1
|
Menier C, Meunier S, Porcheddu V, Romano L, Correia E, Busato F, Tost J, Maillère B. Frequency of natural regulatory T cells specific for factor VIII in the peripheral blood of healthy donors. Eur J Immunol 2024; 54:e2350506. [PMID: 38429238 DOI: 10.1002/eji.202350506] [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: 03/27/2023] [Revised: 12/05/2023] [Accepted: 12/05/2023] [Indexed: 03/03/2024]
Abstract
Tolerance to self-proteins involves multiple mechanisms, including conventional CD4+ T-cell (Tconv) deletion in the thymus and the recruitment of natural regulatory T cells (nTregs). The significant incidence of autoantibodies specific for the blood coagulation factor VIII (FVIII) in healthy donors illustrates that tolerance to self-proteins is not always complete. In contrast to FVIII-specific Tconvs, FVIII-specific nTregs have never been revealed and characterized. To determine the frequency of FVIII-specific Tregs in human peripheral blood, we assessed the specificity of in vitro expanded Tregs by the membrane expression of the CD137 activation marker. Amplified Tregs maintain high levels of FOXP3 expression and exhibit almost complete demethylation of the FOXP3 Treg-specific demethylated region. The cells retained FOXP3 expression after long-term culture in vitro, strongly suggesting that FVIII-specific Tregs are derived from the thymus. From eleven healthy donors, we estimated the frequencies of FVIII-specific Tregs at 0.17 cells per million, which is about 10-fold lower than the frequency of FVIII-specific CD4+ T cells we previously published. Our results shed light on the mechanisms of FVIII tolerance by a renewed approach that could be extended to other self- or non-self-antigens.
Collapse
Affiliation(s)
- Catherine Menier
- CEA, INRAE, Département Médicaments et Technologies pour la Santé, SIMoS, Université de Paris-Saclay, Gif-sur-Yvette, France
| | - Sylvain Meunier
- CEA, INRAE, Département Médicaments et Technologies pour la Santé, SIMoS, Université de Paris-Saclay, Gif-sur-Yvette, France
| | - Valeria Porcheddu
- CEA, INRAE, Département Médicaments et Technologies pour la Santé, SIMoS, Université de Paris-Saclay, Gif-sur-Yvette, France
| | - Laurène Romano
- CEA, INRAE, Département Médicaments et Technologies pour la Santé, SIMoS, Université de Paris-Saclay, Gif-sur-Yvette, France
| | - Evelyne Correia
- CEA, INRAE, Département Médicaments et Technologies pour la Santé, SIMoS, Université de Paris-Saclay, Gif-sur-Yvette, France
| | - Florence Busato
- Laboratory for Epigenetics & Environment, Centre National de Recherche en Génomique Humaine, CEA-Institut de Biologie François Jacob, Evry, France
| | - Jorg Tost
- Laboratory for Epigenetics & Environment, Centre National de Recherche en Génomique Humaine, CEA-Institut de Biologie François Jacob, Evry, France
| | - Bernard Maillère
- CEA, INRAE, Département Médicaments et Technologies pour la Santé, SIMoS, Université de Paris-Saclay, Gif-sur-Yvette, France
| |
Collapse
|
2
|
Porcheddu V, Lhomme G, Giraudet R, Correia E, Maillère B. The self-reactive FVIII T cell repertoire in healthy individuals relies on a short set of epitopes and public clonotypes. Front Immunol 2024; 15:1345195. [PMID: 38510258 PMCID: PMC10951066 DOI: 10.3389/fimmu.2024.1345195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 01/31/2024] [Indexed: 03/22/2024] Open
Abstract
Non-mutated FVIII-specific CD4 T cell epitopes have been recently found to contribute to the development of inhibitors in patients with hemophilia A (HA), while auto-reactive CD4 T cells specific to FVIII circulate in the blood of healthy individuals at a frequency close to the foreign protein ovalbumin. Thus, although FVIII is a self-protein, the central tolerance raised against FVIII appears to be low. In this study, we conducted a comprehensive analysis of the FVIII CD4 T cell repertoire in 29 healthy donors. Sequencing of the CDR3β TCR region from isolated FVIII-specific CD4 T cells revealed a limited usage and pairing of TRBV and TRBJ genes as well as a mostly hydrophobic composition of the CDR3β region according to their auto-reactivity. The FVIII repertoire is dominated by a few clonotypes, with only 13 clonotypes accounting for half of the FVIII response. Through a large-scale epitope mapping of the full-length FVIII sequence, we identified 18 immunodominant epitopes located in the A1, A3, C1, and C2 domains and covering half of the T cell response. These epitopes exhibited a broad specificity for HLA-DR or DP molecules or both. T cell priming with this reduced set of peptides revealed that highly expanded clonotypes specific to these epitopes were responsible individually for up to 32% of the total FVIII repertoire. These FVIII T cell epitopes and clonotypes were shared among HLA-unrelated donors tested and previously reported HA patients. Our study highlights the role of the auto-reactive T cell response against FVIII in HA and its similarity to the response observed in healthy individuals. Thus, it provides valuable insights for the development of new tolerance induction and deimmunization strategies.
Collapse
Affiliation(s)
- Valeria Porcheddu
- Université de Paris-Saclay, Commissariat à l'énergie atomique et aux énergies alternatives (CEA), Institut national de recherche pour l’agriculture, l’alimentation et l’environnement (INRAE), Département Médicaments et Technologies pour la Santé, Service d’Ingénierie Moléculaire pour la Santé (SIMoS), Gif-sur-Yvette, France
| | | | | | | | | |
Collapse
|
3
|
Kaminski TW, Ju EM, Gudapati S, Vats R, Arshad S, Dubey RK, Katoch O, Tutuncuoglu E, Frank J, Brzoska T, Stolz DB, Watkins SC, Chan SY, Ragni MV, Novelli EM, Sundd P, Pradhan-Sundd T. Defenestrated endothelium delays liver-directed gene transfer in hemophilia A mice. Blood Adv 2022; 6:3729-3734. [PMID: 35427414 PMCID: PMC9631574 DOI: 10.1182/bloodadvances.2021006388] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 03/31/2022] [Indexed: 11/23/2022] Open
Abstract
Hemophilia A is an inherited bleeding disorder caused by defective or deficient coagulation factor VIII (FVIII) activity. Until recently, the only treatment for prevention of bleeding involved IV administration of FVIII. Gene therapy with adeno-associated vectors (AAVs) has shown some efficacy in patients with hemophilia A. However, limitations persist due to AAV-induced cellular stress, immunogenicity, and reduced durability of gene expression. Herein, we examined the efficacy of liver-directed gene transfer in FVIII knock-out mice by AAV8-GFP. Surprisingly, compared with control mice, FVIII knockout (F8TKO) mice showed significant delay in AAV8-GFP transfer in the liver. We found that the delay in liver-directed gene transfer in F8TKO mice was associated with absence of liver sinusoidal endothelial cell (LSEC) fenestration, which led to aberrant expression of several sinusoidal endothelial proteins, causing increased capillarization and decreased permeability of LSECs. This is the first study to link impaired liver-directed gene transfer to liver-endothelium maladaptive structural changes associated with FVIII deficiency in mice.
Collapse
Affiliation(s)
- Tomasz W. Kaminski
- Pittsburgh Heart, Lung and Blood Vascular Medicine Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Eun-Mi Ju
- Pittsburgh Heart, Lung and Blood Vascular Medicine Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Shweta Gudapati
- Pittsburgh Heart, Lung and Blood Vascular Medicine Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Ravi Vats
- Pittsburgh Heart, Lung and Blood Vascular Medicine Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Department of Bioengineering, and
| | - Sanya Arshad
- Pittsburgh Heart, Lung and Blood Vascular Medicine Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Rikesh K. Dubey
- Pittsburgh Heart, Lung and Blood Vascular Medicine Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Omika Katoch
- Pittsburgh Heart, Lung and Blood Vascular Medicine Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Egemen Tutuncuoglu
- Pittsburgh Heart, Lung and Blood Vascular Medicine Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Jonathan Frank
- Department of Cell Biology, University of Pittsburgh, Pittsburgh, PA
| | - Tomasz Brzoska
- Pittsburgh Heart, Lung and Blood Vascular Medicine Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Division of Hematology/Oncology, and
| | | | - Simon C. Watkins
- Department of Cell Biology, University of Pittsburgh, Pittsburgh, PA
| | - Stephen Y. Chan
- Pittsburgh Heart, Lung and Blood Vascular Medicine Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Division of Pulmonary Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA; and
| | - Margaret V. Ragni
- Pittsburgh Heart, Lung and Blood Vascular Medicine Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Division of Hematology/Oncology, and
- Hemophilia Center of Western Pennsylvania, Pittsburgh, PA
| | - Enrico M. Novelli
- Pittsburgh Heart, Lung and Blood Vascular Medicine Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Division of Hematology/Oncology, and
| | - Prithu Sundd
- Pittsburgh Heart, Lung and Blood Vascular Medicine Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Department of Bioengineering, and
- Division of Pulmonary Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA; and
| | - Tirthadipa Pradhan-Sundd
- Pittsburgh Heart, Lung and Blood Vascular Medicine Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Department of Bioengineering, and
- Division of Hematology/Oncology, and
| |
Collapse
|
4
|
Pashova S, Balabanski L, Elmadjian G, Savov A, Stoyanova E, Shivarov V, Petrov P, Pashov A. Restriction of the Global IgM Repertoire in Antiphospholipid Syndrome. Front Immunol 2022; 13:865232. [PMID: 35493489 PMCID: PMC9043687 DOI: 10.3389/fimmu.2022.865232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 03/21/2022] [Indexed: 11/22/2022] Open
Abstract
The typical anti-phospholipid antibodies (APLA) in the anti-phospholipid syndrome (APS) are reactive with the phospholipid-binding protein β2GPI as well as a growing list of other protein targets. The relation of APLA to natural antibodies and the fuzzy set of autoantigens involved provoked us to study the changes in the IgM repertoire in APS. To this end, peptides selected by serum IgM from a 7-residue linear peptide phage display library (PDL) were deep sequenced. The analysis was aided by a novel formal representation of the Igome (the mimotope set reflecting the IgM specificities) in the form of a sequence graph. The study involved women with APLA and habitual abortions (n=24) compared to age-matched clinically healthy pregnant women (n=20). Their pooled Igomes (297 028 mimotope sequences) were compared also to the global public repertoire Igome of pooled donor plasma IgM (n=2 796 484) and a set of 7-mer sequences found in the J regions of human immunoglobulins (n=4 433 252). The pooled Igome was represented as a graph connecting the sequences as similar as the mimotopes of the same monoclonal antibody. The criterion was based on previously published data. In the resulting graph, identifiable clusters of vertices were considered related to the footprints of overlapping antibody cross-reactivities. A subgraph based on the clusters with a significant differential expression of APS patients’ mimotopes contained predominantly specificities underrepresented in APS. The differentially expressed IgM footprints showed also an increased cross-reactivity with immunoglobulin J regions. The specificities underexpressed in APS had a higher correlation with public specificities than those overexpressed. The APS associated specificities were strongly related also to the human peptidome with 1 072 mimotope sequences found in 7 519 human proteins. These regions were characterized by low complexity. Thus, the IgM repertoire of the APS patients was found to be characterized by a significant reduction of certain public specificities found in the healthy controls with targets representing low complexity linear self-epitopes homologous to human antibody J regions.
Collapse
Affiliation(s)
- Shina Pashova
- Institute of Biology and Immunology of Reproduction, Bulgarian Academy of Sciences, Sofia, Bulgaria
| | - Lubomir Balabanski
- Department of Medical Genetics, Medical University-Sofia, Sofia, Bulgaria.,Genomics Laboratory, Hospital "Malinov", Sofia, Bulgaria
| | - Gabriel Elmadjian
- Institute of Biology and Immunology of Reproduction, Bulgarian Academy of Sciences, Sofia, Bulgaria
| | - Alexey Savov
- Department of Medical Genetics, Medical University-Sofia, Sofia, Bulgaria
| | - Elena Stoyanova
- Institute of Biology and Immunology of Reproduction, Bulgarian Academy of Sciences, Sofia, Bulgaria
| | | | - Peter Petrov
- Institute Mathematics and Informatics, Bulgarian Academy of Sciences, Sofia, Bulgaria
| | - Anastas Pashov
- Institute of Microbiology, Bulgarian Academy of Sciences, Sofia, Bulgaria
| |
Collapse
|
5
|
Schurgers E, Wraith DC. Induction of Tolerance to Therapeutic Proteins With Antigen-Processing Independent T Cell Epitopes: Controlling Immune Responses to Biologics. Front Immunol 2021; 12:742695. [PMID: 34567009 PMCID: PMC8459012 DOI: 10.3389/fimmu.2021.742695] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 08/18/2021] [Indexed: 11/28/2022] Open
Abstract
The immune response to exogenous proteins can overcome the therapeutic benefits of immunotherapies and hamper the treatment of protein replacement therapies. One clear example of this is haemophilia A resulting from deleterious mutations in the FVIII gene. Replacement with serum derived or recombinant FVIII protein can cause anti-drug antibodies in 20-50% of individuals treated. The resulting inhibitor antibodies override the benefit of treatment and, at best, make life unpredictable for those treated. The only way to overcome the inhibitor issue is to reinstate immunological tolerance to the administered protein. Here we compare the various approaches that have been tested and focus on the use of antigen-processing independent T cell epitopes (apitopes) for tolerance induction. Apitopes are readily designed from any protein whether this is derived from a clotting factor, enzyme replacement therapy, gene therapy or therapeutic antibody.
Collapse
Affiliation(s)
| | - David C Wraith
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| |
Collapse
|
6
|
Camelo RM, Chaves DG, Zuccherato LW, Rezende SM. Predictors of the outcome of immune tolerance induction in patients with haemophilia A and inhibitors: The Brazilian Immune Tolerance (BrazIT) Study protocol. PLoS One 2021; 16:e0256265. [PMID: 34437573 PMCID: PMC8389515 DOI: 10.1371/journal.pone.0256265] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 08/03/2021] [Indexed: 01/19/2023] Open
Abstract
The development of inhibitors is the main complication of haemophilia A (HA) treatment. Immune tolerance induction (ITI) is the treatment of choice for inhibitor eradication. We describe the methodology of the Brazilian Immune Tolerance Induction (BrazIT) Study, aimed to identify clinical, genetic, and immune biomarkers associated with response to ITI and inhibitor recurrence. This cohort study includes people with HA (PwHA) and inhibitors (a) who require bypassing agents to treat and/or prevent bleeding, and (b) who are at any stage of ITI treatment. Patients are included in each haemophilia treatment centre (HTC). Factor VIII (FVIII) and inhibitor assessments are performed at local laboratories of each HTC. The ITI regimen followed the national protocol of the Brazilian Ministry of Health. All PwHA starts with low-dose ITI (50 IU/kg three times weekly); high-dose regimen (100 IU/kg daily) is used if there is lack of response to the low-dose ITI. Outcomes are classified as total or partial success, and failure. Standardized case report forms with clinical, laboratory, and treatment data are collected from medical files and interviews. Blood samples are collected for genetic and immune biomarkers at the time of inclusion in the study and at the end of ITI. The study is ongoing and, currently, 202/250 (80.8%) PwHA from 15 HTCs have been included. BrazIT Study is the largest cohort of PwHA and inhibitor under treatment with the same ITI regimen reported to date. This study is likely to contribute with novel predictors of ITI response.
Collapse
Affiliation(s)
| | | | - Luciana Werneck Zuccherato
- Faculty of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
- Center of Education and Research, Instituto Mario Penna, Belo Horizonte, Brazil
| | - Suely Meireles Rezende
- Faculty of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
- * E-mail: ,
| | | |
Collapse
|
7
|
Coxon CH, Yu X, Beavis J, Diaz-Saez L, Riches-Duit A, Ball C, Diamond SL, Raut S. Characterisation and application of recombinant FVIII-neutralising antibodies from haemophilia A inhibitor patients. Br J Haematol 2021; 193:976-987. [PMID: 33973229 DOI: 10.1111/bjh.17227] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 10/16/2020] [Indexed: 12/20/2022]
Abstract
The development of anti-drug antibodies (ADAs) is a serious outcome of treatment strategies involving biological medicines. Coagulation factor VIII (FVIII) is used to treat haemophilia A patients, but its immunogenicity precludes a third of severe haemophiliac patients from receiving this treatment. The availability of patient-derived anti-drug antibodies can help us better understand drug immunogenicity and identify ways to overcome it. Thus, there were two aims to this work: (i) to develop and characterise a panel of recombinant, patient-derived, monoclonal antibodies covering a range of FVIII epitopes with varying potencies, kinetics and mechanism of action, and (ii) to demonstrate their applicability to assay development, evaluation of FVIII molecules and basic research. For the first objective we used recombinant antibodies to develop a rapid, sensitive, flexible and reproducible ex vivo assay that recapitulates inhibitor patient blood using blood from healthy volunteers. We also demonstrate how the panel can provide important information about the efficacy of FVIII products and reagents without the need for patient or animal material. These materials can be used as experimental exemplars or controls, as well as tools for rational, hypothesis-driven research and assay development in relation to FVIII immunogenicity and FVIII-related products.
Collapse
Affiliation(s)
- Carmen H Coxon
- National Institute for Biological Standards and Control, Hertfordshire, UK
| | - Xinren Yu
- University of Pennsylvania, Philadelphia, PA, USA
| | - James Beavis
- Oxford Haemophilia Centre, Churchill Hospital, Oxford, UK
| | | | - Andrew Riches-Duit
- National Institute for Biological Standards and Control, Hertfordshire, UK
| | - Chris Ball
- National Institute for Biological Standards and Control, Hertfordshire, UK
| | | | - Sanj Raut
- National Institute for Biological Standards and Control, Hertfordshire, UK
| |
Collapse
|
8
|
Role of Regulatory Cells in Immune Tolerance Induction in Hemophilia A. Hemasphere 2021; 5:e557. [PMID: 33898928 PMCID: PMC8061682 DOI: 10.1097/hs9.0000000000000557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 03/09/2021] [Indexed: 11/26/2022] Open
Abstract
The main complication of hemophilia A treatment is the development of neutralizing antibodies (inhibitors) against factor VIII (FVIII). Immune tolerance induction (ITI) is the prescribed treatment for inhibitor eradication, although its working mechanism remains unresolved. To clarify this mechanism, we compared blood samples of hemophilia A patients with and without inhibitors for presence of immunoregulatory cells and markers, including regulatory B-cells (Bregs), regulatory T-cells (Tregs), myeloid-derived suppressor cells (MDSCs), and expression of regulatory markers on T-cells (programmed cell death protein 1 [PD1], inducable T-cell costimulator, cytotoxic T-lymphocyte-associated protein 4 [CTLA4]), by use of flow cytometry. By cross-sectional analysis inhibitor patients (N = 20) were compared with inhibitor-negative (N = 28) and ex-inhibitor (N = 17) patients. In another longitudinal study, changes in immunoregulatory parameters were evaluated during ITI (N = 12) and compared with inhibitor-negative hemophilia A patients (N = 36). The frequency of Bregs, but not of Tregs nor MDSCs, was significantly reduced in inhibitor patients (3.2%) compared with inhibitor-negative (5.9%) and ex-inhibitor patients (8.9%; P < 0.01). CTLA4 expression on T-cells was also reduced (mean fluorescence intensity 133 in inhibitor versus 537 in inhibitor-negative patients; P < 0.01). Fittingly, in patients followed during ITI, inhibitor eradication associated with increased Bregs, increased Tregs, and increased expression of CTLA4 and PD1 on CD4+ T-cells. In conclusion, inhibitor patients express significantly lower frequency of Bregs and Tregs marker expression, which are restored by successful ITI. Our findings suggest that an existing anti-FVIII immune response is associated with deficits in peripheral tolerance mechanisms and that Bregs and changes in immunoregulatory properties of CD4+ T-cells likely contribute to ITI in hemophilia A patients with inhibitors.
Collapse
|
9
|
Thachil J. Potential Clues to the Pathogenesis of Acquired Hemophilia. Semin Thromb Hemost 2021; 47:890-891. [PMID: 33647996 DOI: 10.1055/s-0040-1722294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Jecko Thachil
- Department of Haematology, Manchester University Hospitals, Manchester, United Kingdom
| |
Collapse
|
10
|
de Oliveira LMM, Jardim LL, Santana MAP, Cerqueira MH, Lorenzato CS, Franco VKB, Zuccherato LW, Rezende SM, Chaves DG. Effect of the First Factor VIII Infusions on Immunological Biomarkers in Previously Untreated Patients with Hemophilia A from the HEMFIL Study. Thromb Haemost 2021; 121:891-899. [PMID: 33423244 DOI: 10.1055/s-0040-1722353] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Hemophilia A (HA) is an inherited bleeding disorder which requires continuous replacement with factor (F) VIII concentrate. The main complication of HA is the development of neutralizing alloantibodies which inhibit FVIII activity (inhibitors). The objective of this study was to investigate the effect of the first FVIII infusions on immunological biomarkers in previously untreated patients with HA. Plasma samples were collected at enrollment before any FVIII infusion (T0) and at inhibitor development (INB +/T1) or up to 35 exposure days without inhibitors (INB -/T1). Anti-FVIII antibodies (immunoglobulin M, immunoglobulin G [IgG] 1, IgG3, and IgG4), chemokines (CCL2, CCL5, CXCL8, CXCL9, and CXCL10), and cytokines (interleukin [IL]-2, IL-4, IL-6, IL-10, interferon-γ, tumor necrosis factor, and IL-17) were assessed. A total of 71 children with severe HA were included, of whom 28 (39.4%) developed inhibitors. Plasma levels of anti-FVIII IgG4, IL-6, and CXCL8 were higher at INB +/T1 when compared with INB -/T1. This group presented a mixed cytokine profile and higher plasma levels of CXCL9 and CXL10 when compared with INB +/T1. We conclude that exposure to FVIII triggers a proinflammatory response mediated by IL-6 and CXCL8 in patients with HA who developed inhibitors. Regardless of inhibitor status, the immune system of all HA patients is stimulated after infusions of FVIII.
Collapse
Affiliation(s)
| | - Letícia Lemos Jardim
- Faculty of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil.,Department of Clinical Epidemiology, Leiden University Medical Centre, Leiden, The Netherlands
| | | | | | | | | | - Luciana Werneck Zuccherato
- Faculty of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil.,Instituto Mário Penna, Belo Horizonte, Minas Gerais, Brazil
| | - Suely Meireles Rezende
- Faculty of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | | |
Collapse
|
11
|
Zhou ZY, Raimundo K, Patel AM, Han S, Ji Y, Fang H, Zhong J, Betts KA, Mahajerin A. Model of Short- and Long-Term Outcomes of Emicizumab Prophylaxis Treatment for Persons with Hemophilia A. J Manag Care Spec Pharm 2020; 26:1109-1120. [PMID: 32452276 PMCID: PMC10391239 DOI: 10.18553/jmcp.2020.19406] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Hemophilia A (HA) can result in bleeding events because of low or absent clotting factor VIII (FVIII). Prophylactic treatment for severe HA includes replacement FVIII infusions and emicizumab, a bispecific factor IXa- and factor X-directed antibody. OBJECTIVE To develop an economic model to predict the short- and long-term clinical and economic outcomes of prophylaxis with emicizumab versus short-acting recombinant FVIII among persons with HA in the United States. METHODS A Markov model was developed to compare clinical outcomes and costs of emicizumab versus FVIII prophylaxis among persons with severe HA from U.S. payer and societal perspectives. Patients started prophylaxis at age 1 year in the base case. Mutually exclusive health states considered were "no arthropathy," "arthropathy," "surgery," and "death." Serious adverse events, breakthrough bleeds, and inhibitor development were simulated throughout the modeled time horizon. In addition to the prophylaxis drug costs, patients could incur other direct costs related to breakthrough bleeds treatment, serious adverse events, development of inhibitors, arthropathy, and orthopedic surgery. Indirect costs associated with productivity loss (i.e., missed work or disabilities) were applied for adults. Model inputs were obtained from the HAVEN 3 trial, published literature, and expert opinion. The model used a lifetime horizon, and results for 1 year and 5 years were also reported. Deterministic sensitivity analyses and scenario analyses were conducted to assess robustness of the model. RESULTS Over a lifetime horizon, the cumulative number of all treated bleeds and joint bleeds avoided on emicizumab versus FVIII prophylaxis were 278.2 and 151.7, respectively. Correspondingly, arthropathy (mean age at onset: 12.9 vs. 5.4 years) and FVIII inhibitor development (mean age at development: 13.9 vs. 1.1 years) were delayed. Total direct and indirect costs were lower for emicizumab versus FVIII prophylaxis for all modeled time horizons ($97,159 vs. $331,610 at 1 year; $603,146 vs. $1,459,496 at 5 years; and $15,238,072 vs. $22,820,281 over a lifetime horizon). The sensitivity analyses indicated that clinical outcomes were sensitive to efficacy inputs, while economic outcomes were driven by the discount rate, dosing schedules, and treatments after inhibitor development. Results for moderate to severe patients were consistent with findings in the severe HA population. CONCLUSIONS The model suggests that emicizumab prophylaxis confers additional clinical benefits, resulting in a lower number of bleeding events and delayed onset of arthropathy and inhibitor development across all time assessment horizons. Compared with short-acting recombinant FVIII, emicizumab prophylaxis leads to superior patient outcomes and cost savings from U.S. payer and societal perspectives. DISCLOSURES Funding for this study was provided by Genentech. Raimundo and Patel are employees of Genentech and own stock or stock options. Zhou, Han, Ji, Fang, Zhong, and Betts are employees of Analysis Group, which received consultancy fees from Genentech for conducting this study. Mahajerin received consultancy fees from Genentech for work on this study. Portions of this research were presented as a poster at the 2018 American Society of Hematology Conference; December 1-4, 2018; San Diego, CA.
Collapse
Affiliation(s)
| | | | | | | | - Yusi Ji
- Analysis Group, Beijing, China
| | | | | | | | | |
Collapse
|
12
|
Mimoun A, Delignat S, Peyron I, Daventure V, Lecerf M, Dimitrov JD, Kaveri SV, Bayry J, Lacroix-Desmazes S. Relevance of the Materno-Fetal Interface for the Induction of Antigen-Specific Immune Tolerance. Front Immunol 2020; 11:810. [PMID: 32477339 PMCID: PMC7240014 DOI: 10.3389/fimmu.2020.00810] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 04/08/2020] [Indexed: 12/26/2022] Open
Abstract
In humans, maternal IgGs are transferred to the fetus from the second trimester of pregnancy onwards. The transplacental delivery of maternal IgG is mediated by its binding to the neonatal Fc receptor (FcRn) after endocytosis by the syncytiotrophoblast. IgGs present in the maternal milk are also transferred to the newborn through the digestive epithelium upon binding to the FcRn. Importantly, the binding of IgGs to the FcRn is also responsible for the recycling of circulating IgGs that confers them with a long half-life. Maternally delivered IgG provides passive immunity to the newborn, for instance by conferring protective anti-flu or anti-pertussis toxin IgGs. It may, however, lead to the development of autoimmune manifestations when pathological autoantibodies from the mother cross the placenta and reach the circulation of the fetus. In recent years, strategies that exploit the transplacental delivery of antigen/IgG complexes or of Fc-fused proteins have been validated in mouse models of human diseases to impose antigen-specific tolerance, particularly in the case of Fc-fused factor VIII (FVIII) domains in hemophilia A mice or pre-pro-insulin (PPI) in the case of preclinical models of type 1 diabetes (T1D). The present review summarizes the mechanisms underlying the FcRn-mediated transcytosis of IgGs, the physiopathological relevance of this phenomenon, and the repercussion for drug delivery and shaping of the immune system during its ontogeny.
Collapse
Affiliation(s)
- Angelina Mimoun
- Centre de Recherche des Cordeliers, INSERM, Sorbonne Université, Université de Paris, Paris, France
| | - Sandrine Delignat
- Centre de Recherche des Cordeliers, INSERM, Sorbonne Université, Université de Paris, Paris, France
| | - Ivan Peyron
- HITh, INSERM, UMR_S1176, Université Paris-Sud, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Victoria Daventure
- Centre de Recherche des Cordeliers, INSERM, Sorbonne Université, Université de Paris, Paris, France
| | - Maxime Lecerf
- Centre de Recherche des Cordeliers, INSERM, Sorbonne Université, Université de Paris, Paris, France
| | - Jordan D Dimitrov
- Centre de Recherche des Cordeliers, INSERM, Sorbonne Université, Université de Paris, Paris, France
| | - Srinivas V Kaveri
- Centre de Recherche des Cordeliers, INSERM, Sorbonne Université, Université de Paris, Paris, France
| | - Jagadeesh Bayry
- Centre de Recherche des Cordeliers, INSERM, Sorbonne Université, Université de Paris, Paris, France
| | | |
Collapse
|
13
|
A molecular jewel for hemophilia A treatment. Blood 2020; 135:1417-1419. [DOI: 10.1182/blood.2020005250] [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
|
14
|
Matino D, Afraz S, Zhao G, Tieu P, Gargaro M, Fallarino F, Iorio A. Tolerance to FVIII: Role of the Immune Metabolic Enzymes Indoleamine 2,3 Dyoxigenase-1 and Heme Oxygenase-1. Front Immunol 2020; 11:620. [PMID: 32351505 PMCID: PMC7174632 DOI: 10.3389/fimmu.2020.00620] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 03/18/2020] [Indexed: 11/13/2022] Open
Abstract
The occurrence of neutralizing anti-FVIII antibodies is a major complication in the treatment of patients affected by hemophilia A. The immune response to FVIII is a complex, multi-factorial process that has been extensively studied for the past two decades. The reasons why only a proportion of hemophilic patients treated with FVIII concentrates develop a clinically significant immune response is incompletely understood. The "danger theory" has been proposed as a possible explanation to interpret the findings of some observational clinical studies highlighting the possible detrimental impact of inflammatory stimuli at the time of replacement therapy on inhibitor development. The host immune system is often challenged to react to FVIII under steady state or inflammatory conditions (e.g., bleeding, infections) although fine tuning of mechanisms of immune tolerance can control this reactivity and promote long-term unresponsiveness to the therapeutically administered factor. Recent studies have provided evidence that multiple interactions involving central and peripheral mechanisms of tolerance are integrated by the host immune system with the environmental conditions at the time of FVIII exposure and influence the balance between immunity and tolerance to FVIII. Here we review evidences showing the involvement of two key immunoregulatory oxygenase enzymes (IDO1, HO-1) that have been studied in hemophilia patients and pre-clinical models, showing that the ability of the host immune system to induce such regulatory proteins under inflammatory conditions can play important roles in the balance between immunity and tolerance to exogenous FVIII.
Collapse
Affiliation(s)
- Davide Matino
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada
| | - Sajjad Afraz
- Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada
| | - George Zhao
- McMaster Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Paul Tieu
- Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada
- McMaster Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Marco Gargaro
- Department of Experimental Medicine, University of Perugia, Perugia, Italy
| | | | - Alfonso Iorio
- Department of Health Research Methods, Evidence, and Impact, Hamilton, ON, Canada
| |
Collapse
|
15
|
Delignat S, Rayes J, Dasgupta S, Gangadharan B, Denis CV, Christophe OD, Bayry J, Kaveri SV, Lacroix-Desmazes S. Removal of Mannose-Ending Glycan at Asn 2118 Abrogates FVIII Presentation by Human Monocyte-Derived Dendritic Cells. Front Immunol 2020; 11:393. [PMID: 32273875 PMCID: PMC7117063 DOI: 10.3389/fimmu.2020.00393] [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: 11/26/2019] [Accepted: 02/19/2020] [Indexed: 12/21/2022] Open
Abstract
The development of an immune response against therapeutic factor VIII is the major complication in hemophilia A patients. Oligomannose carbohydrates at N239 and/or N2118 on factor VIII allow its binding to the macrophage mannose receptor expressed on human dendritic cells, thereby leading to factor VIII endocytosis and presentation to CD4+ T lymphocytes. Here, we investigated whether altering the interaction of factor VIII with mannose-sensitive receptors on antigen-presenting cells may be a strategy to reduce factor VIII immunogenicity. Gene transfer experiments in factor VIII-deficient mice indicated that N239Q and/or N2118Q factor VIII mutants have similar specific activities as compared to non-mutated factor VIII; N239Q/N2118Q mutant corrected blood loss upon tail clip. Production of the corresponding recombinant FVIII mutants or light chains indicated that removal of the N-linked glycosylation site at N2118 is sufficient to abrogate in vitro the activation of FVIII-specific CD4+ T cells by human monocyte-derived dendritic cells. However, removal of mannose-ending glycans at N2118 did not alter factor VIII endocytosis and presentation to CD4+ T cells by mouse antigen-presenting cells. In agreement with this, the N2118Q mutation did not reduce factor VIII immunogenicity in factor VIII-deficient mice. Our results highlight differences in the endocytic pathways between human and mouse dendritic cell subsets, and dissimilarities in tissue distribution and function of endocytic receptors such as CD206 in both species. Further investigations in preclinical models of hemophilia A closer to humans are needed to decipher the exact role of mannose-ending glycans in factor VIII immunogenicity.
Collapse
Affiliation(s)
- Sandrine Delignat
- Institut National de la Santé et de la Recherche Médicale, Centre de Recherche des Cordeliers, Sorbonne Université, Université de Paris, Paris, France
| | - Julie Rayes
- Institut National de la Santé et de la Recherche Médicale, Centre de Recherche des Cordeliers, Sorbonne Université, Université de Paris, Paris, France
| | - Suryasarathi Dasgupta
- Institut National de la Santé et de la Recherche Médicale, Centre de Recherche des Cordeliers, Sorbonne Université, Université de Paris, Paris, France
| | - Bagirath Gangadharan
- Institut National de la Santé et de la Recherche Médicale, Centre de Recherche des Cordeliers, Sorbonne Université, Université de Paris, Paris, France
| | - Cécile V Denis
- HITh, UMR_S1176, INSERM, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | | | - Jagadeesh Bayry
- Institut National de la Santé et de la Recherche Médicale, Centre de Recherche des Cordeliers, Sorbonne Université, Université de Paris, Paris, France
| | - Srinivas V Kaveri
- Institut National de la Santé et de la Recherche Médicale, Centre de Recherche des Cordeliers, Sorbonne Université, Université de Paris, Paris, France
| | - Sébastien Lacroix-Desmazes
- Institut National de la Santé et de la Recherche Médicale, Centre de Recherche des Cordeliers, Sorbonne Université, Université de Paris, Paris, France
| |
Collapse
|
16
|
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
| |
Collapse
|
17
|
Lacroix-Desmazes S, Voorberg J, Lillicrap D, Scott DW, Pratt KP. Tolerating Factor VIII: Recent Progress. Front Immunol 2020; 10:2991. [PMID: 31998296 PMCID: PMC6965068 DOI: 10.3389/fimmu.2019.02991] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Accepted: 12/05/2019] [Indexed: 02/02/2023] Open
Abstract
Development of neutralizing antibodies against biotherapeutic agents administered to prevent or treat various clinical conditions is a longstanding and growing problem faced by patients, medical providers and pharmaceutical companies. The hemophilia A community has deep experience with attempting to manage such deleterious immune responses, as the lifesaving protein drug factor VIII (FVIII) has been in use for decades. Hemophilia A is a bleeding disorder caused by genetic mutations that result in absent or dysfunctional FVIII. Prophylactic treatment consists of regular intravenous FVIII infusions. Unfortunately, 1/4 to 1/3 of patients develop neutralizing anti-FVIII antibodies, referred to clinically as “inhibitors,” which result in a serious bleeding diathesis. Until recently, the only therapeutic option for these patients was “Immune Tolerance Induction,” consisting of intensive FVIII administration, which is extraordinarily expensive and fails in ~30% of cases. There has been tremendous recent progress in developing novel potential clinical alternatives for the treatment of hemophilia A, ranging from encouraging results of gene therapy trials, to use of other hemostatic agents (either promoting coagulation or slowing down anti-coagulant or fibrinolytic pathways) to “bypass” the need for FVIII or supplement FVIII replacement therapy. Although these approaches are promising, there is widespread agreement that preventing or reversing inhibitors remains a high priority. Risk profiles of novel therapies are still unknown or incomplete, and FVIII will likely continue to be considered the optimal hemostatic agent to support surgery and manage trauma, or to combine with other therapies. We describe here recent exciting studies, most still pre-clinical, that address FVIII immunogenicity and suggest novel interventions to prevent or reverse inhibitor development. Studies of FVIII uptake, processing and presentation on antigen-presenting cells, epitope mapping, and the roles of complement, heme, von Willebrand factor, glycans, and the microbiome in FVIII immunogenicity are elucidating mechanisms of primary and secondary immune responses and suggesting additional novel targets. Promising tolerogenic therapies include development of FVIII-Fc fusion proteins, nanoparticle-based therapies, oral tolerance, and engineering of regulatory or cytotoxic T cells to render them FVIII-specific. Importantly, these studies are highly applicable to other scenarios where establishing immune tolerance to a defined antigen is a clinical priority.
Collapse
Affiliation(s)
| | - Jan Voorberg
- Sanquin Research and Landsteiner Laboratory, Department of Molecular and Cellular Hemostasis, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - David Lillicrap
- Department of Pathology and Molecular Medicine, Queen's University, Kingston, ON, Canada
| | - David W Scott
- Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | - Kathleen P Pratt
- Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| |
Collapse
|
18
|
O’Connor DJ, Buckland J, Almond N, Boyle J, Coxon C, Gaki E, Martin J, Mattiuzzo G, Metcalfe C, Page M, Rose N, Valdazo-Gonzalez B, Zhao Y, Schneider CK. Commonly setting biological standards in rare diseases. Expert Opin Orphan Drugs 2019. [DOI: 10.1080/21678707.2019.1652598] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
| | - Jenny Buckland
- National Institute for Biological Standards and Control (NIBSC), Blanche Ln, South Mimms, Potters Bar, UK
| | - Neil Almond
- National Institute for Biological Standards and Control (NIBSC), Blanche Ln, South Mimms, Potters Bar, UK
| | - Jennifer Boyle
- National Institute for Biological Standards and Control (NIBSC), Blanche Ln, South Mimms, Potters Bar, UK
| | - Carmen Coxon
- National Institute for Biological Standards and Control (NIBSC), Blanche Ln, South Mimms, Potters Bar, UK
| | - Eleni Gaki
- Medicines & Healthcare products Regulatory Agency (MHRA), London, UK
| | - Javier Martin
- National Institute for Biological Standards and Control (NIBSC), Blanche Ln, South Mimms, Potters Bar, UK
| | - Giada Mattiuzzo
- National Institute for Biological Standards and Control (NIBSC), Blanche Ln, South Mimms, Potters Bar, UK
| | - Clive Metcalfe
- National Institute for Biological Standards and Control (NIBSC), Blanche Ln, South Mimms, Potters Bar, UK
| | - Mark Page
- National Institute for Biological Standards and Control (NIBSC), Blanche Ln, South Mimms, Potters Bar, UK
| | - Nicola Rose
- National Institute for Biological Standards and Control (NIBSC), Blanche Ln, South Mimms, Potters Bar, UK
| | - Begona Valdazo-Gonzalez
- National Institute for Biological Standards and Control (NIBSC), Blanche Ln, South Mimms, Potters Bar, UK
| | - Yuan Zhao
- National Institute for Biological Standards and Control (NIBSC), Blanche Ln, South Mimms, Potters Bar, UK
| | - Christian K. Schneider
- National Institute for Biological Standards and Control (NIBSC), Blanche Ln, South Mimms, Potters Bar, UK
- Twincore Centre for Experimental and Clinical Infection Research GmbH, Hannover, Germany
| |
Collapse
|
19
|
Schep SJ, Boes M, Schutgens RE, van Vulpen LF. An update on the ‘danger theory’ in inhibitor development in hemophilia A. Expert Rev Hematol 2019; 12:335-344. [DOI: 10.1080/17474086.2019.1604213] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Sarah J. Schep
- Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Marianne Boes
- Department of Pediatrics, Laboratory of Translational Immunology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Roger E.G. Schutgens
- Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Lize F.D. van Vulpen
- Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| |
Collapse
|