1
|
Li Z, Zhou Y, Li K, Zhao Y, Song Y, Xiao J. Present status of scheduled vaccinations and vaccination-related bleeding in Chinese children with haemophilia. J Paediatr Child Health 2024; 60:200-205. [PMID: 38700143 DOI: 10.1111/jpc.16554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 03/23/2024] [Accepted: 04/16/2024] [Indexed: 05/05/2024]
Abstract
AIM Many countries have detailed recommendations for haemophilia patients to reduce the risk of vaccination-related bleeding. However, data from developing countries are lacking. We investigated scheduled vaccinations and vaccination-related bleeding complications in Chinese children with haemophilia and analysed issues related to vaccinations. METHODS Children with haemophilia in the PUMCH Haemophilia Treatment Centre were contacted via telephone. We distributed a vaccination questionnaire to their parents. The severity of haemophilia, coagulation factor infusions before vaccination, injection mode, and vaccination-related complications were analysed. RESULTS A total of 440 valid questionnaires were received from 27 of 34 provinces in China. 31.3% (138/440) of the children with haemophilia did not receive all of their vaccinations. Among the children who received vaccinations, 48.1% (197/409) experienced bleeding complications. In patients with severe haemophilia, those on regular prophylaxis had a lower incidence of local hematoma compared to those on intermittent or no prophylaxis (14.3% vs. 26.5% vs. 39.7%, P < 0.05). The incidence of local hematomas was lower by subcutaneous (SQ) injections than by intramuscular injections (24.6% vs. 35.3%, P < 0.05). CONCLUSION The vaccination rate is quite insufficient in Chinese children with haemophilia. Missed vaccinations are related to vaccination-related bleeding complications. Prophylaxis before vaccination and SQ injections would help reduce bleeding complications.
Collapse
Affiliation(s)
- Zhuo Li
- Department of Pediatrics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yin Zhou
- Department of International Medical Services, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Kuixing Li
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yongqiang Zhao
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yuqing Song
- Department of Pediatrics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Juan Xiao
- Department of Pediatrics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| |
Collapse
|
2
|
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.
Collapse
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
| |
Collapse
|
3
|
Li Z, Chen Z, Cheng X, Wu X, Li G, Zhen Y, Poon MC, Wu R. A previously treated severe haemophilia A patient developed high-titre inhibitor after vaccinations. Int J Immunopathol Pharmacol 2021; 34:2058738420934618. [PMID: 32627611 PMCID: PMC7338642 DOI: 10.1177/2058738420934618] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
The factor VIII (FVIII)-neutralizing antibody (inhibitor) seen in 25%–30% of
patients with severe haemophilia A (SHA). Vaccination is a non-genetic risk
factor of inhibitor development as ‘danger signal’ which may provide a
pro-inflammatory microenvironment to increase FVIII immunogenicity. We reported
a previously treated SHA patient postponed the first vaccination to 15-month age
received diphtheria-pertussis-tetanus intramuscularly. At 18-month age, the
patient received Hepatitis A intramuscularly and Varicella Zoster Virus
subcutaneously with 2 weeks interval and FVIII infusion was given <24 h prior
for each. Successive bleedings occurred 1 week later with inefficacy of FVIII
replacement. High-titre inhibitor was tested at 117 exposure days. This case
suggested that continuous vaccinations in close proximity to FVIII could induce
inhibitor. The relationship between vaccination and FVIII immunogenicity still
needs to be revealed by further study.
Collapse
Affiliation(s)
- Zekun Li
- Hemophilia Work Group, Hematology Oncology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Zhenping Chen
- Hemophilia Work Group, Hematology Oncology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Xiaoling Cheng
- Hemophilia Work Group, Hematology Oncology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Xinyi Wu
- Hemophilia Work Group, Hematology Oncology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Gang Li
- Hemophilia Work Group, Hematology Oncology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Yingzi Zhen
- Hemophilia Work Group, Hematology Oncology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Man-Chiu Poon
- Departments of Medicine, Pediatrics and Oncology, University of Calgary, Cumming School of Medicine, and Southern Alberta Rare Blood and Bleeding Disorders Comprehensive Care program, Foothills Hospital, Alberta Health Services, Calgary, AB, Canada
| | - Runhui Wu
- Hemophilia Work Group, Hematology Oncology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| |
Collapse
|
4
|
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.
Collapse
|
5
|
Pfrepper C, Holstein K, Königs C, Heller C, Krause M, Olivieri M, Bidlingmaier C, Sigl-Kraetzig M, Wendisch J, Halimeh S, Horneff S, Richter H, Wieland I, Klamroth R, Oldenburg J, Tiede A. Consensus Recommendations for Intramuscular COVID-19 Vaccination in Patients with Hemophilia. Hamostaseologie 2021; 41:190-196. [PMID: 33860513 DOI: 10.1055/a-1401-2691] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Currently available coronavirus disease 2019 (COVID-19) vaccines are approved for intramuscular injection and efficacy may not be ensured when given subcutaneously. For years, subcutaneous vaccination was recommended in patients with hemophilia to avoid intramuscular bleeds. Therefore, recommendations for the application of COVID-19 vaccines are needed. METHODS The Delphi methodology was used to develop consensus recommendations. An initial list of recommendations was prepared by a steering committee and evaluated by 39 hemophilia experts. Consensus was defined as ≥75% agreement and strong consensus as ≥95% agreement, and agreement as a score ≥7 on a scale of 1 to 9. After four rounds, a final list of statements was compiled. RECOMMENDATIONS Consensus was achieved that COVID-19 vaccines licensed only for intramuscular injection should be administered intramuscularly in hemophilia patients. Prophylactic factor replacement, given on the day of vaccination with a maximum interval between prophylaxis and vaccination of 24 hours (factor VIII and conventional factor IX concentrates) or 48 hours (half-life extended factor IX), should be provided in patients with moderate or severe hemophilia. Strong consensus was achieved that patients with mild hemophilia and residual factor activity greater than 10% with mild bleeding phenotype or patients on emicizumab usually do not need factor replacement before vaccination. Swelling, erythema, and hyperthermia after vaccination are not always signs of bleeding but should prompt consultation of a hemophilia care center. In case of injection-site hematoma, patients should receive replacement therapy until symptoms disappear. CONCLUSIONS Consensus was achieved on recommendations for intramuscular COVID-19 vaccination after replacement therapy for hemophilia patients depending on disease severity.
Collapse
Affiliation(s)
- Christian Pfrepper
- Division of Hemostaseology, Medical Department I, University Hospital Leipzig, Leipzig, Germany
| | | | - Christoph Königs
- Pediatric Hemostaseology, University Hospital Frankfurt, Frankfurt, Germany
| | - Christine Heller
- Pediatric Hemostaseology, University Hospital Frankfurt, Frankfurt, Germany
| | | | - Martin Olivieri
- Pediatric Thrombosis and Hemostasis Unit, Pediatric Hemophilia Centre, Dr. von Hauner Children's Hospital, LMU, Munich, Germany
| | - Christoph Bidlingmaier
- Pediatric Thrombosis and Hemostasis Unit, Pediatric Hemophilia Centre, Dr. von Hauner Children's Hospital, LMU, Munich, Germany
| | - Michael Sigl-Kraetzig
- Blaubeuren and Hemostasis Center South (Pediatric Practice), Institute for Pediatric Research and Further Education (IPFW), Blaubeuren, Germany
| | - Jörg Wendisch
- Health Department of the City of Dresden, Vaccination Centre, Dresden, Germany
| | | | - Silvia Horneff
- Institute for Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Bonn, Germany
| | | | - Ivonne Wieland
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Robert Klamroth
- Vascular Medicine and Haemostaseology, Vivantes Klinikum im Friedrichshain, Berlin, Germany
| | - Johannes Oldenburg
- Institute for Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Bonn, Germany
| | - Andreas Tiede
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | | |
Collapse
|
6
|
Kaczmarek R, El Ekiaby M, Hart DP, Hermans C, Makris M, Noone D, O'Mahony B, Page D, Peyvandi F, Pipe SW, Sannié T, Schlenkrich U, Skinner MW, Srivastava A, Bok A, Pierce GF. Vaccination against COVID-19: Rationale, modalities and precautions for patients with haemophilia and other inherited bleeding disorders. Haemophilia 2021; 27:515-518. [PMID: 33651911 PMCID: PMC8014441 DOI: 10.1111/hae.14271] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 01/05/2021] [Accepted: 01/22/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Radoslaw Kaczmarek
- Coagulation Product Safety, Supply and Access Committee, World Federation of Hemophilia, Montreal, Quebec, Canada
| | - Magdy El Ekiaby
- Coagulation Product Safety, Supply and Access Committee, World Federation of Hemophilia, Montreal, Quebec, Canada.,Shabrawishi Hospital Blood Transfusion & Hemophilia Treatment Center, Giza, Egypt
| | - Daniel P Hart
- Coagulation Product Safety, Supply and Access Committee, World Federation of Hemophilia, Montreal, Quebec, Canada.,The Royal London Hospital Haemophilia Centre, Barts Health NHS Trust, London, UK.,Centre for Immunobiology, Blizard Institute, Barts and The London School of Medicine and Dentistry, QMUL, London, UK
| | - Cedric Hermans
- Coagulation Product Safety, Supply and Access Committee, World Federation of Hemophilia, Montreal, Quebec, Canada.,Hemostasis and Thrombosis Unit, Division of Hematology, Cliniques Universitaires Saint-Luc, UCLouvain, Brussels, Belgium
| | - Mike Makris
- Coagulation Product Safety, Supply and Access Committee, World Federation of Hemophilia, Montreal, Quebec, Canada.,Medical Advisory Group, European Haemophilia Consortium, Brussels, Belgium
| | - Declan Noone
- Coagulation Product Safety, Supply and Access Committee, World Federation of Hemophilia, Montreal, Quebec, Canada.,European Haemophilia Consortium, Brussels, Belgium
| | - Brian O'Mahony
- Coagulation Product Safety, Supply and Access Committee, World Federation of Hemophilia, Montreal, Quebec, Canada.,Irish Haemophilia Society, Dublin, Ireland.,Trinity College, Dublin, Ireland
| | - David Page
- Coagulation Product Safety, Supply and Access Committee, World Federation of Hemophilia, Montreal, Quebec, Canada.,Canadian Hemophilia Society, Montreal, Canada
| | - Flora Peyvandi
- Coagulation Product Safety, Supply and Access Committee, World Federation of Hemophilia, Montreal, Quebec, Canada.,Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy.,Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Steven W Pipe
- Coagulation Product Safety, Supply and Access Committee, World Federation of Hemophilia, Montreal, Quebec, Canada.,Medical and Scientific Advisory Council, National Hemophilia Foundation, New York, NY, USA.,Departments of Pediatrics and Pathology, University of Michigan, Ann Arbor, MI, USA
| | - Thomas Sannié
- Coagulation Product Safety, Supply and Access Committee, World Federation of Hemophilia, Montreal, Quebec, Canada.,European Haemophilia Consortium, Brussels, Belgium.,Association Française des Hémophiles, Paris, France
| | - Uwe Schlenkrich
- Coagulation Product Safety, Supply and Access Committee, World Federation of Hemophilia, Montreal, Quebec, Canada.,German Haemophilia Society, Hamburg, Germany
| | - Mark W Skinner
- Coagulation Product Safety, Supply and Access Committee, World Federation of Hemophilia, Montreal, Quebec, Canada.,Institute for Policy Advancement Ltd, Washington, DC, USA.,McMaster University, Hamilton, Ontario, Canada
| | - Alok Srivastava
- Coagulation Product Safety, Supply and Access Committee, World Federation of Hemophilia, Montreal, Quebec, Canada.,Department of Haematology, Christian Medical College, Vellore, India
| | - Amanda Bok
- European Haemophilia Consortium, Brussels, Belgium
| | - Glenn F Pierce
- Coagulation Product Safety, Supply and Access Committee, World Federation of Hemophilia, Montreal, Quebec, Canada.,World Federation of Hemophilia, Montreal, Quebec, Canada
| | | |
Collapse
|
7
|
Pratt KP, Arruda VR, Lacroix-Desmazes S. Inhibitors-Recent insights. Haemophilia 2020; 27 Suppl 3:28-36. [PMID: 32608138 DOI: 10.1111/hae.14077] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 05/22/2020] [Accepted: 05/23/2020] [Indexed: 12/19/2022]
Abstract
The development of inhibitory antibodies to therapeutic factor VIII (FVIII) in haemophilia A (HA) patients is the major complication in treatment/prevention of haemorrhages. The reasons some HA patients develop inhibitors while others do not remain unclear. This review briefly summarizes our understanding of anti-FVIII immune responses, the roles of T cells, both effector and regulatory, and generally discusses the interplay between FVIII and the immune system, both in factor replacement therapy and gene therapy, with some comparisons to factor IX and haemophilia B therapies. Notably, we propose that the prevailing observed active tolerance to FVIII in both HA and non-HA individuals rests to greater or lesser extents on peripherally induced immune tolerance. We also propose that the immune systems of inhibitor-negative HA patients do not merely ignore therapeutic FVIII, but rather have immunologically assessed and actively tolerized the patients to exogenous FVIII. Induction of such peripheral immune tolerance may further be triggered in HA patients who failed to tolerize upon initial FVIII exposure by 'appropriate' stimulation of their immune system, eg by immune tolerance induction therapy via intensive FVIII therapy, by oral administration of FVIII, by cellular therapies or by gene therapy directed to immuno-tolerogenic sites such as the liver.
Collapse
Affiliation(s)
- Kathleen P Pratt
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Valder R Arruda
- The Raymond G. Perelman Center for Cellular and Molecular Therapeutics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,The Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | | |
Collapse
|
8
|
Zerra PE, Arthur CM, Chonat S, Maier CL, Mener A, Shin S, Allen JWL, Baldwin WH, Cox C, Verkerke H, Jajosky RP, Tormey CA, Meeks SL, Stowell SR. Fc Gamma Receptors and Complement Component 3 Facilitate Anti-fVIII Antibody Formation. Front Immunol 2020; 11:905. [PMID: 32582142 PMCID: PMC7295897 DOI: 10.3389/fimmu.2020.00905] [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: 01/17/2020] [Accepted: 04/20/2020] [Indexed: 01/02/2023] Open
Abstract
Anti-factor VIII (fVIII) alloantibodies, which can develop in patients with hemophilia A, limit the therapeutic options and increase morbidity and mortality of these patients. However, the factors that influence anti-fVIII antibody development remain incompletely understood. Recent studies suggest that Fc gamma receptors (FcγRs) may facilitate recognition and uptake of fVIII by recently developed or pre-existing naturally occurring anti-fVIII antibodies, providing a mechanism whereby the immune system may recognize fVIII following infusion. However, the role of FcγRs in anti-fVIII antibody formation remains unknown. In order to define the influence of FcγRs on the development of anti-fVIII antibodies, fVIII was injected into WT or FcγR knockout recipients, followed by evaluation of anti-fVIII antibodies. Anti-fVIII antibodies were readily observed following fVIII injection into FcγR knockouts, with similar anti-fVIII antibody levels occurring in FcγR knockouts as detected in WT mice injected in parallel. As antibodies can also fix complement, providing a potential mechanism whereby anti-fVIII antibodies may influence anti-fVIII antibody formation independent of FcγRs, fVIII was also injected into complement component 3 (C3) knockout recipients in parallel. Similar to FcγR knockouts, C3 knockout recipients developed a robust response to fVIII, which was likewise similar to that observed in WT recipients. As FcγRs or C3 may compensate for each other in recipients only deficient in FcγRs or C3 alone, we generated mice deficient in both FcγRs and C3 to test for potential antibody effector redundancy in anti-fVIII antibody formation. Infusion of fVIII into FcγRs and C3 (FcγR × C3) double knockouts likewise induced anti-fVIII antibodies. However, unlike individual knockouts, anti-fVIII antibodies in FcγRs × C3 knockouts were initially lower than WT recipients, although anti-fVIII antibodies increased to WT levels following additional fVIII exposure. In contrast, infusion of RBCs expressing distinct alloantigens into FcγRs, C3 or FcγR × C3 knockout recipients either failed to change anti-RBC levels when compared to WT recipients or actually increased antibody responses, depending on the target antigen. Taken together, these results suggest FcγRs and C3 can differentially impact antibody formation following exposure to distinct alloantigens and that FcγRs and C3 work in concert to facilitate early anti-fVIII antibody formation.
Collapse
Affiliation(s)
- Patricia E Zerra
- Department of Pathology and Laboratory Medicine, Center for Transfusion Medicine and Cellular Therapies, Emory University School of Medicine, Atlanta, GA, United States.,Aflac Cancer and Blood Disorders Center at Children's Healthcare of Atlanta and Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, United States
| | - Connie M Arthur
- Department of Pathology and Laboratory Medicine, Center for Transfusion Medicine and Cellular Therapies, Emory University School of Medicine, Atlanta, GA, United States
| | - Satheesh Chonat
- Aflac Cancer and Blood Disorders Center at Children's Healthcare of Atlanta and Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, United States
| | - Cheryl L Maier
- Department of Pathology and Laboratory Medicine, Center for Transfusion Medicine and Cellular Therapies, Emory University School of Medicine, Atlanta, GA, United States
| | - Amanda Mener
- Department of Pathology and Laboratory Medicine, Center for Transfusion Medicine and Cellular Therapies, Emory University School of Medicine, Atlanta, GA, United States
| | - Sooncheon Shin
- Department of Pathology and Laboratory Medicine, Center for Transfusion Medicine and Cellular Therapies, Emory University School of Medicine, Atlanta, GA, United States
| | - Jerry William L Allen
- Department of Pathology and Laboratory Medicine, Center for Transfusion Medicine and Cellular Therapies, Emory University School of Medicine, Atlanta, GA, United States
| | - W Hunter Baldwin
- Aflac Cancer and Blood Disorders Center at Children's Healthcare of Atlanta and Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, United States
| | - Courtney Cox
- Aflac Cancer and Blood Disorders Center at Children's Healthcare of Atlanta and Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, United States
| | - Hans Verkerke
- Department of Pathology and Laboratory Medicine, Center for Transfusion Medicine and Cellular Therapies, Emory University School of Medicine, Atlanta, GA, United States
| | - Ryan P Jajosky
- Department of Pathology and Laboratory Medicine, Center for Transfusion Medicine and Cellular Therapies, Emory University School of Medicine, Atlanta, GA, United States
| | - Christopher A Tormey
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT, United States.,Pathology and Laboratory Medicine Service, VA Conneciticut Healthcare System, West Haven, CT, United States
| | - Shannon L Meeks
- Aflac Cancer and Blood Disorders Center at Children's Healthcare of Atlanta and Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, United States
| | - Sean R Stowell
- Department of Pathology and Laboratory Medicine, Center for Transfusion Medicine and Cellular Therapies, Emory University School of Medicine, Atlanta, GA, United States
| |
Collapse
|
9
|
Bou Jaoudeh M, Delignat S, Varthaman A, Lacroix-Desmazes S. [Origin and nature of the neutralizing immune response against therapeutic factor VIII]. Med Sci (Paris) 2020; 36:341-347. [PMID: 32356710 DOI: 10.1051/medsci/2020060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
The use of therapeutic proteins induces in some patients the appearance of neutralizing antibodies. This is the case of pro-coagulant factor VIII (FVIII) used in patients with hemophilia A. Several parameters related to the protein itself, to the type of pathology or to the patients, condition the immunogenicity of a therapeutic protein. Understanding these parameters would help to anticipate or prevent the development of neutralizing antibodies. In the case of FVIII, we propose that the development of neutralizing antibodies does not result from an unpredicted immune response but rather from the inability of the patient's organism to develop an anti-inflammatory or regulatory response.
Collapse
Affiliation(s)
- Mélissa Bou Jaoudeh
- Centre de recherche des Cordeliers, Inserm, Sorbonne Université, Université de Paris, F-75006, Paris, France
| | - Sandrine Delignat
- Centre de recherche des Cordeliers, Inserm, Sorbonne Université, Université de Paris, F-75006, Paris, France
| | - Aditi Varthaman
- Centre de recherche des Cordeliers, Inserm, Sorbonne Université, Université de Paris, F-75006, Paris, France
| | - Sébastien Lacroix-Desmazes
- Centre de recherche des Cordeliers, Inserm, Sorbonne Université, Université de Paris, F-75006, Paris, France
| |
Collapse
|
10
|
Matino D, Afraz S, Zhao G, Tieu P, Gargaro M, Fallarino F, Iorio A. Tolerance to FVIII: Role of the Immune Metabolic Enzymes Indoleamine 2,3 Dyoxigenase-1 and Heme Oxygenase-1. Front Immunol 2020; 11:620. [PMID: 32351505 PMCID: PMC7174632 DOI: 10.3389/fimmu.2020.00620] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 03/18/2020] [Indexed: 11/13/2022] Open
Abstract
The occurrence of neutralizing anti-FVIII antibodies is a major complication in the treatment of patients affected by hemophilia A. The immune response to FVIII is a complex, multi-factorial process that has been extensively studied for the past two decades. The reasons why only a proportion of hemophilic patients treated with FVIII concentrates develop a clinically significant immune response is incompletely understood. The "danger theory" has been proposed as a possible explanation to interpret the findings of some observational clinical studies highlighting the possible detrimental impact of inflammatory stimuli at the time of replacement therapy on inhibitor development. The host immune system is often challenged to react to FVIII under steady state or inflammatory conditions (e.g., bleeding, infections) although fine tuning of mechanisms of immune tolerance can control this reactivity and promote long-term unresponsiveness to the therapeutically administered factor. Recent studies have provided evidence that multiple interactions involving central and peripheral mechanisms of tolerance are integrated by the host immune system with the environmental conditions at the time of FVIII exposure and influence the balance between immunity and tolerance to FVIII. Here we review evidences showing the involvement of two key immunoregulatory oxygenase enzymes (IDO1, HO-1) that have been studied in hemophilia patients and pre-clinical models, showing that the ability of the host immune system to induce such regulatory proteins under inflammatory conditions can play important roles in the balance between immunity and tolerance to exogenous FVIII.
Collapse
Affiliation(s)
- Davide Matino
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada
| | - Sajjad Afraz
- Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada
| | - George Zhao
- McMaster Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Paul Tieu
- Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada
- McMaster Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Marco Gargaro
- Department of Experimental Medicine, University of Perugia, Perugia, Italy
| | | | - Alfonso Iorio
- Department of Health Research Methods, Evidence, and Impact, Hamilton, ON, Canada
| |
Collapse
|
11
|
Scott DW, Pratt KP. Factor VIII: Perspectives on Immunogenicity and Tolerogenic Strategies. Front Immunol 2020; 10:3078. [PMID: 32010137 PMCID: PMC6978909 DOI: 10.3389/fimmu.2019.03078] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 12/17/2019] [Indexed: 12/19/2022] Open
Abstract
Therapeutic treatment of bleeds with FVIII can lead to an antibody response that effectively inhibits its function. Herein, we review the factors that contribute to this immunogenicity and possible ways to overcome it.
Collapse
Affiliation(s)
- David W. Scott
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | | |
Collapse
|
12
|
Johnsen JM, Brown DL. The national blueprint for pregnancy/birth longitudinal cohorts to study factor VIII immunogenicity: NHLBI State of the Science (SOS) Workshop on factor VIII inhibitors. Haemophilia 2019; 25:603-609. [PMID: 31329365 DOI: 10.1111/hae.13739] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 02/03/2019] [Accepted: 02/21/2019] [Indexed: 01/28/2023]
Abstract
INTRODUCTION Patients with haemophilia can develop inhibitors to exogenous coagulation factors. Some patients are tolerant to factor, while those who develop inhibitors do so early in life. Genetics and environmental factors are known to contribute to inhibitor risk. However, it is not yet possible to predict inhibitor formation or treatment responsiveness in individuals. We hypothesize that factors in the antenatal/neonatal period inform inhibitor risk development. AIM To consider the design of longitudinal studies beginning in the antenatal/neonatal period and the use of new technologies to better understand haemophilia inhibitors. METHODS A working group was formed for the NHLBI State of the Science Workshop: Factor VIII Inhibitors: Generating a National Blueprint for Future Research to solicit input from the US haemophilia community and international collaborators to consider design of pregnancy/birth longitudinal cohorts that leverage -omics, existing phenotypic data, and in silico modelling to study inhibitors. RESULTS An antenatal/neonatal longitudinal cohort should begin with enrolment of pregnant genetic carriers of haemophilia and span the at-risk period for inhibitor development in the child. Data and samples from the mother, placenta, neonate and young child can be obtained that are amenable to existing assays, genomics and other -omics studies. Data can inform in silico prediction and mathematical models. CONCLUSION A longitudinal study beginning before birth offers the unique opportunity to study factors that influence inhibitor development prior to exposure. Advances in -omics and computational biology can study complex phenotypes in this rare disease. This study could be accomplished through interdisciplinary efforts and patient community engagement.
Collapse
Affiliation(s)
- Jill M Johnsen
- Bloodworks Northwest Research Institute, Seattle, Washington.,Washington Center for Bleeding Disorders, Seattle, Washington.,Department of Medicine, University of Washington, Seattle, Washington
| | - Deborah L Brown
- University of Texas Health Science Center, Houston, Texas.,MD Anderson Cancer Center, Houston, Texas.,Gulf States Hemophilia and Thrombophilia Treatment Center, Houston, Texas
| | | |
Collapse
|
13
|
Schep SJ, Boes M, Schutgens RE, van Vulpen LF. An update on the ‘danger theory’ in inhibitor development in hemophilia A. Expert Rev Hematol 2019; 12:335-344. [DOI: 10.1080/17474086.2019.1604213] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Sarah J. Schep
- Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Marianne Boes
- Department of Pediatrics, Laboratory of Translational Immunology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Roger E.G. Schutgens
- Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Lize F.D. van Vulpen
- Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| |
Collapse
|
14
|
Varthaman A, Lacroix-Desmazes S. Pathogenic immune response to therapeutic factor VIII: exacerbated response or failed induction of tolerance? Haematologica 2018; 104:236-244. [PMID: 30514798 PMCID: PMC6355482 DOI: 10.3324/haematol.2018.206383] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 11/23/2018] [Indexed: 01/10/2023] Open
Abstract
Therapeutic factor VIII is highly immunogenic. Despite intensive research in the last decades, the reasons why 5-30% of patients with hemophilia A (of all severities) develop inhibitory anti-factor VIII antibodies (inhibitors) following replacement therapy remain an enigma. Under physiological conditions, endogenous factor VIII is recognized by the immune system. Likewise, numerous observations indicate that, in hemophilia A patients without inhibitors, exogenous therapeutic factor VIII is immunologically assessed and tolerated. A large part of the research on the immunogenicity of therapeutic factor VIII is attempting to identify the ‘danger signals’ that act as adjuvants to the deleterious anti-factor VIII immune responses. However, several of the inflammatory assaults concomitant to factor VIII administration initially hypothesized as potential sources of danger signals (e.g., bleeding, infection, and vaccination) have been disproved to be such signals. Conversely, recent evidence suggests that cells from inhibitor-negative patients are able to activate anti-inflammatory and tolerogenic mechanisms required to suppress deleterious immune responses, while cells from inhibitor-positive patients are not. Based on the available observations, we propose a model in which all hemophilia A patients develop anti-factor VIII immune responses during replacement therapy irrespective of associated danger signals. We further postulate that the onset of clinically relevant factor VIII inhibitors results from an inability to develop counteractive tolerogenic responses to exogenous factor VIII rather than from an exacerbated activation of the immune system at the time of factor VIII administration. A better understanding of the pathogenesis of neutralizing anti-factor VIII antibodies will have repercussions on the clinical management of patients and highlight new strategies to achieve active immune tolerance to therapeutic factor VIII.
Collapse
Affiliation(s)
- Aditi Varthaman
- MRC Human Immunology Unit, Weatherall Institute of Molecular Medicine, University of Oxford, UK.,INSERM, UMR S 1138, Centre de Recherche des Cordeliers, Paris, France.,Sorbonne Université, UMR S 1138, Centre de Recherche des Cordeliers, Paris, France.,Université Paris Descartes, Sorbonne Paris Cité, UMR S 1138, Centre de Recherche des Cordeliers, France
| | - Sébastien Lacroix-Desmazes
- INSERM, UMR S 1138, Centre de Recherche des Cordeliers, Paris, France .,Sorbonne Université, UMR S 1138, Centre de Recherche des Cordeliers, Paris, France.,Université Paris Descartes, Sorbonne Paris Cité, UMR S 1138, Centre de Recherche des Cordeliers, France
| |
Collapse
|
15
|
The inhibitors - a challenge for the management of patients with hereditary haemophilia A. ACTA ACUST UNITED AC 2018; 56:143-152. [PMID: 29791318 DOI: 10.2478/rjim-2018-0013] [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: 03/03/2018] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Our research strategy was aimed at evaluating the possible implication of the type of factor VIII product administered as substitution treatment to haemophilia A patients in the occurrence of inhibitors and their consequences on the management. METHODS Scientific articles from July 2015 to July 2017 were searched using the PubMed and PubMed Central databases. The used search terms included "haemophilia A", "inhibitors", "plasma-derived factor VIII" and "recombinant factor VIII". RESULTS The risk factors for inhibitors occurrence may be patients-related (genetic and nongenetic) and treatment-related. The possibility of a correlation between the increased purity of factor VIII given as substitution treatment and the occurrence of inhibitors is discussed in the light of literature data. Plasma-derived factor VIII is less immunogenic, but not entirely safe from the point of view of the possibility of transmitting biological agents. It is obvious that there is not enough plasma-derived factor VIII for the planet's needs. Recombinant factor VIII products have revolutionized the treatment of patients with haemophilia A over the past 3 decades by the disappearance of transfusion-related infections and their complications. They are safer in terms of pathogens and the new long-acting factor VIII products are based on recombinant DNA technology. CONCLUSION Plasma-derived or recombinant factor VIII products must co-exist on the market for the benefit of haemophilic patients. Future solutions could be: less immunogenic factor VIII products, nonfactor replacement strategies, or bispecific antibody that mimics the function of coagulation factor VIII.
Collapse
|
16
|
Swystun LL, Lai JD, Notley C, Georgescu I, Paine AS, Mewburn J, Nesbitt K, Schledzewski K, Géraud C, Kzhyshkowska J, Goerdt S, Hopman W, Montgomery RR, James PD, Lillicrap D. The endothelial cell receptor stabilin-2 regulates VWF-FVIII complex half-life and immunogenicity. J Clin Invest 2018; 128:4057-4073. [PMID: 30124466 DOI: 10.1172/jci96400] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 07/03/2018] [Indexed: 11/17/2022] Open
Abstract
Quantitative abnormalities of the von Willebrand factor-factor VIII (VWF-FVIII) complex associate with inherited bleeding or thrombotic disorders. Receptor-mediated interactions between plasma VWF-FVIII and phagocytic or immune cells can influence their hemostatic and immunogenic activities. Genetic association studies have demonstrated that variants in the STAB2 gene, which encodes the scavenger receptor stabilin-2, associate with plasma levels of VWF-FVIII. However, the mechanistic basis and pathophysiological consequences of this association are unknown. We have demonstrated that stabilin-2-expressing cells bind and internalize human VWF and FVIII in a VWF-dependent manner, and stabilin-2-deficient mice displayed prolonged human VWF-FVIII half-life compared with controls. The stabilin-2 variant p.E2377K significantly decreased stabilin-2 expression and impaired VWF endocytosis in a heterologous expression system, and common STAB2 variants associated with plasma VWF levels in type 1 von Willebrand disease patients. STAB2-deficient mice displayed a decreased immunogenic response to human VWF-FVIII complex, while coinfusion of human VWF-FVIII with the stabilin-2 ligand hyaluronic acid attenuated the immune response to exogenous FVIII. Collectively, these data suggest that stabilin-2 functions as both a clearance and an immunoregulatory receptor for VWF-FVIII, making stabilin-2 a novel molecular target for modification of the half-life of VWF-FVIII and the immune response to VWF-FVIII concentrates.
Collapse
Affiliation(s)
| | - Jesse D Lai
- Department of Pathology and Molecular Medicine and
| | | | | | | | - Jeff Mewburn
- Division of Cancer Biology and Genetics, Queen's University, Kingston, Ontario, Canada
| | - Kate Nesbitt
- Department of Pathology and Molecular Medicine and
| | - Kai Schledzewski
- Department of Dermatology, Venereology and Allergology, University Medical Center and Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Cyrill Géraud
- Department of Dermatology, Venereology and Allergology, University Medical Center and Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Julia Kzhyshkowska
- Department of Dermatology, Venereology and Allergology, University Medical Center and Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Sergij Goerdt
- Department of Dermatology, Venereology and Allergology, University Medical Center and Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Wilma Hopman
- Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada
| | - Robert R Montgomery
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Paula D James
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | | |
Collapse
|
17
|
Garagiola I, Palla R, Peyvandi F. Risk factors for inhibitor development in severe hemophilia A. Thromb Res 2018; 168:20-27. [DOI: 10.1016/j.thromres.2018.05.027] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 05/11/2018] [Accepted: 05/24/2018] [Indexed: 12/21/2022]
|
18
|
Zuccherato LW, Roberti MRF, Jardim LL, Rezende SM. Successful immune tolerance in a young female with inhibitor and severe haemophilia A due to a complex genetic rearrangement. Haemophilia 2018; 24:e283-e285. [PMID: 30004160 DOI: 10.1111/hae.13560] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/26/2018] [Indexed: 11/29/2022]
Affiliation(s)
- L W Zuccherato
- Faculty of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - M R F Roberti
- Hemocentro de Goiás, Goiânia, Goiás, Brazil.,Faculty of Medicine, Universidade Federal de Goiás, Goiânia, Goiás, Brazil
| | - L L Jardim
- Faculty of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - S M Rezende
- Faculty of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| |
Collapse
|
19
|
Lai JD, Swystun LL, Cartier D, Nesbitt K, Zhang C, Hough C, Dennis JW, Lillicrap D. N-linked glycosylation modulates the immunogenicity of recombinant human factor VIII in hemophilia A mice. Haematologica 2018; 103:1925-1936. [PMID: 30002126 PMCID: PMC6278987 DOI: 10.3324/haematol.2018.188219] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 07/09/2018] [Indexed: 12/18/2022] Open
Abstract
Immune responses to factor VIII remain the greatest complication in the treatment of severe hemophilia A. Recent epidemiological evidence has highlighted that recombinant factor VIII produced in baby hamster kidney cells is more immunogenic than factor VIII produced in Chinese hamster ovary cells. Glycosylation differences have been hypothesized to influence the immunogenicity of these synthetic concentrates. In two hemophilia A mouse models, baby hamster kidney cell-derived factor VIII elicited a stronger immune response compared to Chinese hamster ovary cell-derived factor VIII. Furthermore, factor VIII produced in baby hamster kidney cells exhibited accelerated clearance from circulation independent of von Willebrand factor. Lectin and mass spectrometry analysis of total N-linked glycans revealed differences in high-mannose glycans, sialylation, and the occupancy of glycan sites. Factor VIII desialylation did not influence binding to murine splenocytes or dendritic cells, nor surface co-stimulatory molecule expression. We did, however, observe increased levels of immunoglobulin M specific to baby hamster kidney-derived factor VIII in naïve hemophilia A mice. De-N-glycosylation enhanced immunoglobulin M binding, suggesting that N-glycan occupancy masks epitopes. Elevated levels of immunoglobulin M and immunoglobulin G specific to baby hamster kidney-derived factor VIII were also observed in healthy individuals, and de-N-glycosylation increased immunoglobulin G binding. Collectively, our data suggest that factor VIII produced in baby hamster kidney cells is more immunogenic than that produced in Chinese hamster ovary cells, and that incomplete occupancy of N-linked glycosylation sites leads to the formation of immunoglobulin M- and immunoglobulin G-factor VIII immune complexes that contribute to the enhanced clearance and immunogenicity in these mouse models of hemophilia A.
Collapse
Affiliation(s)
- Jesse D Lai
- Department of Pathology & Molecular Medicine, Queen's University, Kingston
| | - Laura L Swystun
- Department of Pathology & Molecular Medicine, Queen's University, Kingston
| | - Dominique Cartier
- Department of Pathology & Molecular Medicine, Queen's University, Kingston
| | - Kate Nesbitt
- Department of Pathology & Molecular Medicine, Queen's University, Kingston
| | - Cunjie Zhang
- Lunenfeld Tanenbaum Research Institute, Mount Sinai Hospital, ON, Canada
| | - Christine Hough
- Department of Pathology & Molecular Medicine, Queen's University, Kingston
| | - James W Dennis
- Lunenfeld Tanenbaum Research Institute, Mount Sinai Hospital, ON, Canada
| | - David Lillicrap
- Department of Pathology & Molecular Medicine, Queen's University, Kingston
| |
Collapse
|
20
|
Peyvandi F, Garagiola I. Product type and other environmental risk factors for inhibitor development in severe hemophilia A. Res Pract Thromb Haemost 2018; 2:220-227. [PMID: 30046724 PMCID: PMC6055565 DOI: 10.1002/rth2.12094] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Accepted: 02/28/2018] [Indexed: 12/15/2022] Open
Abstract
The development of FVIII inhibitory antibodies is currently the most challenging complication of treatment, affecting ~30% of severe hemophilia A patients. These inhibitors inactivate FVIII, rendering the treatment ineffective, causing disability and increasing morbidity and mortality. Inhibitor development results from a complex multicausal immune response involving both genetic and environmental risk factors. One of the most important modifiable risk factors is the source of FVIII products, eg, plasma-derived or recombinant FVIII. Other environmental risk factors, such as age at first treatment, regimen, and intensity of treatment, could contribute to inhibitor development. Severe bleeds, surgery, concomitant infections, or vaccinations may all be events initiating danger signaling resulting in an immune reaction towards administered FVIII. All in all, the etiology of inhibitor development still remains unclear. The risk factors have been stratified into genetic and environmental, but there are no definitive data to determine the impact of each of them.
Collapse
Affiliation(s)
- Flora Peyvandi
- Department of Pathophysiology and TransplantationUniversità degli Studi di MilanoMilanItaly
- Angelo Bianchi Bonomi Hemophilia and Thrombosis CenterFondazione IRCCS Ca’ Granda Ospedale Maggiore PoliclinicoFondazione Luigi VillaMilanItaly
| | - Isabella Garagiola
- Angelo Bianchi Bonomi Hemophilia and Thrombosis CenterFondazione IRCCS Ca’ Granda Ospedale Maggiore PoliclinicoFondazione Luigi VillaMilanItaly
| |
Collapse
|
21
|
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
| |
Collapse
|
22
|
Marginal zone B cells are critical to factor VIII inhibitor formation in mice with hemophilia A. Blood 2017; 130:2559-2568. [PMID: 28978569 DOI: 10.1182/blood-2017-05-782912] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Accepted: 09/22/2017] [Indexed: 12/25/2022] Open
Abstract
Although factor VIII (FVIII) replacement therapy can be lifesaving for patients with hemophilia A, neutralizing alloantibodies to FVIII, known as inhibitors, develop in a significant number of patients and actively block FVIII activity, making bleeding difficult to control and prevent. Although a variety of downstream immune factors likely regulate inhibitor formation, the identification and subsequent targeting of key initiators in inhibitor development may provide an attractive approach to prevent inhibitor formation before amplification of the FVIII immune response occurs. As the initial steps in FVIII inhibitor development remain incompletely understood, we sought to define early regulators of FVIII inhibitor formation. Our results demonstrate that FVIII localizes in the marginal sinus of the spleen of FVIII-deficient mice shortly after injection, with significant colocalization with marginal zone (MZ) B cells. FVIII not only colocalizes with MZ B cells, but specific removal of MZ B cells also completely prevented inhibitor development following FVIII infusion. Subsequent rechallenge with FVIII following MZ B-cell reconstitution resulted in a primary antibody response, demonstrating that MZ B-cell depletion did not result in FVIII tolerance. Although recipient exposure to the viral-like adjuvant polyinosinic:polycytidylic acid enhanced anti-FVIII antibody formation, MZ B-cell depletion continued to display similar effectiveness in preventing inhibitor formation following FVIII infusion in this inflammatory setting. These data strongly suggest that MZ B cells play a critical role in initiating FVIII inhibitor formation and suggest a potential strategy to prevent anti-FVIII alloantibody formation in patients with hemophilia A.
Collapse
|
23
|
Biological considerations of plasma-derived and recombinant factor VIII immunogenicity. Blood 2017; 129:3147-3154. [DOI: 10.1182/blood-2016-11-750885] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Accepted: 04/19/2017] [Indexed: 02/06/2023] Open
Abstract
Abstract
In hemophilia A, the most severe complication of factor VIII (FVIII) replacement therapy involves the formation of FVIII neutralizing antibodies, also known as inhibitors, in 25% to 30% of patients. This adverse event is associated with a significant increase in morbidity and economic burden, thus highlighting the need to identify methods to limit FVIII immunogenicity. Inhibitor development is regulated by a complex balance of genetic factors, such as FVIII genotype, and environmental variables, such as coexistent inflammation. One of the hypothesized risk factors of inhibitor development is the source of the FVIII concentrate, which could be either recombinant or plasma derived. Differential immunogenicity of these concentrates has been documented in several recent epidemiologic studies, thus generating significant debate within the hemophilia treatment community. To date, these discussions have been unable to reach a consensus regarding how these outcomes might be integrated into enhancing clinical care. Moreover, the biological mechanistic explanations for the observed differences are poorly understood. In this article, we complement the existing epidemiologic investigations with an overview of the range of possible biochemical and immunologic mechanisms that may contribute to the different immune outcomes observed with plasma-derived and recombinant FVIII products.
Collapse
|
24
|
Natarajan P, Santhanakrishnan M, Tormey CA, Hendrickson JE. The impact of vaccination on RBC alloimmunization in a murine model. Vox Sang 2017; 112:598-600. [PMID: 28597520 DOI: 10.1111/vox.12541] [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: 02/25/2017] [Revised: 04/26/2017] [Accepted: 04/27/2017] [Indexed: 11/30/2022]
Abstract
Emerging data in animal models and humans suggest that pathogen-associated and damage-associated molecular patterns variably impact RBC alloantibody formation. In this study, we tested the hypothesis that vaccinations may enhance immune responses to transfused RBCs. The Pneumovax23 vaccine decreased the magnitude of anti-KEL alloimmunization in a murine model, whereas the hepB vaccine did not impact the response; RBC transfusion did not alter immune responses to either vaccine. These data highlight the complexities of the intersection of innate and adaptive immunity and suggest that future studies investigating the pathways through which inflammation impacts alloimmunization are warranted.
Collapse
Affiliation(s)
- P Natarajan
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - M Santhanakrishnan
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - C A Tormey
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT, USA.,Pathology and Laboratory Medicine Service, VA CT Healthcare System, West Haven, CT, USA
| | - J E Hendrickson
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT, USA.,Department of Pediatrics, Yale University School of Medicine, New Haven, CT, USA
| |
Collapse
|
25
|
Lövgren KM, Søndergaard H, Skov S, Wiinberg B. Non-genetic risk factors in haemophilia A inhibitor management - the danger theory and the use of animal models. Haemophilia 2016; 22:657-66. [DOI: 10.1111/hae.13075] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/17/2016] [Indexed: 12/20/2022]
Affiliation(s)
- K. M. Lövgren
- Department of Veterinary Disease Biology; University of Copenhagen; Frederiksberg Denmark
- Translational Haemophilia Pharmacology, Global Research; Novo Nordisk A/S; Maaloev Denmark
| | - H. Søndergaard
- Diabetes Complications Pharmacology; Global Research; Novo Nordisk A/S; Maaloev Denmark
| | - S. Skov
- Department of Veterinary Disease Biology; University of Copenhagen; Frederiksberg Denmark
| | - B. Wiinberg
- Haemophilia Translational Biology, Global Research; Novo Nordisk A/S; Maaloev Denmark
| |
Collapse
|