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van der Zwet K, de Kovel M, Motwani J, van Geet C, Nolan B, Glosli H, Escuriola Ettingshausen C, Königs C, Kenet G, Fischer K. Bleeding control improves after switching to emicizumab: Real-world experience of 177 children in the PedNet registry. Haemophilia 2024. [PMID: 38578720 DOI: 10.1111/hae.15015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 03/20/2024] [Accepted: 03/31/2024] [Indexed: 04/07/2024]
Abstract
INTRODUCTION Despite the rapid uptake of emicizumab in the paediatric haemophilia A (HA) population, real-world data on the safety and efficacy is limited. AIM To report on bleeding and safety in paediatric patients receiving emicizumab prophylaxis. METHODS Data were extracted from the multicentre prospective observational PedNet Registry (NCT02979119). Children with haemophilia A, and ≥50 FVIII exposures or inhibitors present receiving emicizumab maintenance therapy were analysed. Data were summarized as medians with interquartile range (IQR, P25-P75). Mean (95% confidence interval (CI)), annualized (joint) bleeding rate (A(J)BR) during emicizumab and ≤2 years before emicizumab prophylaxis were modelled and compared using negative binomial regression. RESULTS Total of 177 patients started emicizumab at median 8.6 years (IQR 4.8-13.1), most had no FVIII inhibitors (64%). Follow up before emicizumab was median: 1.68 years (IQR: 1.24-1.90) and during emicizumab: 1.32 years (IQR: .94-2.11). In patients without inhibitors, mean ABR reduced after starting emicizumab from 2.41 (CI 1.98-2.95) to 1.11 (CI .90-1.36, p < .001), while AJBR reduced from.74 (CI .56-.98) to.31 (CI .21-.46, p < .001). Concordantly, in patients with inhibitors, mean ABR reduced from 5.08 (CI 4.08-6.38) to .75 (CI .56-1.01, p < .001), while AJBR reduced from 1.90 (CI 1.42-2.58) to .34 (CI .21-.56, p < .001). Five emicizumab-related adverse events were reported (3% of the cohort), including one patient with antidrug antibodies. CONCLUSION This study showed improved bleeding control compared to previous treatment and a favourable safety profile during emicizumab therapy in paediatric haemophilia A patients. TRIAL REGISTRATION Clin.gov.trial-NCT02979119.
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Affiliation(s)
- Konrad van der Zwet
- Center for Benign Haematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | | | - Jayashree Motwani
- Department of Paediatric Haematology, Birmingham Children's Hospital, Birmingham, UK
| | - Chris van Geet
- Department of Pediatrics, University of Leuven, Leuven, Belgium
| | | | - Heidi Glosli
- Centre for Rare Disorders Oslo University Hospital, Oslo, Norway
| | | | - Christoph Königs
- Department of Pediatrics and Adolescents Medicine, Clinical and Molecular Haemostasis, University Hospital Frankfurt, Frankfurt, Germany
| | - Gili Kenet
- National Hemophilia Center, Sheba Medical Center, Tel Hashomer, Israel
- The Amalia Biron Thrombosis Research Institute, Tel Aviv University, Tel Aviv, Israel
| | - Kathelijn Fischer
- Center for Benign Haematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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Carcao M, Schiavulli M, Kulkarni R, Rendo P, Foster M, Santagostino E, Casiano S, Königs C. A post hoc analysis of previously untreated patients with severe hemophilia A who developed inhibitors in the PUPs A-LONG trial. Blood Adv 2024; 8:1494-1503. [PMID: 38266154 PMCID: PMC10951906 DOI: 10.1182/bloodadvances.2023011475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 01/10/2024] [Accepted: 01/14/2024] [Indexed: 01/26/2024] Open
Abstract
ABSTRACT Inhibitor development is a major therapeutic complication for people with hemophilia. The phase 3 PUPs A-LONG study evaluated the safety and efficacy of efmoroctocog alfa (a recombinant factor VIII Fc fusion protein, herein referred to as rFVIIIFc) in previously untreated patients (PUPs) with severe hemophilia A. Male PUPs <6 years old were enrolled and received rFVIIIFc; inhibitor development was the primary end point. Post hoc analyses, including patient treatment regimen patterns and timing of inhibitor development, descriptive and Kaplan-Meier analyses of time to first inhibitor-positive test by treatment regimen and by titer, and consumption, were performed to describe patients who developed inhibitors during PUPs A-LONG. We investigated patient characteristics (eg, demographics and genotype) and nongenetic risk factors (eg, intense factor exposure and central venous access device [CVAD] placement) that may predict inhibitor development and characteristics of inhibitor development (low-titer vs high-titer inhibitor). Baseline characteristics were similarly distributed for age, race, and ethnicity across both patients who were inhibitor-positive and those who were inhibitor-negative (all P > .05). High-risk F8 variants were associated with development of high-titer inhibitors (P = .028). High-titer inhibitor development was often preceded by the presence of a low-titer inhibitor. Patients whose low-titer inhibitor progressed to a high-titer inhibitor received a higher mean dose per infusion (98.4 IU/kg, n = 5) compared with those whose low-titer inhibitor resolved spontaneously (59.2 IU/kg, n = 7; P = .033) or persisted (45.0 IU/kg, n = 5; P = .047). There was no association between CVAD placement surgery and inhibitor development. Post hoc analyses suggest that F8 genotype and dose of factor are as important as inhibitor risk factors and require further investigation. This study was registered at ClinicalTrials.gov as #NCT02234323.
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Affiliation(s)
- Manuel Carcao
- Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | | | | | | | | | | | | | - Christoph Königs
- University Hospital Frankfurt, Goethe University, Frankfurt, Germany
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Alesci RS, Goldmann G, Halimeh S, Holstein K, Königs C, Miesbach W, Pfrepper C, Olivieri M. Patient perspective on living with mild hemophilia in Germany: results from a nationwide survey. Front Med (Lausanne) 2024; 11:1347024. [PMID: 38379557 PMCID: PMC10877726 DOI: 10.3389/fmed.2024.1347024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 01/15/2024] [Indexed: 02/22/2024] Open
Abstract
Introduction The disease burden and bleeding risk of patients with mild hemophilia may be underestimated. Their health-related quality of life (QoL) may be negatively impacted by insufficient treatment and bleed-related joint damage connected to a potentially delayed diagnosis. Aim This study aims to gain information on the care reality and QoL of patients aged ≥12 years with mild hemophilia in Germany. Methods An anonymous cross-sectional patient survey using standardized questionnaires was conducted in a validated electronic patient-reported outcome system. Medical specialists, hemophilia centers, patient organizations, and support groups across Germany invited the patients. Results A total of 43 patients (35 patients with hemophilia A, 5 patients with hemophilia B, and 3 patients for whom the information was missing) with a median age of 33 years were analyzed. The median age at diagnosis was 6.0 years (interquartile range [IQR] 2.0-15.0), and the median factor activity was 14.0% (IQR 12.0-25.0). Nearly 85% of the patients received factor concentrates in the past, and the most common reasons for the treatment were surgery or joint bleeding (each 65.6%). Half of the patients who provided feedback experienced complications during bleeding episodes. Prophylactic treatment with factor concentrates was rare (10.3%). The patients had minor problems regarding their health status. Conclusion Bleeding complications and joint bleeding, in particular, may be highly underestimated in patients with mild hemophilia, highlighting a medical need in this population. Patients with a potential benefit from prophylaxis need to be identified. Mild hemophilia has a negative impact on patients' QoL. Hemophilia centers satisfied the patients' needs. Further research is needed to address the current lack of awareness and improve adequate treatment in the future.
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Affiliation(s)
| | - Georg Goldmann
- Institute of Experimental Hematology and Transfusion Medicine, University of Bonn, Bonn, Germany
| | - Susan Halimeh
- Blood Coagulation Center Rhein-Ruhr, Duisburg-Altstadt, Germany
| | - Katharina Holstein
- II. Medical Department, Coagulation and Hemophilia Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christoph Königs
- Department of Paediatrics and Adolescent Medicine, Clinical and Molecular Haemostasis, Goethe University, University Hospital Frankfurt, Frankfurt, Germany
| | - Wolfgang Miesbach
- Department of Hemostaseology and Hemophilia Center, Medical Clinic 2, University Hospital Frankfurt, Frankfurt, Germany
| | - Christian Pfrepper
- Division of Hemostaseology, Department of Hematology, Cellular Therapy, Hemostaseology and Infectiology, University of Leipzig Medical Center, Leipzig, Germany
| | - Martin Olivieri
- Pediatric Thrombosis and Hemostasis Unit, Pediatric Hemophilia Center, Dr. von Hauner Children’s Hospital, LMU München, Munich, Germany
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Fischer K, Kenet G, Kurnik K, Carcao M, Oldenburg J, Stamm-Mikkelsen T, Cid Haro AR, Koskenvuo M, Blatny J, Königs C. Determinants of bleeding before and during immune tolerance in 222 boys with severe hemophilia A and inhibitors >5 BU. Blood Adv 2024; 8:369-377. [PMID: 38214949 PMCID: PMC10820329 DOI: 10.1182/bloodadvances.2023011442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Accepted: 11/01/2023] [Indexed: 01/13/2024] Open
Abstract
ABSTRACT Prevention of bleeding and its consequences is the main goal of hemophilia treatment and determines treatment choices for patients who develop inhibitors. To assess bleeding before and during immune tolerance induction (ITI) and its association with ITI regimen and inhibitor titer, we selected and analyzed data on patients receiving high-titer inhibitors from the international prospective PedNet cohort study. In total, 222 patients with severe hemophilia A and inhibitor titers of >5 Bethesda units (BU) were followed from the first positive to the first negative inhibitor result (median overall follow-up, 1.7 years). Mean annual (joint) bleeding rates (AJBR) and 95% confidence intervals (CIs) were compared according to treatment and inhibitor titer using multivariable negative binomial regression. Before ITI, 115 patients showed an ABR of 6.1 (5.0-7.4) and an AJBR 2.6 (2.1-3.2). Bleeding was independent of inhibitor titer. During ITI, 202 patients had an ABR of 4.4 (3.9-5.1) and an AJBR of 1.7 (1.5-2.0). AJBR during ITI increased with inhibitor titer (hazard ratio [HR] for ≥200 BU vs 5 to 39 BU [4.9; CI, 3.2-7.4]) and decreased with daily ITI infusions (HR, 0.4; CI, 0.3-0.6) or activated prothrombin complex concentrate prophylaxis (HR, 0.4; CI, 0.2-0.8), whereas ITI dose and recombinant activated factor VII prophylaxis did not independently affect bleeding. These data provide evidence for a protective effect of repeated FVIII infusions (ITI) on bleeding in patients who have developed inhibitors; these data should be used to plan ITI and/or serve as a comparator for prophylaxis with nonreplacement therapy.
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Affiliation(s)
- Kathelijn Fischer
- Center for Benign Haematology, Thrombosis and Haemostasis, Van Creveldkliniek University Medical Center Utrecht, Utrecht, The Netherlands
| | - Gili Kenet
- The Israel National Hemophilia Center & Thrombosis Institute, Sheba Medical Center & The Amalia Biron Thrombosis Research Institute, Tel Aviv University, Tel Aviv-Yafo, Israel
| | - Karin Kurnik
- Department of Paediatric Haemostasis, University Children's Hospital, Munich, Germany
| | - Manuel Carcao
- Division of Haematology/Oncology, Hospital for Sick Children, Toronto, Canada
| | - Johannes Oldenburg
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Medical Faculty, University of Bonn, Bonn, Germany
| | - Torben Stamm-Mikkelsen
- Aarhus University Hospital, Department of Pediatrics and Adolescent Medicine, Aarhus, Denmark
| | - Ana Rosa Cid Haro
- Haemostasia and Thrombosis Unit, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Minna Koskenvuo
- Division of Hematology-Oncology and Stem Cell Transplantation, New Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Jan Blatny
- Department of Paediatric Haematology and Biochemistry, University Hospital and Masaryk University Brno, Brno, Czech Republic
| | - Christoph Königs
- University Hospital Frankfurt, Goethe University, Department of Pediatrics and Adolescent Medicine, Frankfurt, Germany
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Ranta S, Motwani J, Blatny J, Bührlen M, Carcao M, Chambost H, Escuriola C, Fischer K, Kartal-Kaess M, de Kovel M, Kenet G, Male C, Nolan B, d'Oiron R, Olivieri M, Zapotocka E, Andersson NG, Königs C. Dilemmas on emicizumab in children with haemophilia A: A survey of strategies from PedNet centres. Haemophilia 2023; 29:1291-1298. [PMID: 37647211 DOI: 10.1111/hae.14847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 07/30/2023] [Accepted: 08/03/2023] [Indexed: 09/01/2023]
Abstract
INTRODUCTION Haemophilia A care has changed with the introduction of emicizumab. Experience on the youngest children is still scarce and clinical practice varies between haemophilia treatment centres. AIM We aimed to assess the current clinical practice on emicizumab prophylaxis within PedNet, a collaborative research platform for paediatricians treating children with haemophilia. METHODS An electronic survey was sent to all PedNet members (n = 32) between October 2022 and February 2023. The survey included questions on the availability of emicizumab, on the practice of initiating prophylaxis in previously untreated or minimally treated patients (PUPs or MTPs) and emicizumab use in patients with or without inhibitors. RESULTS All but four centres (28/32; 88%) responded. Emicizumab was available in clinical practice in 25/28 centres (89%), and in 3/28 for selected patients only (e.g. with inhibitors). Emicizumab was the preferred choice for prophylaxis in PUPs or MTPs in 20/25 centres; most (85%) started emicizumab prophylaxis before 1 year of age (30% before 6 months of age) and without concomitant FVIII (16/20; 80%). After the loading dose, 13/28 centres administered the recommended dosing, while the others adjusted the interval of injections to give whole vials. In inhibitor patients, the use of emicizumab during ITI was common, with low-dose ITI being the preferred protocol. CONCLUSION Most centres choose to initiate prophylaxis with emicizumab before 12 months of age and without concomitant FVIII. In inhibitor patients, ITI is mostly given in addition to emicizumab, but there was no common practice on how to proceed after successful ITI.
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Affiliation(s)
- Susanna Ranta
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, Sweden and Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | | | - Jan Blatny
- Department of Paediatric Haematology and Biochemistry, University Hospital and Masaryk University, Brno, Czech Republic
| | - Martina Bührlen
- Department of Pediatrics, Klinikum Bremen Mitte, Bremen, Germany
| | - Manuel Carcao
- Haemophilia Clinic and Haemostasis Program, Division of Haematology/Oncology, Department of Paediatrics, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Hervé Chambost
- AP-HM, Department of Pediatric Hematology Oncology, Children Hospital La Timone & Aix Marseille University, INSERM, INRA, C2VN, Marseille, France
| | - Carmen Escuriola
- Haemophilie-Zentrum Rhein Main, HZRM, Mörfelden-Walldorf, Germany
| | - Kathelijn Fischer
- Center for Benign Hematology Thrombosis and Hemostasis, Van Creveldkliniek, University Medical Center, Utrecht University, Utrecht, the Netherlands
| | - Mutlu Kartal-Kaess
- Division of Pediatric Hematology & Oncology, Department of Pediatrics, Inselspital, University Hospital Bern, Bern, Switzerland
| | | | - Gili Kenet
- The National Hemophilia Center& Institute of Thrombosis & Hemostasis, Sheba Medical Center, Tel Hashomer, Israel and The Amalia Biron Research Institute of Thrombosis & Hemostasis, Tel Aviv University, Tel Aviv, Israel
| | - Christoph Male
- Department of Paediatrics, Medical University of Vienna, Vienna, Austria
| | - Beatrice Nolan
- Children's Coagulation Centre, Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Roseline d'Oiron
- Centre de Référence de l'Hémophilie et des Maladies Hémorragiques Constitutionnelles rares, Hôpital Bicêtre AP-HP, et INSERM Hémostase inflammation thrombose HITH U1176, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Martin Olivieri
- Pediatric thrombosis and Hemostasis Unit, Pediatric Hemophilia Centre, Dr. von Hauner Children´s Hospital LMU Munich, Munich, Germany
| | - Ester Zapotocka
- Department of Pediatric Hematology and Oncology, University Hospital Motol, Prague and 2nd Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Nadine G Andersson
- Center for Thrombosis and Hemostasis, Department of Clinical Sciences and Pediatrics, Skåne University Hospital, Malmö, Lund University, Lund, Sweden
| | - Christoph Königs
- Department of Paediatrics and Adolescent Medicine, Goethe University Frankfurt, Frankfurt, Germany
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Fischer K, Carcao M, Male C, Ranta S, Pergantou H, Kenet G, Kartal-Kaess M, Königs C, Carvalho M, Alvarez MT, Brakenhoff T, Chambost H, van den Berg HM. Different inhibitor incidence for individual factor VIII concentrates in 1076 previously untreated patients with severe hemophilia A: data from the PedNet cohort. J Thromb Haemost 2023; 21:700-703. [PMID: 36696215 DOI: 10.1016/j.jtha.2022.11.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 11/04/2022] [Accepted: 11/17/2022] [Indexed: 01/26/2023]
Affiliation(s)
- Kathelijn Fischer
- Center for Benign Hematology Thrombosis and Hemostasis, Van Creveldkliniek, University Medical Center, Utrecht University, The Netherlands.
| | - Manuel Carcao
- Division of Haematology/Oncology, Hospital for Sick Children, Toronto, Canada
| | - Christoph Male
- Department of Paediatrics, Medical University Hospital of Vienna, Vienna, Austria
| | - Susanna Ranta
- Pediatric Coagulation Unit, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Helen Pergantou
- Haemophilia-Haemostasis Unit, St. Sophia Children's Hospital, Athens, Greece
| | - Gili Kenet
- National Hemophilia Center, Sheba Medical Center, Tel Hashomer & Amalia Biron Research Institute of Thrombosis & Hemostasis, Tel Aviv University, Israel
| | - Mutlu Kartal-Kaess
- Division of Pediatric Hematology & Oncology, Department of Pediatrics, Inselspital, University Hospital, University of Bern, Bern, Switzerland
| | - Christoph Königs
- University Hospital Frankfurt, Department of Paediatrics and Adolescent Medicine, Frankfurt, Germany
| | - Manuela Carvalho
- Centro de Referência de Coagulopatias Congénitas do Centro Hospitalar Universitário S. João, EPE, Porto, Portugal
| | | | | | - Hervé Chambost
- Centre de Traitement de l'Hémophilie, AP-HM, Aix Marseille Université, Marseille, France
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Iorio A, Königs C, Reding MT, Rotellini D, Skinner MW, Mancuso ME, Berntorp E. Prophylaxis use of clotting factor replacement products in people with non-severe haemophilia: A review of the literature. Haemophilia 2023; 29:33-44. [PMID: 36224704 PMCID: PMC10091955 DOI: 10.1111/hae.14676] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 09/24/2022] [Accepted: 09/29/2022] [Indexed: 01/25/2023]
Abstract
INTRODUCTION People with non-severe haemophilia appear to be under-treated in many countries, and this may lead to joint damage and worsen quality of life. AIM To review literature for clotting factor replacement prophylaxis in people with non-severe haemophilia A and B (HA/HB) in relation to long-term outcomes to support clinical decision-making. METHODS A targeted literature search was performed to identify studies published between 2000 and 2021 that included prophylaxis in people with non-severe HA/HB and long-term outcomes, including annualized bleeding rates, joint health and quality of life. RESULTS Although eligible articles included 2737 and 2272 people with mild or moderate HA, respectively, only 22% (n = 609) and 29% (n = 668) reported treatment regimens. A total of 549 people with moderate HA were treated with factor replacement prophylaxis and were from high-income countries. On the contrary, nearly all people with mild HA received desmopressin (n = 599). Details of treatment regimens for women with haemophilia and people with HB were sparse. Three studies provided long-term outcomes for people with moderate haemophilia who received prophylaxis with factor concentrate, supporting early prophylaxis in people with a frequent bleeding phenotype regardless of their endogenous clotting factor level to preserve joint health. CONCLUSION There remain large knowledge gaps when considering how to provide optimal treatment for people with non-severe haemophilia. Nonetheless, there is a strong rationale that prophylaxis should be considered early in life according to similar strategies as for severe haemophilia for those with a frequent severe bleeding phenotype.
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Affiliation(s)
- Alfonso Iorio
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada.,Hamilton-Niagara Hemophilia Program, Ontario, Canada
| | - Christoph Königs
- Clinical and Molecular Hemostasis, University Hospital Frankfurt, Goethe University, Department of Paediatrics, Frankfurt am Main, Germany
| | - Mark T Reding
- Center for Bleeding and Clotting Disorders, University of Minnesota, Minneapolis, Minnesota, USA
| | | | - Mark W Skinner
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada.,Institute for Policy Advancement, Ltd., Washington, District of Columbia, USA
| | - Maria Elisa Mancuso
- Center for Thrombosis and Hemorrhagic Diseases, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Erik Berntorp
- Lund University, Skane University Hospital, Malmo, Sweden
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Astermark J, Blatný J, Königs C, Hermans C, Jiménez-Yuste V, Hart DP. Considerations for shared decision management in previously untreated patients with hemophilia A or B. Ther Adv Hematol 2023; 14:20406207231165857. [PMID: 37113810 PMCID: PMC10126613 DOI: 10.1177/20406207231165857] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 01/04/2023] [Indexed: 04/29/2023] Open
Abstract
Recent advances in therapeutics are now providing a wide range of options for adults and children living with hemophilia. Although therapeutic choices are also increasing for the youngest individuals with severe disease, challenges remain about early management decisions, as supporting data are currently limited. Parents and healthcare professionals are tasked with helping children achieve an inclusive quality of life and maintain good joint health into adulthood. Primary prophylaxis is the gold standard to optimize outcomes and is recommended to start before 2 years of age. A range of topics need to be discussed with parents to aid their understanding of the decisions they can make and how these will affect the management of their child/children. For those with a family history of hemophilia, prenatal considerations include the possibility of genetic counseling, prenatal investigations, and planning for delivery, together with monitoring of the mother and neonate, as well as diagnosis of the newborn and treatment of any birth-associated bleeding. Subsequent considerations, which are also applicable to families where infant bleeding has resulted in a new diagnosis of sporadic hemophilia, involve explaining bleed recognition and treatment options, practical aspects of initiating/continuing prophylaxis, dealing with bleeds, and ongoing aspects of treatment, including possible inhibitor development. Over time, optimizing treatment efficacy, in which individualizing therapy around activities can play a role, and long-term considerations, including retaining joint health and tolerance maintenance, become increasingly important. The evolving treatment landscape is creating a need for continually updated guidance. Multidisciplinary teams and peers from patient organizations can help provide relevant information. Easily accessible, multidisciplinary comprehensive care remains a foundation to care. Equipping parents early with the knowledge to facilitate truly informed decision-making will help achieve the best possible longer-term health equity and quality of life for the child and family living with hemophilia. Plain language summary Points to be taken into account to help families make decisions to best care for children born with hemophilia Medical advances are providing a range of treatment options for adults and children with hemophilia. There is, however, relatively limited information about managing newborns with the condition. Doctors and nurses can help parents to understand the choices for infants born with hemophilia. We describe the various points doctors and nurses should ideally discuss with families to enable informed decision-making. We focus on infants who require early treatment to prevent spontaneous or traumatic bleeding (prophylaxis), which is recommended to start before 2 years of age. Families with a history of hemophilia may benefit from discussions before pregnancy, including how an affected child would be treated to protect against bleeds. When mothers are pregnant, doctors can explain investigations that can provide information about their unborn child, plan for the birth, and monitor mother and baby to minimize bleed risks at delivery. Testing will confirm whether the baby is affected by hemophilia. Not all infants with hemophilia will be born to families with a history of the condition. Identification of hemophilia for the first time in a family (which is 'sporadic hemophilia') occurs in previously undiagnosed infants who have bleeds requiring medical advice and possibly hospital treatment. Before any mothers and babies with hemophilia are discharged from hospital, doctors and nurses will explain to parents how to recognize bleeding and available treatment options can be discussed. Over time, ongoing discussions will help parents to make informed treatment decisions:• When and how to start, then continue, prophylaxis.• How to deal with bleeds (reinforcing previous discussions about bleed recognition and treatment) and other ongoing aspects of treatment. ○ For instance, children may develop neutralizing antibodies (inhibitors) to treatment they are receiving, requiring a change to the planned approach.• Ensuring treatment remains effective as their child grows, considering the varied needs and activities of their child.
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Affiliation(s)
| | - Jan Blatný
- Department of Pediatric Hematology, University
Hospital Brno and Masaryk University, Brno, Czech Republic
| | - Christoph Königs
- Clinical and Molecular Hemostasis, Department
of Pediatrics, University Hospital Frankfurt, Goethe University, Frankfurt,
Germany
| | - Cédric Hermans
- Hemostasis and Thrombosis Unit, Division of
Hematology, Cliniques Universitaires Saint-Luc, Université catholique de
Louvain (UCLouvain), Brussels, Belgium
| | - Victor Jiménez-Yuste
- Hematology Department, Hospital Universitario
La Paz, Autónoma University, Madrid, Spain
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10
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Baumann U, Schulze Sturm U, Königs C. HIV-Infektion und -Exposition bei Kindern und Jugendlichen. Gynäkologie 2022. [PMCID: PMC9748901 DOI: 10.1007/s00129-022-05046-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Ulrich Baumann
- Klinik für Pädiatrische Pneumologie, Allergologie und Neonatologie, Bereich Immunologie, Medizinische Hochschule Hannover, Carl-Neuberg-Straße 1, 30625 Hannover, Deutschland
| | - Ulf Schulze Sturm
- Klinik für Kinder- und Jugendmedizin, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Deutschland
| | - Christoph Königs
- Klinik für Kinder- und Jugendmedizin, Universitätsklinikum Frankfurt, Theodor-Stern-Kai 7, 60596 Frankfurt am Main, Deutschland
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11
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Lyons A, Thompson L, Chappell E, Ene L, Galli L, Goetghebuer T, Jourdain G, Noguera-Julian A, Kahlert CR, Königs C, Kosalaraksa P, Lumbiganon P, Marczyńska M, Marques L, Navarro M, Naver L, Okhonskaia L, Prata F, Puthanakit T, Ramos JT, Samarina A, Thorne C, Voronin E, Turkova A, Giaquinto C, Judd A, Collins IJ. Outcomes of etravirine-based antiretroviral treatment in treatment-experienced children and adolescents living with HIV in Europe and Thailand. Antivir Ther 2022; 27:13596535221092182. [PMID: 36029009 DOI: 10.1177/13596535221092182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Etravirine (ETR) is approved as a component of second or third-line antiretroviral treatment (ART) for children living with HIV. We assessed the outcomes of ETR-based ART in children in routine care in Europe and Thailand. METHODS Data on children aged <18 years at ETR start were pooled from 17 observational cohorts. Characteristics at ETR start, immunological and virological outcomes at 12 months, discontinuations, adverse events (AEs) and serious adverse events (SAEs) were described. Follow-up was censored at ETR discontinuation, death or last visit. RESULTS 177 children ever received ETR. At ETR start, median [IQR] age was 15 [12,16] years, CD4 count 480 [287, 713] cells/mm3, 70% had exposure to ≥3 ART classes and 20% had viral load (VL) <50 copies/mL. 95% received ETR in combination with ≥1 potent drug class, mostly protease inhibitor-based regimens. Median time on ETR was 24 [7, 48] months. Amongst those on ETR at 12 months (n=141), 69% had VL<50 copies/mL. Median CD4 increase since ETR start (n=83) was 147 [16, 267] cells/mm3. Overall, 81 (46%) discontinued ETR by last follow-up. Median time to discontinuation was 23 [8, 47] months. Common reasons for discontinuation were treatment simplification (19%), treatment failure (16%) and toxicity (12%). Eight children (5%) had AEs causally associated with ETR, all dermatological/hypersensitivity reactions. Two were SAEs, both Stevens-Johnson Syndrome in children on regimens containing ETR and darunavir and were causally related to either drugs; both resolved following ART discontinuation. CONCLUSION Children receiving ETR were predominantly highly treatment-experienced, over two-thirds were virally suppressed at 12 months.
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Affiliation(s)
- Alex Lyons
- MRC Clinical Trials Unit at UCL, 4919University College London, London, UK
| | - Lindsay Thompson
- MRC Clinical Trials Unit at UCL, 4919University College London, London, UK
| | - Elizabeth Chappell
- MRC Clinical Trials Unit at UCL, 4919University College London, London, UK
| | - Luminita Ene
- Clinical Department of Infectious Diseases (HIV Department), Dr. Victor Babeș Hospital for Infectious and Tropical Diseases, Bucharest, Romania
| | - Luisa Galli
- Infectious Disease Unit, Meyer Children's Hospital, Department of Health Sciences, University of Florence, Florence, Italy
| | | | - Gonzague Jourdain
- Institut de recherche pour le développement (IRD)-PHPT, Marseille, France
- Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand
| | - Antoni Noguera-Julian
- Infectious Diseases and Systemic Inflammatory Response in Pediatrics, Infectious Diseases Unit, Department of Pediatrics, Sant Joan de Déu Hospital Research Foundation, Barcelona, Spain
| | - Christian R Kahlert
- Infectious Diseases and Hospital Epidemiology, Children's Hospital of Eastern Switzerland and Cantonal Hospital, St Gallen, Switzerland
| | - Christoph Königs
- Department for Children and Adolescents, Division for Stem Cell Transplantation and Immunology, University Hospital Frankfurt/Main, Frankfurt, Germany
| | - Pope Kosalaraksa
- Department of Pediatrics, Khon Kaen University, Khon Kaen, Thailand
| | | | - Magdalena Marczyńska
- Hospital of Infectious Diseases, 37803Medical University of Warsaw, Warsaw, Poland
| | - Laura Marques
- Centro Hospitalar e Universitário do Porto, Porto, Portugal
| | - Marissa Navarro
- Hospital General Universitario "Gregorio Marañón", Madrid, Spain
- 16734Universidad Complutense, Madrid, Spain
- 559924Instituto de Investigación Sanitaria Gregorio Marañón (IISGM), Madrid, Spain
- Red de Investigación Translacional en Infectología Pediátrica, RITIP, Madrid, Spain
| | - Lars Naver
- Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
| | - Liubov Okhonskaia
- Federal Budgetary Institution "Republican Clinical Infectious Hospital" of the Ministry of Health of the Russian Federation, Saint-Petersburg, Russian Federation
| | | | - Thanyawee Puthanakit
- Department of Pediatrics, Faculty of Medicine, 26683Chulalongkorn University and HIVNAT, Thai Red Cross AIDS Research Center, Bangkok, Thailand
| | - Jose T Ramos
- Departamento de Salud Pública y Materno-infantil, Universidad Complutense, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | - Anna Samarina
- The City HIV Centre, St Petersburg City AIDS Center, St Petersburg, Russian Federation
| | - Claire Thorne
- University College London Great Ormond Street Institute of Child Health, London, UK
| | - Evgeny Voronin
- Federal Budgetary Institution "Republican Clinical Infectious Hospital" of the Ministry of Health of the Russian Federation, Saint-Petersburg, Russian Federation
| | - Anna Turkova
- MRC Clinical Trials Unit at UCL, 4919University College London, London, UK
- 4956Great Ormond Street Hospital, London, UK
| | - Carlo Giaquinto
- 561043Paediatric European Network for the Treatment of AIDS (Penta), Padova, Italy
| | - Ali Judd
- MRC Clinical Trials Unit at UCL, 4919University College London, London, UK
| | - Intira J Collins
- MRC Clinical Trials Unit at UCL, 4919University College London, London, UK
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12
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Tiede A, Leise H, Horneff S, Oldenburg J, Halimeh S, Heller C, Königs C, Holstein K, Pfrepper C. Safety of intramuscular COVID-19 vaccination in patients with haemophilia. Haemophilia 2022; 28:687-693. [PMID: 35561276 PMCID: PMC9348084 DOI: 10.1111/hae.14586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 04/28/2022] [Accepted: 04/29/2022] [Indexed: 11/30/2022]
Abstract
Background Guidelines recommend that patients with haemophilia should preferably receive vaccination subcutaneously. COVID‐19 and other vaccines, however, are only licenced for intramuscular application. Aims To assess the safety of intramuscular COVID‐19 vaccination in patients living with haemophilia. Methods Part A of this prospective observational study enrolled consecutive patients with haemophilia A (HA) and B (HB) of all ages and severities and assessed injection site bleeding and other complications within 30 days of vaccination. Part B enrolled patients providing informed consent for detailed data collection including medication and prophylaxis around the time of vaccination. Logistic regression was performed to assess potential risk factors for bleeding. Results Four hundred and sixty‐one patients were enrolled into part A. The primary endpoint injection site bleeding occurred in seven patients (1.5%, 95% confidence interval .7–3.1%). Comprehensive analysis of 214 patients (404 vaccinations, part B) revealed that 97% of patients with severe haemophilia had prophylaxis before vaccination, either as part of their routine prophylaxis or using additional doses. 56% and 30% of patients with moderate and mild haemophilia, respectively, received prophylaxis before vaccination. Among the seven bleeds recorded, three occurred when intramuscular vaccination was done without prophylaxis (odds ratio 12). Conclusions This is the first prospective study reporting on the safety of intramuscular vaccination in haemophilia. The rate of injection site bleeding was low in mild haemophilia, and in moderate and severe haemophilia if patients received factor prophylaxis.
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Affiliation(s)
- Andreas Tiede
- Department of Haematology, Haemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Hendrik Leise
- Department of Haematology, Haemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Silvia Horneff
- Institute for Experimental Haematology and Transfusion Medicine, University Hospital Bonn, Bonn, Germany
| | - Johannes Oldenburg
- Institute for Experimental Haematology and Transfusion Medicine, University Hospital Bonn, Bonn, Germany
| | | | - Christine Heller
- Clinical and Molecular Haemostasis, Department of Paediatrics and Adolescent Medicine, University Hospital Frankfurt, Frankfurt, Germany
| | - Christoph Königs
- Clinical and Molecular Haemostasis, Department of Paediatrics and Adolescent Medicine, University Hospital Frankfurt, Frankfurt, Germany
| | | | - Christian Pfrepper
- Division of Haemostaseology, Medical Department I, University Hospital Leipzig, Leipzig, Germany
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13
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Schmidt A, Orlowski A, Salzmann‐Manrique E, Königs C. CD4
+
regulatory and naïve T cells specific for factor VIII stand vis‐à‐vis to balance the immune response in healthy individuals. eJHaem 2021; 2:805-808. [PMID: 35845215 PMCID: PMC9175863 DOI: 10.1002/jha2.319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 10/03/2021] [Accepted: 10/04/2021] [Indexed: 11/16/2022]
Affiliation(s)
- Anja Schmidt
- Department of Paediatrics and Adolescent Medicine, Clinical and Molecular Haemostasis University Hospital Frankfurt, Goethe University Frankfurt am Main Germany
| | - Aleksander Orlowski
- Department of Paediatrics and Adolescent Medicine, Clinical and Molecular Haemostasis University Hospital Frankfurt, Goethe University Frankfurt am Main Germany
| | - Emilia Salzmann‐Manrique
- Department of Paediatrics and Adolescent Medicine, Division for Stem Cell Transplantation and Immunology University Hospital Frankfurt, Goethe University Frankfurt am Main Germany
| | - Christoph Königs
- Department of Paediatrics and Adolescent Medicine, Clinical and Molecular Haemostasis University Hospital Frankfurt, Goethe University Frankfurt am Main Germany
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14
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Hermans C, Noone D, Benson G, Dolan G, Eichler H, Jiménez-Yuste V, Königs C, Lobet S, Pollard D, Zupančić-Šalek S, Mancuso ME. Hemophilia treatment in 2021: Choosing the"optimal" treatment using an integrative, patient-oriented approach to shared decision-making between patients and clinicians. Blood Rev 2021; 52:100890. [PMID: 34736780 DOI: 10.1016/j.blre.2021.100890] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 09/13/2021] [Accepted: 09/23/2021] [Indexed: 01/19/2023]
Abstract
The mainstay of hemophilia treatment is to prevent bleeding through regular long-term prophylaxis and to control acute breakthrough bleeds. Various treatment options are currently available for prophylaxis, and treatment decision-making is a challenging and multifaceted process of identifying the most appropriate option for each patient. A multidisciplinary expert panel convened to develop a practical, patient-oriented algorithm to facilitate shared treatment decision-making between clinicians and patients. Key variables were identified, and an algorithm proposed based on five variables: bleeding phenotype, musculoskeletal status, treatment adherence, venous access, and lifestyle. A complementary, patient-focused preference tool was also hypothesized, with the aim of exploring individual patients' priorities, preferences, and goals. It is hoped that the proposed algorithm and the hypothesized patient preference tool will assist in selecting a treatment for each patient that is as efficient as possible in preventing bleeds while also accounting for the patient's expectations and priorities.
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Affiliation(s)
- Cedric Hermans
- Haemostasis and Thrombosis Unit, Division of Haematology, Cliniques Universitaires Saint-Luc, Université catholique de Louvain (UCLouvain), Brussels, Belgium.
| | | | - Gary Benson
- Haemophilia and Thrombosis Centre, Belfast City Hospital, Belfast, Ireland
| | - Gerry Dolan
- Centre for Haemostasis and Thrombosis, St Thomas' Hospital, London, UK
| | - Hermann Eichler
- University and University Hospital of Saarland, Institute of Clinical Haemostaseology and Transfusion Medicine, Homburg, Saar, Germany
| | - Víctor Jiménez-Yuste
- Hospital Universitario La Paz, Unidad de Coagulopatías, Servicio de Hematología, Autonoma University, Madrid, Spain
| | - Christoph Königs
- Clinical and Molecular Haemostasis, Department of Paediatrics and Adolescent Medicine, Goethe University, Frankfurt, Germany
| | - Sébastien Lobet
- Haemostasis and Thrombosis Unit, Division of Haematology, Cliniques Universitaires Saint-Luc, Université catholique de Louvain (UCLouvain), Brussels, Belgium; Neuromusculoskeletal Lab (NMSK), Institut de Recherche Expérimentale et Clinique, Université catholique de Louvain, Brussels, Belgium
| | - Debra Pollard
- Katharine Dormandy Haemophilia & Thrombosis Centre, Royal Free London NHS Foundation Trust, London, UK
| | | | - Maria Elisa Mancuso
- Center for Thrombosis and Hemorrhagic Diseases, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
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15
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Mancuso ME, Male C, Kenet G, Kavakli K, Königs C, Blatný J, Fijnvandraat K. Prophylaxis in children with haemophilia in an evolving treatment landscape. Haemophilia 2021; 27:889-896. [PMID: 34547160 DOI: 10.1111/hae.14412] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 08/25/2021] [Accepted: 09/02/2021] [Indexed: 01/16/2023]
Abstract
INTRODUCTION For children with haemophilia, early initiation of prophylaxis is crucial to prevent life-threatening bleeds and maintain joint health throughout life. Options for prophylaxis have recently increased from replacement therapy with standard or extended half-life coagulation factor products to include other haemostasis products, such as the non-replacement therapy emicizumab. AIM To review key factors that determine the choice of prophylaxis in young children. METHODS Key clinical questions on the implementation of prophylaxis for haemophilia in children were identified and PubMed was searched for evidence supporting guidance on the implementation of prophylaxis. RESULTS The results of the literature search and the practical experience of the authors were used to build consensus on when to start prophylaxis, the pros and cons of the products available to guide the choice of product, and practical aspects of starting prophylaxis to guide the choice of regimen. CONCLUSIONS In this era of increasing therapeutic choices, available information about the range of treatment options must be considered when initiating prophylaxis in young children. Parents or care givers must be sufficiently informed to allow informed shared decision making. Although plentiful data and clinical experience have been gathered on prophylaxis with clotting factor replacement therapy, its use in young children brings practical challenges, such as the need for intravenous administration. In contrast, our relatively brief experience and limited data with subcutaneously administered non-replacement therapy (i.e., emicizumab) in this patient group imply that starting emicizumab prophylaxis in young children requires careful consideration, despite the more convenient route of administration.
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Affiliation(s)
- Maria Elisa Mancuso
- Centre for Thrombosis and Haemorrhagic Diseases, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Christoph Male
- Thrombosis & Haemostasis Unit, Department of Paediatrics, Medical University of Vienna, Vienna, Austria
| | - Gili Kenet
- The National Haemophilia Centre, The Amalia Biron Thrombosis Research Institute, Sheba Medical Centre, Tel Hashomer, Tel Aviv University, Tel Aviv, Israel
| | - Kaan Kavakli
- Department of Haematology, Ege University Faculty of Medicine, Children's Hospital, Bornova, Izmir, Turkey
| | - Christoph Königs
- Department of Paediatrics and Adolescent Medicine, Clinical and Molecular Haemostasis, University Hospital Frankfurt, Goethe University, Frankfurt, Germany
| | - Jan Blatný
- Department of Paediatric Haematology and Biochemistry, University Hospital Brno and Masaryk University, Brno, Czech Republic
| | - Karin Fijnvandraat
- Department of Paediatric Haematology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
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16
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Lobet S, Timmer M, Königs C, Stephensen D, McLaughlin P, Duport G, Hermans C, Mancuso ME. The Role of Physiotherapy in the New Treatment Landscape for Haemophilia. J Clin Med 2021; 10:jcm10132822. [PMID: 34206923 PMCID: PMC8267623 DOI: 10.3390/jcm10132822] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 06/16/2021] [Accepted: 06/23/2021] [Indexed: 12/21/2022] Open
Abstract
The physiotherapist plays an essential role for people with haemophilia, an inherited bleeding disease responsible for musculoskeletal complications. Yet, with the advent of new and advanced therapies, the medical landscape is changing, and physiotherapy must adapt alongside. This paper considers whether there will still be a need for physiotherapy in the era of advanced therapies, and discusses ways in which services should evolve to complement emerging treatment paradigms for haemostasis in people with haemophilia. Ultimately, physiotherapy will remain an important element of care, even for people with little joint damage and low risks in the era of the new mild phenotype. However, competencies will need to evolve, and physiotherapists in both primary care and specialist treatment centres should work with haematology colleagues to develop more sensitive tools for detecting early joint changes. Physiotherapists will also play a crucial role in counselling and physically coaching, monitoring the musculoskeletal status of people with haemophilia who have transitioned to new treatments.
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Affiliation(s)
- Sébastien Lobet
- Hemostasis and Thrombosis Unit, Division of Hematology, Cliniques Universitaires Saint-Luc, Avenue Hippocrate 10, 1200 Brussels, Belgium;
- Neuromusculoskeletal Lab (NMSK), Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Avenue Mounier 53, 1200 Brussels, Belgium
- Secteur de Kinésithérapie, Cliniques Universitaires Saint-Luc, Avenue Hippocrate 10, 1200 Brussels, Belgium
- Correspondence:
| | - Merel Timmer
- Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, 3584 Utrecht, The Netherlands;
| | - Christoph Königs
- Department of Paediatrics and Adolescent Medicine, Haemophilia Treatment Centre, Goethe University, 60323 Frankfurt, Germany;
| | - David Stephensen
- Kent Haemophilia Centre, East Kent Hospitals University NHS Trust, Canterbury CT1 3NG, UK;
- Haemophilia Centre, Royal London Hospital, Barts Health NHS Trust, London E1 1BB, UK
| | - Paul McLaughlin
- Katharine Dormandy Haemophilia Centre and Thrombosis Unit, Royal Free London NHS Foundation Trust, London NW3 2QG, UK;
| | - Gaetan Duport
- Association Française des Hemophiles, 75739 Paris, France;
| | - Cédric Hermans
- Hemostasis and Thrombosis Unit, Division of Hematology, Cliniques Universitaires Saint-Luc, Avenue Hippocrate 10, 1200 Brussels, Belgium;
| | - Maria Elisa Mancuso
- Center for Thrombosis and Hemorrhagic Diseases, IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy;
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17
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von Hentig N, Angioni C, Königs C. Determination of lopinavir/ritonavir concentrations in four different oral solutions for the application of antiretroviral therapy in very young, HIV-1-infected children. South Afr J HIV Med 2021; 22:1222. [PMID: 34192069 PMCID: PMC8182455 DOI: 10.4102/sajhivmed.v22i1.1222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 03/30/2021] [Indexed: 12/03/2022] Open
Affiliation(s)
- Nils von Hentig
- Internal Medicine II, HIVCENTER, Goethe University Hospital, Frankfurt, Germany
| | - Carlo Angioni
- Institute of Clinical Pharmacology, Goethe University Hospital, Frankfurt, Germany
| | - Christoph Königs
- Department of Pediatrics and Adolescent Medicine, Goethe University Hospital, Frankfurt, Germany
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18
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Pfrepper C, Holstein K, Königs C, Heller C, Krause M, Olivieri M, Bidlingmaier C, Sigl-Kraetzig M, Wendisch J, Halimeh S, Horneff S, Richter H, Wieland I, Klamroth R, Oldenburg J, Tiede A. Consensus Recommendations for Intramuscular COVID-19 Vaccination in Patients with Hemophilia. Hamostaseologie 2021; 41:190-196. [PMID: 33860513 DOI: 10.1055/a-1401-2691] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Currently available coronavirus disease 2019 (COVID-19) vaccines are approved for intramuscular injection and efficacy may not be ensured when given subcutaneously. For years, subcutaneous vaccination was recommended in patients with hemophilia to avoid intramuscular bleeds. Therefore, recommendations for the application of COVID-19 vaccines are needed. METHODS The Delphi methodology was used to develop consensus recommendations. An initial list of recommendations was prepared by a steering committee and evaluated by 39 hemophilia experts. Consensus was defined as ≥75% agreement and strong consensus as ≥95% agreement, and agreement as a score ≥7 on a scale of 1 to 9. After four rounds, a final list of statements was compiled. RECOMMENDATIONS Consensus was achieved that COVID-19 vaccines licensed only for intramuscular injection should be administered intramuscularly in hemophilia patients. Prophylactic factor replacement, given on the day of vaccination with a maximum interval between prophylaxis and vaccination of 24 hours (factor VIII and conventional factor IX concentrates) or 48 hours (half-life extended factor IX), should be provided in patients with moderate or severe hemophilia. Strong consensus was achieved that patients with mild hemophilia and residual factor activity greater than 10% with mild bleeding phenotype or patients on emicizumab usually do not need factor replacement before vaccination. Swelling, erythema, and hyperthermia after vaccination are not always signs of bleeding but should prompt consultation of a hemophilia care center. In case of injection-site hematoma, patients should receive replacement therapy until symptoms disappear. CONCLUSIONS Consensus was achieved on recommendations for intramuscular COVID-19 vaccination after replacement therapy for hemophilia patients depending on disease severity.
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Affiliation(s)
- Christian Pfrepper
- Division of Hemostaseology, Medical Department I, University Hospital Leipzig, Leipzig, Germany
| | | | - Christoph Königs
- Pediatric Hemostaseology, University Hospital Frankfurt, Frankfurt, Germany
| | - Christine Heller
- Pediatric Hemostaseology, University Hospital Frankfurt, Frankfurt, Germany
| | | | - Martin Olivieri
- Pediatric Thrombosis and Hemostasis Unit, Pediatric Hemophilia Centre, Dr. von Hauner Children's Hospital, LMU, Munich, Germany
| | - Christoph Bidlingmaier
- Pediatric Thrombosis and Hemostasis Unit, Pediatric Hemophilia Centre, Dr. von Hauner Children's Hospital, LMU, Munich, Germany
| | - Michael Sigl-Kraetzig
- Blaubeuren and Hemostasis Center South (Pediatric Practice), Institute for Pediatric Research and Further Education (IPFW), Blaubeuren, Germany
| | - Jörg Wendisch
- Health Department of the City of Dresden, Vaccination Centre, Dresden, Germany
| | | | - Silvia Horneff
- Institute for Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Bonn, Germany
| | | | - Ivonne Wieland
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Robert Klamroth
- Vascular Medicine and Haemostaseology, Vivantes Klinikum im Friedrichshain, Berlin, Germany
| | - Johannes Oldenburg
- Institute for Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Bonn, Germany
| | - Andreas Tiede
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
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19
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Chamouni P, Barbay V, Billoir P, Le Cam-Duchez V, Malassigne C, Massy N, Königs C. First observation of inhibitor development against efmoroctocog alfa in France. Transfus Apher Sci 2021; 60:103128. [PMID: 33867284 DOI: 10.1016/j.transci.2021.103128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 03/25/2021] [Accepted: 03/28/2021] [Indexed: 10/21/2022]
Abstract
In patients with severe haemophilia receiving clotting factor concentrates, the risk of immunisation against their usual treatment is still patent and feared. New haemophilia drug treatments with an extended half-life have become available over the past few years. The risk of inhibitor development to these new treatments is unclear. We report the case of a 51-year-old man with severe haemophilia A, who was previously treated with no history of inhibitor development. Soon after a switch in his treatment to efmoroctocog alfa he developed an inhibitor against this recombinant Fc fusion extended half-life FVIII (rFc-FVIII) product. The patient was on an on-demand treatment regimen and was treated for mucosal bleeding. The inhibitor was characterised as type I, with classical epitope mapping. The spontaneous evolution of this inhibitor was favourable, but an anamnestic response led to a switch in his treatment to emicizumab.
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Affiliation(s)
- Pierre Chamouni
- Department of Haematology, Haemophilia Care Centre, Rouen University Hospital, France.
| | - Virginie Barbay
- Department of Haematology, Haemophilia Care Centre, Rouen University Hospital, France
| | - Paul Billoir
- Department of Haematology, Haemophilia Care Centre, Rouen University Hospital, France
| | | | - Céline Malassigne
- Department of Haematology, Haemophilia Care Centre, Rouen University Hospital, France; Department of Haematology, Le Havre Hospital, France
| | - Nathalie Massy
- Department of Pharmacology, Rouen University Hospital, France
| | - Christoph Königs
- Department of Paediatrics, Clinical and Molecular Haemostasis, Frankfurt University Hospital, Frankfurt am Main, Germany
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20
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Male C, Andersson NG, Rafowicz A, Liesner R, Kurnik K, Fischer K, Platokouki H, Santagostino E, Chambost H, Nolan B, Königs C, Kenet G, Ljung R, Van den Berg M. Inhibitor incidence in an unselected cohort of previously untreated patients with severe haemophilia B: a PedNet study. Haematologica 2021; 106:123-129. [PMID: 31919092 PMCID: PMC7776246 DOI: 10.3324/haematol.2019.239160] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Accepted: 01/09/2020] [Indexed: 12/20/2022] Open
Abstract
The incidence of factor IX (FIX) inhibitors in severe hemophilia B (SHB) is not well defined. Frequencies of 3-5% have been reported but most studies to date have been small, including patients with different severities, and without prospective follow up for inhibitor incidence. The study objective was to investigate the inhibitor incidence in patients with SHB followed up for to 500 exposure days (ED), the frequency of allergic reactions, and the relationship with genotypes. Consecutive previously untreated patients (PUP) with SHB enrolled into the PedNet cohort were included. Detailed data was collected for the first 50 ED, followed by the annual collection of the inhibitor status and allergic re-actions. The presence of inhibitors was defined by at least two consecutive positive samples. Additionally, data on FIX gene mutation was collected. One hundred and fifty-four PUP with SHB were included; 75% were followed up until 75 ED, and 43% until 500 ED. Inhibitors developed in 14 patients (seven high-titer). The median number of ED at inhibitor manifestation was 11 (interquartile range [IQR]: 6.5-36.5). The cumulative inhibitor incidence was 9.3% (95% Confidence Interval [CI]: 4.4-14.1) at 75 ED, and 10.2% (95% CI: 5.1-15.3) at 500 ED. Allergic reactions occurred in four (28.6%) inhibitor patients. Missense mutations were most frequent (46.8%) overall but not associated with inhibitors. Nonsense mutations and deletions with large structural changes comprised all mutations among inhibitor patients and were associated with an inhibitor risk of 26.9% and 33.3%, respectively. In an unselected, well-defined cohort of PUP with SHB, the cumulative inhibitor incidence was 10.2% at 500 ED. Nonsense mutations and large deletions were strongly associated with the risk of inhibitor development. The ‘PedNet Registry’ is registered at clinicaltrials.gov; identifier: NCT02979119.
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Affiliation(s)
| | - Nadine G Andersson
- Centre for Thrombosis and Hemostasis, Skane University Hospital, Malmö, Sweden
| | | | - Ri Liesner
- Hemophilia Center, Dept. of Hematology, Great Ormond Street Hospital for Children, London
| | - Karin Kurnik
- Dr. V. Haunersches Kinderspital, University of Munich
| | | | - Helen Platokouki
- Haemophilia-Haemostasis Unit, St. Sophia Children Hospital, Athens
| | | | - Hervé Chambost
- APHM, La Timone Children Hospital, Center for Bleeding Disorders, Marseille
| | - Beatrice Nolan
- Department of Paediatric Hematology, Children Health Ireland at Crumlin, Dublin
| | - Christoph Königs
- J.W. Goethe University Hospital, Department of Pediatrics, Frankfurt
| | - Gili Kenet
- National Hemophilia Center, Ministry of Health, Sheba Medical Center, Tel Hashomer, Israel
| | - Rolf Ljung
- Department of Clinical Sciences, Department of Pediatrics, Lund University, Lund, Sweden
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21
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Schüttfort G, Höfler S, Kann G, Königs C, de Leuw P, Herrmann E, Stephan C, Haberl A. Influence of tenofovir exposure in utero on primary dentition. Eur J Pediatr 2020; 179:1761-1768. [PMID: 32424746 DOI: 10.1007/s00431-020-03660-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 03/24/2020] [Accepted: 04/22/2020] [Indexed: 12/11/2022]
Abstract
Tenofovir disoxoproxil fumarate (TDF) is recommended for antiretroviral treatment for pregnant women living with HIV. As a comparative method to study bone density, we investigated the influence of in utero tenofovir exposure on the prevalence and distribution of developmental defects of enamel (DDE) in the primary dentition, as the mineralization process in teeth is higher and more complex and thus more vulnerable. HIV-exposed children with in utero exposition to tenofovir were included in this prospective observational single-center study. Dental status and enamel defects were assessed by an experienced dentist following a standardized protocol. Further information was collected using a standardized questionnaire, available in German and English. The prevalence of developmental defects in children with intrauterine tenofovir exposure was compared with literature data from a recent study of 377 healthy children in Germany and literature data from a study of 1221 healthy African children. Thirty-one children (mean age 2.1 ± 0.3 years; 41.9% female) were included. Median tenofovir exposure in utero was 28 weeks (mean ± 10.52 SD). Prevalence of developmental defects in the primary dentition in tenofovir-exposed children was similar compared to data of unexposed children (16.1% vs. 5.3%, p = 0.051 (compared to German cohort); 16.1% vs. 33.3%, p = 0.068 (compared to African cohort)).Conclusion: HIV-uninfected infants with in utero exposure to TDF showed no significant differences in the prevalence of DDE in comparison to cross-sectional data of HIV- and TDF-unexposed children; thus, the in utero exposure to TDF did not negatively influence the prevalence or distribution of DDE. What is Known: • There are no data available on the prevalence of developmental defects of enamel (DDE) in the primary dentition in intrauterine HIV- and tenofovir-exposed children. • Conclusions can be drawn from intrauterine milk tooth development to bone development and mineralization. What is New: • Prevalence of developmental defects in the primary dentition in tenofovir-exposed children was similar compared to data of unexposed children. • Preterm birth and hospitalization did not show a significant association on the prevalence of developmental defects in the primary dentition.
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Affiliation(s)
- Gundolf Schüttfort
- Department for Infectious Diseases, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany.
| | - Stephan Höfler
- Department for Infectious Diseases, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany
| | - Gerrit Kann
- Department for Infectious Diseases, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany
| | - Christoph Königs
- Department of Pediatrics and Adolescent Medicine, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany
| | - Philipp de Leuw
- Department for Infectious Diseases, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany
| | - Eva Herrmann
- Department for Biostatistics and Mathematical Modelling, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany
| | - Christoph Stephan
- Department for Infectious Diseases, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany.,Department for Biostatistics and Mathematical Modelling, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany
| | - Annette Haberl
- Department for Infectious Diseases, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany.,Department for Biostatistics and Mathematical Modelling, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany
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22
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De Paula Pohl A, Schmidt A, Zhang AH, Maldonado T, Königs C, Scott DW. Engineered regulatory T cells expressing myelin-specific chimeric antigen receptors suppress EAE progression. Cell Immunol 2020; 358:104222. [PMID: 33053469 DOI: 10.1016/j.cellimm.2020.104222] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 09/11/2020] [Accepted: 09/18/2020] [Indexed: 12/25/2022]
Abstract
The expansion of polyclonal T regulatory cells (Tregs) offers great promise for the treatment of immune-mediated diseases, such as multiple sclerosis (MS). However, polyclonal Tregs can be non-specifically immunosuppressive. Based on the advancements with chimeric antigen receptor (CAR) therapy in leukemia, we previously engineered Tregs to express a T-cell receptor (TCR) specific for a myelin basic protein (MBP) peptide. These TCR-engineered specific Tregs suppressed the proliferation of MBP-reactive T effector cells and ameliorated myelin oligodendrocyte glycoprotein (MOG)-induced experimental autoimmune encephalomyelitis (EAE). Herein, we extend this approach by creating human regulatory T cells expressing functional single-chain chimeric antigen receptors (scFv CAR), targeting either MBP or MOG. These scFv CAR-transduced Tregs retained FoxP3 and Helios, characteristic of Treg cells, after long-term expansion in vitro. Importantly, these engineered CNS targeting CAR-Tregs were able to suppress autoimmune pathology in EAE, demonstrating that these Tregs have the potential to be used as a cellular therapy for MS patients.
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Affiliation(s)
- Alessandra De Paula Pohl
- Department of Medicine, Uniformed Services University of the Health and Sciences, Bethesda, MD, United States
| | - Anja Schmidt
- Department of Pediatrics, Molecular Hemostasis and Immunodeficiency, University Hospital Frankfurt, Goethe University, Frankfurt, Germany
| | - Ai-Hong Zhang
- Department of Medicine, Uniformed Services University of the Health and Sciences, Bethesda, MD, United States
| | - Tania Maldonado
- Department of Medicine, Uniformed Services University of the Health and Sciences, Bethesda, MD, United States
| | - Christoph Königs
- Department of Pediatrics, Molecular Hemostasis and Immunodeficiency, University Hospital Frankfurt, Goethe University, Frankfurt, Germany
| | - David W Scott
- Department of Medicine, Uniformed Services University of the Health and Sciences, Bethesda, MD, United States.
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23
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Escuriola-Ettingshausen C, Auerswald G, Königs C, Kurnik K, Scholz U, Klamroth R, Oldenburg J. Optimizing the management of patients with haemophilia A and inhibitors in the era of emicizumab: Recommendations from a German expert panel. Haemophilia 2020; 27:e305-e313. [PMID: 32937002 DOI: 10.1111/hae.14010] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 04/02/2020] [Accepted: 04/06/2020] [Indexed: 12/14/2022]
Abstract
Standard treatment of haemophilia A is based on replacing the missing coagulation factor VIII (FVIII) to treat and prevent bleeding episodes. The most challenging complication of FVIII therapy is the development of neutralizing antibodies (inhibitors) that can render treatment ineffective. Eradication of the inhibitor through immune tolerance induction (ITI) remains the most effective strategy for managing these patients. Bypassing agents can be used to help restore haemostasis in inhibitor patients. Several novel agents have recently been developed, such as the FVIII mimetic agent emicizumab, which has been effective in reducing the annualized bleeding rate in haemophilia A patients with inhibitors. When coadministered with repetitive high doses of activated prothrombin complex concentrate (ie >100 U/kg/d for ≥24 hours), emicizumab was associated with thrombotic microangiopathy and thrombosis events. As a consequence the United Kingdom Haemophilia Centres Doctors' Organisation (UKHCDO) issued the first guidance on the treatment of bleeding episodes in patients receiving emicizumab. To build on and extend this work, a panel of German haemophilia specialists met to discuss the UK guidance, review current evidence and provide additional guidance for German healthcare professionals on how to optimize the management of patients with haemophilia A receiving emicizumab. Recommendations are provided on the use of bypassing and other agents to manage breakthrough bleeding, ITI in the emicizumab era, haemostatic support during surgery and issues relating to laboratory monitoring.
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Affiliation(s)
| | - Günter Auerswald
- Department of Comprehensive Care in Haemostasis and Thrombosis, Professor Hess Children's Hospital, Bremen, Germany
| | - Christoph Königs
- Department of Pediatrics and Adolescent Medicine, Centre for Hemostasis, University Hospital Frankfurt, Frankfurt, Germany
| | - Karin Kurnik
- Department of Paediatric Haemostasis, University Children's Hospital, Munich, Germany
| | | | - Robert Klamroth
- Department for Internal Medicine, Vascular Medicine and Haemostaseology, Vivantes Klinikum, Berlin, Germany
| | - Johannes Oldenburg
- Institute of Experimental Hematology and Transfusion Medicine, University Clinic Bonn, Bonn, Germany
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24
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Holstein K, Albisetti M, Bidlingmaier C, Halimeh S, Heine S, Klamroth R, Königs C, Kurnik K, Male C, Oldenburg J, Streif W, Wermes C, Escuriola-Ettingshausen C. Practical Guidance of the GTH Haemophilia Board on the Use of Emicizumab in Patients with Haemophilia A. Hamostaseologie 2020; 40:561-571. [PMID: 32588417 DOI: 10.1055/a-1127-6476] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Emicizumab has been approved for bleeding prophylaxis in patients with haemophilia A (PWHAs) with or without inhibitors. Because of substantial differences between factor VIII (FVIII) and Emicizumab, the 'Ständige Kommission Hämophilie' of the German, Austrian, Swiss Society for Thrombosis and Haemostasis Research (GTH) established a practical guidance for the use of Emicizumab in PWHAs. A systematic literature research was conducted in PubMed. Based on this and on personal experience, this practical guidance has been developed. Each single statement has been discussed among members of the 'Ständige Kommission Hämophilie' and revised accordingly. The final set of recommendations has been approved by all authors analogous to the Delphi method. This practical guidance is provided for physicians treating PWHAs with regard to general aspects, patient education, bleeding treatment, surgery, use of Emicizumab in previously untreated patients (PUPs), patients with newly diagnosed inhibitors and elderly patients. Patients should be treated in expert centres and adequate laboratory tests to monitor Emicizumab levels, FVIII replacement and inhibitors should be available. Early experience of immune tolerance induction protocols integrating Emicizumab is reviewed, and the limited experience in PUPs and very young children is described. So far, no thromboembolic complications have been reported with the concomitant use of FVIII or recombinant activated FVII for bleeding treatment or surgery. Activated prothrombin complex concentrate doses of >100 U/kg for >24 hours should be avoided whenever possible because of the high risk of thrombosis and/or thrombotic microangiopathy. In conclusion, this study is designed to support haemophilia physicians using Emicizumab in physicians treating hemophilia and using (PWHAs). With further post-marketing experience and trials, regular updates are necessary.
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Affiliation(s)
- Katharina Holstein
- Haematology and Clinical Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Manuela Albisetti
- Division of Hematology, University Children's Hospital, Zurich, Switzerland
| | - Christoph Bidlingmaier
- Centre for Development and Complex Chronic Diseases in Children (iSPZHauner), Department of Paediatrics, Paediatric Haemophilia Centre, LMU Munich, Munich, Germany
| | | | - Sabine Heine
- Department of Paediatric Oncology/Haematology, Saarland University Hospital, Homburg, Germany
| | - Robert Klamroth
- Internal Medicine, Angiology and Haemostaseology, Haemophilia Centre, Vivantes Hospital Friedrichshain, Berlin, Germany
| | - Christoph Königs
- Department of Paediatrics and Adolescent Medicine, University Hospital Frankfurt, Goethe University, Frankfurt, Germany
| | - Karin Kurnik
- Paediatric Haemophilia Centre, Department of Paediatrics, LMU Munich, Munich, Germany
| | - Christoph Male
- Department of Paediatrics, Medical University of Vienna, Vienna, Austria
| | - Johannes Oldenburg
- Institute for Experimental Haematology and Transfusion Medicine, University Hospital Bonn, Bonn, Germany
| | - Werner Streif
- Department of Paediatrics 1, Medical University of Innsbruck (MUI), Innsbruck, Austria
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25
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van den Berg HM, Mancuso ME, Königs C, D'Oiron R, Platokouki H, Mikkelsen TS, Motwani J, Nolan B, Santagostino E. ITI Treatment is not First-Choice Treatment in Children with Hemophilia A and Low-Responding Inhibitors: Evidence from a PedNet Study. Thromb Haemost 2020; 120:1166-1172. [PMID: 32572865 DOI: 10.1055/s-0040-1713097] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Limited data exist on the clinical impact of low-responding inhibitors and the requirement for immune tolerance induction (ITI) treatment to establish tolerance, reduce bleeding, and improve outcome. The aim of this article is to describe the therapeutic management of children with severe hemophilia A and low-responding inhibitors and its effect on bleeding phenotype. METHODS The REMAIN (Real-life Management of Inhibitors) study is a satellite study of the PedNet registry. It included unselected children with severe hemophilia A (factor VIII [FVIII] < 0.01 IU/mL) born between January 1, 1990 and December 31, 2009 who developed clinically relevant inhibitors and were followed-up for at least 3 years after the first positive inhibitor test. RESULTS A total of 260 patients with inhibitors were identified and 68 of them (26%) had low-responding inhibitors (peak < 5 BU/mL). Five patients were lost to follow-up and 63 were included in this study. The median follow-up was 3.7 years (interquartile range: 3.0-7.5). ITI was started in 51/63 (81%) patients. The median time from ITI start to first negative inhibitor titer was similar with low-dose and high-dose ITI regimens (2.5 and 3.1 months, respectively). Ten of the 12 patients who did not receive ITI were treated with regular prophylaxis and reached a negative titer after a median of 6.5 months. Bleeding rate was low in all patients with no difference between treatment regimens. CONCLUSION In children with low-responding inhibitors negative titers were reached with regular FVIII treatment irrespective of the regimen (i.e., prophylaxis or ITI).
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Affiliation(s)
| | - Maria Elisa Mancuso
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Ospedale Maggiore Policlinico, Fondazione IRCCS Ca' Granda, Milan, Italy
| | - Christoph Königs
- Department of Paediatrics and Adolescent Medicine, University Hospital Frankfurt, Frankfurt, Germany
| | - Roseline D'Oiron
- Centre de Référence pour le Traitement des Maladies Hémorragiques, Hôpital Bicêtre, Paris, France
| | - Helen Platokouki
- Haemophilia Centre, Haemostasis Unit, "Aghia Sophia" Children's Hospital, Athens, Greece
| | - Torben Stamm Mikkelsen
- Division of Pediatric and Adolescent Medicine, Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Jayashree Motwani
- Haematology Department, Birmingham Women's and Children's Hospital, Birmingham, United Kingdom
| | | | - Elena Santagostino
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Ospedale Maggiore Policlinico, Fondazione IRCCS Ca' Granda, Milan, Italy
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26
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Karim AF, Soltis AR, Sukumar G, Königs C, Ewing NP, Dalgard CL, Wilkerson MD, Pratt KP. Hemophilia A Inhibitor Subjects Show Unique PBMC Gene Expression Profiles That Include Up-Regulated Innate Immune Modulators. Front Immunol 2020; 11:1219. [PMID: 32595650 PMCID: PMC7303277 DOI: 10.3389/fimmu.2020.01219] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 05/15/2020] [Indexed: 12/18/2022] Open
Abstract
Formation of pathological anti-FVIII antibodies, or "inhibitors," is the most serious complication of therapeutic FVIII infusions, affecting up to 1/3 of severe Hemophilia A (HA) patients. Inhibitor formation is a classical T-cell dependent adaptive immune response. As such, it requires help from the innate immune system. However, the roles of innate immune cells and mechanisms of inhibitor development vs. immune tolerance, achieved with or without Immune Tolerance Induction (ITI) therapy, are not well-understood. To address these questions, temporal transcriptomics profiling of FVIII-stimulated peripheral blood mononuclear cells (PBMCs) was carried out for HA subjects with and without a current or historic inhibitor using RNA-Seq. PBMCs were isolated from 40 subjects in the following groups: HA with an inhibitor that resolved either following ITI or spontaneously; HA with a current inhibitor; HA with no inhibitor history and non-HA controls. PBMCs were stimulated with 5 nM FVIII and RNA was isolated 4, 16, 24, and 48 h following stimulation. Time-series differential expression analysis was performed and distinct transcriptional signatures were identified for each group, providing clues as to cellular mechanisms leading to or accompanying their disparate anti-FVIII antibody responses. Subjects with a current inhibitor showed differential expression of 56 genes and a clustering analysis identified three major temporal profiles. Interestingly, gene ontology enrichments featured innate immune modulators, including NLRP3, TLR8, IL32, CLEC10A, and COLEC12. NLRP3 and TLR8 are associated with enhanced secretion of the pro-inflammatory cytokines IL-1β and TNFα, while IL32, which has several isoforms, has been associated with both inflammatory and regulatory immune processes. RNA-Seq results were validated by RT-qPCR, ELISAs, multiplex cytokine analysis, and flow cytometry. The inflammatory status of HA patients suffering from an ongoing inhibitor includes up-regulated innate immune modulators, which may act as ongoing danger signals that influence the responses to, and eventual outcomes of, ITI therapy.
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Affiliation(s)
- Ahmad Faisal Karim
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, United States.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, United States
| | - Anthony R Soltis
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, United States.,Collaborative Health Initiative Research Program, Henry Jackson Foundation for the Advancement of Military Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, United States.,The American Genome Center, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | - Gauthaman Sukumar
- Collaborative Health Initiative Research Program, Henry Jackson Foundation for the Advancement of Military Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, United States.,The American Genome Center, Uniformed Services University of the Health Sciences, Bethesda, MD, United States.,Department of Anatomy, Physiology & Genetics, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | | | - Nadia P Ewing
- City of Hope National Medical Center, Duarte, CA, United States
| | - Clifton L Dalgard
- Collaborative Health Initiative Research Program, Henry Jackson Foundation for the Advancement of Military Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, United States.,The American Genome Center, Uniformed Services University of the Health Sciences, Bethesda, MD, United States.,Department of Anatomy, Physiology & Genetics, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | - Matthew D Wilkerson
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, United States.,Collaborative Health Initiative Research Program, Henry Jackson Foundation for the Advancement of Military Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, United States.,The American Genome Center, Uniformed Services University of the Health Sciences, Bethesda, MD, United States.,Department of Anatomy, Physiology & Genetics, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | - Kathleen P Pratt
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
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27
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Miesbach W, Kittler S, Bauhofer A, Königs C, Becker T, Nemes L, Staus A, Schüttrumpf J. Long-term analysis of the benefit of prophylaxis for adult patients with severe or moderate haemophilia A. Haemophilia 2020; 26:467-477. [PMID: 32293085 DOI: 10.1111/hae.13988] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 03/02/2020] [Accepted: 03/16/2020] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Prophylaxis with factor VIII (FVIII) concentrates in children with haemophilia A (HA) is current standard of care. The benefit of prophylactic treatment for adult HA patients is not commonly accepted. AIM To investigate the benefit of prophylaxis over on-demand treatment in adult and elderly patients with severe or non-severe HA in a real-life setting. METHODS Data from 163 patients comprising 1202 patient-years were evaluated for 7.5 (±5.3) years. The effects on the annual bleeding rate (ABR, including spontaneous and traumatic bleeds) of treatment with a plasma-derived FVIII concentrate, the patient's age and disease severity were investigated. The effect of changing the treatment from on demand to continuous prophylaxis on the patients' ABRs was further analysed. RESULTS Prophylaxis had the greatest effect on the ABRs of patients of any age with severe or non-severe HA. The difference in ABR of all patients treated on demand (median 31.4; interquartile range (IQR) 27.6; N = 83) compared with those treated prophylactically (median 1.3; IQR 3.6; N = 122) was statistically significant (P < .05), even for patients with non-severe HA (median 8.4; IQR 15.5; N = 11) vs median 1.5; IQR 4.2 (N = 17), P < .05). Patients, aged up to 88 years, switching from on demand to continuous prophylaxis showed the lowest median ABR (1.1; N = 51) after their regimen change. CONCLUSION Any (even low-frequency) prophylaxis results in lower ABR than on-demand treatment. Patients switching to prophylaxis benefitted the most, irrespective of age or HA severity. Prophylactic treatment-even tertiary-is the regimen of choice for patients of any age, including elderly patients, with severe or non-severe HA.
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Affiliation(s)
- Wolfgang Miesbach
- Haemophilia Centre, Medical Clinic 2, Institute of Transfusion Medicine, University Hospital Frankfurt, Frankfurt/Main, Germany
| | | | | | - Christoph Königs
- Haemophilia Centre, Department of Paediatrics, University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany
| | | | - László Nemes
- National Haemophilia Centre and Haemostasis Department, Medical Centre, Hungarian Defence Forces, Budapest, Hungary
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Türkantoz H, Königs C, Knöbl P, Klamroth R, Holstein K, Huth-Kühne A, Heinz J, Eichler H, Tiede A. Cross-reacting inhibitors against recombinant porcine factor VIII in acquired hemophilia A: Data from the GTH-AH 01/2010 Study. J Thromb Haemost 2020; 18:36-43. [PMID: 31448877 DOI: 10.1111/jth.14618] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 08/22/2019] [Indexed: 02/05/2023]
Abstract
BACKGROUND Recombinant porcine factor VIII (rpFVIII, OBI-1, susoctocog alfa) is used for the treatment of acute bleeds in patients with acquired hemophilia A (AHA). Inhibitors in AHA can sometimes cross-react with rpFVIII. OBJECTIVES To assess the frequency, strength, and determinants of cross-reactivity. PATIENTS/METHODS Baseline samples from 70 patients of the prospective, observational cohort study GTH-AH 01/2010 were assessed for anti-human FVIII and anti-rpFVIII inhibitors using modified Nijmegen-Bethesda assays, as well as anti-human FVIII domain reactivity using enzyme-linked immunoassay (ELISA). RESULTS Anti-human FVIII inhibitors were present in all samples ranging between 0.7 and 3891 Bethesda Units (BU)/mL. Inhibitors from 31 of 70 patients (44%) partially inhibited rpFVIII with anti-rpFVIII titers ranging between 0.5 and 471 BU/mL. Anti-rpFVIII titers were ≤5 BU in most patients. Patients with cross-reacting inhibitors, as compared to patients without, had significantly higher anti-human FVIII titers (27.8 versus 5.4 BU/mL) and lower baseline FVIII activity (<1 versus 2.6 IU/dL). The ratio between anti-rpFVIII to anti-human titers was highest for inhibitors involving the C1 domain. Cross-reactivity was very rare, if inhibitors reacted only with the C2 domain of FVIII (6%). An anti-human FVIII titer of >100 BU/mL predicted cross-reactivity with 97% likelihood, whereas an anti-human FVIII titer of <3.8 BU/mL predicted absent cross-reactivity with 90% likelihood. CONCLUSION Cross-reacting inhibitors should be considered when choosing a treatment for bleeding patients with AHA. Cross-reactivity is frequent in patients with anti-human FVIII titers of >100 BU/mL.
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Affiliation(s)
- Halet Türkantoz
- Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Christoph Königs
- Department of Pediatrics, Clinical and Molecular Hemostasis, University Hospital, Goethe University, Frankfurt am Main, Germany
| | - Paul Knöbl
- Hematology and Hemostasis, Vienna Medical University, Vienna, Austria
| | - Robert Klamroth
- Internal Medicine, Vivantes Clinic Friedrichshain, Berlin, Germany
| | - Katharina Holstein
- Hematology and Clinical Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Angela Huth-Kühne
- Hemophilia Care Center, SRH Kurpfalzkrankenhaus Heidelberg, Heidelberg, Germany
| | - Jürgen Heinz
- Hematology and Oncology, Freiburg University Hospital, Freiburg, Germany
| | - Hermann Eichler
- Institute of Clinical Hemostaseology and Transfusion Medicine, Saarland University and Saarland University Hospital, Homburg/Saar, Germany
| | - Andreas Tiede
- Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
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Türkantoz H, Vollack N, Varnholt D, Königs C, Tiede A. Neutralizationof Porcine Recombinant Factor VIII (Susoctocog Alfa) in Acquired Hemophilia A (AHA): Data from the GTH-AH 01/2010 Study. Hamostaseologie 2019. [DOI: 10.1055/s-0039-3400728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Affiliation(s)
- Halet Türkantoz
- Klinik für Hämatologie, Hämostaseologie, Onkologie und Stammzelltransplantation, Medizinische Hochschule Hannover, Hannover, Germany
| | - Nadine Vollack
- Klinik für Hämatologie, Hämostaseologie, Onkologie und Stammzelltransplantation, Medizinische Hochschule Hannover, Hannover, Germany
| | - Dirk Varnholt
- Klinik für Hämatologie, Hämostaseologie, Onkologie und Stammzelltransplantation, Medizinische Hochschule Hannover, Hannover, Germany
| | - Christoph Königs
- Zentrum für Kinderund Jugendmedizin, Johann-Wolfgang- Goethe-Universität Frankfurt/M., Frankfurt, Germany
| | - Andreas Tiede
- Klinik für Hämatologie, Hämostaseologie, Onkologie und Stammzelltransplantation, Medizinische Hochschule Hannover, Hannover, Germany
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Pfrepper C, Krause M, Sigl-Kraetzig M, Königs C, Wendisch J, Olivieri M. Impfungen bei Patienten mit Blutgerinnungsstörungen – eine Online-Umfrage hämostaseologisch tätiger Ärzte in Deutschland. Hamostaseologie 2019. [DOI: 10.1055/s-0039-3400720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Affiliation(s)
- Christian Pfrepper
- Abteilung für Hämostaseologie, Universitätsklinikum Leipzig, Leipzig, Germany
| | - Manuela Krause
- Fachbereich Hämostaseologie, DKD HELIOS Klinik Wiesbaden, Wiesbaden, Germany
| | | | - Christoph Königs
- Gerinnungszentrum, Klinik für Kinder- und Jugendmedizin Frankfurt, Frankfurt, Germany
| | - Jörg Wendisch
- Impfstelle des Gesundheitsamtes Dresden, Dresden, Germany
| | - Martin Olivieri
- Zentrum für Hämostaseologie, Kinderklinik im Dr. v. Haunerschen Kinderspital München, München, Germany
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31
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Bidlingmaier C, Escuriola-Ettingshausen C, Kentouche K, Olivieri M, Eberl W, Zieger B, Kurnik K, Königs C, Studiengruppe FDGEPHARD. Die German Pediatric Hemophilia Research Database (GEPHARD) – Update 2018. Hamostaseologie 2019. [DOI: 10.1055/s-0039-3400719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Affiliation(s)
- Christoph Bidlingmaier
- Integriertes Sozialpädiatrisches Zentrum im Dr. v. Haunerschen Kinderspital, München, Germany
| | | | | | - Martin Olivieri
- Dr. v. Haunersches Kinderspital, Klinikum der Universität München, München, Germany
| | | | | | - Karin Kurnik
- Dr. v. Haunersches Kinderspital, Klinikum der Universität München, München, Germany
| | - Christoph Königs
- Universitätskinderklinik Frankfurt am Main, Frankfurt am Main, Germany
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32
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Kittler SFK, Miesbach W, Bauhofer A, Becker T, Schüttrumpf J, Dubovy P, Nemes L, Richter H, Königs C. Long-Term Safety and Efficacy Data of a Plasma-Derived Factor VIII Concentrate with von Willebrand Factor for Treatment of Patients with Hemophilia A Covering 18 Years. Hamostaseologie 2019; 39:360-367. [DOI: 10.1055/s-0039-1698810] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
AbstractWe describe the results of the (to our knowledge) longest long-term noninterventional study so far performed to obtain real-life data on the treatment of hemophilia A patients with a single plasma-derived FVIII concentrate containing von Willebrand factor (pdFVIII; Haemoctin/Faktor VIII SDH Intersero). A total of 198 patients (146 in Germany and 52 in Hungary), of whom 160 had severe and 38 nonsevere hemophilia A, representing all age groups (0–88 years; mean ∼25 years at inclusion) were analyzed during prophylactic or on-demand treatment over 18 years (overall 1,418 patient-years; mean >7 years). pdFVIII was very effective and well tolerated. The mean annual bleeding rate, including spontaneous and traumatic bleeds, was considerably lower for patients treated prophylactically (mean 5.4; median 3.1) than for patients treated on demand (mean 26.1; median 21.9). Inhibitors were found in 13% (3/23) and high-titer inhibitors in 4% (1/23) of previously untreated patients with severe hemophilia A. Four previously treated patients with severe hemophilia A developed inhibitors, thereof three high-titer inhibitors (3.3 and 2.5 high-titer inhibitors in 1,000 patient-years). No unexpected adverse effect on the health of the patients, no pdFVIII-related thrombosis, thromboembolic event, or hypersensitivity reaction, and no suspected viral transmission related to pdFVIII were documented.
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Affiliation(s)
| | - Wolfgang Miesbach
- Hemophilia Center, Institute of Transfusion Medicine, University Hospital Frankfurt, Frankfurt/Main, Germany
| | | | | | | | | | - László Nemes
- National Hemophilia Center and Hemostasis Department, Medical Center, Hungarian Defence Forces, Budapest, Hungary
| | | | - Christoph Königs
- Department of Pediatrics, Hemophilia Center, Goethe University, University Hospital Frankfurt, Frankfurt/Main, Germany
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Bachelet D, Albert T, Mbogning C, Hässler S, Zhang Y, Schultze-Strasser S, Repessé Y, Rayes J, Pavlova A, Pezeshkpoor B, Liphardt K, Davidson JE, Hincelin-Méry A, Dönnes P, Lacroix-Desmazes S, Königs C, Oldenburg J, Broët P. Risk stratification integrating genetic data for factor VIII inhibitor development in patients with severe hemophilia A. PLoS One 2019; 14:e0218258. [PMID: 31194850 PMCID: PMC6564000 DOI: 10.1371/journal.pone.0218258] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Accepted: 05/29/2019] [Indexed: 12/20/2022] Open
Abstract
Replacement therapy in severe hemophilia A leads to factor VIII (FVIII) inhibitors in 30% of patients. Factor VIII gene (F8) mutation type, a family history of inhibitors, ethnicity and intensity of treatment are established risk factors, and were included in two published prediction tools based on regression models. Recently investigated immune regulatory genes could also play a part in immunogenicity. Our objective is to identify bio-clinical and genetic markers for FVIII inhibitor development, taking into account potential genetic high order interactions. The study population consisted of 593 and 79 patients with hemophilia A from centers in Bonn and Frankfurt respectively. Data was collected in the European ABIRISK tranSMART database. A subset of 125 severely affected patients from Bonn with reliable information on first treatment was selected as eligible for risk stratification using a hybrid tree-based regression model (GPLTR). In the eligible subset, 58 (46%) patients developed FVIII inhibitors. Among them, 49 (84%) were “high risk” F8 mutation type. 19 (33%) had a family history of inhibitors. The GPLTR model, taking into account F8 mutation risk, family history of inhibitors and product type, distinguishes two groups of patients: a high-risk group for immunogenicity, including patients with positive HLA-DRB1*15 and genotype G/A and A/A for IL-10 rs1800896, and a low-risk group of patients with negative HLA-DRB1*15 / HLA-DQB1*02 and T/T or G/T for CD86 rs2681401. We show associations between genetic factors and the occurrence of FVIII inhibitor development in severe hemophilia A patients taking into account for high-order interactions using a generalized partially linear tree-based approach.
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Affiliation(s)
- Delphine Bachelet
- CESP, INSERM UMR 1018, Faculty of Medicine, Paris-Sud University, UVSQ, Paris-Saclay University, Villejuif, France
| | - Thilo Albert
- Institute of Experimental Haematology and Transfusion Medicine, University Clinic Bonn, Bonn, Germany
| | - Cyprien Mbogning
- CESP, INSERM UMR 1018, Faculty of Medicine, Paris-Sud University, UVSQ, Paris-Saclay University, Villejuif, France
| | - Signe Hässler
- CESP, INSERM UMR 1018, Faculty of Medicine, Paris-Sud University, UVSQ, Paris-Saclay University, Villejuif, France
| | - Yuan Zhang
- CESP, INSERM UMR 1018, Faculty of Medicine, Paris-Sud University, UVSQ, Paris-Saclay University, Villejuif, France
| | - Stephan Schultze-Strasser
- University Hospital Frankfurt, Goethe University, Department of Pediatrics, Molecular Haemostasis and Immunodeficiency, Frankfurt am Main, Germany
| | | | - Julie Rayes
- Sorbonne Universités, UPMC Univ Paris 06, INSERM, Université Paris Descartes, Sorbonne Paris Cité, UMR_S 1138, Centre de Recherche des Cordeliers, Paris, France
| | - Anna Pavlova
- Institute of Experimental Haematology and Transfusion Medicine, University Clinic Bonn, Bonn, Germany
| | - Behnaz Pezeshkpoor
- Institute of Experimental Haematology and Transfusion Medicine, University Clinic Bonn, Bonn, Germany
| | - Kerstin Liphardt
- Institute of Experimental Haematology and Transfusion Medicine, University Clinic Bonn, Bonn, Germany
| | | | | | | | - Sébastien Lacroix-Desmazes
- Sorbonne Universités, UPMC Univ Paris 06, INSERM, Université Paris Descartes, Sorbonne Paris Cité, UMR_S 1138, Centre de Recherche des Cordeliers, Paris, France
| | - Christoph Königs
- University Hospital Frankfurt, Goethe University, Department of Pediatrics, Molecular Haemostasis and Immunodeficiency, Frankfurt am Main, Germany
| | - Johannes Oldenburg
- Institute of Experimental Haematology and Transfusion Medicine, University Clinic Bonn, Bonn, Germany
| | - Philippe Broët
- CESP, INSERM UMR 1018, Faculty of Medicine, Paris-Sud University, UVSQ, Paris-Saclay University, Villejuif, France
- AP-HP, Paris-Sud University Hospitals, Villejuif, France
- * E-mail:
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Pfrepper C, Krause M, Sigl-Kraetzig M, Königs C, Wendisch J, Olivieri M. Vaccination in patients with haemophilia-Results from an online survey among haemophilia treatment centres in Germany. Haemophilia 2019; 25:e304-e306. [DOI: 10.1111/hae.13781] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Revised: 04/25/2019] [Accepted: 05/07/2019] [Indexed: 12/16/2022]
Affiliation(s)
- Christian Pfrepper
- Division of Haemostaseology, Medical Department I; University Hospital Leipzig; Leipzig Germany
| | - Manuela Krause
- Internal Medicine; German Diagnostic Clinic; Wiesbaden Germany
| | - Michael Sigl-Kraetzig
- IPFW (Institute for Paediatric Research and Further Education) and Haemophilia Treatment Centre for Children and Adolescents (Gerinnungszentrum Süd); Blaubeuren Germany
| | - Christoph Königs
- Paediatric Haemophilia Centre, University Hospital Frankfurt; Goethe University Frankfurt; Frankfurt Germany
| | - Jörg Wendisch
- Health Department of the City of Dresden, Vaccination Centre; Dresden Germany
| | - Martin Olivieri
- Paediatric Haemophilia Centre, Dr. von Hauner Children’s Hospital; LMU Munich; Munich Germany
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Eichler H, Pedroni MA, Halimeh S, Königs C, Langer F, Miesbach W, Oldenburg J, Scholz U, Streif W, Klamroth R. [Leitlinie der Gesellschaft für Thrombose- und Hämostaseforschung (GTH) zur Struktur- und Prozessqualität von Hämophilie-Zentren]. Hamostaseologie 2019; 39:311-321. [PMID: 31018219 DOI: 10.1055/s-0039-1688450] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Affiliation(s)
- Hermann Eichler
- Institut für Klinische Hämostaseologie und Transfusionsmedizin, Universitätsklinikum des Saarlandes, Kirrbergerstraße, Homburg/Saar, Germany
| | - Manuela Albisetti Pedroni
- Abteilung Hämatologie, Universitäts-Kinderspital Zürich, Eleonorenstiftung, Steinwiesstraße, Zürich, Switzerland
| | | | - Christoph Königs
- Klinik für Kinder- und Jugendmedizin, Klinische und Molekulare Hämostaseologie, UK Frankfurt, Frankfurt am Main, Germany
| | - Florian Langer
- Zentrum für Onkologie, II. Medizinische Klinik und Poliklinik, Gerinnungsambulanz und Hämophiliezentrum, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Wolfgang Miesbach
- Hämostaseologie/Hämophiliezentrum, Medizinische Klinik 2/Institut für Transfusionsmedizin, Universitätsklinikum Frankfurt, Frankfurt am Main, Germany
| | - Johannes Oldenburg
- Institut für Experimentelle Hämatologie und Transfusionsmedizin, Universitätsklinikum Bonn, Sigmund-Freud-Straße, Bonn, Germany
| | - Ute Scholz
- Zentrum für Blutgerinnungsstörungen, Strümpellstraße, Leipzig, Germany
| | - Werner Streif
- Universitätsklinik für Kinder- u. Jugendheilkunde, Anichstraße, Innsbruck, Austria
| | - Robert Klamroth
- Vivantes Klinikum im Friedrichshain, Zentrum für Hämophilie und Hämostaseologie, Landsberger Allee, Berlin, Germany
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Olivieri M, Königs C, Heller C, Horneff S, Oldenburg J, Halimeh S, Kentouche K, Knöfler R, Fischer L, Pfrepper C, Kurnik K, Bidlingmaier C. Prevalence of Obesity in Young Patients with Severe Haemophilia and Its Potential Impact on Factor VIII Consumption in Germany. Hamostaseologie 2019; 39:355-359. [DOI: 10.1055/s-0039-1677874] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
AbstractSimilar to the general population, overweight and obesity have increasingly become a medical and economic burden also in patients with haemophilia in industrialized nations. In this study in seven German haemophilia centres, we identified a prevalence of overweight and obesity of 25.2% among 254 young patients <30 years (median: 13 years; range: 0–30 years) with severe haemophilia A and without a history of inhibitors. The median FVIII dosage based on bodyweight was significantly higher in normal weight compared with overweight or obese patients (96.9 vs. 72.9 IU/kg/week, respectively; p < 0.0001). This suggests that an individualized dosing regime which might be based on FVIII pharmacokinetics, physical activity and pre-existing haemophilic arthropathy is applied rather than dosing by bodyweight only. The bleeding rates observed in obese (median: 1; range: 0–17) versus normal weight patients (median: 2; range: 0–28) did not differ significantly (p = 0.057). Lower bleeding rates might be due to reduced activity or expected higher FVIII plasma levels in overweight patients. Due to the increasing prevalence of overweight/obesity in patients with haemophilia an interdisciplinary approach for individualized haemophilia treatment and weight loss programmes might be helpful for optimal and economical treatment for this group of patients.
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Affiliation(s)
- Martin Olivieri
- Paediatric Haemophilia Centre, Dr. von Hauner Children's Hospital, LMU Munich, Munich, Germany
| | - Christoph Königs
- Department of Paediatrics, Paediatric Haemophilia Centre, Goethe University, University Hospital Frankfurt, Frankfurt, Germany
| | - Christine Heller
- Department of Paediatrics, Paediatric Haemophilia Centre, Goethe University, University Hospital Frankfurt, Frankfurt, Germany
| | - Silvia Horneff
- Institute of Experimental Haematology and Transfusion Medicine, University Clinic Bonn, Bonn, Germany
| | - Johannes Oldenburg
- Institute of Experimental Haematology and Transfusion Medicine, University Clinic Bonn, Bonn, Germany
| | - Susan Halimeh
- Coagulation Centre Rhine-Ruhr, Medical Thrombosis and Haemophilia Treatment Centre and Specialized Laboratory for Coagulation Disorders/Haemophilia, Duisburg, Germany
| | - Karim Kentouche
- Department of Paediatric Haematology and Oncology, University Hospital for Children and Adolescents, Friedrich Schiller University, Jena, Germany
| | - Ralf Knöfler
- Department of Paediatric Haemostaseology, University Hospital ‘Carl Gustav Carus’, Technical University, Dresden, Germany
| | - Lars Fischer
- Department of Paediatric Haematology, Oncology and Haemostaseology, University Childrens Hospital Leipzig, Leipzig, Germany
| | - Christian Pfrepper
- Centre for Haemostaseology, University Hospital Leipzig, Leipzig, Germany
| | - Karin Kurnik
- Paediatric Haemophilia Centre, Dr. von Hauner Children's Hospital, LMU Munich, Munich, Germany
| | - Christoph Bidlingmaier
- Paediatric Haemophilia Centre, Dr. von Hauner Children's Hospital, LMU Munich, Munich, Germany
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Brettschneider K, Schmidt A, Kahle J, Orlowski A, Stichel D, Schwabe D, Königs C. Elimination of factor VIII-specific B cells by immunotoxins composed of a single factor VIII domain fused to Pseudomonas exotoxin A. J Thromb Haemost 2018; 16:2223-2232. [PMID: 30152083 DOI: 10.1111/jth.14273] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Indexed: 01/19/2023]
Abstract
Essentials There is still a need for novel therapeutic approaches for hemophilia A patients with inhibitors. A factor VIII domain was used as the targeting moiety for elimination of FVIII-specific B cells. The immunodominant C2 domain was fused to exotoxin A from Pseudomonas aeruginosa (hC2-ETA). Murine C2 domain-specific B cells were selectively and efficiently eliminated by hC2-ETA ex vivo. SUMMARY: Background Today, the most serious complication for patients with hemophilia A undergoing factor VIII (FVIII) replacement therapy is the development of neutralizing antibodies (inhibitors). Although inhibitors can be eradicated by application of high doses of FVIII, the immune tolerance induction therapy fails in up to 30% of patients. Hence, there is still an urgent need for novel therapeutic approaches for patients with persisting inhibitors. Objectives In the present study, the potential use of immunotoxins containing exotoxin A (ETA) from Pseudomonas aeruginosa for selective elimination of FVIII-specific B cells was explored. Methods The immunodominant C2 domain of human FVIII was used as a targeting moiety instead of the full-length FVIII protein and the resulting human C2 domain-ETA fusion protein (hC2-ETA) was produced in Escherichia coli. Results Binding studies with monoclonal C2 domain-specific antibodies confirmed the conformational integrity of the C2 domain in hC2-ETA. The functionality of hC2-ETA was tested ex vivo by incubation of splenocytes from inhibitor-positive FVIII knockout mice with hC2-ETA and controls. FVIII-specific memory B cells from splenocytes were differentiated by FVIII stimulation in antibody-secreting cells (ASC) and detected by an enzyme-linked immunospot assay. Although the controls showed no effect, incubation of splenocytes with hC2-ETA reduced the number of C2-specific ASC in a dose-dependent fashion, indicating specific and efficient elimination of C2-specific memory B cells. Conclusions Overall, the results of the study support the fact that FVIII domain immunotoxins might be a potential new tool for the elimination of FVIII-specific B cells in patients with hemophilia A and persisting inhibitors.
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Affiliation(s)
- K Brettschneider
- Department of Pediatrics and Adolescent Medicine, University Hospital, Goethe University, Frankfurt am Main, Germany
- Faculty of Biological Science, Goethe University, Frankfurt am Main, Germany
| | - A Schmidt
- Department of Pediatrics and Adolescent Medicine, University Hospital, Goethe University, Frankfurt am Main, Germany
| | - J Kahle
- Department of Pediatrics and Adolescent Medicine, University Hospital, Goethe University, Frankfurt am Main, Germany
| | - A Orlowski
- Department of Pediatrics and Adolescent Medicine, University Hospital, Goethe University, Frankfurt am Main, Germany
| | - D Stichel
- Department of Pediatrics and Adolescent Medicine, University Hospital, Goethe University, Frankfurt am Main, Germany
| | - D Schwabe
- Department of Pediatrics and Adolescent Medicine, University Hospital, Goethe University, Frankfurt am Main, Germany
| | - C Königs
- Department of Pediatrics and Adolescent Medicine, University Hospital, Goethe University, Frankfurt am Main, Germany
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Judd A, Chappell E, Turkova A, Le Coeur S, Noguera-Julian A, Goetghebuer T, Doerholt K, Galli L, Pajkrt D, Marques L, Collins IJ, Gibb DM, González Tome MI, Navarro M, Warszawski J, Königs C, Spoulou V, Prata F, Chiappini E, Naver L, Giaquinto C, Thorne C, Marczynska M, Okhonskaia L, Posfay-Barbe K, Ounchanum P, Techakunakorn P, Kiseleva G, Malyuta R, Volokha A, Ene L, Goodall R. Long-term trends in mortality and AIDS-defining events after combination ART initiation among children and adolescents with perinatal HIV infection in 17 middle- and high-income countries in Europe and Thailand: A cohort study. PLoS Med 2018; 15:e1002491. [PMID: 29381702 PMCID: PMC5790238 DOI: 10.1371/journal.pmed.1002491] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 12/13/2017] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Published estimates of mortality and progression to AIDS as children with HIV approach adulthood are limited. We describe rates and risk factors for death and AIDS-defining events in children and adolescents after initiation of combination antiretroviral therapy (cART) in 17 middle- and high-income countries, including some in Western and Central Europe (W&CE), Eastern Europe (Russia and Ukraine), and Thailand. METHODS AND FINDINGS Children with perinatal HIV aged <18 years initiating cART were followed until their 21st birthday, transfer to adult care, death, loss to follow-up, or last visit up until 31 December 2013. Rates of death and first AIDS-defining events were calculated. Baseline and time-updated risk factors for early/late (≤/>6 months of cART) death and progression to AIDS were assessed. Of 3,526 children included, 32% were from the United Kingdom or Ireland, 30% from elsewhere in W&CE, 18% from Russia or Ukraine, and 20% from Thailand. At cART initiation, median age was 5.2 (IQR 1.4-9.3) years; 35% of children aged <5 years had a CD4 lymphocyte percentage <15% in 1997-2003, which fell to 15% of children in 2011 onwards (p < 0.001). Similarly, 53% and 18% of children ≥5 years had a CD4 count <200 cells/mm3 in 1997-2003 and in 2011 onwards, respectively (p < 0.001). Median follow-up was 5.6 (2.9-8.7) years. Of 94 deaths and 237 first AIDS-defining events, 43 (46%) and 100 (42%) were within 6 months of initiating cART, respectively. Multivariable predictors of early death were: being in the first year of life; residence in Russia, Ukraine, or Thailand; AIDS at cART start; initiating cART on a nonnucleoside reverse transcriptase inhibitor (NNRTI)-based regimen; severe immune suppression; and low BMI-for-age z-score. Current severe immune suppression, low current BMI-for-age z-score, and current viral load >400 c/mL predicted late death. Predictors of early and late progression to AIDS were similar. Study limitations include incomplete recording of US Centers for Disease Control (CDC) disease stage B events and serious adverse events in some countries; events that were distributed over a long time period, and that we lacked power to analyse trends in patterns and causes of death over time. CONCLUSIONS In our study, 3,526 children and adolescents with perinatal HIV infection initiated antiretroviral therapy (ART) in countries in Europe and Thailand. We observed that over 40% of deaths occurred ≤6 months after cART initiation. Greater early mortality risk in infants, as compared to older children, and in Russia, Ukraine, or Thailand as compared to W&CE, raises concern. Current severe immune suppression, being underweight, and unsuppressed viral load were associated with a higher risk of death at >6 months after initiation of cART.
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Affiliation(s)
| | - Ali Judd
- MRC Clinical Trials Unit, University College London (UCL), London, United Kingdom
- * E-mail:
| | - Elizabeth Chappell
- MRC Clinical Trials Unit, University College London (UCL), London, United Kingdom
| | - Anna Turkova
- MRC Clinical Trials Unit, University College London (UCL), London, United Kingdom
| | - Sophie Le Coeur
- Institut National d'Etude Demographique (INED), Mortality, Health and Epidemiology Unit, Paris, France
- Institut de Recherche pour le Developpement (IRD), UMI 174/PHPT, Chiang Mai, Thailand
| | - Antoni Noguera-Julian
- Unitat d’Infectologia, Servei de Pediatria, Hospital Sant Joan de Deu, Universitat de Barcelona, Barcelona, Spain
| | | | - Katja Doerholt
- St George’s Healthcare NHS Trust, London, United Kingdom
| | - Luisa Galli
- Department of Health Sciences, Pediatric Unit, University of Florence, Florence, Italy
| | - Dasja Pajkrt
- Department of Pediatric Infectious Diseases, Emma Children’s Hospital, Academic Medical Center, Amsterdam, the Netherlands
| | | | - Intira J. Collins
- MRC Clinical Trials Unit, University College London (UCL), London, United Kingdom
| | - Diana M. Gibb
- MRC Clinical Trials Unit, University College London (UCL), London, United Kingdom
| | | | - Marisa Navarro
- Hospital General Universitario "Gregorio Marañón", Madrid, Spain
| | - Josiane Warszawski
- Institut National de la Santé et de la Recherche (INSERM), Paris, France
| | - Christoph Königs
- University Hospital Frankfurt, Department of Paediatrics, Goethe University, Frankfurt, Germany
| | - Vana Spoulou
- University of Athens Medical School, Athens, Greece
| | | | - Elena Chiappini
- Department of Health Sciences, Pediatric Unit, University of Florence, Florence, Italy
| | - Lars Naver
- Karolinska University Hospital, Stockholm, Sweden
| | - Carlo Giaquinto
- Paediatric European Network for the Treatment of AIDS (PENTA), Padova, Italy
| | - Claire Thorne
- UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | | | | | | | | | | | - Galina Kiseleva
- Shupyk National Medical Academy of Postgraduate Education, Kiev, Ukraine
| | - Ruslan Malyuta
- Perinatal Prevention of AIDS Initiative, Odessa, Ukraine
| | - Alla Volokha
- Shupyk National Medical Academy of Postgraduate Education, Kiev, Ukraine
| | | | - Ruth Goodall
- MRC Clinical Trials Unit, University College London (UCL), London, United Kingdom
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Königs C, Schultze-Strasser S, Quaiser A, Bochennek K, Schwabe D, Klingebiel TE, Koehl U, Cappel C, Rolle U, Bader P, Bremm M, Huenecke S, Bakhtiar S. An Exponential Regression Model Reveals the Continuous Development of B Cell Subpopulations Used as Reference Values in Children. Front Pediatr 2018; 6:121. [PMID: 29780793 PMCID: PMC5945839 DOI: 10.3389/fped.2018.00121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Accepted: 04/13/2018] [Indexed: 11/13/2022] Open
Abstract
B lymphocytes are key players in humoral immunity, expressing diverse surface immunoglobulin receptors directed against specific antigenic epitopes. The development and profile of distinct subpopulations have gained awareness in the setting of primary immunodeficiency disorders, primary or secondary autoimmunity and as therapeutic targets of specific antibodies in various diseases. The major B cell subpopulations in peripheral blood include naïve (CD19+ or CD20+IgD+CD27-), non-switched memory (CD19+ or CD20+IgD+CD27+) and switched memory B cells (CD19+ or CD20+IgD-CD27+). Furthermore, less common B cell subpopulations have also been described as having a role in the suppressive capacity of B cells to maintain self-tolerance. Data on reference values for B cell subpopulations are limited and only available for older age groups, neglecting the continuous process of human B cell development in children and adolescents. This study was designed to establish an exponential regression model to produce continuous reference values for main B cell subpopulations to reflect the dynamic maturation of the human immune system in healthy children.
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Affiliation(s)
- Christoph Königs
- Department of Pediatric and Adolescent Medicine, University Hospital Frankfurt, Frankfurt, Germany
| | | | - Andrea Quaiser
- Department of Pediatric and Adolescent Medicine, University Hospital Frankfurt, Frankfurt, Germany
| | - Konrad Bochennek
- Department of Pediatric and Adolescent Medicine, University Hospital Frankfurt, Frankfurt, Germany
| | - Dirk Schwabe
- Department of Pediatric and Adolescent Medicine, University Hospital Frankfurt, Frankfurt, Germany
| | - Thomas E Klingebiel
- Department of Pediatric and Adolescent Medicine, University Hospital Frankfurt, Frankfurt, Germany
| | - Ulrike Koehl
- GMP Development, Integriertes Forschungs- und Behandlungszentrum Transplantation (IFB-TX), Hannover Medical School, Institute of Cellular Therapeutics, Hannover, Germany
| | - Claudia Cappel
- Department of Pediatric and Adolescent Medicine, University Hospital Frankfurt, Frankfurt, Germany
| | - Udo Rolle
- Department of Pediatric Surgery, University Hospital Frankfurt, Frankfurt, Germany
| | - Peter Bader
- Department of Pediatric and Adolescent Medicine, University Hospital Frankfurt, Frankfurt, Germany
| | - Melanie Bremm
- Department of Pediatric and Adolescent Medicine, University Hospital Frankfurt, Frankfurt, Germany
| | - Sabine Huenecke
- Department of Pediatric and Adolescent Medicine, University Hospital Frankfurt, Frankfurt, Germany
| | - Shahrzad Bakhtiar
- Department of Pediatric and Adolescent Medicine, University Hospital Frankfurt, Frankfurt, Germany
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Naumann A, Scherger AK, Neuwirth J, Orlowski A, Kahle J, Schwabe D, Königs C. Selection and characterisation of FVIII-specific single chain variable fragments. Hamostaseologie 2017. [DOI: 10.1055/s-0037-1619801] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Abstract
SummaryThe development of inhibitory anti-FVIII antibodies is currently the most severe complication in the treatment of haemophilia A patients. Inhibitor eradication can be achieved by immune tolerance induction (ITI). Recent findings suggest a correlation between the FVIII-specific IgG subclass distribution and the duration or outcome of ITI. To quantify FVIII-specific IgG subclasses in patients’ plasma FVIII-specific IgG standards are required. Here, the isolation of FVIII-specific single chain variable fragments (scFvs) from synthetic phage display libraries and the characterisation of their FVIII domain specificity are described. The isolated scFv 1G10, which binds to the FVIII A2 domain, was cloned into the context of the four human IgG (hIgG) subclasses and expressed in mammalian cells. Purified 1G10-hIgG1, -hIgG2, -hIgG3 and -hIgG4 are used as standards to determine the absolute amounts and relative contribution of the different FVIII-specific IgG subclasses in future studies. The results from these studies will eventually add to understanding the role of the FVIII-specific IgG subclass distribution as prognostic factor for the outcome of ITI.
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41
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Königs C, James A, Federici A. Contemporary issues in the management of von Willebrand disease. Thromb Haemost 2017; 116 Suppl 1:S18-25. [DOI: 10.1160/th16-01-0050] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Accepted: 06/22/2016] [Indexed: 01/28/2023]
Abstract
SummaryVon Willebrand disease (VWD) is the most common inherited bleeding disorder. Bleeding scores in VWD, focused in particular on mucosal bleeding, can be very useful in the diagnosis and validation of different types of treatment. The results of an extended prospective study with a large amount of information on clinical phenotype and implications in treatment are reviewed in this article. Treatment of mucosal and joint bleeding in severe VWD remains difficult in some patients. Due to the lack of data on the use of prophylaxis in these patients it is difficult to establish optimal treatment regimens. An overview of the literature, with a focus on the ongoing PRO.WILL study, is provided here. Furthermore, understanding the changes in von Willebrand factor (VWF) levels during pregnancy is very important for establishing the optimal management strategy for pregnancy and delivery in women with VWD. A recently published prospective observational cohort study in women with and without VWD during the postpartum period provides important data that should allow the improvement of postpartum treatment protocols.
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42
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Kahle J, Orlowski A, Stichel D, Becker-Peters K, Kabiri A, Healey JF, Brettschneider K, Naumann A, Scherger AK, Lollar P, Schwabe D, Königs C. Epitope mapping via selection of anti-FVIII antibody-specific phagepresented peptide ligands that mimic the antibody binding sites. Thromb Haemost 2017; 113:396-405. [DOI: 10.1160/th14-01-0101] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Accepted: 08/15/2014] [Indexed: 11/05/2022]
Abstract
SummaryThe most serious complication in today’s treatment of congenital haemophilia A is the development of neutralising antibodies (inhibitors) against factor VIII (FVIII). Although FVIII inhibitors can be eliminated by immune tolerance induction (ITI) based on repeated administration of high doses of FVIII, 20–30% of patients fail to become tolerant. Persistence of FVIII inhibitors is associated with increased morbidity and mortality. Data from recent studies provide evidence for a potential association between ITI outcome and epitope specificity of FVIII inhibitors. Nevertheless the determination of epitopes and their clinical relevance has not yet been established. In this study a general strategy for the identification of anti-FVIII antibody epitopes in haemophilia A patient plasma was to be demonstrated. Phage-displayed peptide libraries were screened against anti-FVIII antibodies to isolate specific peptides. Peptide specificity was confirmed by FVIII-sensitive ELISA binding. Peptide residues essential for antibody binding were identified by mutational analysis and epitopes were predicted via FVIII homology search. The proposed mapping strategy was validated for the monoclonal murine antibody (mAb) 2–76. Binding studies with FVIII variants confirmed the location of the predicted epitope at the level of individual amino acids. In addition, anti-FVIII antibody-specific peptide ligands were selected for 10 haemophilia A patients with FVIII inhibitors. Detailed epitope mapping for three of them showed binding sites on the A2, A3 and C2 domains. Precise epitope mapping of anti-FVIII antibodies using antibody-specific peptide ligands can be a useful approach to identify antigenic sites on FVIII.
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43
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Weber V, Radeloff D, Reimers B, Salzmann-Manrique E, Bader P, Schwabe D, Königs C. Neurocognitive development in HIV-positive children is correlated with plasma viral loads in early childhood. Medicine (Baltimore) 2017; 96:e6867. [PMID: 28591025 PMCID: PMC5466203 DOI: 10.1097/md.0000000000006867] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Because of neurocognitive impairments in perinatally human immunodeficiency virus (HIV)-infected children and adolescents, this study aimed to demonstrate the effect of plasma viral loads and early initiation of sufficient combined antiretroviral therapy (cART) on neurocognitive development.In total, 14 perinatally infected HIV-positive children (median age 8.24 years [range: 6.0-16.74]) receiving lopinavir/ritonavir (LPV/r)-based ART underwent neurocognitive testing using the Wechsler Intelligence Score for Children, 4th Edition (WISC-IV). All 14 patients participated in a pharmacokinetic study in which they were hospitalized for an entire day. As a child's ability to concentrate varies over the course of the day, all tests were performed in the morning.The patients' neurocognitive development did not significantly differ from the normative collective pattern for any of the following composite scores that were examined: full-scale intelligence quotient (IQ) (mean: 106.5, P = .1060), verbal comprehension index (mean: 106.0, P = .1356), perceptual reasoning index (mean: 106.0, P = .1357), working memory index (mean: 106.3, P = .1171), and processing speed index (mean: 98.1, P = .6313). The overall full-scale IQ scores were significantly higher in children who began ART within the first year of life (P = .0379), whereas low lopinavir/r plasma levels (P = .0070) and high viral load area under the curves (AUCs) in the first 3 years of life, but not later, significantly correlated with reduced neurocognitive performance (Spearman r = -0.64, P = .0278).In this cohort of cART treated HIV-positive children and adolescents, neurocognitive performance correlated with early and sufficient viral load suppression within the first 3 years of life.
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Affiliation(s)
| | - Daniel Radeloff
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital, Goethe University, Frankfurt am Main
- Department of Child and Adolescent Psychiatry, Psychotherapy and Psychosomatics, University Hospital Leipzig, Leipzig, Germany
| | | | | | - Peter Bader
- Department of Pediatrics and Adolescent Medicine
| | - Dirk Schwabe
- Department of Pediatrics and Adolescent Medicine
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Huenecke S, Cappel C, Esser R, Pfirrmann V, Salzmann-Manrique E, Betz S, Keitl E, Banisharif-Dehkordi J, Bakhtiar S, Königs C, Jarisch A, Soerensen J, Ullrich E, Klingebiel T, Bader P, Bremm M. Development of Three Different NK Cell Subpopulations during Immune Reconstitution after Pediatric Allogeneic Hematopoietic Stem Cell Transplantation: Prognostic Markers in GvHD and Viral Infections. Front Immunol 2017; 8:109. [PMID: 28239380 PMCID: PMC5300968 DOI: 10.3389/fimmu.2017.00109] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Accepted: 01/23/2017] [Indexed: 02/03/2023] Open
Abstract
Natural killer (NK) cells play an important role following allogeneic hematopoietic stem cell transplantation (HSCT) exerting graft-versus-leukemia/tumor effect and mediating pathogen-specific immunity. Although NK cells are the first donor-derived lymphocytes reconstituting post-HSCT, their distribution of CD56++CD16- (CD56bright), CD56++CD16+ (CD56intermediate=int), and CD56+CD16++ (CD56dim) NK cells is explicitly divergent from healthy adults, but to some extent comparable to the NK cell development in early childhood. The proportion of CD56bright/CD56int/CD56dim changed from 15/8/78% in early childhood to 6/4/90% in adults, respectively. Within this study, we first compared the NK cell reconstitution post-HSCT to reference values of NK cell subpopulations of healthy children. Afterward, we investigated the reconstitution of NK cell subpopulations post-HSCT in correlation to acute graft versus host disease (aGvHD) and chronic graft versus host disease (cGvHD) as well as to viral infections. Interestingly, after a HSCT follow-up phase of 12 months, the distribution of NK cell subpopulations largely matched the 50th percentile of the reference range for healthy individuals. Patients suffering from aGvHD and cGvHD showed a delayed reconstitution of NK cells. Remarkably, within the first 2 months post-HSCT, patients suffering from aGvHD had significantly lower levels of CD56bright NK cells compared to patients without viral infection or without graft versus host disease (GvHD). Therefore, the amount of CD56bright NK cells might serve as an early prognostic factor for GvHD development. Furthermore, a prolonged and elevated peak in CD56int NK cells seemed to be characteristic for the chronification of GvHD. In context of viral infection, a slightly lower CD56 and CD16 receptor expression followed by a considerable reduction in the absolute CD56dim NK cell numbers combined with reoccurrence of CD56int NK cells was observed. Our results suggest that a precise analysis of the reconstitution of NK cell subpopulations post-HSCT might indicate the occurrence of undesired events post-HSCT such as severe aGvHD.
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Affiliation(s)
- Sabine Huenecke
- Clinic for Pediatric and Adolescent Medicine, University Hospital , Frankfurt , Germany
| | - Claudia Cappel
- Clinic for Pediatric and Adolescent Medicine, University Hospital , Frankfurt , Germany
| | - Ruth Esser
- GMP Development Unit, Hannover Medical School, Institute of Cellular Therapeutics , Hannover , Germany
| | - Verena Pfirrmann
- Clinic for Pediatric and Adolescent Medicine, University Hospital , Frankfurt , Germany
| | | | - Sibille Betz
- Clinic for Pediatric and Adolescent Medicine, University Hospital , Frankfurt , Germany
| | - Eileen Keitl
- Clinic for Pediatric and Adolescent Medicine, University Hospital , Frankfurt , Germany
| | | | - Shahrzad Bakhtiar
- Clinic for Pediatric and Adolescent Medicine, University Hospital , Frankfurt , Germany
| | - Christoph Königs
- Clinic for Pediatric and Adolescent Medicine, University Hospital , Frankfurt , Germany
| | - Andrea Jarisch
- Clinic for Pediatric and Adolescent Medicine, University Hospital , Frankfurt , Germany
| | - Jan Soerensen
- Clinic for Pediatric and Adolescent Medicine, University Hospital , Frankfurt , Germany
| | - Evelyn Ullrich
- Clinic for Pediatric and Adolescent Medicine, University Hospital, Frankfurt, Germany; LOEWE Center for Cell and Gene Therapy, Goethe University, Frankfurt, Germany
| | - Thomas Klingebiel
- Clinic for Pediatric and Adolescent Medicine, University Hospital , Frankfurt , Germany
| | - Peter Bader
- Clinic for Pediatric and Adolescent Medicine, University Hospital , Frankfurt , Germany
| | - Melanie Bremm
- Clinic for Pediatric and Adolescent Medicine, University Hospital , Frankfurt , Germany
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Kahle J, Orlowski A, Stichel D, Healey JF, Parker ET, Donfield SM, Astermark J, Berntorp E, Lollar P, Schwabe D, Königs C. Anti-factor VIII antibodies in brothers with haemophilia A share similar characteristics. Haemophilia 2016; 23:292-299. [DOI: 10.1111/hae.13105] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/22/2016] [Indexed: 12/19/2022]
Affiliation(s)
- J. Kahle
- Department of Paediatrics; Clinical and Molecular Haemostasis and Immunodeficiency; University Hospital Frankfurt; Frankfurt am Main Germany
| | - A. Orlowski
- Department of Paediatrics; Clinical and Molecular Haemostasis and Immunodeficiency; University Hospital Frankfurt; Frankfurt am Main Germany
| | - D. Stichel
- Department of Paediatrics; Clinical and Molecular Haemostasis and Immunodeficiency; University Hospital Frankfurt; Frankfurt am Main Germany
| | - J. F. Healey
- Department of Pediatrics; Aflac Cancer and Blood Disorders Center; Children's Healthcare of Atlanta and Emory University; Atlanta GA USA
| | - E. T. Parker
- Department of Pediatrics; Aflac Cancer and Blood Disorders Center; Children's Healthcare of Atlanta and Emory University; Atlanta GA USA
| | - S. M. Donfield
- Department of Biostatistics; Rho Inc.; Chapel Hill NC USA
| | - J. Astermark
- Centre for Thrombosis and Haemostasis; Lund University; Skåne University Hospital; Malmö Sweden
| | - E. Berntorp
- Centre for Thrombosis and Haemostasis; Lund University; Skåne University Hospital; Malmö Sweden
| | - P. Lollar
- Department of Pediatrics; Aflac Cancer and Blood Disorders Center; Children's Healthcare of Atlanta and Emory University; Atlanta GA USA
| | - D. Schwabe
- Department of Paediatrics; Clinical and Molecular Haemostasis and Immunodeficiency; University Hospital Frankfurt; Frankfurt am Main Germany
| | - C. Königs
- Department of Paediatrics; Clinical and Molecular Haemostasis and Immunodeficiency; University Hospital Frankfurt; Frankfurt am Main Germany
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Schmidt A, Königs C. Regulatory T cells and their potential for tolerance induction in haemophilia A patients. Hamostaseologie 2016; 36:S5-S12. [PMID: 27824212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Accepted: 06/07/2016] [Indexed: 06/06/2023] Open
Abstract
FVIII inhibitors still are the major concern in treatment of haemophilia A patients by FVIII replacement therapy. Immune tolerance induction to reverse inhibitor formation fails in about 30% of treated patients. These patients face increased morbidity and mortality producing a need for new therapy strategies in the treatment of FVIII inhibitor-positive patients. Regulatory T cells are important modulators of the immune response and are also involved in the immune response to FVIII in haemophilia A patients. Additionally, regulatory T cells have been shown to play a role in tolerance induction induced by multiple experimental treatment regimes. This review summarises the current knowledge on the role of regulatory T cells in the immune response to FVIII and tolerance induction strategies. Additionally, possible ways to engineer regulatory T cells as therapeutic agent in haemophilia A and current challenges of regulatory T cell therapies are discussed.
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Affiliation(s)
- A Schmidt
- Anja Schmidt, Biochemist, PhD, Molekulare Hämostaseologie & Immundefizienz, Universitätsklinikum Frankfurt, Klinik für Kinder- und Jugendmedizin, Theodor-Stern-Kai 7, 60596 Frankfurt am Main, Germany, Tel. +49/(0)69/630 18-57 12, Fax -39 91,
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Huenecke S, Fryns E, Wittekindt B, Buxmann H, Königs C, Quaiser A, Fischer D, Bremm M, Klingebiel T, Koehl U, Schloesser R, Bochennek K. Percentiles of Lymphocyte Subsets in Preterm Infants According to Gestational Age Compared to Children and Adolescents. Scand J Immunol 2016; 84:291-298. [DOI: 10.1111/sji.12474] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Accepted: 08/17/2016] [Indexed: 12/31/2022]
Affiliation(s)
- S. Huenecke
- Clinic for Pediatric and Adolescent Medicine, University Hospital; Frankfurt Germany
| | - E. Fryns
- Clinic for Pediatric and Adolescent Medicine, University Hospital; Frankfurt Germany
| | - B. Wittekindt
- Clinic for Pediatric and Adolescent Medicine, University Hospital; Frankfurt Germany
| | - H. Buxmann
- Clinic for Pediatric and Adolescent Medicine, University Hospital; Frankfurt Germany
| | - C. Königs
- Clinic for Pediatric and Adolescent Medicine, University Hospital; Frankfurt Germany
| | - A. Quaiser
- Clinic for Pediatric and Adolescent Medicine, University Hospital; Frankfurt Germany
| | - D. Fischer
- Clinic for Pediatric and Adolescent Medicine, University Hospital; Frankfurt Germany
| | - M. Bremm
- Clinic for Pediatric and Adolescent Medicine, University Hospital; Frankfurt Germany
| | - T. Klingebiel
- Clinic for Pediatric and Adolescent Medicine, University Hospital; Frankfurt Germany
| | - U. Koehl
- Institute of Cellular Therapeutics; GMP Development Unit, IFB-TX; Hannover Medical School; Hannover Germany
| | - R. Schloesser
- Clinic for Pediatric and Adolescent Medicine, University Hospital; Frankfurt Germany
| | - K. Bochennek
- Clinic for Pediatric and Adolescent Medicine, University Hospital; Frankfurt Germany
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Buxmann H, Reitter A, Bapistella S, Stürmer M, Königs C, Ackermann H, Louwen F, Bader P, Schlößer RL, Willasch AM. Maternal CD4+ microchimerism in HIV-exposed newborns after spontaneous vaginal delivery or caesarean section. Early Hum Dev 2016; 98:49-55. [PMID: 27351353 DOI: 10.1016/j.earlhumdev.2016.06.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2016] [Revised: 05/24/2016] [Accepted: 06/14/2016] [Indexed: 01/21/2023]
Abstract
BACKGROUND Maternal CD4+ cell microchimerism may be greater after caesarean section compared to spontaneous vaginal delivery and could cause mother-to-child transmission (MTCT) in HIV-exposed newborns. AIMS To evaluate maternal CD4+ cell microchimerism in HIV-exposed newborns after spontaneous vaginal delivery or caesarean section. STUDY DESIGN AND SUBJECTS In this prospective single-centre study, neonates whose mothers were infected with HIV and had normal MTCT risk according to the German Austrian Guidelines were considered for study enrolment. Maternal CD4+ cell microchimerism in the newborns' umbilical cord blood was measured and compared by mode of delivery. RESULTS Thirty-seven HIV-infected mothers and their 39 newborns were included in the study. None of the 17 (0.0%) newborns delivered vaginally had quantifiable maternal CD4+ cells (95% confidence interval (CI): 0.00-0.00) in their circulation at birth compared with four of 16 (25.0%) newborns delivered via planned caesarean section, who showed 0.01-0.66% maternal cells (95% CI: -0.06-0.16; P=0.02) in their circulation. The intention to treat analysis, which included six additional newborns delivered by unplanned caesarean section, showed quantifiable maternal CD4+ cells in one (0.05%; 95% CI: -0.02-0.04) of 23 (4.3%) newborn at birth compared to four of 16 (25.0%) born via planned caesarean section (95% CI: -0.06-0.16; P=0.04). There was no MTCT in any of the newborns. CONCLUSION In this small cohort, spontaneous vaginal delivery in HIV-infected women with normal MTCT risk was associated with lower maternal CD4+ cell transfer to newborns compared to planned caesarean section.
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Affiliation(s)
- H Buxmann
- Goethe University, Department for Children and Adolescents, Division for Neonatology, University Hospital Frankfurt/Main, Germany.
| | - A Reitter
- Department of Gynecology and Obstetrics, Division of Obstetrics and Prenatal Medicine, University Hospital Frankfurt/Main, Germany
| | - S Bapistella
- Goethe University, Department for Children and Adolescents, Division for Neonatology, University Hospital Frankfurt/Main, Germany
| | - M Stürmer
- Institute for Medical Virology, University Hospital Frankfurt/Main, Germany
| | - C Königs
- Department for Children and Adolescents, Division for Stem Cell Transplantation and Immunology, University Hospital Frankfurt/Main, Germany
| | - H Ackermann
- Institute of Biostatistics and Mathematical Modeling, University Hospital Frankfurt/Main, Germany
| | - F Louwen
- Department of Gynecology and Obstetrics, Division of Obstetrics and Prenatal Medicine, University Hospital Frankfurt/Main, Germany
| | - P Bader
- Department for Children and Adolescents, Division for Stem Cell Transplantation and Immunology, University Hospital Frankfurt/Main, Germany
| | - R L Schlößer
- Goethe University, Department for Children and Adolescents, Division for Neonatology, University Hospital Frankfurt/Main, Germany
| | - A M Willasch
- Department for Children and Adolescents, Division for Stem Cell Transplantation and Immunology, University Hospital Frankfurt/Main, Germany
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49
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Barnbrock A, Heller C, Königs C, Budde U, Schwabe D. Lupus anticoagulants associated inhibitor against factor IX in a young patient with haemophilia B. Haemophilia 2016; 22:e437-9. [PMID: 27353656 DOI: 10.1111/hae.12956] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/01/2016] [Indexed: 01/13/2023]
Affiliation(s)
- A Barnbrock
- Comprehensive Care Centre for Thrombosis and Hemostasis, University Hospital Frankfurt, Goethe University, Frankfurt, Germany.
| | - C Heller
- Comprehensive Care Centre for Thrombosis and Hemostasis, University Hospital Frankfurt, Goethe University, Frankfurt, Germany
| | - C Königs
- Comprehensive Care Centre for Thrombosis and Hemostasis, University Hospital Frankfurt, Goethe University, Frankfurt, Germany
| | - U Budde
- Medylis Laborgesellschaft mbH, Hamburg, Germany
| | - D Schwabe
- Comprehensive Care Centre for Thrombosis and Hemostasis, University Hospital Frankfurt, Goethe University, Frankfurt, Germany
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50
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Feiterna-Sperling C, Königs C, Notheis G, Buchholz B, Krüger R, Weizsäcker K, Eberle J, Hanhoff N, Gärtner B, Heider H, Krüger DH, Hofmann J. High seroprevalence of antibodies against Kaposi's sarcoma-associated herpesvirus (KSHV) among HIV-1-infected children and adolescents in a non-endemic population. Med Microbiol Immunol 2016; 205:425-34. [PMID: 27240652 DOI: 10.1007/s00430-016-0458-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Accepted: 05/09/2016] [Indexed: 11/28/2022]
Abstract
Human herpesvirus-8 (HHV-8) is the etiological agent of Kaposi's sarcoma (KS), which primarily affects human immunodeficiency virus (HIV)-infected adults with advanced immunodeficiency. Currently, only limited prevalence data for HHV-8 infection in HIV-infected children living in non-endemic areas are available. This multicenter cross-sectional study was conducted in four university hospitals in Germany specializing in pediatric HIV care. Stored serum specimens obtained from 207 vertically HIV-1-infected children and adolescents were tested for antibodies against lytic and latent HHV-8 antigens. Logistic regression was used to assess independent risk factors associated with HHV-8 seropositivity. The overall HHV-8 seroprevalence was 24.6 % (n = 51/207) without significant differences related to sex, age, or ethnicity. In univariate analysis, HHV-8 seropositivity was significantly associated with a child having being born outside Germany, maternal origin from sub-Saharan Africa, a history of breastfeeding, CDC immunologic category 3, and deferred initiation of antiretroviral therapy (>24 months of age). In multivariate analysis, a child's birth outside Germany was the only significant risk factor for HHV-8 seropositivity (odds ratio 3.98; 95 % confidence interval 1.27-12.42). HHV-8-associated malignancies were uncommon; only one patient had a history of KS. Serum specimen of vertically HIV-infected children and adolescents living in Germany showed a high HHV-8 seroprevalence. These findings suggest that primary HHV-8 infection-a risk factor for KS and other HHV-8-associated malignancies-occurs early in life. Thus, management of perinatally HIV-infected children should include testing for HHV-8 coinfection and should consider future risks of HHV-8-associated malignancies.
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Affiliation(s)
- Cornelia Feiterna-Sperling
- Department of Pediatric Pneumology and Immunology, Charité University Medicine Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
| | - Christoph Königs
- Department of Pediatrics, University Hospital Frankfurt, Goethe University, Frankfurt, Germany
| | - Gundula Notheis
- Ludwig-Maximilians-University of Munich, Dr. von Haunersches Kinderspital, Munich, Germany
| | - Bernd Buchholz
- Medical Faculty Mannheim, University Children's Hospital, Heidelberg University, Heidelberg, Germany
| | - Renate Krüger
- Department of Pediatric Pneumology and Immunology, Charité University Medicine Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | | | - Josef Eberle
- Max von Pettenkofer-Institut, Ludwig-Maximilians-University of Munich, Munich, Germany
| | - Nikola Hanhoff
- German Association of Physicians in HIV Care, Berlin, Germany
| | - Barbara Gärtner
- Institute of Microbiology and Hygiene, University of Saarland Medical School, Homburg/Saar, Germany
| | - Harald Heider
- Institute of Medical Virology, Helmut-Ruska-Haus, Charité University Medicine Berlin, Berlin, Germany
| | - Detlev H Krüger
- Institute of Medical Virology, Helmut-Ruska-Haus, Charité University Medicine Berlin, Berlin, Germany
| | - Jörg Hofmann
- Institute of Medical Virology, Helmut-Ruska-Haus, Charité University Medicine Berlin, Berlin, Germany
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