1
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Ljung R. Prophylactic Treatment of Children with Hemophilia in Sweden. Semin Thromb Hemost 2024; 50:714-719. [PMID: 38499191 DOI: 10.1055/s-0044-1782518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/20/2024]
Abstract
Hemophilia A/B are caused by deficiency or lack of coagulation factors VIII (FVIII) or factor IX (FIX), respectively, in plasma. A person with hemophilia develops bleeding in the joints and muscles at an early age, which, if left untreated, leads to early arthropathy. Preventive treatment can be achieved by regular (prophylactic) administration of FVIII/FIX. In 1958, this was implemented on a small scale in Sweden with FVIII in patients with severe hemophilia A, and in those with hemophilia B in 1972 when FIX became available. However, there were problems with human immunodeficiency virus and hepatitis infection from contaminated blood products. In the 1990s, recombinant FVIII and FIX concentrates were introduced. The major remaining problems then were the development of inhibitors, and the need for a venous route for the injections in very young children. High-titer inhibitors were treated by immune tolerance induction according to a modified model of the original Bonn high-dose protocol. A central venous line, i.e., Port-A-Cath, has enabled early prophylaxis in many children with poor venous access and has enabled the early start of home treatment with adequate injection frequency. Scoring systems for X-rays, magnetic resonance imaging, and function of joints were developed early in Sweden and have been widely disseminated worldwide, partly with modifications. Extended half-life products with half-life increased three to five times have been developed, which can provide superior bleed protection when dosed once-weekly and can maintain therapeutic trough levels when administered less frequently. The ultimate prophylaxis therapy in the future may be gene therapy.
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Affiliation(s)
- Rolf Ljung
- Department of Clinical Sciences Lund - Pediatrics, Lund University, Lund, Sweden
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2
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Ljung R, Matino D, Shapiro AD. Recombinant factor IX Fc for the treatment of hemophilia B. Eur J Haematol 2024; 112:678-691. [PMID: 38369860 DOI: 10.1111/ejh.14176] [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: 10/17/2023] [Revised: 01/11/2024] [Accepted: 01/12/2024] [Indexed: 02/20/2024]
Abstract
Current hemophilia B treatment guidelines recommend routine prophylaxis with factor IX (FIX) replacement products, tailored to maintain plasma activity at levels that will prevent bleeds. However, plasma FIX activity may not be the primary determinant or best indicator of hemostatic efficacy due to its extravascular distribution. FIX replacement therapy has evolved to include extended half-life (EHL) products that provide effective bleed protection when administered at intervals of 7 days or longer. rFIXFc is a recombinant fusion protein with an extended circulation time. rFIXFc has a biodistribution profile consistent with distribution into extravascular space, where it may support hemostasis at sites of vessel injury independent of circulating plasma activity levels. The safety and efficacy of rFIXFc prophylaxis is well established in adults, adolescents and children including previously untreated patients with hemophilia B, with substantial evidence from clinical trials and real-world clinical practice. This review describes the pharmacokinetic characteristics of rFIXFc, summarizes available safety and efficacy data, and evaluates the use of rFIXFc in special populations. Current hemophilia B treatment challenges, including target FIX plasma levels, perioperative use, and management of patients with comorbidities, are discussed together with the potential role of EHL products in the future treatment landscape of hemophilia B.
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Affiliation(s)
- Rolf Ljung
- Department of Clinical Sciences-Pediatrics, Lund University, Lund, Sweden
| | - Davide Matino
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Amy D Shapiro
- Indiana Hemophilia & Thrombosis Center, Inc, Indianapolis, Indiana, USA
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3
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Leuci A, Enjolras N, Marano M, Daniel M, Brevet M, Connes P, Dargaud Y. Extravascular factor IX pool fed by prophylaxis is a true hemostatic barrier against bleeding. J Thromb Haemost 2024; 22:700-708. [PMID: 38072379 DOI: 10.1016/j.jtha.2023.11.023] [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: 07/25/2023] [Revised: 11/06/2023] [Accepted: 11/29/2023] [Indexed: 01/01/2024]
Abstract
BACKGROUND Factor (F)IX can bind to type IV collagen in the endothelial basement membrane and diffuse into extravascular spaces. Previous studies in rodents have reported a large biodistribution of FIX. OBJECTIVES The aim of the study was to evaluate the potential hemostatic activity of extravascular FIX and its role in protecting against joint bleeds. METHODS The capacity of 4 different FIX molecules (plasma-derived and recombinant) to bind type I and type IV collagen was studied here. FIX molecules were also administered intravenously at doses of 50 to 3000 IU/kg in FIX knockout mice. RESULTS A specific FIX signal was detected in immunohistochemistry in the liver as well as in muscles and knee joints with recombinant FIX molecules injected at 1000 and 3000 IU/kg but not at the usual clinical doses of 50 to 100 IU/kg, while plasma-derived FIX generated a FIX signal at all doses, including 50 IU/kg. Such a signal was also detected after five 100 IU/kg daily infusions of recombinant FIX, suggesting that FIX can accumulate in the extravascular space during prophylaxis. The extravascular procoagulant activity of FIX, assessed in saphenous vein bleeding assays, was significantly higher in hemophilia B mice after these 5 days of prophylaxis compared to a single infusion of 100 IU/kg of FIX and assessment of FIX activity 7 days later. CONCLUSION Taken together, these results show that in individuals with severe hemophilia B receiving regular prophylaxis with FIX, extravascular accumulation of FIX over time may have a significant impact on the coagulation capacity and protection toward bleeding.
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Affiliation(s)
- Alexandre Leuci
- UR4609 Hémostase et Thrombose, Université Claude Bernard Lyon 1, Lyon, France
| | - Nathalie Enjolras
- UR4609 Hémostase et Thrombose, Université Claude Bernard Lyon 1, Lyon, France
| | - Muriel Marano
- UR4609 Hémostase et Thrombose, Université Claude Bernard Lyon 1, Lyon, France
| | - Melanie Daniel
- UR4609 Hémostase et Thrombose, Université Claude Bernard Lyon 1, Lyon, France
| | | | - Philippe Connes
- Laboratoire interuniversitaire de Biologie de la Motricité EA7424, Team Vascular Biology and Red Blood Cell, Université Claude Bernard Lyon 1, Université de Lyon, Lyon, France
| | - Yesim Dargaud
- UR4609 Hémostase et Thrombose, Université Claude Bernard Lyon 1, Lyon, France; Centre de Référence de l'Hémophilie, Unité d'Hémostase Clinique, Hospices Civils de Lyon, Lyon, France.
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4
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van der Flier A, Hong V, Liu Z, Piepenhagen P, Ulinski G, Dumont JA, Orcutt KD, Goel A, Peters R, Salas J. Biodistribution of recombinant factor IX, extended half-life recombinant factor IX Fc fusion protein, and glycoPEGylated recombinant factor IX in hemophilia B mice. Blood Coagul Fibrinolysis 2023; 34:353-363. [PMID: 37577860 PMCID: PMC10481914 DOI: 10.1097/mbc.0000000000001230] [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: 04/15/2022] [Revised: 03/01/2023] [Accepted: 04/26/2023] [Indexed: 08/15/2023]
Abstract
Extended half-life recombinant FIX (rFIX) molecules have been generated to reduce the dosing burden and increase the protection of patients with hemophilia B. Clinical pharmacology studies with recombinant factor IX Fc fusion protein (rFIXFc) report a similar initial peak plasma recovery to that of rFIX, but with a larger volume of distribution. Although the pegylation of N9-GP results in a larger plasma recovery, there is a smaller volume of distribution, suggesting less extravasation of the latter drug. In this study, we set out to compare the biodistribution and tissue localization of rFIX, rFIXFc, and glycoPEGylated rFIX in a hemophilia B mouse model. Radiolabeled rFIX, rFIXFc, and rFIX-GP were employed in in vivo single-photon emission computed tomography imaging (SPECT/CT), microautoradiography (MARG), and histology to assess the distribution of FIX reagents over time. Immediately following injection, vascularized tissues demonstrated intense signal irrespective of FIX reagent. rFIX and rFIXFc were retained in joint and muscle areas through 5 half-lives, unlike rFIX-GP (assessed by SPECT). MARG and immunohistochemistry showed FIX agents localized at blood vessels among tissues, including liver, spleen, and kidney. Microautoradiographs, as well as fluorescent-labeled images of knee joint areas, demonstrated retention over time of FIX signal at the trabecular area of bone. Data indicate that rFIXFc is similar to rFIX in that it distributes outside the plasma compartment and is retained in certain tissues over time, while also retained at higher plasma levels. Overall, data suggest that Fc fusion does not impede the extravascular distribution of FIX.
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Affiliation(s)
| | | | | | | | | | | | - Kelly D. Orcutt
- Invicro LLC, A Konica Minolta Company, Boston, Massachusetts, USA
| | - Apollina Goel
- Invicro LLC, A Konica Minolta Company, Boston, Massachusetts, USA
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5
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Machado SK, Peil H, Kraushaar T, Claar P, Mischnik M, Lind H, Herzog E, Bacher M, Nolte MW, Bielohuby M, Pestel S, Ponnuswamy P. Modulation of Extravascular Binding of Recombinant Factor IX Impacts the Duration of Efficacy in Mouse Models. Thromb Haemost 2023; 123:751-762. [PMID: 37164314 PMCID: PMC10365885 DOI: 10.1055/a-2090-9739] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 01/11/2023] [Indexed: 05/12/2023]
Abstract
BACKGROUND There is an emerging concept that in addition to circulating coagulation factor IX (FIX), extravascular FIX contributes to hemostasis. OBJECTIVE Our objective was to evaluate the efficacy of extravascular FIX using animal models of tail clip bleeding and ferric chloride-induced thrombosis. METHODS Mutant rFIX proteins with described enhanced (rFIXK5R) or reduced (rFIXK5A) binding to extracellular matrix were generated and characterized using in vitro aPTT, one-stage clotting, and modified FX assays. Using hemophilia B mice, pharmacokinetic (PK) parameters and in vivo efficacy of these proteins were compared against rFIX wild-type protein (rFIXWT) in a tail clip bleeding and FeCl3-induced thrombosis model. Respective tissue disposition of FIX was evaluated using immunofluorescence. RESULTS In vitro characterization demonstrated comparable clotting activity of rFIX proteins. The PK profile showed that rFIXK5A displayed the highest plasma exposure compared to rFIXWT and rFIXK5R. Immunofluorescence evaluation of liver tissue showed that rFIXK5R was detectable up to 24 hours, whereas rFIXWT and rFIXK5A were detectable only up to 15 minutes. In the tail clip bleeding model, rFIXK5R displayed significant hemostatic protection against bleeding incidence for up to 72 hours postintravenous administration of 50 IU/kg, whereas the efficacy of rFIXK5A was already reduced at 24 hours. Similarly, in the mesenteric artery thrombus model, rFIXK5R and rFIXWT demonstrated prolonged efficacy compared to rFIXK5A. CONCLUSION Using two different in vivo models of hemostasis and thrombosis, we demonstrate that mutated rFIX protein with enhanced binding (rFIXK5R) to extravascular space confers prolonged hemostatic efficacy in vivo despite lower plasma exposure, whereas rFIXK5A rapidly lost its efficacy despite higher plasma exposure.
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Affiliation(s)
| | | | | | | | | | - Holger Lind
- CSL Behring Innovation GmbH, Marburg, Germany
| | - Eva Herzog
- CSL Behring LLC, King of Prussia, Pennsylvania, United States
| | - Michael Bacher
- Institute of Immunology—Philipps University Marburg, Marburg, Germany
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6
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Morfini M, Agnelli Giacchiello J, Baldacci E, Carulli C, Castaman G, Giuffrida AC, Malcangi G, Rocino A, Siragusa S, Zanon E. Managing Relevant Clinical Conditions of Hemophilia A/B Patients. Hematol Rep 2023; 15:384-397. [PMID: 37367088 PMCID: PMC10298198 DOI: 10.3390/hematolrep15020039] [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: 02/09/2023] [Revised: 04/21/2023] [Accepted: 05/31/2023] [Indexed: 06/28/2023] Open
Abstract
The Medical Directors of nine Italian Hemophilia Centers reviewed and discussed the key issues concerning the replacement therapy of hemophilia patients during a one-day consensus conference held in Rome one year ago. Particular attention was paid to the replacement therapy needed for surgery using continuous infusion (CI) versus bolus injection (BI) of standard and extended half-life Factor VIII (FVIII) concentrates in severe hemophilia A patients. Among the side effects, the risk of development of neutralizing antibodies (inhibitors) and thromboembolic complications was addressed. The specific needs of mild hemophilia A patients were described, as well as the usage of bypassing agents to treat patients with high-responding inhibitors. Young hemophilia A patients may take significant advantages from primary prophylaxis three times or twice weekly, even with standard half-life (SHL) rFVIII concentrates. Patients affected by severe hemophilia B probably have a less severe clinical phenotype than severe hemophilia A patients, and in about 30% of cases may undergo weekly prophylaxis with an rFIX SHL concentrate. The prevalence of missense mutations in 55% of severe hemophilia B patients allows the synthesis of a partially changed FIX molecule that can play some hemostatic role at the level of endothelial cells or the subendothelial matrix. The flow back of infused rFIX from the extravascular to the plasma compartment allows a very long half-life of about 30 h in some hemophilia B patients. Once weekly, prophylaxis can assure a superior quality of life in a large severe or moderate hemophilia B population. According to the Italian registry of surgery, hemophilia B patients undergo joint replacement by arthroplasty less frequently than hemophilia A patients. Finally, the relationships between FVIII/IX genotypes and the pharmacokinetics of clotting factor concentrates have been investigated.
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Affiliation(s)
- Massimo Morfini
- Italian Association of Haemophilia Centers (AICE), 21121 Milan, Italy
| | - Jacopo Agnelli Giacchiello
- Hemostasis and Thrombosis Center, Azienda Ospedaliera SS Antonio e Biagio e Cesare Arrigo, 15121 Alessandria, Italy
| | - Erminia Baldacci
- Haematology, “Umberto I” Policlinico, Department of Translational and Precision Medicine, Sapienza University of Rome, 00118 Rome, Italy
| | - Christian Carulli
- Department of Orthopaedic Surgery, Orthopaedic Clinic, University of Florence, 50121 Florence, Italy
| | - Giancarlo Castaman
- Department of Oncology, Center for Bleeding Disorders and Coagulation, Careggi University Hospital, 50121 Florence, Italy
| | | | - Giuseppe Malcangi
- UOSD Centro Emofilia e Trombosi, Azienda Ospedaliero Universitaria Policlinico di Bari, 70121 Bari, Italy
| | - Angiola Rocino
- Haemophilia and Thrombosis Centre, Haematology, S.M. di Loreto Nuovo Hospital, 80121 Naples, Italy
| | - Sergio Siragusa
- Department PROMISE, University of Palermo, 90121 Palermo, Italy
| | - Ezio Zanon
- Haemophilia Centre, General Medicine, Padua University Hospital, 35121 Padua, Italy
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7
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Sidonio RF, Casiano S, Falk A, Altincatal A, Katragadda S, Santagostino E, Windyga J. Pharmacokinetic parameters of recombinant factor IX Fc fusion protein are not influenced by factor IX antigen levels in subjects from the Phase 3 B-LONG trial. Haemophilia 2023; 29:404-407. [PMID: 36548200 DOI: 10.1111/hae.14727] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 11/11/2022] [Accepted: 12/04/2022] [Indexed: 12/24/2022]
Affiliation(s)
- Robert F Sidonio
- Aflac Cancer and Blood Disorders, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
| | | | - Aletta Falk
- Swedish Orphan Biovitrum AB, Stockholm, Sweden
| | | | | | | | - Jerzy Windyga
- Department of Hemostasis Disorders and Internal Medicine, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
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8
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Hart DP, Matino D, Astermark J, Dolan G, d’Oiron R, Hermans C, Jiménez-Yuste V, Linares A, Matsushita T, McRae S, Ozelo MC, Platton S, Stafford D, Sidonio RF, Tiede A. International consensus recommendations on the management of people with haemophilia B. Ther Adv Hematol 2022; 13:20406207221085202. [PMID: 35392437 PMCID: PMC8980430 DOI: 10.1177/20406207221085202] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 02/17/2022] [Indexed: 01/19/2023] Open
Abstract
Haemophilia B is a rare X-linked genetic deficiency of coagulation factor IX (FIX) that, if untreated, can cause recurrent and disabling bleeding, potentially leading to severe arthropathy and/or life-threatening haemorrhage. Recent decades have brought significant improvements in haemophilia B management, including the advent of recombinant FIX and extended half-life FIX. This therapeutic landscape continues to evolve with several non-factor replacement therapies and gene therapies under investigation. Given the rarity of haemophilia B, the evidence base and clinical experience on which to establish clinical guidelines are relatively sparse and are further challenged by features that are distinct from haemophilia A, precluding extrapolation of existing haemophilia A guidelines. Due to the paucity of formal haemophilia B-specific clinical guidance, an international Author Group was convened to develop a clinical practice framework. The group comprised 15 haematology specialists from Europe, Australia, Japan, Latin America and North America, covering adult and paediatric haematology, laboratory medicine and biomedical science. A hybrid approach combining a systematic review of haemophilia B literature with discussion of clinical experience utilized a modified Delphi format to develop a comprehensive set of clinical recommendations. This approach resulted in 29 recommendations for the clinical management of haemophilia B across five topics, including product treatment choice, therapeutic agent laboratory monitoring, pharmacokinetics considerations, inhibitor management and preparing for gene therapy. It is anticipated that this clinical practice framework will complement existing guidelines in the management of people with haemophilia B in routine clinical practice and could be adapted and applied across different regions and countries.
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Affiliation(s)
- Daniel P. Hart
- The Royal London Hospital Haemophilia Centre, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, Whitechapel Road, London E1 2AD, UK
| | - Davide Matino
- Department of Medicine, McMaster University and The Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada
| | - Jan Astermark
- Institution of Translational Medicine and Department of Hematology, Oncology and Radiation Physics, Lund University, Skåne University Hospital, Malmö, Sweden
| | - Gerard Dolan
- Centre for Haemostasis and Thrombosis, St Thomas’ Hospital, London, UK
| | - Roseline d’Oiron
- Centre for Haemophilia and Constitutional Bleeding Disorders, Hôpital Bicêtre AP-HP Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Cédric Hermans
- Haemostasis and Thrombosis Unit, Division of Haematology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain (UCLouvain), Brussels, Belgium
| | | | - Adriana Linares
- Grupo de Oncohematología Pediátrica, Universidad Nacional de Colombia, Bogotá, Colombia
- Programa de Hemofilia, Clínica Infantil Colsubsidio, Bogotá, Colombia
| | - Tadashi Matsushita
- Department of Transfusion Medicine, Nagoya University Hospital, Nagoya, Japan
| | - Simon McRae
- Launceston General Hospital, Launceston, TAS, Australia
| | | | - Sean Platton
- The Royal London Hospital Haemophilia Centre, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Darrel Stafford
- Department of Biology, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Robert F. Sidonio
- Aflac Cancer and Blood Disorders, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Andreas Tiede
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
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9
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Shen G, Gao M, Cao Q, Li W. The Molecular Basis of FIX Deficiency in Hemophilia B. Int J Mol Sci 2022; 23:2762. [PMID: 35269902 PMCID: PMC8911121 DOI: 10.3390/ijms23052762] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 02/23/2022] [Accepted: 02/27/2022] [Indexed: 12/15/2022] Open
Abstract
Coagulation factor IX (FIX) is a vitamin K dependent protein and its deficiency causes hemophilia B, an X-linked recessive bleeding disorder. More than 1000 mutations in the F9 gene have been identified in hemophilia B patients. Here, we systematically summarize the structural and functional characteristics of FIX and the pathogenic mechanisms of the mutations that have been identified to date. The mechanisms of FIX deficiency are diverse in these mutations. Deletions, insertions, duplications, and indels generally lead to severe hemophilia B. Those in the exon regions generate either frame shift or inframe mutations, and those in the introns usually cause aberrant splicing. Regarding point mutations, the bleeding phenotypes vary from severe to mild in hemophilia B patients. Generally speaking, point mutations in the F9 promoter region result in hemophilia B Leyden, and those in the introns cause aberrant splicing. Point mutations in the coding sequence can be missense, nonsense, or silent mutations. Nonsense mutations generate truncated FIX that usually loses function, causing severe hemophilia B. Silent mutations may lead to aberrant splicing or affect FIX translation. The mechanisms of missense mutation, however, have not been fully understood. They lead to FIX deficiency, often by affecting FIX's translation, protein folding, protein stability, posttranslational modifications, activation to FIXa, or the ability to form functional Xase complex. Understanding the molecular mechanisms of FIX deficiency will provide significant insight for patient diagnosis and treatment.
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Affiliation(s)
- Guomin Shen
- Henan International Joint Laboratory of Thrombosis and Hemostasis, Henan University of Science and Technology, Luoyang 471023, China; (M.G.); (Q.C.)
- School of Basic Medical Science, Henan University of Science and Technology, Luoyang 471023, China
| | - Meng Gao
- Henan International Joint Laboratory of Thrombosis and Hemostasis, Henan University of Science and Technology, Luoyang 471023, China; (M.G.); (Q.C.)
- School of Basic Medical Science, Henan University of Science and Technology, Luoyang 471023, China
| | - Qing Cao
- Henan International Joint Laboratory of Thrombosis and Hemostasis, Henan University of Science and Technology, Luoyang 471023, China; (M.G.); (Q.C.)
- School of Basic Medical Science, Henan University of Science and Technology, Luoyang 471023, China
| | - Weikai Li
- Department of Biochemistry and Molecular Biophysics, Washington University in St. Louis School of Medicine, St. Louis, MO 63110, USA
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10
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Branchini A, Morfini M, Lunghi B, Belvini D, Radossi P, Bury L, Serino ML, Giordano P, Cultrera D, Molinari AC, Napolitano M, Bigagli E, Castaman G, Pinotti M, Bernardi F. F9 missense mutations impairing factor IX activation are associated with pleiotropic plasma phenotypes. J Thromb Haemost 2022; 20:69-81. [PMID: 34626083 PMCID: PMC9298354 DOI: 10.1111/jth.15552] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 10/06/2021] [Accepted: 10/06/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Circulating dysfunctional factor IX (FIX) might modulate distribution of infused FIX in hemophilia B (HB) patients. Recurrent substitutions at FIX activation sites (R191-R226, >300 patients) are associated with variable FIX activity and antigen (FIXag) levels. OBJECTIVES To investigate the (1) expression of a complete panel of missense mutations at FIX activation sites and (2) contribution of F9 genotypes on the FIX pharmacokinetics (PK). METHODS We checked FIX activity and antigen and activity assays in plasma and after recombinant expression of FIX variants and performed an analysis of infused FIX PK parameters in patients (n = 30), mostly enrolled in the F9 Genotype and PK HB Italian Study (GePKHIS; EudraCT ID2017-003902-42). RESULTS The variable FIXag amounts and good relation between biosynthesis and activity of multiple R191 variants results in graded moderate-to-mild severity of the R191C>L>P>H substitutions. Recombinant expression may predict the absence in the HB mutation database of the benign R191Q/W/K and R226K substitutions. Equivalent changes at R191/R226 produced higher FIXag levels for R226Q/W/P substitutions, as also observed in p.R226W female carrier plasma. Pharmacokinetics analysis in patients suggested that infused FIX Alpha distribution and Beta elimination phases positively correlated with endogenous FIXag levels. Mean residence time was particularly prolonged (79.4 h, 95% confidence interval 44.3-114.5) in patients (n = 7) with the R191/R226 substitutions, which in regression analysis were independent predictors (β coefficient 0.699, P = .004) of Beta half-life, potentially prolonged by the increasing over time ratio between endogenous and infused FIX. CONCLUSIONS FIX activity and antigen levels and specific features of the dysfunctional R191/R226 variants may exert pleiotropic effects both on HB patients' phenotypes and substitutive treatment.
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Affiliation(s)
- Alessio Branchini
- Department of Life Sciences and Biotechnology and LTTA CentreUniversity of FerraraFerraraItaly
| | | | - Barbara Lunghi
- Department of Life Sciences and Biotechnology and LTTA CentreUniversity of FerraraFerraraItaly
| | - Donata Belvini
- Transfusion ServiceHaemophilia Centre and HaematologyCastelfranco Veneto HospitalCastelfranco VenetoItaly
| | - Paolo Radossi
- Oncohematology‐Oncologic Institute of VenetoCastelfranco Veneto HospitalCastelfranco VenetoItaly
| | - Loredana Bury
- Department of Medicine and SurgeryUniversity of PerugiaPerugiaItaly
| | - Maria Luisa Serino
- Haemostasis and Thrombosis CentreUniversity Hospital of FerraraFerraraItaly
| | - Paola Giordano
- Paediatric SectionDepartment of Biomedicine and Human OncologyA. Moro” UniversityBariItaly
| | - Dorina Cultrera
- Haemophilia Regional Reference CenterVittorio Emanuele” University HospitalCataniaItaly
| | | | - Mariasanta Napolitano
- Haematology UnitThrombosis and Haemostasis Reference Regional Center and PROMISE DepartmentUniversity of PalermoPalermoItaly
| | - Elisabetta Bigagli
- Department of Neuroscience, PsychologyDrug Research and Child Health (NEUROFARBA)Section of Pharmacology and ToxicologyUniversity of FlorenceFlorenceItaly
| | - Giancarlo Castaman
- Department of Oncology, Center for Bleeding DisordersCareggi University HospitalFirenzeItaly
| | - Mirko Pinotti
- Department of Life Sciences and Biotechnology and LTTA CentreUniversity of FerraraFerraraItaly
| | - Francesco Bernardi
- Department of Life Sciences and Biotechnology and LTTA CentreUniversity of FerraraFerraraItaly
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11
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Sidonio RF, Batsuli G. Plasma factor IX: The tip of the iceberg? Haemophilia 2021; 27:329-331. [PMID: 33964097 DOI: 10.1111/hae.14324] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 04/09/2021] [Accepted: 04/10/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Robert F Sidonio
- Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta and Department of Pediatrics, Emory University, Atlanta, GA, USA
| | - Glaivy Batsuli
- Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta and Department of Pediatrics, Emory University, Atlanta, GA, USA
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12
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Mann DM, Stafford KA, Poon MC, Matino D, Stafford DW. The Function of extravascular coagulation factor IX in haemostasis. Haemophilia 2021; 27:332-339. [PMID: 33780107 DOI: 10.1111/hae.14300] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 03/07/2021] [Accepted: 03/09/2021] [Indexed: 12/21/2022]
Abstract
INTRODUCTION The majority of clotting factor IX (FIX) resides extravascularly, in the subendothelial basement membrane, where it is important for haemostasis. AIM We summarize preclinical studies demonstrating extravascular FIX and its role in haemostasis and discuss clinical observations supporting this. We compare the in vivo binding of BeneFIX® and the extended half-life FIX, Alprolix® , to extravascular type IV collagen (Col4). METHODS Three mouse models of haemophilia were used: the FIX knockout as the CRM- model and two knock-in mice, representing a CRM+ model of a commonly occurring patient mutation (FIXR333Q ) or a mutation that binds poorly to Col4 (FIXK5A ). The murine saphenous vein bleeding model was used to assess haemostatic competency. Clinical publications were reviewed for relevance to extravascular FIX. RESULTS CRM status affects recovery and prophylactic efficacy. Prophylactic protection decreases ~5X faster in CRM+ animals. Extravascular haemostasis can explain unexpected breakthrough bleeding in patients treated with some EHL-FIX therapeutics. In mice, both Alprolix® and BeneFIX® bind Col4 with similar affinities (Kd~20-40 nM) and show dose-dependent recoveries. As expected, the concentration of binding sites in the mouse calculated for Alprolix® (574 nM) was greater than for BeneFIX® (405 nM), due to Alprolix® binding to both Col4 and the endothelial cell neonatal Fc receptor. CONCLUSION Preclinical and clinical results support the interpretation that FIX plays a role in haemostasis from its extravascular location. We believe that knowing the CRM status of haemophilia B patients is important for optimizing prophylactic dosing with less trial and error, thereby decreasing clinical morbidity.
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Affiliation(s)
| | | | - Man-Chiu Poon
- University of Calgary Foothills Medical Center, Calgary, AB, Canada
| | - Davide Matino
- McMaster University Medical Center, Hamilton, ON, Canada
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Lillicrap D. Evaluating the potential benefits of the extravascular pool of factor IX. Blood Coagul Fibrinolysis 2021; 32:68-69. [PMID: 33170819 PMCID: PMC7810412 DOI: 10.1097/mbc.0000000000000969] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 09/04/2020] [Accepted: 09/22/2020] [Indexed: 11/26/2022]
Affiliation(s)
- David Lillicrap
- Richardson Laboratory, Department of Pathology and Molecular Medicine, Queen's University, Kingston, Ontario, Canada
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Pierce GF. Uncertainty in an era of transformative therapy for haemophilia: Addressing the unknowns. Haemophilia 2020; 27 Suppl 3:103-113. [PMID: 32484283 DOI: 10.1111/hae.14023] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 03/24/2020] [Indexed: 12/12/2022]
Abstract
Haemophilia is at the dawn of a new era in therapeutic management, one that can generate greater protection from bleeding and a functional cure in some individuals. Prior advances in protein engineering and monoclonal antibody technology have facilitated therapeutic options to maintain decreased risk of bleeding and less burdensome treatment. The use of gene transfer, first proposed in 1971 for monogenic diseases, is emerging as an effective long-term treatment for a variety of diseases. Transfer of functional factor VIII (FVIII) and factor IX (FIX) genes has witnessed a series of advances and setbacks since the first non-clinical experiments in animals were initiated nearly 30 years ago. More recently, multiyear therapeutic levels of FVIII and FIX activity have been achieved in human clinical trials, translated into meaningful clinical benefit and a functional cure. While clinical progress has been definitive, many questions remain unanswered as prelicensure phase 3 clinical trials are underway. These unanswered questions translate into a state of uncertainty about the known unknowns and unknown unknowns intrinsic to any new therapeutic platform. Accepting this modality as a means to functionally cure haemophilia also means accepting the uncertainty regarding the biology of viral vector-mediated gene transfer, which remains inadequately understood. Gene therapy is a far more complex biological 'drug' than small molecule and protein drugs, where manufacturing processes and the drugs themselves are now well characterized. Extent of community acceptance of uncertainty and acknowledgement of the need for an uncompromising drive for answers to the unknowns will characterize the introduction of this first generation of gene therapy for haemophilia to the wider patient population in both resource-rich and resource-poor countries.
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