1
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Zemer VS, Mousa K, Herscovici T, Steinberg-Shemer O, Bonstein L, Yacobovich J. Neonatal Thrombocytopenia: Differing Characteristics of NAIT Versus Non-NAIT. J Pediatr Hematol Oncol 2023; 45:e728-e732. [PMID: 37027241 DOI: 10.1097/mph.0000000000002669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 02/23/2023] [Indexed: 04/08/2023]
Abstract
While neonatal alloimmune thrombocytopenia (NAIT) is the most common cause of severe neonatal thrombocytopenia good clinical predictors are lacking. We analyzed cases of neonatal thrombocytopenia in Schneider Children's Medical Center of Israel to pinpoint qualifiers of NAIT (NAIT+) in comparison to non-NAIT (NAIT-) thrombocytopenia. Patient and maternal data were retrospectively collected on all thrombocytopenic newborns undergoing a workup for NAIT in our tertiary center between 2001 and 2016. Among 26 thrombocytopenic neonates, the mean nadir in NAIT+ patients (25×10 9 /L) was significantly lower than NAIT- patients (64×10 9 /L) ( P <0.001). 61.5% of NAIT+ infants required treatment compared with 23% of non-NAIT ( P =0.015). NAIT+ patients also required more therapeutic modalities than infants with NAIT- thrombocytopenia. Human platelet antigen (HPA)-1a and HPA-5b alloantibodies most frequently caused NAIT. In summary, thrombocytopenia in NAIT+ was significantly more severe compared with NAIT- and more likely to require treatment. In addition, despite the varied ethnic population in Israel, the HPA alloantibodies found in our population were most similar to those common in Western countries. In the absence of rigorous prenatal screening options, we suggest platelet counts below 40 to 50×10 9 /L in a healthy newborn be considered most suggestive for NAIT and warrant urgent NAIT-specific analysis.
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Affiliation(s)
- Vered S Zemer
- Clalit Health Services
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv
| | | | - Tina Herscovici
- Departments of Neonatology
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv
| | - Orna Steinberg-Shemer
- Pediatric Hematology-Oncology, Schneider Children's Medical Center of Israel, Petach Tikva
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv
| | - Lilach Bonstein
- Blood Bank and Platelet Immunology Laboratories, Rambam Health Care Campus, Haifa, Israel
| | - Joanne Yacobovich
- Pediatric Hematology-Oncology, Schneider Children's Medical Center of Israel, Petach Tikva
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv
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2
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Stam W, Wachholz GE, de Pereda JM, Kapur R, van der Schoot E, Margadant C. Fetal and neonatal alloimmune thrombocytopenia: Current pathophysiological insights and perspectives for future diagnostics and treatment. Blood Rev 2022; 59:101038. [PMID: 36581513 DOI: 10.1016/j.blre.2022.101038] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 12/18/2022] [Accepted: 12/19/2022] [Indexed: 12/24/2022]
Abstract
FNAIT is a pregnancy-associated condition caused by maternal alloantibodies against paternally-inherited platelet antigens, most frequently HPA-1a on integrin β3. The clinical effects range from no symptoms to fatal intracranial hemorrhage, but underlying pathophysiological determinants are poorly understood. Accumulating evidence suggests that differential antibody-Fc-glycosylation, activation of complement/effector cells, and integrin function-blocking effects contribute to clinical outcome. Furthermore, some antibodies preferentially bind platelet integrin αIIbβ3, but others bind αvβ3 on endothelial cells and trophoblasts. Defects in endothelial cells and angiogenesis may therefore contribute to severe anti-HPA-1a associated FNAIT. Moreover, anti-HPA-1a antibodies may cause placental damage, leading to intrauterine growth restriction. We discuss current insights into diversity and actions of HPA-1a antibodies, gathered from clinical studies, in vitro studies, and mouse models. Assessment of all factors determining severity and progression of anti-HPA-1a-associated FNAIT may importantly improve risk stratification and potentially reveal novel treatment strategies, both for FNAIT and other immunohematological disorders.
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Affiliation(s)
- Wendy Stam
- Institute of Biology, Leiden University, Leiden, the Netherlands; Cancer Center Amsterdam, Amsterdam UMC, Amsterdam, the Netherlands.
| | | | - Jose Maria de Pereda
- Centro de Investigación del Cáncer and Instituto de Biología Molecular y Celular del Cáncer, Consejo Superior de Investigaciones Científicas (CSIC), Universidad de Salamanca, 37007 Salamanca, Spain.
| | - Rick Kapur
- Sanquin Research, Department of Experimental Immunohematology, Landsteiner Laboratory, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.
| | - Ellen van der Schoot
- Sanquin Research, Department of Experimental Immunohematology, Landsteiner Laboratory, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.
| | - Coert Margadant
- Institute of Biology, Leiden University, Leiden, the Netherlands; Cancer Center Amsterdam, Amsterdam UMC, Amsterdam, the Netherlands.
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3
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Xu X, Chen D, Ye X, Xia W, Xu Y, Chen Y, Shao Y, Deng J, Ding H, Liu J, Wang J, Ni H, Fu Y, Santoso S. Successful prenatal therapy for anti-CD36-mediated severe FNAIT by deglycosylated antibodies in a novel murine model. Blood 2021; 138:1757-1767. [PMID: 34041523 PMCID: PMC8701625 DOI: 10.1182/blood.2021011131] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 05/01/2021] [Indexed: 11/20/2022] Open
Abstract
Recent studies have shown that maternal anti-CD36 antibodies represent a frequent cause of fetal/neonatal alloimmune thrombocytopenia (FNAIT) in Asian and African populations. However, little is known about the pathomechanism and antenatal treatment of anti-CD36-mediated FNAIT. Here, we established a novel animal model to examine the clinical features of pups from immunized Cd36-/- female mice after breeding with wild-type male mice. Mild thrombocytopenia was observed, but high pup mortality was also documented (40.26%). Administration of intravenous immunoglobulin (IVIG) (1 g/kg) on days 7, 12, and 17 to immunized Cd36-/- mothers after breeding reduced fetal death (12.70%). However, delaying the IVIG administration series on days 10, 15, and 20 did not reduce fetal death (40.00%). In contrast, injection of deglycosylated anti-CD36 (deg-anti-CD36) polyclonal antibodies (5 mg/kg) on days 10, 15, and 20 significantly reduced fetal death (5.26%). Subsequently, monoclonal antibodies (mAbs) against mouse CD36 were developed, and one clone producing high-affinity anti-CD36 (termed 32-106) effectively inhibited maternal antibody binding and was therefore selected. Using the same approach of deg-anti-CD36, the administration of deg-32-106 significantly reduced fetal death (2.17%). Furthermore, immunized Cd36-/- mothers exhibited placental deficiency. Accordingly, maternal anti-CD36 antibodies inhibited angiogenesis of placenta endothelial cells, which could be restored by deg-32-106. In summary, maternal anti-CD36 antibodies caused a high frequency of fetal death in our animal model, associated with placental dysfunction. This deleterious effect could be diminished by the antenatal administration of IVIG and deg-mAb 32-106. Interestingly, treatment with deg-32-106 seems more beneficial considering the lower dose, later start of treatment, and therapy success.
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Affiliation(s)
- Xiuzhang Xu
- Institute of Blood Transfusion, Guangzhou Blood Centre, Guangzhou, Guangdong, China
- Institute for Clinical Immunology and Transfusion Medicine, Justus Liebig University, Giessen, Germany
| | - Dawei Chen
- Institute of Blood Transfusion, Guangzhou Blood Centre, Guangzhou, Guangdong, China
- Institute for Clinical Immunology and Transfusion Medicine, Justus Liebig University, Giessen, Germany
| | - Xin Ye
- Institute of Blood Transfusion, Guangzhou Blood Centre, Guangzhou, Guangdong, China
| | - Wenjie Xia
- Institute of Blood Transfusion, Guangzhou Blood Centre, Guangzhou, Guangdong, China
| | - Yaori Xu
- Institute of Blood Transfusion, Guangzhou Blood Centre, Guangzhou, Guangdong, China
| | - Yangkai Chen
- Institute of Blood Transfusion, Guangzhou Blood Centre, Guangzhou, Guangdong, China
| | - Yuan Shao
- Institute of Blood Transfusion, Guangzhou Blood Centre, Guangzhou, Guangdong, China
| | - Jing Deng
- Institute of Blood Transfusion, Guangzhou Blood Centre, Guangzhou, Guangdong, China
| | - Haoqiang Ding
- Institute of Blood Transfusion, Guangzhou Blood Centre, Guangzhou, Guangdong, China
| | - Jing Liu
- Institute of Blood Transfusion, Guangzhou Blood Centre, Guangzhou, Guangdong, China
| | - Jiali Wang
- Institute of Blood Transfusion, Guangzhou Blood Centre, Guangzhou, Guangdong, China
| | - Heyu Ni
- Department of Laboratory Medicine and Pathobiology, LKSKI-Keenan Research Centre, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
- Canadian Blood Services Centre for Innovation, Toronto, ON, Canada
| | - Yongshui Fu
- Institute of Blood Transfusion, Guangzhou Blood Centre, Guangzhou, Guangdong, China
- Department of Transfusion Medicine, School of Laboratory Medicine and Biotechnology, Southern Medical University, Guangzhou, Guangdong, China; and
- Zhujiang Hospital of Southern Medical University, Guangzhou, Guangdong, China
| | - Sentot Santoso
- Institute of Blood Transfusion, Guangzhou Blood Centre, Guangzhou, Guangdong, China
- Institute for Clinical Immunology and Transfusion Medicine, Justus Liebig University, Giessen, Germany
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4
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Preclinical evaluation of immunotherapeutic regimens for fetal/neonatal alloimmune thrombocytopenia. Blood Adv 2021; 5:3552-3562. [PMID: 34470046 DOI: 10.1182/bloodadvances.2021004371] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 05/10/2021] [Indexed: 11/20/2022] Open
Abstract
Fetal/neonatal alloimmune thrombocytopenia (FNAIT) is a life-threatening bleeding disorder caused by maternal antibodies directed against paternally inherited antigens present on the surface of fetal platelets. The human platelet alloantigen HPA-1a (formerly known as the PlA1 alloantigen), is the most frequently implicated HPA for causing FNAIT in Whites. A single Leu33Pro amino acid polymorphism residing within the ∼50-amino-acid plexin-semaphorin-integrin domain near the N-terminus of the integrin β3 subunit (platelet membrane glycoprotein IIIa [GPIIIa]) is responsible for generating the HPA-1a and HPA-1b epitopes in human GPIIIa and serves as the central target for alloantibody-mediated platelet destruction. To simulate the etiology of human FNAIT, wild-type female mice were pre-immunized with platelets derived from transgenic mice engineered to express the human HPA-1a epitope on a murine GPIIIa backbone. These mice developed a strong alloimmune response specific for HPA-1a, and when bred with HPA-1a+ males, gave birth to severely thrombocytopenic pups that exhibited an accompanying bleeding phenotype. Administering either polyclonal intravenous immunoglobulin G or a human monoclonal blocking antibody specific for the HPA-1a epitope into pregnant female mice resulted in significant elevation of the neonatal platelet count, normalized hemostasis, and prevented bleeding. The establishment of an alloantigen-specific murine model that recapitulates many of the clinically important features of FNAIT should pave the way for the preclinical development and testing of novel therapeutic and prophylactic modalities to treat or prevent FNAIT in humans.
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D'Mello RJ, Hsu CD, Chaiworapongsa P, Chaiworapongsa T. Update on the Use of Intravenous Immunoglobulin in Pregnancy. Neoreviews 2021; 22:e7-e24. [PMID: 33386311 DOI: 10.1542/neo.22-1-e7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Intravenous immunoglobulin (IVIG) was first administered to humans in the 1980s. The mechanism of action of IVIG is still a subject of debate but the pharmacokinetics have been well characterized, albeit outside of pregnancy. IVIG has been used in pregnancy to treat several nonobstetrical and obstetrical-related conditions. However, current evidence suggests that IVIG use during pregnancy can be recommended for 1) in utero diagnosis of neonatal alloimmune thrombocytopenia; 2) gestational alloimmune liver disease; 3) hemolytic disease of the fetus and newborn for early-onset severe intrauterine disease; 4) antiphospholipid syndrome (APS) when refractory to or contraindicated to standard treatment, or in catastrophic antiphospholipid syndrome; and 5) immune thrombocytopenia when standard treatment is ineffective or rapid increase of platelet counts is needed. All recommendations are based on case series and cohort studies without randomized trials usually because of the rare prevalence of the conditions, the high incidence of adverse outcomes if left untreated, and ethical concerns. In contrast, IVIG therapy cannot be recommended for recurrent pregnancy loss, and the use of IVIG in subgroups of those with recurrent pregnancy loss requires further investigations. For non-obstetrical-related conditions, we recommend using IVIG as indicated for nonpregnant patients. In conclusion, the use of IVIG during pregnancy is an effective treatment in some obstetrical-related conditions with rare serious maternal side effects. However, the precise mechanisms of action and the long-term immunologic effects on the fetus and neonate are poorly understood and merit further investigations.
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Affiliation(s)
- Rahul J D'Mello
- Department of Obstetrics and Gynecology, Detroit Medical Center, Detroit, MI
| | - Chaur-Dong Hsu
- Department of Obstetrics and Gynecology and.,Department of Physiology, Wayne State University School of Medicine, Detroit, MI
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6
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Marks K, Coutinho E, Vincent A. Maternal-Autoantibody-Related (MAR) Autism: Identifying Neuronal Antigens and Approaching Prospects for Intervention. J Clin Med 2020; 9:jcm9082564. [PMID: 32784803 PMCID: PMC7465310 DOI: 10.3390/jcm9082564] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 07/31/2020] [Accepted: 08/03/2020] [Indexed: 02/06/2023] Open
Abstract
Recent studies indicate the existence of a maternal-autoantibody-related subtype of autism spectrum disorder (ASD). To date, a large number of studies have focused on describing patterns of brain-reactive serum antibodies in maternal-autoantibody-related (MAR) autism and some have described attempts to define the antigenic targets. This article describes evidence on MAR autism and the various autoantibodies that have been implicated. Among other possibilities, antibodies to neuronal surface protein Contactin Associated Protein 2 (CASPR2) have been found more frequently in mothers of children with neurodevelopmental disorders or autism, and two independent experimental studies have shown pathogenicity in mice. The N-methyl-D-aspartate receptor (NMDAR) is another possible target for maternal antibodies as demonstrated in mice. Here, we discuss the growing evidence, discuss issues regarding biomarker definition, and summarise the therapeutic approaches that might be used to reduce or prevent the transfer of pathogenic maternal antibodies.
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Affiliation(s)
- Katya Marks
- Medical Sciences Division, John Radcliffe Hospital, University of Oxford, OX3 9DU Oxford, UK;
| | - Ester Coutinho
- Department of Basic and Clinical Neuroscience, Institute of Psychiatry, Psychology and Neuroscience, Maurice Wohl Clinical Neuroscience Institute, King’s College London, SE5 9RT London, UK;
- Nuffield Department of Clinical Neurosciences and Weatherall Institute for Molecular Medicine, University of Oxford, OX3 9DS Oxford, UK
| | - Angela Vincent
- Medical Research Council Centre for Neurodevelopmental Disorders, King’s College London, SE1 1UL London, UK
- Correspondence: ; Tel.: +44-781-722-4849 or +44-186-555-9636
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7
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Kjær M, Geisen C, Akkök ÇA, Wikman A, Sachs U, Bussel JB, Nielsen K, Walles K, Curtis BR, Vidarsson G, Järås K, Skogen B. Strategies to develop a prophylaxis for the prevention of HPA-1a immunization and fetal and neonatal alloimmune thrombocytopenia. Transfus Apher Sci 2019; 59:102712. [PMID: 31948915 DOI: 10.1016/j.transci.2019.102712] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Indexed: 01/20/2023]
Abstract
Anti-HPA-1a-antibodies are the main cause of fetal and neonatal alloimmune thrombocytopenia (FNAIT) which may result in intracranial hemorrhage (ICH) and death among fetuses and newborns. Advances in understanding the pathogenesis of FNAIT and proof of concept for prophylaxis to prevent immunization suggest that development of hyperimmune anti-HPA-1a IgG aimed at preventing immunization against HPA-1a and FNAIT is feasible. Anti-HPA-1a IgG can be obtained either by isolating immunoglobulin from already-immunized women or by development of monoclonal anti-HPA-1a antibodies. Here we discuss recent advances that may lead to the development of a prenatal and postnatal prophylactic treatment for the prevention of HPA-1a-associated FNAIT and life-threatening FNAIT-induced complications.
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Affiliation(s)
- Mette Kjær
- Department of Laboratory Medicine, University Hospital of North Norway, Tromsø, Norway; Finnmark Hospital Trust, Hammerfest, Norway.
| | | | | | | | | | - James B Bussel
- Dept of Pediatrics, Weill Cornell Medicine, New York, NY, USA
| | | | | | | | | | | | - Bjørn Skogen
- Department of Medical Biology, UiT- The Artic University of Norway, Tromsø, Norway
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8
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Regan F, Lees CC, Jones B, Nicolaides KH, Wimalasundera RC, Mijovic A. Prenatal Management of Pregnancies at Risk of Fetal Neonatal Alloimmune Thrombocytopenia (FNAIT): Scientific Impact Paper No. 61. BJOG 2019; 126:e173-e185. [PMID: 30968555 DOI: 10.1111/1471-0528.15642] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
WHAT IS IT?: Fetal neonatal alloimmune thrombocytopenia (FNAIT), also known as neonatal alloimmune thrombocytopenia (NAIT) or fetomaternal alloimmune thrombocytopenia (FMAIT), is a rare condition which affects a baby's platelets. This can put them at risk of problems with bleeding, particularly into the brain. One baby per week in the UK may be seriously affected and milder forms can affect one in every 1000 births. HOW IS IT CAUSED?: Platelets are blood cells that are very important in helping blood to clot. All platelets have natural proteins on their surface called human platelet antigens (HPAs). In babies, half of these antigens are inherited from the mother and half from the father. During pregnancy, some of the baby's platelets can cross into the mother's bloodstream. In most cases, this does not cause a problem. But in cases of FNAIT, the mother's immune system does not recognise the baby's HPAs that were inherited from the father and develops antibodies, which can cross the placenta and attack the baby's platelets. These antibodies are called anti-HPAs, and the commonest antibody implicated is anti-HPA-1a, but there are other rarer antibody types. If this happens, the baby's platelets may be destroyed causing their platelet count to fall dangerously low. If the platelet count is very low there is a risk to the baby of bleeding into their brain before they are born. This is very rare but if it happens it can have serious effects on the baby's health. HOW IS IT INHERITED?: A baby inherits half of their HPAs from its mother and half from its father. Consequently, a baby may have different HPAs from its mother. As the condition is very rare, and even if the baby is at risk of the condition we have no way of knowing how severely they will be affected, routine screening is not currently recommended. WHAT CAN BE DONE?: FNAIT is usually diagnosed if a previous baby has had a low platelet count. The parents are offered blood tests and the condition can be confirmed or ruled out. There are many other causes of low platelets in babies, which may also need to be tested for. As the condition is so rare, expertise is limited to specialist centres and normally a haematologist and fetal medicine doctor will perform and interpret the tests together. Fortunately, there is an effective treatment for the vast majority of cases called immunoglobulin, or IVIg. This 'blood product' is given intravenously through a drip every week to women at risk of the condition. It may be started from as early as 16 weeks in the next pregnancy, until birth, which would be offered at around 36-37 weeks. Less common treatments that may be considered depending on individual circumstances include steroid tablets or injections, or giving platelet transfusions to the baby. WHAT DOES THIS PAPER TELL YOU?: This paper considers the latest evidence in relation to treatment options in the management of pregnancies at risk of FNAIT. Specifically, we discuss the role of screening, when IVIg should be started, what dose should be used, and what evidence there is for maternal steroids. We also consider in very rare selected cases, the use of fetal blood sampling and giving platelet transfusions to the baby before birth. Finally, we consider the approaches to blood testing mothers to tell if babies are at risk, which is offered in some countries, and development of new treatments to reduce the risk of FNAIT.
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MESH Headings
- Antigens, Human Platelet
- Female
- Fetal Diseases/genetics
- Fetal Diseases/prevention & control
- Fetal Diseases/therapy
- Genetic Testing
- Humans
- Immunoglobulins, Intravenous/therapeutic use
- Infant, Newborn
- Infant, Newborn, Diseases/genetics
- Infant, Newborn, Diseases/therapy
- Integrin beta3
- Mass Screening/methods
- Medical History Taking
- Platelet Count
- Pregnancy
- Prenatal Care/methods
- Thrombocytopenia, Neonatal Alloimmune/diagnosis
- Thrombocytopenia, Neonatal Alloimmune/genetics
- Thrombocytopenia, Neonatal Alloimmune/prevention & control
- Thrombocytopenia, Neonatal Alloimmune/therapy
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9
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Winkelhorst D, Oepkes D. Foetal and neonatal alloimmune thrombocytopenia. Best Pract Res Clin Obstet Gynaecol 2019; 58:15-27. [PMID: 30827816 DOI: 10.1016/j.bpobgyn.2019.01.017] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2018] [Revised: 01/23/2019] [Accepted: 01/31/2019] [Indexed: 12/19/2022]
Abstract
Foetal or neonatal thrombocytopenia results from alloimmunisation during pregnancy. Maternal alloantibodies can be formed following exposure to paternally derived human platelet antigens (HPAs) on foetal platelets, in case of incompatible HPA type. These alloantibodies are of the immunoglobulin G subclass and can therefore enter the foetal circulation through active placental transport mediated by the neonatal Fc-receptor. After entering the foetal circulation, these alloantibodies can cause destruction of foetal platelets and potentially damage other foetal cells containing the specific antigen. Subsequent clinical presentation in foetuses or neonates can vary widely, from an asymptomatic thrombocytopenia to a broad spectrum of bleeding complications. Most frequently encountered are minor skin haemorrhages, such as hematomas or petechiae, but also more devastating haemorrhages can occur. Of these, an intracranial haemorrhage is the most feared complication because of its high risk of life-long major neurological handicaps or perinatal death.
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Affiliation(s)
- Dian Winkelhorst
- Department of Obstetrics, Leiden University Medical Center, K6-35, P.O. Box 9600, 2300 RC, Leiden, the Netherlands.
| | - Dick Oepkes
- Department of Obstetrics, Leiden University Medical Center, K6-35, P.O. Box 9600, 2300 RC, Leiden, the Netherlands.
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10
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Stapleton NM, Armstrong-Fisher SS, Andersen JT, van der Schoot CE, Porter C, Page KR, Falconer D, de Haas M, Williamson LM, Clark MR, Vidarsson G, Armour KL. Human IgG lacking effector functions demonstrate lower FcRn-binding and reduced transplacental transport. Mol Immunol 2018; 95:1-9. [PMID: 29367080 DOI: 10.1016/j.molimm.2018.01.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 01/07/2018] [Accepted: 01/10/2018] [Indexed: 11/24/2022]
Abstract
We have previously generated human IgG1 antibodies that were engineered for reduced binding to the classical Fcγ receptors (FcγRI-III) and C1q, thereby eliminating their destructive effector functions (constant region G1Δnab). In their potential use as blocking agents, favorable binding to the neonatal Fc receptor (FcRn) is important to preserve the long half-life typical of IgG. An ability to cross the placenta, which is also mediated, at least in part, by FcRn is desirable in some indications, such as feto-maternal alloimmune disorders. Here, we show that G1Δnab mutants retain pH-dependent binding to human FcRn but that the amino acid alterations reduce the affinity of the IgG1:FcRn interaction by 2.0-fold and 1.6-fold for the two antibodies investigated. The transport of the modified G1Δnab mutants across monolayers of human cell lines expressing FcRn was approximately 75% of the wild-type, except that no difference was observed with human umbilical vein endothelial cells. G1Δnab mutation also reduced transport in an ex vivo placenta model. In conclusion, we demonstrate that, although the G1Δnab mutations are away from the FcRn-binding site, they have long-distance effects, modulating FcRn binding and transcellular transport. Our findings have implications for the design of therapeutic human IgG with tailored effector functions.
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Affiliation(s)
- Nigel M Stapleton
- Department of Experimental Immunohematology, Sanquin Research, and Landsteiner Laboratory, Academic Medical Center, University of Amsterdam, Plesmanlaan 125, Amsterdam, 1066 CX, The Netherlands
| | - Sylvia S Armstrong-Fisher
- RDI Clinical Transfusion Group, Scottish National Blood Transfusion Service, Foresterhill, Aberdeen, AB25 2ZW, UK; Institute of Medical Sciences, University of Aberdeen, Foresterhill, Aberdeen, AB25 2ZD, UK
| | - Jan Terje Andersen
- Department of Immunology, Oslo University Hospital Rikshospitalet and University of Oslo, PO Box 4950, Nydalen, Oslo, 0424, Norway; Centre for Immune Regulation and Department of Biosciences, University of Oslo, PO box 1041, Blindern, Oslo, 0316, Norway; Department of Pharmacology, Institute of Clinical Medicine, University of Oslo and Oslo University Hospital, Problemveien 7, 0315, Oslo, Norway
| | - C Ellen van der Schoot
- Department of Experimental Immunohematology, Sanquin Research, and Landsteiner Laboratory, Academic Medical Center, University of Amsterdam, Plesmanlaan 125, Amsterdam, 1066 CX, The Netherlands
| | - Charlene Porter
- Immunology Laboratory, Department of Pathology, Aberdeen Royal Infirmary, Aberdeen, AB25 2ZB, UK
| | - Kenneth R Page
- Institute of Medical Sciences, University of Aberdeen, Foresterhill, Aberdeen, AB25 2ZD, UK
| | - Donald Falconer
- Institute of Medical Sciences, University of Aberdeen, Foresterhill, Aberdeen, AB25 2ZD, UK
| | - Masja de Haas
- Department of Experimental Immunohematology, Sanquin Research, and Landsteiner Laboratory, Academic Medical Center, University of Amsterdam, Plesmanlaan 125, Amsterdam, 1066 CX, The Netherlands
| | - Lorna M Williamson
- Department of Haematology, University of Cambridge, UK; NHS Blood and Transplant, Long Road, Cambridge, CB2 2PT, UK
| | - Michael R Clark
- Department of Pathology, University of Cambridge, Tennis Court Road, Cambridge, CB2 1QP, UK
| | - Gestur Vidarsson
- Department of Experimental Immunohematology, Sanquin Research, and Landsteiner Laboratory, Academic Medical Center, University of Amsterdam, Plesmanlaan 125, Amsterdam, 1066 CX, The Netherlands.
| | - Kathryn L Armour
- Department of Haematology, University of Cambridge, UK; Department of Pathology, University of Cambridge, Tennis Court Road, Cambridge, CB2 1QP, UK
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11
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[Thirty years of platelet immunology in fetal and neonatal alloimmune thrombocytopenia management, current situation]. Transfus Clin Biol 2017; 24:166-171. [PMID: 28673503 DOI: 10.1016/j.tracli.2017.05.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Accepted: 05/30/2017] [Indexed: 11/21/2022]
Abstract
Fetal and neonatal allo-immune thrombocytopenia (FNAIT) is considered as a rare disease due to the incidence (1/1000-1/2000 births). The major complication of severe thrombocytopenia is bleeding and particularly intra-cranial hemorrhage and neurologic sequelae following. Serology and molecular biology developments have reconfigured the platelet immunology diagnosis. Anti-HPA-1a allo-immunisation is responsible for more than 80% FNAIT cases with a high recurrence rate of severe bleeding complications. Therapeutic management has changed over the coming years from an invasive concept associating fetal blood sampling and in utero platelet transfusion to a non invasive treatment by intravenous immunoglobulins injection (IVIg). The purpose of this article is to provide an update on FNAIT management in the light of current developments over the past 30years.
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12
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Moreau T, Evans AL, Vasquez L, Tijssen MR, Yan Y, Trotter MW, Howard D, Colzani M, Arumugam M, Wu WH, Dalby A, Lampela R, Bouet G, Hobbs CM, Pask DC, Payne H, Ponomaryov T, Brill A, Soranzo N, Ouwehand WH, Pedersen RA, Ghevaert C. Large-scale production of megakaryocytes from human pluripotent stem cells by chemically defined forward programming. Nat Commun 2016; 7:11208. [PMID: 27052461 PMCID: PMC4829662 DOI: 10.1038/ncomms11208] [Citation(s) in RCA: 180] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 03/02/2016] [Indexed: 02/02/2023] Open
Abstract
The production of megakaryocytes (MKs)--the precursors of blood platelets--from human pluripotent stem cells (hPSCs) offers exciting clinical opportunities for transfusion medicine. Here we describe an original approach for the large-scale generation of MKs in chemically defined conditions using a forward programming strategy relying on the concurrent exogenous expression of three transcription factors: GATA1, FLI1 and TAL1. The forward programmed MKs proliferate and differentiate in culture for several months with MK purity over 90% reaching up to 2 × 10(5) mature MKs per input hPSC. Functional platelets are generated throughout the culture allowing the prospective collection of several transfusion units from as few as 1 million starting hPSCs. The high cell purity and yield achieved by MK forward programming, combined with efficient cryopreservation and good manufacturing practice (GMP)-compatible culture, make this approach eminently suitable to both in vitro production of platelets for transfusion and basic research in MK and platelet biology.
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Affiliation(s)
- Thomas Moreau
- Department of Haematology, University of Cambridge and NHS Blood and Transplant, Long Road, Cambridge CB2 0PT, UK,The Anne McLaren Laboratory, Wellcome Trust-Medical Research Council Cambridge Stem Cell Institute and Department of Surgery, University of Cambridge, West Forvie Site, Robinson Way, Cambridge CB2 0SZ, UK,Wellcome Trust-Medical Research Council Cambridge Stem Cell Institute, Tennis Court Road, Cambridge CB2 1QR, UK
| | - Amanda L. Evans
- Department of Haematology, University of Cambridge and NHS Blood and Transplant, Long Road, Cambridge CB2 0PT, UK,Wellcome Trust-Medical Research Council Cambridge Stem Cell Institute, Tennis Court Road, Cambridge CB2 1QR, UK
| | - Louella Vasquez
- Human Genetics, Wellcome Trust Sanger Institute, Genome Campus, Hinxton CB10 1RQ, UK
| | - Marloes R. Tijssen
- Department of Haematology, University of Cambridge and NHS Blood and Transplant, Long Road, Cambridge CB2 0PT, UK
| | - Ying Yan
- Human Genetics, Wellcome Trust Sanger Institute, Genome Campus, Hinxton CB10 1RQ, UK
| | - Matthew W. Trotter
- The Anne McLaren Laboratory, Wellcome Trust-Medical Research Council Cambridge Stem Cell Institute and Department of Surgery, University of Cambridge, West Forvie Site, Robinson Way, Cambridge CB2 0SZ, UK
| | - Daniel Howard
- Department of Haematology, University of Cambridge and NHS Blood and Transplant, Long Road, Cambridge CB2 0PT, UK,Wellcome Trust-Medical Research Council Cambridge Stem Cell Institute, Tennis Court Road, Cambridge CB2 1QR, UK
| | - Maria Colzani
- Department of Haematology, University of Cambridge and NHS Blood and Transplant, Long Road, Cambridge CB2 0PT, UK,Wellcome Trust-Medical Research Council Cambridge Stem Cell Institute, Tennis Court Road, Cambridge CB2 1QR, UK
| | - Meera Arumugam
- Department of Haematology, University of Cambridge and NHS Blood and Transplant, Long Road, Cambridge CB2 0PT, UK,Wellcome Trust-Medical Research Council Cambridge Stem Cell Institute, Tennis Court Road, Cambridge CB2 1QR, UK
| | - Wing Han Wu
- Department of Haematology, University of Cambridge and NHS Blood and Transplant, Long Road, Cambridge CB2 0PT, UK,Wellcome Trust-Medical Research Council Cambridge Stem Cell Institute, Tennis Court Road, Cambridge CB2 1QR, UK
| | - Amanda Dalby
- Department of Haematology, University of Cambridge and NHS Blood and Transplant, Long Road, Cambridge CB2 0PT, UK,Wellcome Trust-Medical Research Council Cambridge Stem Cell Institute, Tennis Court Road, Cambridge CB2 1QR, UK
| | - Riina Lampela
- Wellcome Trust-Medical Research Council Cambridge Stem Cell Institute, Tennis Court Road, Cambridge CB2 1QR, UK
| | - Guenaelle Bouet
- Department of Haematology, University of Cambridge and NHS Blood and Transplant, Long Road, Cambridge CB2 0PT, UK,Wellcome Trust-Medical Research Council Cambridge Stem Cell Institute, Tennis Court Road, Cambridge CB2 1QR, UK
| | - Catherine M. Hobbs
- Department of Haematology, University of Cambridge and NHS Blood and Transplant, Long Road, Cambridge CB2 0PT, UK,Wellcome Trust-Medical Research Council Cambridge Stem Cell Institute, Tennis Court Road, Cambridge CB2 1QR, UK
| | - Dean C. Pask
- Department of Haematology, University of Cambridge and NHS Blood and Transplant, Long Road, Cambridge CB2 0PT, UK,Wellcome Trust-Medical Research Council Cambridge Stem Cell Institute, Tennis Court Road, Cambridge CB2 1QR, UK
| | - Holly Payne
- Institute of Cardiovascular Sciences, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
| | - Tatyana Ponomaryov
- Institute of Cardiovascular Sciences, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
| | - Alexander Brill
- Institute of Cardiovascular Sciences, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
| | - Nicole Soranzo
- Human Genetics, Wellcome Trust Sanger Institute, Genome Campus, Hinxton CB10 1RQ, UK
| | - Willem H. Ouwehand
- Department of Haematology, University of Cambridge and NHS Blood and Transplant, Long Road, Cambridge CB2 0PT, UK
| | - Roger A. Pedersen
- The Anne McLaren Laboratory, Wellcome Trust-Medical Research Council Cambridge Stem Cell Institute and Department of Surgery, University of Cambridge, West Forvie Site, Robinson Way, Cambridge CB2 0SZ, UK,Wellcome Trust-Medical Research Council Cambridge Stem Cell Institute, Tennis Court Road, Cambridge CB2 1QR, UK,
| | - Cedric Ghevaert
- Department of Haematology, University of Cambridge and NHS Blood and Transplant, Long Road, Cambridge CB2 0PT, UK,Wellcome Trust-Medical Research Council Cambridge Stem Cell Institute, Tennis Court Road, Cambridge CB2 1QR, UK,
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Brojer E, Husebekk A, Dębska M, Uhrynowska M, Guz K, Orzińska A, Dębski R, Maślanka K. Fetal/Neonatal Alloimmune Thrombocytopenia: Pathogenesis, Diagnostics and Prevention. Arch Immunol Ther Exp (Warsz) 2015; 64:279-90. [PMID: 26564154 PMCID: PMC4939163 DOI: 10.1007/s00005-015-0371-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2015] [Accepted: 08/31/2015] [Indexed: 01/10/2023]
Abstract
Fetal/neonatal alloimmune thrombocytopenia (FNAIT) is a relatively rare condition (1/1000–1/2000) that was granted orphan status by the European Medicines Agency in 2011. Clinical consequences of FNAIT, however, may be severe. A thrombocytopenic fetus or new-born is at risk of intracranial hemorrhage that may result in lifelong disability or death. Preventing such bleeding is thus vital and requires a solution. Anti-HPA1a antibodies are the most frequent cause of FNAIT in Caucasians. Its pathogenesis is similar to hemolytic disease of the newborn (HDN) due to anti-RhD antibodies, but is characterized by platelet destruction and is more often observed in the first pregnancy. In 75 % of these women, alloimmunization by HPA-1a antigens, however, occurs at delivery, which enables development of antibody-mediated immune suppression to prevent maternal immunization. As for HDN, the recurrence rate of FNAIT is high. For advancing diagnostic efforts and treatment, it is thereby crucial to understand the pathogenesis of FNAIT, including cellular immunity involvement. This review presents the current knowledge on FNAIT. Also described is a program for HPA-1a screening in identifying HPA-1a negative pregnant women at risk of immunization. This program is now performed at the Institute of Hematology and Transfusion Medicine in cooperation with the Department of Obstetrics and Gynecology of the Medical Centre of Postgraduate Education in Warsaw as well as the UiT The Arctic University of Norway.
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Affiliation(s)
- Ewa Brojer
- Department of Immunohematology and Immunology of Transfusion Medicine, Institute of Hematology and Transfusion Medicine, Warsaw, Poland.
| | - Anne Husebekk
- Institute of Medical Biology, UiT The Arctic University of Norway, Tromsø, Norway
| | - Marzena Dębska
- 2nd Department of Obstetrics and Gynecology, Medical Centre of Postgraduate Education, Warsaw, Poland
| | - Małgorzata Uhrynowska
- Department of Immunohematology and Immunology of Transfusion Medicine, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Katarzyna Guz
- Department of Immunohematology and Immunology of Transfusion Medicine, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Agnieszka Orzińska
- Department of Immunohematology and Immunology of Transfusion Medicine, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Romuald Dębski
- 2nd Department of Obstetrics and Gynecology, Medical Centre of Postgraduate Education, Warsaw, Poland
| | - Krystyna Maślanka
- Department of Immunohematology and Immunology of Transfusion Medicine, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
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14
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Curtis BR. Recent progress in understanding the pathogenesis of fetal and neonatal alloimmune thrombocytopenia. Br J Haematol 2015; 171:671-82. [PMID: 26344048 DOI: 10.1111/bjh.13639] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Fetal and neonatal alloimmune thrombocytopenia (FNAIT) occurs in c. 1 in 1000 births and is caused by maternal antibodies against human platelet alloantigens that bind incompatible fetal platelets and promote their clearance from the circulation. Affected infants can experience bleeding, bruising and, in severe cases, intracranial haemorrhage and even death. As maternal screening is not routinely performed, and first pregnancies can be affected, most cases are diagnosed at delivery of a first affected pregnancy. Unlike its erythrocyte counterpart, Haemolytic Disease of the Fetus and Newborn, there is no prophylactic treatment for FNAIT. This report will review recent advances made in understanding the pathogenesis of FNAIT: the platelet alloantigens involved, maternal exposure and sensitization to fetal platelet antigens, properties of platelet Immunoglobulin G antibodies, maternal-fetal antibody transport mechanisms and efforts to develop an effective FNAIT prophylaxis.
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Affiliation(s)
- Brian R Curtis
- Platelet & Neutrophil Immunology Laboratory and Blood Research Institute, BloodCenter of Wisconsin, Milwaukee, WI, USA
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15
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Zenonos ZA, Dummler SK, Müller-Sienerth N, Chen J, Preiser PR, Rayner JC, Wright GJ. Basigin is a druggable target for host-oriented antimalarial interventions. ACTA ACUST UNITED AC 2015. [PMID: 26195724 PMCID: PMC4516795 DOI: 10.1084/jem.20150032] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Zenonos et al. report the development of a new therapeutic for P. falciparum malaria. A recombinant chimeric antibody targeting basigin—a receptor essential for erythrocyte invasion—inhibited parasite invasion and rapidly cleared an established blood-stage infection in vivo. Plasmodium falciparum is the parasite responsible for the most lethal form of malaria, an infectious disease that causes a large proportion of childhood deaths and poses a significant barrier to socioeconomic development in many countries. Although antimalarial drugs exist, the repeated emergence and spread of drug-resistant parasites limit their useful lifespan. An alternative strategy that could limit the evolution of drug-resistant parasites is to target host factors that are essential and universally required for parasite growth. Host-targeted therapeutics have been successfully applied in other infectious diseases but have never been attempted for malaria. Here, we report the development of a recombinant chimeric antibody (Ab-1) against basigin, an erythrocyte receptor necessary for parasite invasion as a putative antimalarial therapeutic. Ab-1 inhibited the PfRH5-basigin interaction and potently blocked erythrocyte invasion by all parasite strains tested. Importantly, Ab-1 rapidly cleared an established P. falciparum blood-stage infection with no overt toxicity in an in vivo infection model. Collectively, our data demonstrate that antibodies or other therapeutics targeting host basigin could be an effective treatment for patients infected with multi-drug resistant P. falciparum.
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Affiliation(s)
- Zenon A Zenonos
- Cell Surface Signalling Laboratory and Malaria Program, Wellcome Trust Sanger Institute, Cambridge CB10 2DP, England, UK Cell Surface Signalling Laboratory and Malaria Program, Wellcome Trust Sanger Institute, Cambridge CB10 2DP, England, UK
| | - Sara K Dummler
- SMART Singapore-MIT-Alliance for Research and Technology, Infectious Disease IRG, Singapore 138602, Singapore
| | - Nicole Müller-Sienerth
- Cell Surface Signalling Laboratory and Malaria Program, Wellcome Trust Sanger Institute, Cambridge CB10 2DP, England, UK
| | - Jianzhu Chen
- SMART Singapore-MIT-Alliance for Research and Technology, Infectious Disease IRG, Singapore 138602, Singapore Koch Institute for Integrative Cancer Research and Department of Biology, Massachusetts Institute of Technology, Cambridge, MA 02420
| | - Peter R Preiser
- SMART Singapore-MIT-Alliance for Research and Technology, Infectious Disease IRG, Singapore 138602, Singapore Nanyang Technological University, School of Biological Sciences, Singapore 637551, Singapore
| | - Julian C Rayner
- Cell Surface Signalling Laboratory and Malaria Program, Wellcome Trust Sanger Institute, Cambridge CB10 2DP, England, UK
| | - Gavin J Wright
- Cell Surface Signalling Laboratory and Malaria Program, Wellcome Trust Sanger Institute, Cambridge CB10 2DP, England, UK Cell Surface Signalling Laboratory and Malaria Program, Wellcome Trust Sanger Institute, Cambridge CB10 2DP, England, UK
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16
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Eksteen M, Tiller H, Averina M, Heide G, Kjaer M, Ghevaert C, Michaelsen TE, Ihle Ø, Husebekk A, Skogen B, Stuge TB. Characterization of a human platelet antigen-1a-specific monoclonal antibody derived from a B cell from a woman alloimmunized in pregnancy. THE JOURNAL OF IMMUNOLOGY 2015; 194:5751-60. [PMID: 25972474 DOI: 10.4049/jimmunol.1401599] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Accepted: 04/09/2015] [Indexed: 11/19/2022]
Abstract
Human platelet Ag (HPA)-1a, located on integrin β3, is the main target for alloantibodies responsible for fetal and neonatal alloimmune thrombocytopenia (FNAIT) in the white population. There are ongoing efforts to develop an Ab prophylaxis and therapy to prevent or treat FNAIT. In this study, an mAb specific for HPA-1a, named 26.4, was derived from an immortalized B cell from an alloimmunized woman who had an infant affected by FNAIT. It is the only HPA-1a-specific human mAb with naturally paired H and L chains. Specific binding of mAb 26.4, both native and recombinant forms, to platelets and to purified integrins αIIbβ3 (from platelets) and αVβ3 (from trophoblasts) from HPA-1a(+) donors was demonstrated by flow cytometry and surface plasmon resonance technology, respectively. No binding to HPA-1a(-) platelets or integrins was detected. Moreover, the Ab binds with higher affinity to integrin αVβ3 compared with a second HPA-1a-specific human mAb, B2G1. Further in vitro experimentation demonstrated that mAb 26.4 can opsonize HPA-1a(+) platelets for enhanced phagocytosis by monocytes, inhibit binding of maternal polyclonal anti-HPA-1a Abs, and weakly inhibit aggregation of HPA-1a-heterozygous platelets, the latter with no predicted clinical relevance. Thus, mAb 26.4 is highly specific for HPA-1a and could potentially be explored for use as a prophylactic or therapeutic reagent for FNAIT intervention and as a phenotyping reagent to identify women at risk for immunization.
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Affiliation(s)
- Mariana Eksteen
- Immunology Research Group, Department of Medical Biology, Faculty of Health Sciences, University of Tromsø - The Arctic University of Norway, N-9037 Tromsø, Norway
| | - Heidi Tiller
- Immunology Research Group, Department of Medical Biology, Faculty of Health Sciences, University of Tromsø - The Arctic University of Norway, N-9037 Tromsø, Norway; Department of Obstetrics and Gynecology, University Hospital of North Norway, N-9038 Tromsø, Norway
| | - Maria Averina
- Department of Laboratory Medicine, Diagnostic Clinic, University Hospital of North Norway, N-9038 Tromsø, Norway
| | - Gøril Heide
- Immunology Research Group, Department of Medical Biology, Faculty of Health Sciences, University of Tromsø - The Arctic University of Norway, N-9037 Tromsø, Norway
| | - Mette Kjaer
- Immunology Research Group, Department of Medical Biology, Faculty of Health Sciences, University of Tromsø - The Arctic University of Norway, N-9037 Tromsø, Norway; Department of Laboratory Medicine, Diagnostic Clinic, University Hospital of North Norway, N-9038 Tromsø, Norway; Prophylix Pharma AS, Forskningsparken, N-9294 Tromsø, Norway
| | - Cedric Ghevaert
- Department of Haematology, University of Cambridge, Cambridge CB2 0XY, United Kingdom; National Health Service Blood and Transplant, Cambridge Biomedical Campus, Cambridge CB2 0PT, United Kingdom
| | - Terje E Michaelsen
- The Norwegian Institute of Public Health, N-0403 Oslo, Norway; and School of Pharmacy, University of Oslo, N-0316 Oslo, Norway
| | - Øistein Ihle
- The Norwegian Institute of Public Health, N-0403 Oslo, Norway; and
| | - Anne Husebekk
- Immunology Research Group, Department of Medical Biology, Faculty of Health Sciences, University of Tromsø - The Arctic University of Norway, N-9037 Tromsø, Norway; Department of Laboratory Medicine, Diagnostic Clinic, University Hospital of North Norway, N-9038 Tromsø, Norway
| | - Bjørn Skogen
- Immunology Research Group, Department of Medical Biology, Faculty of Health Sciences, University of Tromsø - The Arctic University of Norway, N-9037 Tromsø, Norway; Department of Laboratory Medicine, Diagnostic Clinic, University Hospital of North Norway, N-9038 Tromsø, Norway; Prophylix Pharma AS, Forskningsparken, N-9294 Tromsø, Norway
| | - Tor B Stuge
- Immunology Research Group, Department of Medical Biology, Faculty of Health Sciences, University of Tromsø - The Arctic University of Norway, N-9037 Tromsø, Norway;
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17
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Advances in alloimmune thrombocytopenia: perspectives on current concepts of human platelet antigens, antibody detection strategies, and genotyping. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2015; 13:380-90. [PMID: 26057488 DOI: 10.2450/2015.0275-14] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Accepted: 02/15/2015] [Indexed: 12/22/2022]
Abstract
Alloimmunisation to platelets leads to the production of antibodies against platelet antigens and consequently to thrombocytopenia. Numerous molecules located on the platelet surface are antigenic and induce immune-mediated platelet destruction with symptoms that can be serious. Human platelet antigens (HPA) cause thrombocytopenias, such as neonatal alloimmune thrombocytopenia, post-transfusion purpura, and platelet transfusion refractoriness. Thirty-four HPA are classified into 28 systems. Assays to identify HPA and anti-HPA antibodies are critically important for preventing and treating thrombocytopenia caused by anti-HPA antibodies. Significant progress in furthering our understanding of HPA has been made in the last decade: new HPA have been discovered, antibody-detection methods have improved, and new genotyping methods have been developed. We review these advances and discuss issues that remain to be resolved as well as future prospects for preventing and treating immune thrombocytopenia.
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Carr R, Kelly AM, Williamson LM. Neonatal thrombocytopenia and platelet transfusion - a UK perspective. Neonatology 2015; 107:1-7. [PMID: 25301082 DOI: 10.1159/000365163] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Five percent of newborn infants admitted to UK neonatal units during a recent study developed a platelet count <60 × 10(9)/l, and 60% of these were transfused platelets. This review summarises the common causes and mechanisms of thrombocytopenia in the newborn. Relevant evidence relating the platelet count to the risk of haemorrhage is reviewed, and current UK guidance on transfusion thresholds outlined. The UK policy for the provision of platelets for transfusion to neonates is described, including the particular requirements for neonatal allo-immune thrombocytopenia. Finally, we look towards the future and prospects for reducing the need to expose newborns to donor-derived platelets.
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Affiliation(s)
- Robert Carr
- Department of Haematology, Guy's and St Thomas' Hospital, King's College London, London, UK
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19
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Kerr J, Quinti I, Eibl M, Chapel H, Späth PJ, Sewell WAC, Salama A, van Schaik IN, Kuijpers TW, Peter HH. Is dosing of therapeutic immunoglobulins optimal? A review of a three-decade long debate in europe. Front Immunol 2014; 5:629. [PMID: 25566244 PMCID: PMC4263903 DOI: 10.3389/fimmu.2014.00629] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Accepted: 11/25/2014] [Indexed: 12/13/2022] Open
Abstract
The consumption of immunoglobulins (Ig) is increasing due to better recognition of antibody deficiencies, an aging population, and new indications. This review aims to examine the various dosing regimens and research developments in the established and in some of the relevant off-label indications in Europe. The background to the current regulatory settings in Europe is provided as a backdrop for the latest developments in primary and secondary immunodeficiencies and in immunomodulatory indications. In these heterogeneous areas, clinical trials encompassing different routes of administration, varying intervals, and infusion rates are paving the way toward more individualized therapy regimens. In primary antibody deficiencies, adjustments in dosing and intervals will depend on the clinical presentation, effective IgG trough levels and IgG metabolism. Ideally, individual pharmacokinetic profiles in conjunction with the clinical phenotype could lead to highly tailored treatment. In practice, incremental dosage increases are necessary to titrate the optimal dose for more severely ill patients. Higher intravenous doses in these patients also have beneficial immunomodulatory effects beyond mere IgG replacement. Better understanding of the pharmacokinetics of Ig therapy is leading to a move away from simplistic "per kg" dosing. Defective antibody production is common in many secondary immunodeficiencies irrespective of whether the causative factor was lymphoid malignancies (established indications), certain autoimmune disorders, immunosuppressive agents, or biologics. This antibody failure, as shown by test immunization, may be amenable to treatment with replacement Ig therapy. In certain immunomodulatory settings [e.g., idiopathic thrombocytopenic purpura (ITP)], selection of patients for Ig therapy may be enhanced by relevant biomarkers in order to exclude non-responders and thus obtain higher response rates. In this review, the developments in dosing of therapeutic immunoglobulins have been limited to high and some medium priority indications such as ITP, Kawasaki' disease, Guillain-Barré syndrome, chronic inflammatory demyelinating polyradiculoneuropathy, myasthenia gravis, multifocal motor neuropathy, fetal alloimmune thrombocytopenia, fetal hemolytic anemia, and dermatological diseases.
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Affiliation(s)
- Jacqueline Kerr
- Section Poly- and Monoclonal Antibodies, Paul Ehrlich Institut, Langen, Germany
| | - Isabella Quinti
- Department of Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | | | - Helen Chapel
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Peter J. Späth
- Institute of Pharmacology, University of Bern, Bern, Switzerland
| | | | - Abdulgabar Salama
- Zentrum für Transfusionsmedizin u. Zelltherapie, Charité, Berlin, Germany
| | - Ivo N. van Schaik
- Department of Neurology, Academic Medical Center (AMC), University of Amsterdam, Amsterdam, Netherlands
| | - Taco W. Kuijpers
- Department of Pediatric Hematology, Immunology and Infectious disease, Academic Medical Center (AMC), University of Amsterdam, Amsterdam, Netherlands
| | - Hans-Hartmut Peter
- Centrum für chronische Immunodeficienz (CCI), University Medical Centre, University of Freiburg, Freiburg im Breisgau, Germany
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20
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Avent ND. Prenatal testing for hemolytic disease of the newborn and fetal neonatal alloimmune thrombocytopenia – current status. Expert Rev Hematol 2014; 7:741-5. [DOI: 10.1586/17474086.2014.970160] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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21
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Bertrand G, Kaplan C. How do we treat fetal and neonatal alloimmune thrombocytopenia? Transfusion 2014; 54:1698-703. [DOI: 10.1111/trf.12671] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2013] [Revised: 02/27/2014] [Accepted: 02/27/2014] [Indexed: 11/27/2022]
Affiliation(s)
- Gérald Bertrand
- Platelet Immunology Department; Institut National de la Transfusion Sanguine; Paris France
| | - Cécile Kaplan
- Platelet Immunology Department; Institut National de la Transfusion Sanguine; Paris France
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22
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Armour KL, Smith CS, Turner CP, Kirton CM, Wilkes AM, Hadley AG, Ghevaert C, Williamson LM, Clark MR. Low-affinity FcγR interactions can decide the fate of novel human IgG-sensitised red blood cells and platelets. Eur J Immunol 2014; 44:905-14. [PMID: 24285214 PMCID: PMC4209800 DOI: 10.1002/eji.201343825] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2013] [Revised: 10/11/2013] [Accepted: 11/25/2013] [Indexed: 11/11/2022]
Abstract
G1Δnab is a mutant human IgG1 constant region with a lower ability to interact with FcγR than the natural IgG constant regions. Radiolabelled RBCs and platelets sensitised with specific G1Δnab Abs were cleared more slowly from human circulation than IgG1-sensitised counterparts. However, non-destructive splenic retention of G1Δnab-coated RBCs required investigation and plasma radioactivities now suggest this also occurred for platelets sensitised with an IgG1/G1Δnab mixture. In vitro assays with human cells showed that G1Δnab-sensitised RBCs did not cause FcγRI-mediated monocyte activation, FcγRIIIa-mediated antibody-dependent cell-mediated cytotoxicity (ADCC) or macrophage phagocytosis although they did adhere to macrophages. Thus, FcγRII was implicated in the adhesion despite the Δnab mutation reducing the already low-affinity binding to this receptor class. Additional contacts via P-selectin enhance the interaction of sensitised platelets with monocytes and this system provided evidence of FcγRII-dependent activation by G1Δnab. These results emphasise the physiological relevance of low-affinity interactions: It appears that FcγRII interactions of G1Δnab allowed splenic retention of G1Δnab-coated RBCs with inhibitory FcγRIIb binding preventing RBC destruction and that FcγRIIb engagement by G1Δnab on IgG1/G1Δnab-sensitised platelets overcame activation by IgG1. Considering therapeutic blocking Abs, G1Δnab offers lower FcγR binding and a greater bias towards inhibition than IgG2 and IgG4 constant regions.
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23
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Curtis BR, McFarland JG. Human platelet antigens - 2013. Vox Sang 2013; 106:93-102. [PMID: 24102564 DOI: 10.1111/vox.12085] [Citation(s) in RCA: 93] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2012] [Revised: 08/12/2013] [Accepted: 08/21/2013] [Indexed: 01/25/2023]
Abstract
To date, 33 human platelet alloantigens (HPAs) have been identified on six functionally important platelet glycoprotein (GP) complexes and have been implicated in alloimmune platelet disorders including foetal and neonatal alloimmune thrombocytopenia (FNAIT), posttransfusion purpura (PTP) and multitransfusion platelet refractoriness (MPR). The greatest number of recognized HPA (20 of 33) resides on the GPIIb/IIIa complex, which serves as the receptor for ligands important in mediating haemostasis and inflammation. These include HPA-1a, the most commonly implicated HPA in FNAIT and PTP in Caucasian populations. Other platelet GP complexes, GPIb/V/IX, GPIa/IIa and CD109, express the remaining 13 HPAs. Of the recognized HPAs, 12 occur as six serologically and genetically defined biallelic 'systems' where the -a form designates the higher frequency allele and the -b form, the lower. Twenty-one other HPAs are low-frequency or rare antigens for which postulated higher frequency -a alleles have not yet been identified as antibody specificities. In addition to the HPA markers, platelets also express ABO and human leucocyte antigen (HLA) antigens; antibodies directed at the former are occasionally important in FNAIT, and to the latter, in MPR.
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Affiliation(s)
- B R Curtis
- Platelet & Neutrophil Immunology Laboratory, BloodCenter of Wisconsin, Milwaukee, WI, USA
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