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Jardim LL, Schieber TA, Santana MP, Cerqueira MH, Lorenzato CS, Franco VKB, Zuccherato LW, da Silva Santos BA, Chaves DG, Ravetti MG, Rezende SM. Prediction of inhibitor development in previously untreated and minimally treated children with severe and moderately severe hemophilia A using a machine-learning network. J Thromb Haemost 2024; 22:2426-2437. [PMID: 38810700 DOI: 10.1016/j.jtha.2024.05.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Revised: 05/02/2024] [Accepted: 05/12/2024] [Indexed: 05/31/2024]
Abstract
BACKGROUND Prediction of inhibitor development in patients with hemophilia A (HA) remains a challenge. OBJECTIVES To construct a predictive model for inhibitor development in HA using a network of clinical variables and biomarkers based on the individual similarity network. METHODS Previously untreated and minimally treated children with severe/moderately severe HA, participants of the HEMFIL Cohort Study, were followed up until reaching 75 exposure days (EDs) without inhibitor (INH-) or upon inhibitor development (INH+). Clinical data and biological samples were collected before the start of factor (F)VIII replacement (T0). A predictive model (HemfilNET) was built to compare the networks and potential global topological differences between INH- and INH+ at T0, considering the network robustness. For validation, the "leave-one-out" cross-validation technique was employed. Accuracy, precision, recall, and F1-score were used as evaluation metrics for the machine-learning model. RESULTS We included 95 children with HA (CHA), of whom 31 (33%) developed inhibitors. The algorithm, featuring 37 variables, identified distinct patterns of networks at T0 for INH+ and INH-. The accuracy of the model was 74.2% for CHA INH+ and 98.4% for INH-. By focusing the analysis on CHA with high-risk F8 mutations for inhibitor development, the accuracy in identifying CHA INH+ increased to 82.1%. CONCLUSION Our machine-learning algorithm demonstrated an overall accuracy of 90.5% for predicting inhibitor development in CHA, which further improved when restricting the analysis to CHA with a high-risk F8 genotype. However, our model requires validation in other cohorts. Yet, missing data for some variables hindered more precise predictions.
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Affiliation(s)
- Letícia Lemos Jardim
- Instituto René Rachou (Fiocruz Minas), Belo Horizonte, Minas Gerais, Brazil; Department of Clinical Epidemiology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Tiago A Schieber
- Faculdade de Ciências Econômicas, School of Economics, Universidade Federal de Minas Gerais, Brazil
| | | | | | | | | | | | | | | | - Martín Gomez Ravetti
- Departamento de Ciência da Computação, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Suely Meireles Rezende
- Faculty of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil.
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Hassan S, Baselli G, Mollica L, Rossi RL, Chand H, El-Beshlawy A, Elalfy M, Ramanan V, Eshghi P, Karimi M, Palla R, Rosendaal FR, Peyvandi F. Predicting inhibitor development using a random peptide phage-display library approach in the SIPPET cohort. Blood Adv 2024; 8:2880-2889. [PMID: 38593222 PMCID: PMC11176960 DOI: 10.1182/bloodadvances.2023011388] [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: 08/07/2023] [Revised: 03/28/2024] [Accepted: 03/28/2024] [Indexed: 04/11/2024] Open
Abstract
ABSTRACT Inhibitor development is the most severe complication of hemophilia A (HA) care and is associated with increased morbidity and mortality. This study aimed to use a novel immunoglobulin G epitope mapping method to explore the factor VIII (FVIII)-specific epitope profile in the SIPPET cohort population and to develop an epitope mapping-based inhibitor prediction model. The population consisted of 122 previously untreated patients with severe HA who were followed up for 50 days of exposure to FVIII or 3 years, whichever occurred first. Sampling was performed before FVIII treatment and at the end of the follow-up. The outcome was inhibitor development. The FVIII epitope repertoire was assessed by means of a novel random peptide phage-display assay. A least absolute shrinkage and selection operator (LASSO) regression model and a random forest model were fitted on posttreatment sample data and validated in pretreatment sample data. The predictive performance of these models was assessed by the C-statistic and a calibration plot. We identified 27 775 peptides putatively directed against FVIII, which were used as input for the statistical models. The C-statistic of the LASSO and random forest models were good at 0.78 (95% confidence interval [CI], 0.69-0.86) and 0.80 (95% CI, 0.72-0.89). Model calibration of both models was moderately good. Two statistical models, developed on data from a novel random peptide phage display assay, were used to predict inhibitor development before exposure to exogenous FVIII. These models can be used to set up diagnostic tests that predict the risk of inhibitor development before starting treatment with FVIII.
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Affiliation(s)
- Shermarke Hassan
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Guido Baselli
- Department of Transfusion Medicine and Hematology, Translational Medicine, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Luca Mollica
- Department of Medical Biotechnologies and Translational Medicine, LITA/University of Milan, Milan, Italy
| | - Riccardo L. Rossi
- Bioinformatics, Istituto Nazionale Genetica Molecolare “Romeo ed Enrica Invernizzi,” Milan, Italy
| | - Himani Chand
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Amal El-Beshlawy
- Pediatric Hematology Department, Cairo University Pediatric Hospital, Cairo, Egypt
| | - Mohsen Elalfy
- Faculty of Medicine, Ain Shams University, Department of Pediatrics, Cairo, Egypt
| | - Vijay Ramanan
- Department of Hematology, Jehangir Clinical Development Centre, Jehangir Hospital Premises, Pune, India
| | - Peyman Eshghi
- Congenital Pediatric Hematologic Disorders Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mehran Karimi
- Pediatric Hematology-Oncology Department, American Hospital Dubai, Dubai, United Arab Emirates
| | - Roberta Palla
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Frits R. Rosendaal
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Flora Peyvandi
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
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Horling FM, Reipert BM, Allacher P, Engl W, Pan L, Tangada S. Immunogenicity profile of rurioctocog alfa pegol in previously treated patients with severe congenital hemophilia A. Blood Adv 2024; 8:2726-2739. [PMID: 38564770 PMCID: PMC11170177 DOI: 10.1182/bloodadvances.2023011780] [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: 09/29/2023] [Revised: 02/22/2024] [Accepted: 03/14/2024] [Indexed: 04/04/2024] Open
Abstract
ABSTRACT Rurioctocog alfa pegol is an extended-half-life full-length recombinant factor VIII (FVIII) bound to 20-kDa polyethylene glycol (PEG) that has been shown to be well tolerated and efficacious in the treatment and prevention of bleeding events in previously treated patients with severe hemophilia A. Here, we present a comprehensive analysis of immunogenicity data collected during 6 clinical studies of rurioctocog alfa pegol, including a total of 360 unique previously treated patients with severe hemophilia A. The analysis included treatment-emerging FVIII-neutralizing antibodies (FVIII inhibitors); preexisting and treatment-emerging antibodies binding to FVIII, PEG-FVIII, or PEG; and treatment-emerging antibodies binding to Chinese hamster ovary host cell proteins. Moreover, the potential association between the presence of these binding antibodies and adverse events (AEs) observed in patients was investigated, and the potential impact of these antibodies on the incremental recovery of rurioctocog alfa pegol in patients was analyzed. Overall, the data indicate that rurioctocog alfa pegol is not associated with any unexpected immunogenicity characteristics. Of 360 patients, 1 patient developed a transient FVIII inhibitor with a titer of 0.6 Bethesda units per mL, which was not associated with any serious AEs. Antibodies binding to FVIII, PEG-FVIII, or PEG were not detected at the time when the inhibitor was present. Moreover, 54 of 360 patients either entered the clinical studies with preexisting binding antibodies or developed these antibodies after exposure to rurioctocog alfa pegol. These antibodies were transient in most patients and did not show any causal relationship to either AEs or spontaneous bleeding episodes.
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Affiliation(s)
- Frank M. Horling
- Institute Krems Bioanalytics, IMC University of Applied Sciences Krems, Krems, Austria
| | - Birgit M. Reipert
- Institute Krems Bioanalytics, IMC University of Applied Sciences Krems, Krems, Austria
| | - Peter Allacher
- Institute Krems Bioanalytics, IMC University of Applied Sciences Krems, Krems, Austria
| | - Werner Engl
- Baxalta Innovations GmbH, a Takeda company, Vienna, Austria
| | - Luying Pan
- Takeda Development Center Americas, Inc, Cambridge, MA
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Pezeshkpoor B, Berkemeier AC, Herbst K, Albert T, Müller J, Oldenburg J. Comprehensive domain-specific analysis and immunoglobulin G profiling of anti-factor VIII antibodies using a bead-based multiplex immunoassay. J Thromb Haemost 2024; 22:1591-1604. [PMID: 38453023 DOI: 10.1016/j.jtha.2024.02.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 01/27/2024] [Accepted: 02/24/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND Antibodies against factor (F)VIII are a major complication in the treatment of patients with severe hemophilia A. The Nijmegen-Bethesda assay (NBA) is the gold standard for detection of neutralizing antibodies (inhibitors), whereas both inhibitors and nonneutralizing antibodies can be detected by immunoassays such as enzyme-linked immunosorbent assay (ELISA) and multiplex bead-based assays. OBJECTIVES Evaluation of an in-house Luminex bead-based assay (LumiTope) compared with a commercially available ELISA and NBA. METHODS The LumiTope method comprised full-length and B-domain-deleted FVIII as well as 9 purified FVIII single or multidomains. The respective proteins were coupled to magnetic beads to detect domain-specific immunoglobulin (IgG; IgG1-4) anti-FVIII antibodies in a large cohort of patients with hemophilia A with and without inhibitors. RESULTS Overall, LumiTope assay had a high sensitivity (94.9%) and specificity (91.2%), particularly in patients with low-titer inhibitors compared with ELISA (sensitivity of 72.2% vs 27.7%). IgG4 was the most abundant IgG subclass in NBA-positive patients. NBA-positive and -negative patients showed different domain profiles. Patients with genetic variants in the heavy chain predominantly exhibited antibodies specific to this chain, while those with a light-chain variant showed a more diverse distribution of antibody specificities. Patients with an intron 22 inversion resembled those with a light-chain defect, with a majority of antibodies targeting the light chain. CONCLUSION LumiTope assay provides a sensitive and specific method for not only detection but also domain specification of anti-FVIII-antibodies. Implementation of bead-based assays could improve antibody detection, profiling, and comparability of results and complement NBA.
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Affiliation(s)
- Behnaz Pezeshkpoor
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Medical Faculty, University of Bonn, Bonn, Germany.
| | - Ann-Cristin Berkemeier
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Medical Faculty, University of Bonn, Bonn, Germany
| | - Kerstin Herbst
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Medical Faculty, University of Bonn, Bonn, Germany
| | - Thilo Albert
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Medical Faculty, University of Bonn, Bonn, Germany
| | - Jens Müller
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Medical Faculty, University of Bonn, Bonn, Germany
| | - Johannes Oldenburg
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Medical Faculty, University of Bonn, Bonn, Germany; Center for Rare Diseases Bonn (ZSEB), University Clinic Bonn, Bonn, Germany.
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Tręda C, Włodarczyk A, Rieske P. The hope, hype and obstacles surrounding cell therapy. J Cell Mol Med 2024; 28:e18359. [PMID: 38770886 PMCID: PMC11107145 DOI: 10.1111/jcmm.18359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 03/29/2024] [Accepted: 04/12/2024] [Indexed: 05/22/2024] Open
Abstract
Cell therapy offers hope, but it also presents challenges, most particularly the limited ability of human organs and tissues to regenerate. Since many diseases are associated with irreversible pathophysiological or traumatic changes, stem cells and their derivatives are unable to secure healing. Although regenerative medicine offers chances for improvements in many diseases, such as type one diabetes and Parkinson's disease, it cannot eliminate the primary cause of many of them. While successes can be expected for diseases such as sickle cell disease, this is not the case for hereditary diseases with varied mutation types or for ciliopathies, which start in embryogenesis. In this complicated medical environment, synthetic biology offers some solutions, but their implementation will take many years. Still, positive examples such as CAR-T therapy offer hope.
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Affiliation(s)
- Cezary Tręda
- Department of Tumor BiologyMedical University of LodzLodzPoland
| | | | - Piotr Rieske
- Department of Tumor BiologyMedical University of LodzLodzPoland
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6
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Oomen I, Verhagen M, Miranda M, Allacher P, Beckers EAM, Blijlevens NMA, van der Bom JG, Coppens M, Driessens M, Eikenboom JCJ, Fijnvandraat K, Hassan S, van Heerde WL, Hooimeijer HL, Jansen JH, Kaijen P, Leebeek FWG, Meijer D, Paul H, Rijpma SR, Rosendaal FR, Smit C, van Vulpen LFD, Voorberg J, Schols SEM, Gouw SC. The spectrum of neutralizing and non-neutralizing anti-FVIII antibodies in a nationwide cohort of 788 persons with hemophilia A. Front Immunol 2024; 15:1355813. [PMID: 38455035 PMCID: PMC10918462 DOI: 10.3389/fimmu.2024.1355813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 01/22/2024] [Indexed: 03/09/2024] Open
Abstract
Objectives Anti-factor VIII (FVIII) antibodies have been reported to exhibit both neutralizing and non-neutralizing characteristics. This is the first study investigating the full spectrum of FVIII-specific antibodies, including non-neutralizing antibodies, very-low titer inhibitors, and inhibitors, in a large nationwide population of persons with hemophilia A of all severities. Methods All persons with hemophilia A (mild (FVIII > 5-40 IU/dL)/moderate [FVIII 1-5 IU/dL)/severe (FVIII < 1 IU/dL)] with an available plasma sample who participated in the sixth Hemophilia in the Netherlands study between 2018 and 2019 were included. The presence of anti-FVIII antibodies of the immunoglobulin A, M, and G isotypes and IgG subclasses, along with antibody titer levels, were assessed using direct-binding ELISAs. FVIII specificity was assessed using a competition-based ELISA approach. The inhibitor status was determined using the Nijmegen ultra-sensitive Bethesda assay (NusBA) and the Nijmegen Bethesda assay (NBA). Results In total, 788 persons with hemophilia A (336 (42.6%) mild, 123 (15.6%) moderate, 329 (41.8%) severe hemophilia) were included. The median age was 45 years (IQR 24-60), and the majority (50.9%) had over 150 exposure days to FVIII concentrates. Within our population, 144 (18.3%) individuals had non-neutralizing FVIII-specific antibodies, 10 (1.3%) had very low-titer inhibitors (NusBA positive; NBA negative), and 13 (1.6%) had inhibitors (both NusBA and NBA positive). IgG1 was the most abundant FVIII-specific antibody subclass, and the highest titer levels were found for IgG4. In individuals without a reported history of inhibitor development, no clear differences were observed in antibody patterns between those who were minimally or highly exposed to FVIII concentrates. IgG4 subclass antibodies were only observed in persons with a reported history of FVIII inhibitor or in those with a currently detected (very low-titer) inhibitor. Conclusion In this cross-sectional study, we identified non-neutralizing antibodies in a relatively large proportion of persons with hemophilia A. In contrast, in our population, consisting of persons highly exposed to FVIII concentrates, (very low-titer) inhibitors were detected only in a small proportion of persons, reflecting a well-tolerized population. Hence, our findings suggest that only a small subpopulation of non-neutralizing FVIII-specific antibodies is associated with clinically relevant inhibitors.
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Affiliation(s)
- Ilja Oomen
- Department of Pediatric Hematology, Amsterdam University Medical Center (UMC) Location University of Amsterdam, Amsterdam, Netherlands
- Department of Molecular Hematology, Sanquin Research, Amsterdam, Netherlands
| | - Marieke Verhagen
- Department of Hematology, Radboud University Medical Center, Nijmegen, Netherlands
- Hemophilia Treatment Center Nijmegen-Eindhoven-Maastricht, Nijmegen, Netherlands
- Laboratory of Hematology, Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, Netherlands
| | | | - Peter Allacher
- Institute Krems Bioanalytics, International Management Center (IMC) University of Applied Sciences Krems, Krems, Austria
| | - Erik A. M. Beckers
- Division of Hematology, Department of Internal Medicine, Maastricht University Medical Center, Maastricht University, Maastricht, Netherlands
| | - Nicole M. A. Blijlevens
- Department of Hematology, Radboud University Medical Center, Nijmegen, Netherlands
- Hemophilia Treatment Center Nijmegen-Eindhoven-Maastricht, Nijmegen, Netherlands
| | - Johanna G. van der Bom
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Netherlands
| | - Michiel Coppens
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, Location University of Amsterdam, Amsterdam, Netherlands
| | | | - Jeroen C. J. Eikenboom
- Division of Thrombosis and Hemostasis, Department of Internal Medicine, Leiden University Medical Center, Leiden University, Leiden, Netherlands
| | - Karin Fijnvandraat
- Department of Pediatric Hematology, Amsterdam University Medical Center (UMC) Location University of Amsterdam, Amsterdam, Netherlands
- Department of Molecular Hematology, Sanquin Research, Amsterdam, Netherlands
| | - Shermarke Hassan
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Netherlands
- Infectious Diseases Data Observatory, Center for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
| | - Waander L. van Heerde
- Department of Hematology, Radboud University Medical Center, Nijmegen, Netherlands
- Hemophilia Treatment Center Nijmegen-Eindhoven-Maastricht, Nijmegen, Netherlands
- Enzyre BV, Nijmegen, Netherlands
| | - H. Louise Hooimeijer
- Division of Hematology/Oncology, Department of Pediatrics, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Joop H. Jansen
- Laboratory of Hematology, Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, Netherlands
| | - Paul Kaijen
- Department of Molecular Hematology, Sanquin Research, Amsterdam, Netherlands
| | - Frank W. G. Leebeek
- Department of Hematology, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Daniëlle Meijer
- Laboratory of Hematology, Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, Netherlands
| | - Helmut Paul
- Institute Krems Bioanalytics, International Management Center (IMC) University of Applied Sciences Krems, Krems, Austria
| | - Sanna R. Rijpma
- Laboratory of Hematology, Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, Netherlands
| | - Frits R. Rosendaal
- Division of Thrombosis and Hemostasis, Department of Internal Medicine, Leiden University Medical Center, Leiden University, Leiden, Netherlands
| | - Cees Smit
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, Location University of Amsterdam, Amsterdam, Netherlands
- Division of Thrombosis and Hemostasis, Department of Internal Medicine, Leiden University Medical Center, Leiden University, Leiden, Netherlands
| | - Lize F. D. van Vulpen
- Center for Benign Hematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, University Utrecht, Utrecht, Netherlands
| | - Jan Voorberg
- Department of Molecular Hematology, Sanquin Research, Amsterdam, Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Netherlands
| | - Saskia E. M. Schols
- Department of Hematology, Radboud University Medical Center, Nijmegen, Netherlands
- Hemophilia Treatment Center Nijmegen-Eindhoven-Maastricht, Nijmegen, Netherlands
| | - Samantha C. Gouw
- Department of Pediatric Hematology, Amsterdam University Medical Center (UMC) Location University of Amsterdam, Amsterdam, Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Netherlands
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Cormier M, Burnett E, Mo A, Notley C, Tijet N, Christie-Holmes N, Hough C, Lillicrap D. Mice possess a more limited natural antihuman factor VIII antibody repertoire than humans that is produced disproportionately by marginal zone B cells. J Thromb Haemost 2024; 22:76-89. [PMID: 37678547 PMCID: PMC10872961 DOI: 10.1016/j.jtha.2023.08.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 08/22/2023] [Accepted: 08/30/2023] [Indexed: 09/09/2023]
Abstract
BACKGROUND One-third of patients with severe hemophilia A develop neutralizing antibodies to the factor VIII (FVIII) protein in response to intravenous replacement therapy. Patients may also generate natural, nonneutralizing antibodies to FVIII before FVIII exposure. These patients are at increased risk of developing neutralizing antibodies to FVIII. However, natural anti-FVIII antibodies are also present in healthy human donors. OBJECTIVES To further characterize the natural antihuman (h) FVIII antibody repertoire in mice and humans. METHODS An in-house ELISA was developed using a purified polyclonal immunoglobulin (Ig) standard to quantify anti-hFVIII Ig in cell culture supernatant or plasma from mice (wild-type and FVIII-/-) and adult human donors. RESULTS All naïve wild-type and FVIII-/- mice, as well as healthy human donors, possess natural anti-hFVIII antibodies. Mice only have natural anti-hFVIII IgM, which is present in germ-free mice, suggesting that they are germline encoded. Although murine marginal zone B cells (MZBs) contribute 44% to all circulating natural IgM, they contribute disproportionately to the anti-hFVIII IgM repertoire (82%). This naturally occurring murine MZB-derived IgM is not B-domain specific and is reduced by intravenously administered hFVIII, suggesting that it may form immune complexes immediately upon hFVIII administration. Natural anti-hFVIII antibodies of IgG, IgM, and IgA isotypes can be detected in adult human donors. There were increased levels of B-domain-favoring anti-hFVIII IgG in 14% of healthy donors, which were markedly different from the rest of the "low-titer" population. CONCLUSIONS There is a preponderance of natural anti-hFVIII antibodies in both mice and healthy adult human donors.
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Affiliation(s)
- Matthew Cormier
- Department of Pathology and Molecular Medicine, Queen's University, Kingston, Ontario, Canada.
| | - Erin Burnett
- Department of Pathology and Molecular Medicine, Queen's University, Kingston, Ontario, Canada
| | - Aomei Mo
- Department of Pathology and Molecular Medicine, Queen's University, Kingston, Ontario, Canada
| | - Colleen Notley
- Department of Pathology and Molecular Medicine, Queen's University, Kingston, Ontario, Canada
| | - Nathalie Tijet
- Department of Pathology and Molecular Medicine, Queen's University, Kingston, Ontario, Canada
| | - Natasha Christie-Holmes
- Emerging & Pandemic Infections Consortium, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Christine Hough
- Department of Pathology and Molecular Medicine, Queen's University, Kingston, Ontario, Canada
| | - David Lillicrap
- Department of Pathology and Molecular Medicine, Queen's University, Kingston, Ontario, Canada.
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Müller J, Neimanis S, Kahle J, Albert T, Schultze Strasser S, Rup B, Pötzsch B, Königs C, Oldenburg J. Two-center validation of assays for the detection of binding and neutralizing anti-factor VIII antibodies. Haemophilia 2024; 30:224-231. [PMID: 37824540 DOI: 10.1111/hae.14885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 09/29/2023] [Accepted: 09/29/2023] [Indexed: 10/14/2023]
Abstract
INTRODUCTION Patients with hemophilia A treated with coagulation Factor VIII (FVIII) products are at risk for developing anti-FVIII antibodies. The ABIRISK Consortium aimed to provide knowledge on the formation and detection of anti-drug antibodies against biopharmaceutical products, including FVIII. Accordingly, standardized and validated assays for the detection of binding (total) and neutralizing antibodies are needed. AIM Two-center validation of an ELISA for the detection of total FVIII-binding IgG-antibodies and Nijmegen-Bethesda assays for the quantification of FVIII-neutralizing antibodies according to consensus validation guidelines. METHODS Validation of assays at both sites was done according to published recommendations and included preanalytics, the determination of key assay parameters, including cut-points, assay sensitivity, precision, and FVIII interference. RESULTS The validated assays reproducibly detected FVIII-binding and -neutralizing antibodies with comparable performance in both laboratories. Floating screening cut-points were established for both assays. Determined mass-based sensitivity of both assays (all values ≤66 ng/mL) complied with the minimum sensitivity for the detection of anti-drug antibodies as recommended by the FDA (<100 ng/mL). Intra- and inter-assay coefficients of variation did not exceed 25%. Assay validation further revealed that pre-analytical heat treatment led to potentially false-positive ELISA results, while up to 0.15 IU/mL, residual FVIII showed no significant impact. Overall, good agreement of results was found for patient samples analyzed at both study sites. CONCLUSION Comprehensive validation of different anti-FVIII-antibody assays in two laboratories gave novel insights into the impact of pre-analytical sample treatment as well as the comparability of test results generated by the use of methodically different assays.
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Affiliation(s)
- Jens Müller
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Bonn, Germany
| | - Sonja Neimanis
- Department of Pediatrics and Adolescent Medicine, Clinical and Molecular Hemostasis, Goethe University Frankfurt, University Hospital, Frankfurt am Main, Germany
| | - Jörg Kahle
- Department of Pediatrics and Adolescent Medicine, Clinical and Molecular Hemostasis, Goethe University Frankfurt, University Hospital, Frankfurt am Main, Germany
| | - Thilo Albert
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Bonn, Germany
| | - Stephan Schultze Strasser
- Department of Pediatrics and Adolescent Medicine, Clinical and Molecular Hemostasis, Goethe University Frankfurt, University Hospital, Frankfurt am Main, Germany
| | - Bonita Rup
- Pfizer, Immunogenicity Sciences Disciple, Pharmacokinetics, Dynamics and Metabolism, New York, NY, USA
| | - Bernd Pötzsch
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Bonn, Germany
| | - Christoph Königs
- Department of Pediatrics and Adolescent Medicine, Clinical and Molecular Hemostasis, Goethe University Frankfurt, University Hospital, Frankfurt am Main, Germany
| | - Johannes Oldenburg
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Bonn, Germany
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Reipert BM, Hofbauer CJ, Gangadharan B, Berg V, Donnachie E, Meeks S, Mancuso ME, Bowen J, Brown DL. Qualification of Hemophilia Treatment Centers to Enable Multi-Center Studies of Gene Expression Signatures in Blood Cells from Pediatric Patients. J Clin Med 2023; 12:jcm12052080. [PMID: 36902866 PMCID: PMC10004246 DOI: 10.3390/jcm12052080] [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: 12/30/2022] [Revised: 02/25/2023] [Accepted: 03/02/2023] [Indexed: 03/09/2023] Open
Abstract
Hemophilia A is a rare congenital bleeding disorder caused by a deficiency of functionally active coagulation factor VIII (FVIII). Most patients with the severe form of the disease require FVIII replacement therapies, which are often associated with the development of neutralizing antibodies against FVIII. Why some patients develop neutralizing antibodies while others do not is not fully understood. Previously, we could demonstrate that the analysis of FVIII-induced gene expression signatures in peripheral blood mononuclear cells (PBMC) obtained from patients exposed to FVIII replacement therapies provides novel insights into underlying immune mechanisms regulating the development of different populations of FVIII-specific antibodies. The aim of the study described in this manuscript was the development of training and qualification test procedures to enable local operators in different European and US clinical Hemophilia Treatment Centers (HTC) to produce reliable and valid data for antigen-induced gene expression signatures in PBMC obtained from small blood volumes. For this purpose, we used the model antigen Cytomegalovirus (CMV) phosphoprotein (pp) 65. We trained and qualified 39 local HTC operators from 15 clinical sites in Europe and the US, of whom 31 operators passed the qualification at first attempt, and eight operators passed at the second attempt.
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Affiliation(s)
- Birgit M. Reipert
- Baxalta Innovations GmbH, Takeda Company, 1220 Vienna, Austria
- Krems Bioanalytics, IMC University of Applied Sciences Krems, 3500 Krems an der Donau, Austria
- Correspondence:
| | | | | | - Verena Berg
- Krems Bioanalytics, IMC University of Applied Sciences Krems, 3500 Krems an der Donau, Austria
| | - Elizabeth Donnachie
- College of Pharmacy and Health Sciences, University of Texas Health Science Center at Houston, Houston, TX 77030, USA
| | - Shannon Meeks
- Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Emory University, Atlanta, GA 30342, USA
| | - Maria Elisa Mancuso
- IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Joel Bowen
- Indiana Hemophilia and Thrombosis Center Inc., Indianapolis, IN 46260, USA
| | - Deborah L. Brown
- Department of Pediatrics, University of Texas Health Science Center at Houston, Houston, TX 77030, USA
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10
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Martin M, Augustsson C, Lind V, Al-Sabti R, Lam MC, Andersson NG, Strandberg K. Methods for anti-factor VIII antibody levels in haemophilia A patients - validation of a multiplex immunoassay and comparability with assays measuring non-neutralising and neutralising antibodies (inhibitors). Haemophilia 2023; 29:336-347. [PMID: 36193002 DOI: 10.1111/hae.14669] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 09/14/2022] [Accepted: 09/18/2022] [Indexed: 01/25/2023]
Abstract
INTRODUCTION The development of neutralising (inhibitors) and non-neutralising antibodies (NNAs) is a complication to factor replacement therapy in haemophilia. The diagnostic methods available lack standardisation, have high inter-laboratory variation, and false-negative as well as false-positive results may affect treatment. Both functional inhibitors and NNAs may be detected with higher reproducibility, sensitivity and specificity using the immunological Luminex xMAP-based fluorescence-immunoassay (xFLI). AIM Validation of our xFLI and comparability with enzyme-linked immunosorbent assay (ELISA) and chromogenic Nijmegen-Bethesda assay (CBA) for anti-FVIII antibodies in haemophilia A (HA) patients. METHODS The xFLI method was developed with full-length and B-domain deleted factor coupled to magnetic beads, optimised and validated for performance characteristics. Comparability with ELISA and CBA was evaluated in HA patient samples (n = 112), serial samples in six inhibitor patients and reference interval and decision-limits in healthy donors (n = 44). RESULTS The intra- and inter-assay precision (CV%) for the xFLI method was below 6% and detection limit (LLOQ) .084 ng/mL (NovoEight). All ELISA-positive samples were positive with either Advate or NovoEight. Additionally, 10.7%-14.3% were xFLI-positive and ELISA-negative. All but one CBA-positive sample was above 3SD with xFLI; one was between 2 and 3SD. 29.1% were xFLI-positive and CBA negative. The overall concordance between xFLI and ELISA was 82.1% and xFLI and CBA 77.9%. CONCLUSION The anti-FVIII antibody xFLI method is adaptable to clinical practice and more sensitive and reproducible than ELISA and CBA. Actual NNA titers are determined to both full-length and B-domain deleted FVIII. The xFLI is thus valuable for confirmation of all anti-FVIII antibodies.
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Affiliation(s)
- Myriam Martin
- Department of Clinical Chemistry and Pharmacology, Division of Laboratory Medicine, Coagulation Laboratory, University and Regional Laboratories Region Skåne, Malmö, Sweden
| | - Cecilia Augustsson
- Department of Clinical Chemistry and Pharmacology, Division of Laboratory Medicine, Coagulation Laboratory, University and Regional Laboratories Region Skåne, Malmö, Sweden
| | - Vivian Lind
- Department of Clinical Chemistry and Pharmacology, Division of Laboratory Medicine, Coagulation Laboratory, University and Regional Laboratories Region Skåne, Malmö, Sweden
| | - Riam Al-Sabti
- Department of Clinical Chemistry and Pharmacology, Division of Laboratory Medicine, Coagulation Laboratory, University and Regional Laboratories Region Skåne, Malmö, Sweden
| | - My Chi Lam
- Department of Clinical Chemistry and Pharmacology, Division of Laboratory Medicine, Coagulation Laboratory, University and Regional Laboratories Region Skåne, Malmö, Sweden
| | - Nadine G Andersson
- Department of Thrombosis and Haemostasis, Hematology, Oncology and Radiation Physics, Skåne University Hospital, Malmö, Sweden
| | - Karin Strandberg
- Department of Clinical Chemistry and Pharmacology, Division of Laboratory Medicine, Coagulation Laboratory, University and Regional Laboratories Region Skåne, Malmö, Sweden
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11
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Luo L, Zheng Q, Chen Z, Huang M, Fu L, Hu J, Shi Q, Chen Y. Hemophilia a patients with inhibitors: Mechanistic insights and novel therapeutic implications. Front Immunol 2022; 13:1019275. [PMID: 36569839 PMCID: PMC9774473 DOI: 10.3389/fimmu.2022.1019275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Accepted: 11/09/2022] [Indexed: 12/14/2022] Open
Abstract
The development of coagulation factor VIII (FVIII) inhibitory antibodies is a serious complication in hemophilia A (HA) patients after FVIII replacement therapy. Inhibitors render regular prophylaxis ineffective and increase the risk of morbidity and mortality. Immune tolerance induction (ITI) regimens have become the only clinically proven therapy for eradicating these inhibitors. However, this is a lengthy and costly strategy. For HA patients with high titer inhibitors, bypassing or new hemostatic agents must be used in clinical prophylaxis due to the ineffective ITI regimens. Since multiple genetic and environmental factors are involved in the pathogenesis of inhibitor generation, understanding the mechanisms by which inhibitors develop could help identify critical targets that can be exploited to prevent or eradicate inhibitors. In this review, we provide a comprehensive overview of the recent advances related to mechanistic insights into anti-FVIII antibody development and discuss novel therapeutic approaches for HA patients with inhibitors.
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Affiliation(s)
- Liping Luo
- Department of Hematology, Fujian Provincial Key Laboratory of Hematology, Fujian Institute of Hematology, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Qiaoyun Zheng
- Department of Hematology, Fujian Provincial Key Laboratory of Hematology, Fujian Institute of Hematology, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Zhenyu Chen
- Department of Hematology, Fujian Provincial Key Laboratory of Hematology, Fujian Institute of Hematology, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
- Medical Technology and Engineering College of Fujian Medical University, Fuzhou, Fujian, China
| | - Meijuan Huang
- Department of Hematology, Fujian Provincial Key Laboratory of Hematology, Fujian Institute of Hematology, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Lin Fu
- Department of Hematology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Jianda Hu
- Department of Hematology, Fujian Provincial Key Laboratory of Hematology, Fujian Institute of Hematology, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Qizhen Shi
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, United States
- Blood Research Institute, Versiti, Milwaukee, WI, United States
- Children’s Research Institute, Children’s Wisconsin, Milwaukee, WI, United States
- Midwest Athletes Against Childhood Cancer (MACC) Fund Research Center, Milwaukee, WI, United States
| | - Yingyu Chen
- Department of Hematology, Fujian Provincial Key Laboratory of Hematology, Fujian Institute of Hematology, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
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12
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Usefulness of anti-factor VIII IgG ELISA in acquired hemophilia A follow-up. Ann Hematol 2022; 101:2453-2460. [PMID: 36125542 DOI: 10.1007/s00277-022-04972-y] [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: 03/28/2022] [Accepted: 08/28/2022] [Indexed: 11/01/2022]
Abstract
Acquired hemophilia A (AHA) is a rare autoimmune bleeding disorder due to the presence of neutralizing autoantibodies directed against the coagulation factor VIII (FVIII). The reference method to detect and quantify anti-FVIII antibodies is the Bethesda assay (BA), but it presents some limitations such as a lack of sensitivity for low titers of inhibitor and the need for experienced laboratory. A commercially available ELISA detecting anti-FVIII antibodies has demonstrated excellent sensitivity and specificity. The aim of our study was to assess the performance of this ELISA for the detection of anti-FVIII IgG in AHA patients during the follow-up. In total, 11 acquired hemophilia A patients were recruited, and anti-FVIII antibody levels were monitored by BA and ELISA. Anti-FVIII IgG ELISA showed 100% sensitivity and 100% specificity, and it correlated with the BA. Discrepancies observed in 13.3% of cases were consistent with patients' biological evolution. All these data suggest the possible use of anti-FVIII IgG ELISA for both diagnosis and follow-up of AHA patients.
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13
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Factor IX antibodies and tolerance in hemophilia B in the Nordic countries - The impact of F9 variants and complications. Thromb Res 2022; 217:22-32. [PMID: 35842956 DOI: 10.1016/j.thromres.2022.06.015] [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: 02/24/2022] [Revised: 06/19/2022] [Accepted: 06/23/2022] [Indexed: 11/21/2022]
Abstract
INTRODUCTION The development of inhibitory antibodies (inhibitors) in persons with hemophilia B (PwHB) causes significant morbidity. Data on the impact of the F9 variant and immune tolerance induction (ITI) outcome are limited. The aim of this study was to investigate the presence of neutralizing and non-neutralizing antibodies (NNA) in severe hemophilia B (HB) and to evaluate ITI outcome and complications in relation to the pathogenic F9 variant. MATERIALS AND METHODS Persons with severe HB in the Nordic countries were enrolled and information on F9 variants, inhibitors, ITI and complications were collected. Analyses of anti-FIX antibodies with a fluorescence-immunoassay (xFLI) and an ELISA method were conducted. RESULTS Seventy-nine PwHB were enrolled. Null variants were seen in 33 (42 %) PwHB and 12 (15 %) had a current or former inhibitor. Eleven (92 %) of the inhibitor patients had experienced allergic manifestations and three (25 %) nephrotic syndrome. Of 10 PwHB with at least one ITI attempt, eight (80 %) were considered tolerant at enrolment. Immunosuppression was included in seven of eight successful or partially successful attempts. Five PwHB had at least one ITI failure before a successful or partially successful ITI. No NNA could be identified. CONCLUSION A high proportion of severe F9 gene defects among persons with severe HB in the Nordic countries may explain the observed relatively high prevalence of inhibitors. ITI success was independent of the F9 variant and attained despite allergic manifestations and previous ITI failures. Inclusion of immunosuppression tentatively enhances the chances of ITI success. No NNA were observed.
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14
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Escuriola Ettingshausen C, Yang R, Wu W, Meeks SL. Inhibitors: Diagnostic challenges, unknowns of inhibitor development, treatment of bleeding and surgery, and insights into diagnosis and treatment in China. Haemophilia 2022; 28 Suppl 4:111-118. [PMID: 35521731 DOI: 10.1111/hae.14553] [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: 01/07/2022] [Revised: 03/07/2022] [Accepted: 03/07/2022] [Indexed: 11/30/2022]
Abstract
Factor (F) VIII inhibitors develop in around 30% of previously untreated patients (PUPs) with severe haemophilia, to a lesser extend in moderate and mild haemophilia A and in up to 10% in severe haemophilia B. Diagnostic challenges and questions remain including access to high quality testing, the role for functional inhibitor testing and binding antibody testing, and the adaptations needed in the presence of non-factor replacement therapy. Despite significant gains in knowledge there are still many unanswered questions underlying the immunologic mechanisms of inhibitor development and tolerance. Therapeutic options include eradication of inhibitors using immune tolerance induction therapy (ITI), prophylaxis with bypassing agents (i.e., recombinant activated factor VII /rFVIIa or activated prothrombin complex concentrate/aPCC) or non-factor replacement therapies (e.g., emicizumab) and treatment of bleeds or coverage of surgeries/invasive procedure. Recently a haemophilia centre capacity building program was launched in China to further develop the infrastructure and support needed to improve the diagnosis of haemophilia, detection of inhibitors, and continue to improve the care of patients with haemophilia and inhibitors.
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Affiliation(s)
| | - Renchi Yang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Wenman Wu
- Department of Laboratory Medicine, Ruijin Hospital affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Shannon L Meeks
- Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta and Department of Pediatrics, Emory University, Atlanta, Georgia, USA
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15
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Osaki T, Souri M, Ogawa Y, Sato H, Mitsui T, Ichinose A. Retrospective examination of coagulation parameters in 33 patients with autoimmune coagulation factor deficiencies in Japan: A single-center analysis. Thromb Res 2022; 213:154-162. [DOI: 10.1016/j.thromres.2022.03.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 02/22/2022] [Accepted: 03/07/2022] [Indexed: 11/25/2022]
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16
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Awasthi NP, Tiwari V, Riaz K, Arshad S, Husain N. Revealing and IgG4 analysis to factor VIII in haemophilia-A patients with and without inhibitors. Transfus Apher Sci 2021; 61:103343. [DOI: 10.1016/j.transci.2021.103343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 12/13/2021] [Indexed: 10/19/2022]
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17
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Nonneutralizing FVIII-specific antibody signatures in patients with Hemophilia A and in healthy donors. Blood Adv 2021; 6:946-958. [PMID: 34847225 PMCID: PMC8945293 DOI: 10.1182/bloodadvances.2021005745] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 10/29/2021] [Indexed: 11/21/2022] Open
Abstract
Isotypes and IgG subclasses of nonneutralizing FVIII-specific antibodies are similar in hemophilia A patients and healthy subjects. Prevalences, titers, and affinities of nonneutralizing antibodies, however, differ significantly between patients and healthy subjects.
Previous studies identified nonneutralizing FVIII-specific antibodies in the circulation of severe and nonsevere hemophilia A (sHA and nsHA) patients without FVIII inhibitors and also in some healthy individuals. To gain a better understanding of the nature of these nonneutralizing antibody responses, we analyzed and compared anti-FVIII antibody signatures in 3 study cohorts: previously treated sHA as well as nsHA patients without FVIII inhibitors, and healthy donors. FVIII-binding IgM, IgG1-4, and IgA antibodies were differentiated, FVIII-specificity was assessed, and associated apparent affinity constants were determined. Our results indicate that the nonneutralizing FVIII-specific antibody response in all study cohorts is dominated by IgG1 and IgA. Prevalences, titers, and affinities of these nonneutralizing antibodies were higher in the hemophilia A cohorts than in healthy donors. Stratification for the anti-hepatitis C virus (HCV) antibody status demonstrated the presence of FVIII-specific IgA with elevated titers in sHA patients with an active or past HCV infection when compared with HCV antibody-positive nsHA patients or HCV antibody-negative patients and healthy donors. Increased titers and affinities of FVIII-specific IgG1 antibodies were observed in a considerable number of hemophilia A patients as opposed to healthy subjects independently of the patients’ anti-HCV antibody status. Overall, our findings support the hypothesis that the generation of nonneutralizing anti-FVIII antibodies in healthy individuals and in noninhibitor hemophilia A patients might be based on similar immune mechanisms. However, differences in prevalences, titers, and affinities of these antibodies indicate distinct differences in the antibody evolution between healthy individuals and patients.
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18
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Witarto BS, Visuddho V, Witarto AP, Sutanto H, Wiratama BS, Wungu CDK. Efficacy, safety, and immunogenicity of rurioctocog alfa pegol for prophylactic treatment in previously treated patients with severe hemophilia A: a systematic review and meta-analysis of clinical trials. F1000Res 2021; 10:1049. [PMID: 35136579 PMCID: PMC8787562 DOI: 10.12688/f1000research.73884.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/04/2021] [Indexed: 04/06/2024] Open
Abstract
Background: Patients with severe hemophilia often present with painful joint and soft tissue bleeding which may restrict them from their daily activities. The current standard of care still relies on a regular prophylactic factor VIII (FVIII), which has a high daily treatment burden. Recently, rurioctocog alfa pegol, a third-generation recombinant FVIII with a modification in its polyethylene glycol (PEG) component, has been developed. Several trials have studied this synthetic drug as bleeding prophylaxis in severe hemophilia A. This study aims to evaluate the efficacy, safety, and immunogenicity of rurioctocog alfa pegol for previously treated patients with severe hemophilia A. Methods: This study was conducted in conformity with the PRISMA guidelines. Data were retrieved from PubMed, Scopus, Cochrane Library, Wiley Online Library, and CINAHL (via EBSCOhost). Study qualities were assessed using the Methodological Index for Non-Randomized Studies (MINORS) and Modified Jadad scales. Results: Four studies involving 517 previously treated severe hemophilia A patients were included in this study. The pooled mean of total annualized bleeding rate (ABR) and hemostatic efficacy was 2.59 (95% CI = 2.04-3.14) and 92% (95% CI = 85%-97%), respectively. Only 30 (2.3%) non-serious and one (1.4%) serious adverse events were considered related to rurioctocog alfa pegol treatment. At the end of the studies, no development of FVIII inhibitory antibodies was observed. None of the developed binding antibodies to FVIII, PEG-FVIII, or PEG was correlated to the treatment efficacy and safety. Conclusions: Despite the limited availability of direct comparison studies, our analyses indicate that rurioctocog alfa pegol could serve as a safe and effective alternative for bleeding prophylaxis in previously treated hemophilia A patients. Moreover, it appears to have low immunogenicity, which further increases the safety profile of the drug in such clinical conditions.
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Affiliation(s)
| | - Visuddho Visuddho
- Medical Program, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia
| | | | - Henry Sutanto
- Department of Physiology and Pharmacology, SUNY Downstate Health Sciences University, Brooklyn, New York, USA
| | - Bayu Satria Wiratama
- Department of Epidemiology, Biostatistics, and Population Health, Universitas Gadjah Mada, Yogyakarta, Indonesia
- Graduate Institute of Injury Prevention and Control, Taipei Medical University, Taipei, Taiwan
| | - Citrawati Dyah Kencono Wungu
- Department of Physiology and Medical Biochemistry, Universitas Airlangga, Surabaya, Indonesia
- Institute of Tropical Disease, Universitas Airlangga, Surabaya, Indonesia
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19
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Witarto BS, Visuddho V, Witarto AP, Sutanto H, Wiratama BS, Wungu CDK. Efficacy safety and immunogenicity of rurioctocog alfa pegol for prophylactic treatment in previously treated patients with severe hemophilia A: a systematic review and meta-analysis of clinical trials. F1000Res 2021; 10:1049. [PMID: 35136579 PMCID: PMC8787562 DOI: 10.12688/f1000research.73884.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/06/2021] [Indexed: 04/06/2024] Open
Abstract
Background: Patients with severe hemophilia often present with painful joint and soft tissue bleeding which may restrict them from their daily activities. The current standard of care still relies on a regular prophylactic factor VIII (FVIII), which has a high daily treatment burden. Recently, rurioctocog alfa pegol, a third-generation recombinant FVIII with a modification in its polyethylene glycol (PEG) component, has been developed. Several trials have studied this synthetic drug as bleeding prophylaxis in severe hemophilia A. This study aims to evaluate the efficacy, safety, and immunogenicity of rurioctocog alfa pegol for previously treated patients with severe hemophilia A. Methods: This study was conducted in conformity with the PRISMA guidelines. Data were retrieved from PubMed, Scopus, Cochrane Library, Wiley Online Library, and CINAHL (via EBSCOhost). Study qualities were assessed using the Methodological Index for Non-Randomized Studies (MINORS) and Modified Jadad scales. Results: Four studies involving 517 previously treated severe hemophilia A patients were included in this study. The pooled mean of total annualized bleeding rate (ABR) and hemostatic efficacy was 2.59 (95% CI = 2.04-3.14) and 92% (95% CI = 85%-97%), respectively. Only 30 (2.3%) non-serious and one (1.4%) serious adverse events were considered related to rurioctocog alfa pegol treatment. At the end of the studies, no development of FVIII inhibitory antibodies was observed. None of the developed binding antibodies to FVIII, PEG-FVIII, or PEG was correlated to the treatment efficacy and safety. Conclusions: Despite the limited availability of direct comparison studies, our analyses indicate that rurioctocog alfa pegol could serve as a safe and effective alternative for bleeding prophylaxis in previously treated hemophilia A patients. Moreover, it appears to have low immunogenicity, which further increases the safety profile of the drug in such clinical conditions.
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Affiliation(s)
| | - Visuddho Visuddho
- Medical Program, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia
| | | | - Henry Sutanto
- Department of Physiology and Pharmacology, SUNY Downstate Health Sciences University, Brooklyn, New York, USA
| | - Bayu Satria Wiratama
- Department of Epidemiology, Biostatistics, and Population Health, Universitas Gadjah Mada, Yogyakarta, Indonesia
- Graduate Institute of Injury Prevention and Control, Taipei Medical University, Taipei, Taiwan
| | - Citrawati Dyah Kencono Wungu
- Department of Physiology and Medical Biochemistry, Universitas Airlangga, Surabaya, Indonesia
- Institute of Tropical Disease, Universitas Airlangga, Surabaya, Indonesia
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20
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Witarto BS, Visuddho V, Witarto AP, Sutanto H, Wiratama BS, Wungu CDK. Efficacy, safety, and immunogenicity of rurioctocog alfa pegol for prophylactic treatment in previously treated patients with severe hemophilia A: a systematic review and meta-analysis of clinical trials. F1000Res 2021; 10:1049. [PMID: 35136579 PMCID: PMC8787562 DOI: 10.12688/f1000research.73884.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/10/2022] [Indexed: 11/30/2022] Open
Abstract
Background: Patients with severe hemophilia often present with painful joint and soft tissue bleeding which may restrict them from their daily activities. The current standard of care still relies on a regular prophylactic factor VIII (FVIII), which has a high daily treatment burden. Recently, rurioctocog alfa pegol, a third-generation recombinant FVIII with a modification in its polyethylene glycol (PEG) component, has been developed. Several trials have studied this synthetic drug as bleeding prophylaxis in severe hemophilia A. This study aims to evaluate the efficacy, safety, and immunogenicity of rurioctocog alfa pegol for previously treated patients with severe hemophilia A. Methods: This study was conducted in conformity with the PRISMA guidelines. Data were retrieved from PubMed, Scopus, Cochrane Library, Wiley Online Library, and CINAHL (via EBSCOhost). Study qualities were assessed using the Methodological Index for Non-Randomized Studies (MINORS) and Modified Jadad scales. Results: Four studies involving 517 previously treated severe hemophilia A patients were included in this study. The pooled mean of total annualized bleeding rate (ABR) and hemostatic efficacy was 2.59 (95% CI = 2.04-3.14) and 92% (95% CI = 85%-97%), respectively. Only 30 (2.3%) non-serious and one (1.4%) serious adverse events were considered related to rurioctocog alfa pegol treatment. At the end of the studies, no development of FVIII inhibitory antibodies was observed. None of the developed binding antibodies to FVIII, PEG-FVIII, or PEG was correlated to the treatment efficacy and safety. Conclusions: Despite the limited availability of direct comparison studies, our analyses indicate that rurioctocog alfa pegol could serve as a safe and effective alternative for bleeding prophylaxis in previously treated hemophilia A patients. Moreover, it appears to have low immunogenicity, which further increases the safety profile of the drug in such clinical conditions.
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Affiliation(s)
| | - Visuddho Visuddho
- Medical Program, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia
| | | | - Henry Sutanto
- Department of Physiology and Pharmacology, SUNY Downstate Health Sciences University, Brooklyn, New York, USA
| | - Bayu Satria Wiratama
- Department of Epidemiology, Biostatistics, and Population Health, Universitas Gadjah Mada, Yogyakarta, Indonesia
- Graduate Institute of Injury Prevention and Control, Taipei Medical University, Taipei, Taiwan
| | - Citrawati Dyah Kencono Wungu
- Department of Physiology and Medical Biochemistry, Universitas Airlangga, Surabaya, Indonesia
- Institute of Tropical Disease, Universitas Airlangga, Surabaya, Indonesia
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21
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Jardim LL, Santana MP, Chaves DG, van der Bom J, Rezende SM. Risk factors for antibody formation in children with hemophilia: methodological aspects and clinical characteristics of the HEMFIL cohort study. Blood Coagul Fibrinolysis 2021; 32:443-450. [PMID: 34127617 DOI: 10.1097/mbc.0000000000001057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Up to 35% of patients with hemophilia A and 5% with hemophilia B develop neutralizing antibodies which can inhibit the therapeutic activity of factor replacement (inhibitors). Despite the clinical relevance of antifactor VIII and IX neutralizing antibodies, there is still a major gap on the knowledge of risk factors for their development. Furthermore, most of the studies on risk factors for inhibitor development come from Caucasian and Afro-American populations. The HEMFIL is a Brazilian prospective cohort study of previously untreated children with hemophilia, which primary aim is to identify new risk factors related to inhibitor development. This manuscript aims at describing the study design and its methodology. After the diagnosis, children are followed up to 75 exposure days or to inhibitor development. Standardized forms and blood samples are collected to describe clinical characteristics and to perform the measurement of immunological and genetic biomarkers at three time points; Inclusion time (T0), at inhibitor development or at 75 exposure days without inhibitors (T1) and after immune tolerance induction for patients in whom it is indicated and performed (T2). Currently, 120 children have been included, of whom, 95 have completed the follow-up. For severe/moderately severe hemophilia A, the cumulative incidence of inhibitors at 75 exposure days was 35% (95% confidence interval, 26-46%). The inclusion of additional patients and a longer follow-up will allow the analysis of risk factors for inhibitor development.
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Affiliation(s)
- Letícia L Jardim
- Faculty of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
- Department of Clinical Epidemiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Marcio P Santana
- Hemocentro de Belo Horizonte, Fundação HEMOMINAS, Belo Horizonte, Brazil
| | - Daniel G Chaves
- Hemocentro de Belo Horizonte, Fundação HEMOMINAS, Belo Horizonte, Brazil
| | - Johanna van der Bom
- Department of Clinical Epidemiology, Leiden University Medical Centre, Leiden, The Netherlands
- Center for Clinical Transfusion Research, Sanquin, Leiden, The Netherlands
| | - Suely M Rezende
- Faculty of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
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22
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Abdi A, Eckhardt CL, van Velzen AS, Vuong C, Coppens M, Castaman G, Hart DP, Hermans C, Laros‐van Gorkom B, Leebeek FWG, Mancuso ME, Mazzucconi MG, McRae S, Oldenburg J, Male C, van der Bom JG, Fijnvandraat K, Gouw SC. Treatment-related risk factors for inhibitor development in non-severe hemophilia A after 50 cumulative exposure days: A case-control study. J Thromb Haemost 2021; 19:2171-2181. [PMID: 34107158 PMCID: PMC8457239 DOI: 10.1111/jth.15419] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 06/01/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND Non-severe hemophilia A patients have a life-long inhibitor risk. Yet, no studies have analyzed risk factors for inhibitor development after 50 factor VIII (FVIII) exposure days (EDs). OBJECTIVES This case-control study investigated treatment-related risk factors for inhibitor development in non-severe hemophilia A and assessed whether these risk factors were different for early versus late inhibitor development. PATIENTS/METHODS Non-severe hemophilia A patients (FVIII:C 2%-40%) were selected from the INSIGHT study. Inhibitor-positive patients were defined as early (<50 EDs) or late (>50EDs) cases and matched to 1-4 inhibitor-negative controls by year of birth, cumulative number of EDs, and center/country. We investigated treatment intensity during the last 10 EDs prior to inhibitor development. Intensive treatment was defined as: surgery, peak treatment (10 consecutive EDs), and high mean FVIII dose (>45 IU/kg/ED). Odds ratios (OR) were calculated by logistic regression. RESULTS Of 2709 patients, we analyzed 63 early and 26 late cases and 195 and 71 respectively matched controls. Peak treatment was associated with early and late inhibitor risk (crude OR 1.8, 95% confidence interval [CI] 1.0-3.4; 4.0, 95%CI 1.1-14.3). This association was slightly less pronounced after adjustment for mean FVIII dose. High mean FVIII dose was also associated with early and late inhibitor risk (crude OR 2.8, 95%CI 1.5-5.1; 4.5, 95%CI 1.2-16.6). Surgery increased inhibitor risk for early cases. This was less pronounced for late cases. CONCLUSIONS Our findings suggest that intensive FVIII treatment remains a risk factor for inhibitor development in non-severe hemophilia A after more than 50 EDs. Therefore, persistent caution is required throughout the life-time treatment course.
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Affiliation(s)
- Amal Abdi
- Pediatric HematologyEmma Children’s HospitalAmsterdam University Medical CenterUniversity of AmsterdamAmsterdamThe Netherlands
| | - Corien L. Eckhardt
- Pediatric HematologyEmma Children’s HospitalAmsterdam University Medical CenterUniversity of AmsterdamAmsterdamThe Netherlands
| | - Alice S. van Velzen
- Pediatric HematologyEmma Children’s HospitalAmsterdam University Medical CenterUniversity of AmsterdamAmsterdamThe Netherlands
| | - Caroline Vuong
- Pediatric HematologyEmma Children’s HospitalAmsterdam University Medical CenterUniversity of AmsterdamAmsterdamThe Netherlands
| | - Michiel Coppens
- Vascular MedicineAmsterdam University Medical CenterUniversity of AmsterdamAmsterdamThe Netherlands
| | - Giancarlo Castaman
- OncologyCenter for Bleeding Disorders and CoagulationCareggi University HospitalFlorenceItaly
| | - Dan P. Hart
- Barts and The London School of Medicine and DentistryThe Royal London Hospital Haemophilia CentreQMULLondonUK
| | - Cedric Hermans
- Haemostasis and Thrombosis UnitCliniques Universitaires Saint‐LucUniversité Catholique de LouvainBrusselsBelgium
| | | | - Frank W. G. Leebeek
- HematologyErasmus MCUniversity Medical Center RotterdamRotterdamThe Netherlands
| | - Maria Elisa Mancuso
- Center for Thrombosis and Hemorrhagic DiseasesHumanitas Clinical and Research CenterRozzanoItaly
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center MilanFondazione IRCCS Ca’ Granda Ospedale Maggiore PoliclinicoMilanItaly
| | | | - Simon McRae
- HematologyLaunceston General HospitalLauncestonTasmaniaAustralia
| | - Johannes Oldenburg
- Institute of Experimental Haematology and Transfusion Medicine BonnUniversity Clinic BonnBonnGermany
| | | | - Johanna G. van der Bom
- Clinical EpidemiologyLeiden University Medical CenterLeidenThe Netherlands
- Center for Clinical Transfusion ResearchSanquin ResearchLeidenThe Netherlands
| | - Karin Fijnvandraat
- Pediatric HematologyEmma Children’s HospitalAmsterdam University Medical CenterUniversity of AmsterdamAmsterdamThe Netherlands
- Molecular Cellular HemostasisSanquin Research and Landsteiner LaboratoryAmsterdamThe Netherlands
| | - Samantha C. Gouw
- Pediatric HematologyEmma Children’s HospitalAmsterdam University Medical CenterUniversity of AmsterdamAmsterdamThe Netherlands
- Clinical EpidemiologyLeiden University Medical CenterLeidenThe Netherlands
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23
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The prospective Hemophilia Inhibitor PUP Study reveals distinct antibody signatures prior to FVIII inhibitor development. Blood Adv 2021; 4:5785-5796. [PMID: 33232473 DOI: 10.1182/bloodadvances.2020002731] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 10/16/2020] [Indexed: 01/30/2023] Open
Abstract
Preventing factor VIII (FVIII) inhibitors following replacement therapies with FVIII products in patients with hemophilia A remains an unmet medical need. Better understanding of the early events of evolving FVIII inhibitors is essential for risk identification and the design of novel strategies to prevent inhibitor development. The Hemophilia Inhibitor Previously Untreated Patients (PUPs) Study (HIPS; www.clinicaltrials.gov #NCT01652027) is the first prospective cohort study to evaluate comprehensive changes in the immune system during the first 50 exposure days (EDs) to FVIII in patients with severe hemophilia A. HIPS participants were enrolled prior to their first exposure to FVIII or blood products ("true PUPs") and were evaluated for different immunological and clinical parameters at specified time points during their first 50 EDs to a single source of recombinant FVIII. Longitudinal antibody data resulting from this study indicate that there are 4 subgroups of patients expressing distinct signatures of FVIII-binding antibodies. Subgroup 1 did not develop any detectable FVIII-binding immunoglobulin G (IgG) antibodies. Subgroup 2 developed nonneutralizing, FVIII-binding IgG1 antibodies, but other FVIII-binding IgG subclasses were not observed. Subgroup 3 developed transient FVIII inhibitors associated with FVIII-binding IgG1 antibodies, similar to subgroup 2. Subgroup 4 developed persistent FVIII inhibitors associated with an initial development of high-affinity, FVIII-binding IgG1 antibodies, followed by IgG3 and IgG4 antibodies. Appearance of FVIII-binding IgG3 was always associated with persistent FVIII inhibitors and the subsequent development of FVIII-binding IgG4. Some of the antibody signatures identified in HIPS could serve as candidates for early biomarkers of FVIII inhibitor development.
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24
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Hassan S, Palla R, Valsecchi C, Garagiola I, El-Beshlawy A, Elalfy M, Ramanan V, Eshghi P, Karimi M, Gouw SC, Mannucci PM, Rosendaal FR, Peyvandi F. Performance of a clinical risk prediction model for inhibitor formation in severe haemophilia A. Haemophilia 2021; 27:e441-e449. [PMID: 33988289 PMCID: PMC8360203 DOI: 10.1111/hae.14325] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 04/06/2021] [Accepted: 04/12/2021] [Indexed: 12/20/2022]
Abstract
Background There is a need to identify patients with haemophilia who have a very low or high risk of developing inhibitors. These patients could be candidates for personalized treatment strategies. Aims The aim of this study was to externally validate a previously published prediction model for inhibitor development and to develop a new prediction model that incorporates novel predictors. Methods The population consisted of 251 previously untreated or minimally treated patients with severe haemophilia A enrolled in the SIPPET study. The outcome was inhibitor formation. Model discrimination was measured using the C‐statistic, and model calibration was assessed with a calibration plot. The new model was internally validated using bootstrap resampling. Results Firstly, the previously published prediction model was validated. It consisted of three variables: family history of inhibitor development, F8 gene mutation and intensity of first treatment with factor VIII (FVIII). The C‐statistic was 0.53 (95% CI: 0.46–0.60), and calibration was limited. Furthermore, a new prediction model was developed that consisted of four predictors: F8 gene mutation, intensity of first treatment with FVIII, the presence of factor VIII non‐neutralizing antibodies before treatment initiation and lastly FVIII product type (recombinant vs. plasma‐derived). The C‐statistic was 0.66 (95 CI: 0.57–0.75), and calibration was moderate. Using a model cut‐off point of 10%, positive‐ and negative predictive values were 0.22 and 0.95, respectively. Conclusion Performance of all prediction models was limited. However, the new model with all predictors may be useful for identifying a small number of patients with a low risk of inhibitor formation.
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Affiliation(s)
- Shermarke Hassan
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Roberta Palla
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Carla Valsecchi
- Angelo Bianchi Bonomi Haemophilia and Thrombosis Centre and Luigi Villa Foundation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Isabella Garagiola
- Angelo Bianchi Bonomi Haemophilia and Thrombosis Centre and Luigi Villa Foundation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Amal El-Beshlawy
- Pediatric Hematology Department, Cairo University Pediatric Hospital, Cairo, Egypt
| | - Mohsen Elalfy
- Department of Pediatrics, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Vijay Ramanan
- Department of Hematology, Jehangir Clinical Development Centre, Jehangir Hospital Premises, Pune, India
| | - Peyman Eshghi
- Congenital Pediatric Hematologic Disorders Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mehran Karimi
- Hematology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Samantha Claudia Gouw
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands.,Pediatric Hematology, Emma Children's Hospital, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Pier Mannuccio Mannucci
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.,Angelo Bianchi Bonomi Haemophilia and Thrombosis Centre and Luigi Villa Foundation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Frits Richard Rosendaal
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Flora Peyvandi
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.,Angelo Bianchi Bonomi Haemophilia and Thrombosis Centre and Luigi Villa Foundation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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25
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Peyvandi F, Miri S, Garagiola I. Immune Responses to Plasma-Derived Versus Recombinant FVIII Products. Front Immunol 2021; 11:591878. [PMID: 33552050 PMCID: PMC7862552 DOI: 10.3389/fimmu.2020.591878] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 12/04/2020] [Indexed: 11/27/2022] Open
Abstract
The most severe side effect of hemophilia treatment is the inhibitor development occurring in 30% of patients, during the earliest stages of treatment with factor (F)VIII concentrates. These catastrophic immune responses rapidly inactivate the infused FVIII, rendering the treatment ineffective. This complication is associated with a substantial morbidity and mortality. The risk factors involved in the onset of the inhibitors are both genetic and environmental. The source of FVIII products, i.e. plasma-derived or recombinant FVIII products, is considered one of the most relevant factors for inhibitor development. Numerous studies in the literature report conflicting data on the different immunogenicity of the products. The SIPPET randomized trial showed an increased in the inhibitor rate in patients using recombinant FVIII products than those receiving plasma-derived products in the first exposure days. The SIPPET randomized trial showed an increase in the inhibitor rate in patients using recombinant FVIII products compared to those treated with plasma-derived products in the first days of exposure. The potential increase in the immunogenicity of recombinant products can be attributed to several factors such as: the different post-translational modification in different cell lines, the presence of protein aggregates, and the role played by the chaperon protein of FVIII, the von Willebrand factor, which modulates the uptake of FVIII by antigen presenting cells (APCs). Furthermore, the presence of non-neutralizing antibodies against FVIII has shown to be in increased inhibitor development as demonstrated in a sub-analysis of the SIPPET study. In addition, the presence of the specific subclasses of the immunoglobulins may also be an important biomarker to indicate whether the inhibitor will evolve into a persistent neutralizing antibody or a transient one that would disappear without any specific treatment. Recently, the availability of novel non-replacement therapies as well as emicizumab, administered by weekly subcutaneous infusion, have significantly changed the quality of life of patients with inhibitors showing a considerable reduction of the annual bleeding rate and in most patients the absence of bleeding. Although, these novel drugs improve patients' quality of life, they do not abolish the need to infuse FVIII during acute bleeding or surgery. Therefore, the issue of immunogenicity against FVIII still remains an important side effect of hemophilia treatment.
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Affiliation(s)
- Flora Peyvandi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Syna Miri
- Department of Biomedical Sciences for Health, Università degli Studi di Milano, Milan, Italy
| | - Isabella Garagiola
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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26
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Peyvandi F, Miri S, Bucciarelli P, Valsecchi C, Schiavone L, Boscarino M, Palla R, Mannucci PM, Rosendaal FR. IgG subclasses as biomarkers for persistence of factor VIII inhibitors in previously untreated patients with severe haemophilia A. Br J Haematol 2020; 192:621-625. [PMID: 33316077 DOI: 10.1111/bjh.17249] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 11/03/2020] [Indexed: 12/20/2022]
Abstract
We investigated longitudinally the behaviour of anti-factor VIII (anti-FVIII) IgG subclasses for 6 months from inhibitor development in 43 patients from the Survey of Inhibitors in Plasma-Products Exposed Toddlers (SIPPET) trial who developed persistent or transient inhibitors. We first analysed 43 patients within 60 days post inhibitor detection. Then, 14 of these 43 patients were studied at five time points over 6 months. Our study showed that during the first 60 days, the risk of inhibitor persistence increased with the concomitant presence of an increasing number of IgG subclasses. Over the 6-month period post inhibitor detection, only the IgG2 subclass could be considered a hallmark of inhibitor persistence.
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Affiliation(s)
- Flora Peyvandi
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.,Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Syna Miri
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| | - Paolo Bucciarelli
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Carla Valsecchi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Lucia Schiavone
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Marco Boscarino
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Roberta Palla
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Pier Mannuccio Mannucci
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Frits Richard Rosendaal
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
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27
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Oudat R, Al-Maharmeh M, Al-Ghrayeb R, Ogeilat T, Mustafa MK. Prevalence of FVIII Inhibitors Among Children with Hemophilia A: Experience at the Jordanian Royal Medical Services. Med Arch 2020; 74:187-190. [PMID: 32801433 PMCID: PMC7406006 DOI: 10.5455/medarh.2020.74.187-190] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Introduction: Replacement therapy is constantly required by Hemophilia A (HA) patients lacking coagulation factor VIII (FVIII). The most serious complication of this treatment is the development of neutralizing antibodies (inhibitors). Aim: The aim of this study is to determine the frequency of FVIII inhibitors among children treated for HA at the Jordanian Royal Medical Services. Methods: A total of 165 diagnosed HA patients receiving on-demand treatment, were tested for FVIII inhibitors between 2003 and 2018. The age range was 6 months to 16 years. Coagulation and inhibitor screening assays were performed, followed by Bethesda assay for inhibitor-positive samples to quantify FVIII inhibitor titers. Results: Out of the 165 patients, 111 had severe hemophilia with FVIII level < 1%, 26 had moderate hemophilia with FVIII levels of 1–5% and 28 had mild hemophilia with FVIII levels of > 5%. Twenty patients had FVIII inhibitors, of whom 18 had high titers, 2 had low titers. The mean inhibitor level in low (titer) responders was 2.40 ± 0.85 BU, as opposed to 116.25 ±169.25 BU in high (titer) responders. In terms of disease severity, 18 of the 20 patients with FVIII inhibitors had severe HA, whereas two had moderate HA. No inhibitors were encountered in the mild HA group. Conclusion: Inhibitors only developed in moderate and severe cases of HA. The severity of the disease and age were the main contributing factors. The association between family history of inhibitors and the incidence of inhibitor formation warrants genetic evaluations to look for relevant mutations.
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Affiliation(s)
- Raida Oudat
- Department of Hematopathology. Princess Iman Research and Laboratory Siences Centre, Royal Medical Services, Amman, Jordan
| | - Muna Al-Maharmeh
- Department of Hematopathology. Princess Iman Research and Laboratory Siences Centre, Royal Medical Services, Amman, Jordan
| | - Rasha Al-Ghrayeb
- Department of Hematopathology. Princess Iman Research and Laboratory Siences Centre, Royal Medical Services, Amman, Jordan
| | - Tunia Ogeilat
- Department of Hematopathology. Princess Iman Research and Laboratory Siences Centre, Royal Medical Services, Amman, Jordan
| | - Maher Kh Mustafa
- Department of Pediatric Hematology and Medical Oncology, Queen Rania Hospital, Amman, Jordan
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28
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Meunier S, de Bourayne M, Hamze M, Azam A, Correia E, Menier C, Maillère B. Specificity of the T Cell Response to Protein Biopharmaceuticals. Front Immunol 2020; 11:1550. [PMID: 32793213 PMCID: PMC7387651 DOI: 10.3389/fimmu.2020.01550] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 06/12/2020] [Indexed: 12/17/2022] Open
Abstract
The anti-drug antibody (ADA) response is an undesired humoral response raised against protein biopharmaceuticals (BPs) which can dramatically disturb their therapeutic properties. One particularity of the ADA response resides in the nature of the immunogens, which are usually human(ized) proteins and are therefore expected to be tolerated. CD4 T cells initiate, maintain and regulate the ADA response and are therefore key players of this immune response. Over the last decade, advances have been made in characterizing the T cell responses developed by patients treated with BPs. Epitope specificity and phenotypes of BP-specific T cells have been reported and highlight the effector and regulatory roles of T cells in the ADA response. BP-specific T cell responses are assessed in healthy subjects to anticipate the immunogenicity of BP prior to their testing in clinical trials. Immunogenicity prediction, also called preclinical immunogenicity assessment, aims at identifying immunogenic BPs and immunogenic BP sequences before any BP injection in humans. All of the approaches that have been developed to date rely on the detection of BP-specific T cells in donors who have never been exposed to BPs. The number of BP-specific T cells circulating in the blood of these donors is therefore limited. T cell assays using cells collected from healthy donors might reveal the weak tolerance induced by BPs, whose endogenous form is expressed at a low level. These BPs have a complete human sequence, but the level of their endogenous form appears insufficient to promote the negative selection of autoreactive T cell clones. Multiple T cell epitopes have also been identified in therapeutic antibodies and some other BPs. The pattern of identified T cell epitopes differs across the antibodies, notwithstanding their humanized, human or chimeric nature. However, in all antibodies, the non-germline amino acid sequences mainly found in the CDRs appear to be the main driver of immunogenicity, provided they can be presented by HLA class II molecules. Considering the fact that the BP field is expanding to include new formats and gene and cell therapies, we face new challenges in understanding and mastering the immunogenicity of new biological products.
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Affiliation(s)
- Sylvain Meunier
- Université Paris-Saclay, CEA, INRAE, Département Médicaments et Technologies pour la Santé, SIMoS, Gif-sur-Yvette, France
| | - Marie de Bourayne
- Université Paris-Saclay, CEA, INRAE, Département Médicaments et Technologies pour la Santé, SIMoS, Gif-sur-Yvette, France
| | - Moustafa Hamze
- Université Paris-Saclay, CEA, INRAE, Département Médicaments et Technologies pour la Santé, SIMoS, Gif-sur-Yvette, France
| | - Aurélien Azam
- Université Paris-Saclay, CEA, INRAE, Département Médicaments et Technologies pour la Santé, SIMoS, Gif-sur-Yvette, France
| | - Evelyne Correia
- Université Paris-Saclay, CEA, INRAE, Département Médicaments et Technologies pour la Santé, SIMoS, Gif-sur-Yvette, France
| | - Catherine Menier
- Université Paris-Saclay, CEA, INRAE, Département Médicaments et Technologies pour la Santé, SIMoS, Gif-sur-Yvette, France
| | - Bernard Maillère
- Université Paris-Saclay, CEA, INRAE, Département Médicaments et Technologies pour la Santé, SIMoS, Gif-sur-Yvette, France
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29
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Abdi A, Bordbar MR, Hassan S, Rosendaal FR, van der Bom JG, Voorberg J, Fijnvandraat K, Gouw SC. Prevalence and Incidence of Non-neutralizing Antibodies in Congenital Hemophilia A- A Systematic Review and Meta-Analysis. Front Immunol 2020; 11:563. [PMID: 32457734 PMCID: PMC7221178 DOI: 10.3389/fimmu.2020.00563] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 03/12/2020] [Indexed: 12/21/2022] Open
Abstract
Objectives: In hemophilia A the presence of non-neutralizing antibodies (NNAs) against Factor VIII (FVIII) may predict the development of neutralizing antibodies (inhibitors) and accelerate the clearance of administrated FVIII concentrates. This systematic review aimed to assess: (1) the prevalence and incidence of NNAs in patients with congenital hemophilia without inhibitors and (2) the association between NNAs and patient and treatment characteristics. Methods: We conducted a search in MEDLINE, Embase, Web of Science and the Cochrane database. We included cross-sectional and longitudinal studies reporting on NNAs in patients with hemophilia A and B, who were inhibitor-negative at the start of the observation period. Data were extracted on: hemophilia type and severity, patient and treatment characteristics, NNA prevalence and incidence, NNA assays and inhibitor development. Two independent reviewers performed study selection, data extraction and risk of bias assessment, using adapted criteria of the Joanna Briggs Institute. Studies were classified as high-quality when ≥5/9 criteria were met. NNA assays were classified as high-quality when both quality criteria were met: (1) use of positive controls and (2) competition with FVIII to establish FVIII-specificity. We reported NNA prevalence and incidence for each study. The pooled NNA prevalence was assessed for well-designed studies in previously treated patients, employing high-quality NNA assays. Results: We included data from 2,723 inhibitor-negative patients with hemophilia A, derived from 28 studies. Most studies were cross-sectional (19/28) and none reported on NNAs in hemophilia B. Study design was of high quality in 16/28 studies and the NNA assay quality was high in 9/28 studies. Various NNA assays were used, predominantly ELISA (18/28) with different cut-off values. We found a large variety in NNA prevalence (Range, 0–100%). The pooled NNA prevalence in high-quality studies was 25% (95% CI, 16–38%). The incidence of new NNA development was reported in one study (0.01 NNA per person-exposure day). Conclusion: This systematic review identified studies that were heterogeneous in study design, patient population and NNA assay type, with NNA prevalence ranging from 0 to 100% in inhibitor-negative patients with hemophilia A. The pooled NNA prevalence was 25% in high-quality studies including only previously treated patients and performing high-quality NNA assays.
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Affiliation(s)
- A Abdi
- Department of Pediatric Hematology, Amsterdam UMC, Emma Children's Hospital, University of Amsterdam, Amsterdam, Netherlands
| | - M R Bordbar
- Hematology Research Center, Nemazee Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - S Hassan
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Netherlands
| | - F R Rosendaal
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Netherlands
| | - J G van der Bom
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Netherlands.,Center for Clinical Transfusion Research, Sanquin Research, Leiden, Netherlands
| | - J Voorberg
- Department of Molecular Cellular Hemostasis, Sanquin Research and Landsteiner Laboratory, Amsterdam, Netherlands.,Department of Experimental Vascular Medicine, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - K Fijnvandraat
- Department of Pediatric Hematology, Amsterdam UMC, Emma Children's Hospital, University of Amsterdam, Amsterdam, Netherlands.,Department of Molecular Cellular Hemostasis, Sanquin Research and Landsteiner Laboratory, Amsterdam, Netherlands
| | - S C Gouw
- Department of Pediatric Hematology, Amsterdam UMC, Emma Children's Hospital, University of Amsterdam, Amsterdam, Netherlands.,Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Netherlands
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30
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Merlin S, Follenzi A. Escape or Fight: Inhibitors in Hemophilia A. Front Immunol 2020; 11:476. [PMID: 32265927 PMCID: PMC7105606 DOI: 10.3389/fimmu.2020.00476] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 03/02/2020] [Indexed: 01/07/2023] Open
Abstract
Replacement therapy with coagulation factor VIII (FVIII) represents the current clinical treatment for patients affected by hemophilia A (HA). This treatment while effective is, however, hampered by the formation of antibodies which inhibit the activity of infused FVIII in up to 30% of treated patients. Immune tolerance induction (ITI) protocols, which envisage frequent infusions of high doses of FVIII to confront this side effect, dramatically increase the already high costs associated to a patient's therapy and are not always effective in all treated patients. Therefore, there are clear unmet needs that must be addressed in order to improve the outcome of these treatments for HA patients. Taking advantage of preclinical mouse models of hemophilia, several strategies have been proposed in recent years to prevent inhibitor formation and eradicate the pre-existing immunity to FVIII inhibitor positive patients. Herein, we will review some of the most promising strategies developed to avoid and eradicate inhibitors, including the use of immunomodulatory drugs or molecules, oral or transplacental delivery as well as cell and gene therapy approaches. The goal is to improve and potentiate the current ITI protocols and eventually make them obsolete.
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Affiliation(s)
- Simone Merlin
- Laboratory of Histology, Department of Health Sciences, Università degli Studi del Piemonte Orientale "A. Avogadro", Novara, Italy.,Interdisciplinary Research Center of Autoimmune Diseases (IRCAD), Novara, Italy
| | - Antonia Follenzi
- Laboratory of Histology, Department of Health Sciences, Università degli Studi del Piemonte Orientale "A. Avogadro", Novara, Italy.,Interdisciplinary Research Center of Autoimmune Diseases (IRCAD), Novara, Italy
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Cormier M, Batty P, Tarrant J, Lillicrap D. Advances in knowledge of inhibitor formation in severe haemophilia A. Br J Haematol 2020; 189:39-53. [DOI: 10.1111/bjh.16377] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Matthew Cormier
- Department of Pathology and Molecular Medicine Richardson Laboratory Queen’s University Kingston ON Canada
| | - Paul Batty
- Department of Pathology and Molecular Medicine Richardson Laboratory Queen’s University Kingston ON Canada
| | - Julie Tarrant
- Department of Pathology and Molecular Medicine Richardson Laboratory Queen’s University Kingston ON Canada
| | - David Lillicrap
- Department of Pathology and Molecular Medicine Richardson Laboratory Queen’s University Kingston ON Canada
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Evaluation of nonneutralizing antibodies against factor VIII in severe haemophilia A patients from India. Blood Coagul Fibrinolysis 2019; 30:337-340. [DOI: 10.1097/mbc.0000000000000843] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Nakar C, Shapiro A. Hemophilia A with inhibitor: Immune tolerance induction (ITI) in the mirror of time. Transfus Apher Sci 2019; 58:578-589. [PMID: 31447396 DOI: 10.1016/j.transci.2019.08.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Inhibitor (neutralizing antibodies) development remains the most significant complication in patients with severe congenital hemophilia A receiving exogenous factor VIII (FVIII). Although our understanding of the pathophysiology of inhibitor development has advanced, the knowledge gained has not yet translated into a robust decline in incidence, with the overall risk remaining at ∼30%. Immune Tolerance Induction (ITI) is the only current method to successfully eradicate an inhibitor and achieve long-term tolerance. Although current practice utilizes a wide variety of ITI regimens, identification of an optimal regimen has not emerged. Over the last decade, the number of replacement products available in hemophilia has greatly expanded. The cumulative evidence with each product for use in ITI is often lacking. Most recently emicizumab, a humanized monoclonal bi-specific antibody that substitutes for the scaffolding effect of FVIIIa was approved; this agent prevents bleeding in both inhibitor and non-inhibitor patients. The use of emicizumab will bring about a new era in care that will require clinicians to challenge current practice paradigms including use and administration of ITI. This review will summarize the main clinical ITI data and practices for patients with severe congenital hemophilia A with inhibitors (CHAwI) over the last four decades and will highlight current studies in the field, with attention to open questions.
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Affiliation(s)
- Charles Nakar
- The Indiana Hemophilia and Thrombosis Center (IHTC), Indianapolis, IN, USA.
| | - Amy Shapiro
- The Indiana Hemophilia and Thrombosis Center (IHTC), Indianapolis, IN, USA
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van der Veen SJ, van Kuilenburg ABP, Hollak CEM, Kaijen PHP, Voorberg J, Langeveld M. Antibodies against recombinant alpha-galactosidase A in Fabry disease: Subclass analysis and impact on response to treatment. Mol Genet Metab 2019; 126:162-168. [PMID: 30473480 DOI: 10.1016/j.ymgme.2018.11.008] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Revised: 10/16/2018] [Accepted: 11/12/2018] [Indexed: 12/24/2022]
Abstract
BACKGROUND Treatment of Fabry disease (FD) with recombinant alpha-galactosidase A (r-αGAL A) is complicated by the formation of anti-drug antibodies in the majority of male patients with the classical disease phenotype. Detailed information regarding antibody subtypes, onset and persistence of antibody development and their effect on treatment efficacy is sparse. METHODS A retrospective study was carried out in 39 male patients with classical FD, treated with either agalsidase-alfa or agalsidase-beta (mean follow up of 10 years). With six to twelve months intervals plasma-induced in vitro inhibition of enzyme activity, lysoglobotriaosylsphingosine (lysoGb3) levels and renal function were assessed. In a subset of 12 patients, additionally anti- r-αGAL A IgM, IgA and IgG1, 2, 3 and 4 levels were analyzed. RESULTS In 23 out of 39 patients, plasma-induced in vitro inhibition of r-αGAL A activity was observed (inhibition-positive). The inhibition titer was strongly negatively correlated to the decrease in lysoGb3: agalsidase-alfa (FElog10(inhibition) = -10.3, P ≤.001), agalsidase-beta (FElog10(inhibition) = -4.7, P ≤.001). Inhibition-positive patients had an accelerated decline in renal function (FE = 1.21, p = .042). During treatment IgG1 anti-r-αGAL A levels increased only in inhibition-positive patients (p = .0045). IgG4 anti-r-αGAL A antibodies developed in 7 out of 9 inhibition-positive patients. Other antibody subclasses were either not present or too low to quantify. CONCLUSION Development of inhibiting antibodies against r-αGAL A negatively affects the biochemical response to ERT and resulted in an accelerated decline in renal function. The presence of IgG1 and IgG4 anti-r-αGAL A antibodies is associated with in vitro αGAL A activity inhibition.
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Affiliation(s)
- S J van der Veen
- Amsterdam UMC, University of Amsterdam, Department of Endocrinology and Metabolism, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
| | - A B P van Kuilenburg
- Amsterdam UMC, University of Amsterdam, Department of Clinical Chemistry, Gastroenterology & Metabolism Laboratory, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
| | - C E M Hollak
- Amsterdam UMC, University of Amsterdam, Department of Endocrinology and Metabolism, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
| | - P H P Kaijen
- Department of Plasma Proteins, Sanquin-AMC Landsteiner Laboratory, Sanquin Research, Plesmanlaan 125, 1066 CX Amsterdam, the Netherlands
| | - J Voorberg
- Department of Plasma Proteins, Sanquin-AMC Landsteiner Laboratory, Sanquin Research, Plesmanlaan 125, 1066 CX Amsterdam, the Netherlands; Amsterdam UMC, University of Amsterdam, Department of Vascular Medicine, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
| | - M Langeveld
- Amsterdam UMC, University of Amsterdam, Department of Endocrinology and Metabolism, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands.
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Coppo P, Cuker A, George JN. Thrombotic thrombocytopenic purpura: Toward targeted therapy and precision medicine. Res Pract Thromb Haemost 2019; 3:26-37. [PMID: 30656273 PMCID: PMC6332733 DOI: 10.1002/rth2.12160] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Accepted: 09/18/2018] [Indexed: 12/21/2022] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a thrombotic microangiopathy characterized by severe congenital or immune-mediated deficiency in ADAMTS13, the enzyme that cleaves von Willebrand factor multimers. This rare condition leads invariably and rapidly to a fatal outcome in the absence of treatment, and therefore raises multiple diagnostic and therapeutic challenges. The novel concepts and mechanisms identified in the laboratory for this disease have been rapidly and successfully translated into the clinic for the benefit of patients, making TTP an archetypal disease that has benefited from targeted therapies. After decades of empirical treatment with plasma exchange, identification of ADAMTS13 as the key enzyme involved in TTP pathophysiology provided an explanation for the remarkable efficacy of plasma administration, in which the missing enzyme is replenished, and paved the way for development of a recombinant form of the enzyme. Similarly, the demonstration of a major role of anti-ADAMTS13 antibodies through models of passive transfer of autoimmunity spurred development of immunomodulatory strategies based on B-cell depletion. More recently, an inhibitor of the platelet-von Willebrand factor interaction demonstrated efficacy in large clinical trials through prevention of formation of further microthrombi and protection of organs from ischemia. These translational breakthroughs in TTP are described in our review.
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Affiliation(s)
- Paul Coppo
- Centre de Référence des Microangiopathies ThrombotiquesParisFrance
- Service d'HématologieHôpital Saint‐AntoineAP‐HPParisFrance
- Sorbonne UniversitésParisFrance
| | - Adam Cuker
- Departments of Medicine and Pathology & Laboratory MedicinePerelman School of Medicine, University of PennsylvaniaPhiladelphiaPennsylvania
| | - James N. George
- Departments of Epidemiology & Biostatistics, MedicineUniversity of Oklahoma Health Sciences CenterOklahoma CityOklahoma
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36
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Batsuli G, Ito J, Mercer R, Baldwin WH, Cox C, Parker ET, Healey JF, Lollar P, Meeks SL. Anti-C1 domain antibodies that accelerate factor VIII clearance contribute to antibody pathogenicity in a murine hemophilia A model. J Thromb Haemost 2018; 16:1779-1788. [PMID: 29981270 PMCID: PMC6123829 DOI: 10.1111/jth.14233] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Indexed: 01/06/2023]
Abstract
Essentials Inhibitor formation remains a challenging complication of hemophilia A care. The Bethesda assay is the primary method used for determining bleeding risk and management. Antibodies that block factor VIII binding to von Willebrand factor can increase FVIII clearance. Antibodies that increase clearance contribute to antibody pathogenicity. SUMMARY Background The development of neutralizing anti-factor VIII (FVIII) antibodies remains a challenging complication of modern hemophilia A care. In vitro assays are the primary method used for quantifying inhibitor titers, predicting bleeding risk, and determining bleeding management. However, other mechanisms of inhibition are not accounted for in these assays, which may result in discrepancies between the inhibitor titer and clinical bleeding symptoms. Objectives To evaluate FVIII clearance in vivo as a potential mechanism for antibody pathogenicity and to determine whether increased FVIII dosing regimens correct the associated bleeding phenotype. Methods FVIII-/- or FVIII-/- /von Willebrand factor (VWF)-/- mice were infused with anti-FVIII mAbs directed against the FVIII C1, C2 or A2 domains, followed by infusion of FVIII. Blood loss via the tail snip bleeding model, FVIII activity and FVIII antigen levels were subsequently measured. Results Pathogenic anti-C1 mAbs that compete with VWF for FVIII binding increased the clearance of FVIII-mAb complexes in FVIII-/- mice but not in FVIII-/- /VWF-/- mice. Additionally, pathogenic anti-C2 mAbs that inhibit FVIII binding to VWF increased FVIII clearance in FVIII-/- mice. Anti-C1, anti-C2 and anti-A2 mAbs that do not inhibit VWF binding did not accelerate FVIII clearance. Infusion of increased doses of FVIII in the presence of anti-C1 mAbs partially corrected blood loss in FVIII-/- mice. Conclusions A subset of antibodies that inhibit VWF binding to FVIII increase the clearance of FVIII-mAb complexes, which contributes to antibody pathogenicity. This may explain differences in the bleeding phenotype observed despite factor replacement in some patients with hemophilia A and low-titer inhibitors.
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MESH Headings
- Animals
- Antibodies, Heterophile/administration & dosage
- Antibodies, Heterophile/immunology
- Antibodies, Heterophile/toxicity
- Antibodies, Monoclonal/administration & dosage
- Antibodies, Monoclonal/immunology
- Antibodies, Monoclonal/toxicity
- Antibodies, Neutralizing/administration & dosage
- Antibodies, Neutralizing/immunology
- Antibodies, Neutralizing/toxicity
- Epitopes/immunology
- Factor VIII/antagonists & inhibitors
- Factor VIII/immunology
- Factor VIII/pharmacokinetics
- Hemophilia A/drug therapy
- Hemophilia A/immunology
- Hemorrhage/etiology
- Inhibitory Concentration 50
- Mice
- Mice, 129 Strain
- Mice, Inbred C57BL
- Models, Animal
- Phenotype
- Protein Domains
- von Willebrand Diseases
- von Willebrand Factor/metabolism
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Affiliation(s)
- G Batsuli
- Department of Pediatrics, Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta, Emory University, Atlanta, GA, USA
| | - J Ito
- Department of Pediatrics, Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta, Emory University, Atlanta, GA, USA
| | - R Mercer
- Department of Pediatrics, Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta, Emory University, Atlanta, GA, USA
| | - W H Baldwin
- Department of Pediatrics, Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta, Emory University, Atlanta, GA, USA
| | - C Cox
- Department of Pediatrics, Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta, Emory University, Atlanta, GA, USA
| | - E T Parker
- Department of Pediatrics, Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta, Emory University, Atlanta, GA, USA
| | - J F Healey
- Department of Pediatrics, Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta, Emory University, Atlanta, GA, USA
| | - P Lollar
- Department of Pediatrics, Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta, Emory University, Atlanta, GA, USA
| | - S L Meeks
- Department of Pediatrics, Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta, Emory University, Atlanta, GA, USA
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Fallon PG, Lavin M, O'Donnell JS. SIPPET: insights into factor VIII immunogenicity. J Thromb Haemost 2018; 16:36-38. [PMID: 29080389 DOI: 10.1111/jth.13886] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Indexed: 11/27/2022]
Affiliation(s)
- P G Fallon
- School of Medicine, Trinity Translational Medicine Institute, St James's Hospital, Trinity College Dublin, Dublin, Ireland
| | - M Lavin
- Irish Centre for Vascular Biology, Royal College of Surgeons in Ireland, Dublin, Ireland
- National Coagulation Centre, St James's Hospital, Dublin, Ireland
| | - J S O'Donnell
- Irish Centre for Vascular Biology, Royal College of Surgeons in Ireland, Dublin, Ireland
- National Coagulation Centre, St James's Hospital, Dublin, Ireland
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Raso S, Hermans C. Lonoctocog alfa (rVIII-SingleChain) for the treatment of haemophilia A. Expert Opin Biol Ther 2017; 18:87-94. [PMID: 29256333 DOI: 10.1080/14712598.2018.1416088] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION The administration of factor VIII (FVIII) concentrates on-demand or on long-term prophylaxis is the effective and safe standard of care of patients with hemophilia A (HA). Development of neutralizing antibodies against exogenous FVIII and the short half-life of the current available products remain major challenges. There is currently a great interest towards newer FVIII products with the goal of reducing the inhibitor risk and increasing the half-life. Area covered: In this review, the authors describe the efficacy and safety of rVIII-SingleChain (Lonoctocog alfa), the first and only single chain recombinant FVIII (rFVIII) molecule developed for the prevention and treatment of bleeding episodes in HA patients. The pre-clinical and clinical studies of rVIII-SingleChain as well as the results of the AFFINITY trial program in previously treated patients both adults and pediatric are presented and discussed. Expert opinion: The results from PTP studies document the efficacy and safety profile of the rVIII-SingleChain. However, even if rFVIII-SingleChain presents advantageous pharmacokinetic features compared to conventional rFVIII, it should not be considered as an EHL-FVIII while its immunogenicity is currently being studied in PUPs. The slightly better PK profile of rFVIII-SingleChain could however allow a small number of selected patients to be treated with a less intensive regimen.
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Affiliation(s)
- Simona Raso
- a Haemostasis and Thrombosis Unit, Division of Haematology , Cliniques Universitaires Saint-Luc , Brussels , Belgium.,b Division of Haematology, Biomedical Department of Internal Medicine and Specialties (DiBiMIS) , Paolo Giaccone Hospital, University of Palermo , Palermo , Italy
| | - Cedric Hermans
- a Haemostasis and Thrombosis Unit, Division of Haematology , Cliniques Universitaires Saint-Luc , Brussels , Belgium
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CD4 T cells specific for factor VIII are present at high frequency in healthy donors and comprise naïve and memory cells. Blood Adv 2017; 1:1842-1847. [PMID: 29296830 DOI: 10.1182/bloodadvances.2017008706] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Accepted: 08/14/2017] [Indexed: 12/20/2022] Open
Abstract
We investigated the frequency and subset origin of circulating factor VIII (FVIII)-specific CD4 T cells in healthy donors. Total CD4 T cells and purified CD4 T-cell subsets were stimulated with FVIII-loaded autologous dendritic cells and challenged for specificity in interferon-γ enzyme-linked immunospots. The number of specific T-cell lines allowed estimation of the frequency of T cells circulating in the blood of the donors. All the 16 healthy donors generated strong in vitro T-cell responses, leading to the generation of 154 FVIII-specific T-cell lines. The mean frequency of FVIII-specific CD4 T cells in healthy donors was similar to that of T cells specific for foreign antigens and greater than that of T cells specific for known immunogenic therapeutic proteins. Normal levels of endogenous FVIII in healthy donors therefore do not prevent a significant escape of FVIII-specific CD4 T cells from negative thymic selection. FVIII-specific T cells mainly originated from both the naïve and central memory cell subsets, but their frequencies remained low as compared with those of cells specific for foreign antigens in immunized donors. The observation of a spontaneous generation of FVIII-specific memory T cells without a global expansion suggests peculiar peripheral tolerance mechanisms to FVIII in healthy donors.
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40
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Moving from parked to neutral(izing). Blood 2017; 129:1233-1234. [DOI: 10.1182/blood-2017-01-760538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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