilia A patients. However, polyclonal Tregs are nonspecific and therefore could potentially cause global immunosuppression. To avoid this undesirable outcome, the generation of antigen-specific Tregs would be advantageous. Herein, we report the production and properties of engineered antigen-specific Tregs, created by transduction of a recombinant T-cell receptor obtained from a hemophilia A subject's T-cell clone, into expanded human FoxP3(+) Tregs. Such engineered factor VIII (FVIII)-specific Tregs efficiently suppressed the proliferation and cytokine production of FVIII-specific T-effector cells. Moreover, studies with an HLA-transgenic, FVIII-deficient mouse model demonstrated that antibody production from FVIII-primed spleen cells in vitro were profoundly inhibited in the presence of these FVIII-specific Tregs, suggesting potential utility to treat anti-FVIII inhibitory antibody formation in hemophilia A patients.
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Oldenburg J, Austin SK, Kessler CM. ITI choice for the optimal management of inhibitor patients - from a clinical and pharmacoeconomic perspective. Haemophilia 2014; 20 Suppl 6:17-26. [DOI: 10.1111/hae.12466] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- J. Oldenburg
- Institute for Experimental Haematology and Transfusion Medicine; University Clinic Bonn; Bonn Germany
| | - S. K. Austin
- St. George's Healthcare NHS Trust Haemophilia Centre; St. George's Hospital; London UK
| | - C. M. Kessler
- Hemophilia and Thrombophilia Comprehensive Care Center; Georgetown University Hospital; Washington DC USA
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Role of B Cells in Breaking and Maintaining Tolerance to Clotting Factor VIII in Congenital and Acquired Hemophilia A. Antibodies (Basel) 2014. [DOI: 10.3390/antib3020192] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
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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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Annoni A, Cantore A, Della Valle P, Goudy K, Akbarpour M, Russo F, Bartolaccini S, D'Angelo A, Roncarolo MG, Naldini L. Liver gene therapy by lentiviral vectors reverses anti-factor IX pre-existing immunity in haemophilic mice. EMBO Mol Med 2013; 5:1684-97. [PMID: 24106222 PMCID: PMC3840485 DOI: 10.1002/emmm.201302857] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2013] [Revised: 07/18/2013] [Accepted: 08/08/2013] [Indexed: 01/24/2023] Open
Abstract
A major complication of factor replacement therapy for haemophilia is the development of anti-factor neutralizing antibodies (inhibitors). Here we show that liver gene therapy by lentiviral vectors (LVs) expressing factor IX (FIX) strongly reduces pre-existing anti-FIX antibodies and eradicates FIX inhibitors in haemophilia B mice. Concomitantly, plasma FIX levels and clotting activity rose to 50–100% of normal. The treatment was effective in 75% of treated mice. FIX-specific plasma cells (PCs) and memory B cells were reduced, likely because of memory B-cell depletion in response to constant exposure to high doses of FIX. Regulatory T cells displaying FIX-specific suppressive capacity were induced in gene therapy treated mice and controlled FIX-specific T helper cells. Gene therapy proved safer than a regimen mimicking immune tolerance induction (ITI) by repeated high-dose FIX protein administration, which induced severe anaphylactoid reactions in inhibitors-positive haemophilia B mice. Liver gene therapy can thus reverse pre-existing immunity, induce active tolerance to FIX and establish sustained FIX activity at therapeutic levels. These data position gene therapy as an attractive treatment option for inhibitors-positive haemophilic patients.
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Affiliation(s)
- Andrea Annoni
- TIGET, San Raffaele Telethon Institute for Gene Therapy, San Raffaele Scientific Institute, Milan, Italy
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Abstract
A major problem in treating hemophilia A patients with therapeutic factor VIII (FVIII) is that 20% to 30% of these patients produce neutralizing anti-FVIII antibodies. These antibodies block (inhibit) the procoagulant function of FVIII and thus are termed "inhibitors." The currently accepted clinical method to attempt to eliminate inhibitors is immune tolerance induction (ITI) via a protocol requiring intensive FVIII treatment until inhibitor titers drop. Although often successful, ITI is extremely costly and is less likely to succeed in patients with high-titer inhibitors. During the past decade, significant progress has been made in clarifying mechanisms of allo- and autoimmune responses to FVIII and in suppression of these responses. Animal model studies are suggesting novel, less costly methods to induce tolerance to FVIII. Complementary studies of anti-FVIII T-cell responses using blood samples from human donors are identifying immunodominant T-cell epitopes in FVIII and possible targets for tolerogenic efforts. Mechanistic experiments using human T-cell clones and lines are providing a clinically relevant counterpoint to the animal model studies. This review highlights recent progress toward the related goals of lowering the incidence of anti-FVIII immune responses and promoting durable, functional immune tolerance to FVIII in patients with an existing inhibitor.
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