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Focosi D, Franchini M, Pirofski LA, Burnouf T, Fairweather D, Joyner MJ, Casadevall A. COVID-19 Convalescent Plasma Is More than Neutralizing Antibodies: A Narrative Review of Potential Beneficial and Detrimental Co-Factors. Viruses 2021; 13:1594. [PMID: 34452459 PMCID: PMC8402718 DOI: 10.3390/v13081594] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Revised: 08/03/2021] [Accepted: 08/10/2021] [Indexed: 12/12/2022]
Abstract
COVID-19 convalescent plasma (CCP) is currently under investigation for both treatment and post-exposure prophylaxis. The active component of CCP mediating improved outcome is commonly reported as specific antibodies, particularly neutralizing antibodies, with clinical efficacy characterized according to the level or antibody affinity. In this review, we highlight the potential role of additional factors in CCP that can be either beneficial (e.g., AT-III, alpha-1 AT, ACE2+ extracellular vesicles) or detrimental (e.g., anti-ADAMTS13, anti-MDA5 or anti-interferon autoantibodies, pro-coagulant extracellular vesicles). Variations in these factors in CCP may contribute to varied outcomes in patients with COVID-19 and undergoing CCP therapy. We advise careful, retrospective investigation of such co-factors in randomized clinical trials that use fresh frozen plasma in control arms. Nevertheless, it might be difficult to establish a causal link between these components and outcome, given that CCP is generally safe and neutralizing antibody effects may predominate.
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Affiliation(s)
- Daniele Focosi
- North-Western Tuscany Blood Bank, Pisa University Hospital, 56124 Pisa, Italy
| | - Massimo Franchini
- Division of Transfusion Medicine, Carlo Poma Hospital, 46100 Mantua, Italy
| | - Liise-Anne Pirofski
- Division of Infectious Diseases, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY 10467, USA
| | - Thierry Burnouf
- Graduate Institute of Biomedical Materials and Tissue Engineering & International PhD Program in Biomedical Engineering, College of Biomedical Engineering, Taipei Medical University, Taipei 110, Taiwan
| | - DeLisa Fairweather
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, FL 32224, USA
| | - Michael J Joyner
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Arturo Casadevall
- Department of Medicine, Johns Hopkins School of Medicine, Johns Hopkins University, Baltimore, MD 21205, USA
- Department of Medicine, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205, USA
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2
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Demchuk AM, Yue P, Zotova E, Nakamya J, Xu L, Milling TJ, Ohara T, Goldstein JN, Middeldorp S, Verhamme P, Lopez-Sendon JL, Conley PB, Curnutte JT, Eikelboom JW, Crowther M, Connolly SJ. Hemostatic Efficacy and Anti-FXa (Factor Xa) Reversal With Andexanet Alfa in Intracranial Hemorrhage: ANNEXA-4 Substudy. Stroke 2021; 52:2096-2105. [PMID: 33966491 PMCID: PMC8140631 DOI: 10.1161/strokeaha.120.030565] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 01/29/2021] [Accepted: 03/11/2021] [Indexed: 12/12/2022]
Abstract
Background and Purpose Andexanet alfa is a recombinant modified human FXa (factor Xa) developed to reverse FXa inhibition from anticoagulants. Hemostatic efficacy and reversal of anti-FXa activity with andexanet were assessed in patients from the ANNEXA-4 study (Andexanet Alfa, a Novel Antidote to the Anticoagulation Effects of FXa Inhibitors) with intracranial hemorrhage (ICrH). Methods ANNEXA-4 was a single-arm study evaluating andexanet in patients presenting with major bleeding ≤18 hours after taking an FXa inhibitor. Patients received a bolus plus 2-hour infusion of andexanet. Brain imaging in patients with ICrH was performed at baseline and at 1 and 12 hours postandexanet infusion. Coprimary efficacy outcomes were change in anti-FXa activity and hemostatic efficacy at 12 hours (excellent/good efficacy defined as ≤35% increase in hemorrhage volume/thickness). Safety outcomes included occurrence of thrombotic events and death at 30 days. Results A total of 227 patients with ICrH were included in the safety population (51.5% male; mean age 79.3 years) and 171 in the efficacy population (99 spontaneous and 72 traumatic bleeds). In efficacy evaluable patients, excellent/good hemostasis 12 hours postandexanet occurred in 77 out of 98 (78.6%) and in 58 out of 70 (82.9%) patients with spontaneous and traumatic bleeding, respectively. In the subanalysis by FXa inhibitor treatment group in the efficacy population, median of percent change in anti-FXa from baseline to nadir showed a decrease of 93.8% for apixaban-treated patients (n=99) and by 92.6% for rivaroxaban-treated patients (n=59). Within 30 days, death occurred in 34 out of 227 (15.0%) patients and thrombotic events occurred in 21 out of 227 (9.3%) patients (safety population). Conclusions Andexanet reduced anti-FXa activity in FXa inhibitor-treated patients with ICrH, with a high rate of hemostatic efficacy. Andexanet may substantially benefit patients with ICrH, the most serious complication of anticoagulation. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02329327.
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Affiliation(s)
- Andrew M. Demchuk
- Departments of Clinical Neurosciences and Radiology, Cumming School of Medicine, University of Calgary, AB, Canada (A.M.D.)
| | - Patrick Yue
- Portola Pharmaceuticals, Inc, now Alexion Pharmaceuticals, Inc, South San Francisco, CA (P.Y., P.B.C., J.T.C.)
| | - Elena Zotova
- Department of Medicine, McMaster University, Hamilton, ON, Canada (E.Z., J.N., L.X., J.W.E., M.C., S.J.C.)
| | - Juliet Nakamya
- Department of Medicine, McMaster University, Hamilton, ON, Canada (E.Z., J.N., L.X., J.W.E., M.C., S.J.C.)
| | - Lizhen Xu
- Department of Medicine, McMaster University, Hamilton, ON, Canada (E.Z., J.N., L.X., J.W.E., M.C., S.J.C.)
| | - Truman J. Milling
- Department of Neurology, Seton Dell Medical School Stroke Institute, Austin, TX (T.J.M.)
| | - Tomoyuki Ohara
- Department of Neurology, Kyoto Prefectural University of Medicine, Japan (T.O.)
| | - Joshua N. Goldstein
- Department of Emergency Medicine, Massachusetts General Hospital, Boston (J.N.G.)
| | - Saskia Middeldorp
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Meibergdreef, the Netherlands (S.M.)
| | - Peter Verhamme
- Center for Molecular and Vascular Biology, University of Leuven, Belgium (P.V.)
| | - Jose Luis Lopez-Sendon
- Department of Cardiology, Hospital Universitario La Paz, IdiPaz, Universidad Autonoma de Madrid, Spain (J.L.L.-S.)
| | - Pamela B. Conley
- Portola Pharmaceuticals, Inc, now Alexion Pharmaceuticals, Inc, South San Francisco, CA (P.Y., P.B.C., J.T.C.)
| | - John T. Curnutte
- Portola Pharmaceuticals, Inc, now Alexion Pharmaceuticals, Inc, South San Francisco, CA (P.Y., P.B.C., J.T.C.)
| | - John W. Eikelboom
- Department of Medicine, McMaster University, Hamilton, ON, Canada (E.Z., J.N., L.X., J.W.E., M.C., S.J.C.)
| | - Mark Crowther
- Department of Medicine, McMaster University, Hamilton, ON, Canada (E.Z., J.N., L.X., J.W.E., M.C., S.J.C.)
| | - Stuart J. Connolly
- Department of Medicine, McMaster University, Hamilton, ON, Canada (E.Z., J.N., L.X., J.W.E., M.C., S.J.C.)
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Mizumachi K, Tsumura Y, Nakajima Y, Koh K, Nogami K. Clot waveform analysis for perioperative hemostatic monitoring of arthroscopic synovectomy in a pediatric patient with hemophilia A and inhibitor receiving emicizumab prophylaxis. Int J Hematol 2021; 113:930-935. [PMID: 33566316 DOI: 10.1007/s12185-021-03095-w] [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] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 01/26/2021] [Accepted: 01/28/2021] [Indexed: 11/25/2022]
Abstract
Emicizumab reduces bleeding in patients with hemophilia A and inhibitors (PwHA-I). Coagulation potential during the perioperative period in emicizumab-treated PwHA-I undergoing surgery remains to be evaluated. We describe a 14-year-old boy with HA-I receiving emicizumab prophylaxis who experienced arthroscopic synovectomy. He was treated with a bolus infusion of recombinant factor VIIa (rFVIIa; 80 μg/kg) immediately before surgery, and treatment continued at the same dose every 3 h on day 1, every 4 h on day 2, and every 6 h on day 3. Treatment with rFVIIa was discontinued on day 4. No perioperative bleeding or thrombotic events were observed. Coagulation potential throughout the perioperative period was retrospectively assessed with an easy-to-use clot waveform analysis (CWA). Measurements from CWA returned to within or near the normal range, suggesting successful hemostatic management. Coagulation potentials assessed by CWA showed a significant correspondence with those from a thrombin generation assay (TGA) that is already in use. CWA and TGA could both provide useful data for assessing coagulation potential in the perioperative hemostatic management of emicizumab-treated PwHA-I.
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Affiliation(s)
- Kuniyoshi Mizumachi
- Department of Pediatrics, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Yusuke Tsumura
- Department of Hematology/Oncology, Saitama Children's Medical Center, Saitama, Japan
| | - Yuto Nakajima
- Department of Pediatrics, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan.
| | - Katsuyoshi Koh
- Department of Hematology/Oncology, Saitama Children's Medical Center, Saitama, Japan
| | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
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Lim MY, Cheng D, Recht M, Kempton CL, Key NS. Management of inhibitors in persons with non-severe hemophilia A in the United States. Am J Hematol 2021; 96:E9-E11. [PMID: 32976635 DOI: 10.1002/ajh.26011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 09/22/2020] [Indexed: 11/07/2022]
Affiliation(s)
- Ming Y Lim
- Division of Hematology and Hematologic Malignancies, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Dunlei Cheng
- American Thrombosis and Hemostasis Network, Rochester, New York
| | - Michael Recht
- American Thrombosis and Hemostasis Network, Rochester, New York
- Division of Hematology and Oncology, School of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Christine L Kempton
- Department of Hematology and Medical Oncology and Hemophilia of Georgia Center for Bleeding & Clotting Disorders of Emory, Emory University School of Medicine, Atlanta, Georgia
| | - Nigel S Key
- Division of Hematology and UNC Blood Research Center, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina
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5
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Recht M. Safety first: Tracking adverse events associated with new therapies for people with hemophilia. J Thromb Haemost 2021; 19 Suppl 1:3-5. [PMID: 33331044 DOI: 10.1111/jth.15188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 10/19/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Michael Recht
- American Thrombosis and Hemostasis Network, Rochester, NY, USA
- The Hemophilia Center, Oregon Health & Science University, Portland, OR, USA
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6
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Uchida E, Komori K, Kurata T, Taki M, Sakashita K. Prophylaxis Using a Mixture of Plasma-Derived Activated Factor VII and Factor X (pdFVIIa/FX) in a Patient with Hemophilia B Complicated by Inhibitors and Allergy to Factor IX Concentrates: A Case Report. Acta Haematol 2020; 144:293-296. [PMID: 32702700 DOI: 10.1159/000508722] [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] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 05/17/2020] [Indexed: 12/31/2022]
Abstract
Treating patients with hemophilia and inhibitors is often problematic. The presence of inhibitors negatively impacts the effectiveness of treatment to achieve hemostasis especially in patients with hemophilia B, owing mainly to allergic reactions to factor IX (FIX) concentrates and the low success rate of immune tolerance therapy. A 9-month-old boy had intracranial hemorrhage and was diagnosed with hemophilia B. After replacement therapy, he developed inhibitors and an allergic reaction to FIX. Prophylactic therapy was initiated with recombinant activated factor VII (rFVIIa) and later switched to pdFVIIa/factor X (FX; 120 μg/kg as the FVII dose, every other day) because of a recurrence of intracranial hemorrhage. Since then, he remained well without life-threatening bleeding for more than 2 years. Our case suggests that pdFVIIa/FX may be useful for prophylactic therapy in hemophilia B complicated by inhibitors and allergic reaction to FIX concentrates.
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Affiliation(s)
- Eriko Uchida
- Department of Hematology and Oncology, Nagano Children's Hospital, Azumino, Japan
| | - Kazutoshi Komori
- Department of Hematology and Oncology, Nagano Children's Hospital, Azumino, Japan
| | - Takashi Kurata
- Department of Hematology and Oncology, Nagano Children's Hospital, Azumino, Japan
| | - Masashi Taki
- Department of Pediatrics, St. Marianna University School of Medicine Yokohama City Seibu Hospital, Yokohama, Japan
| | - Kazuo Sakashita
- Department of Hematology and Oncology, Nagano Children's Hospital, Azumino, Japan,
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7
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Mihara M, Ogawa Y, Nagasaka M, Kobayashi N, Shimizu H, Shinozawa K, Fukutake K, Inoue M, Murakami M, Handa H. Successful Management of Acquired Factor V Inhibitor by Monitoring Factor V Activity, Antigen, and Inhibitor Values during Immunosuppressive Therapy. Acta Haematol 2019; 143:486-490. [PMID: 31563916 DOI: 10.1159/000502730] [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] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Accepted: 08/15/2019] [Indexed: 11/19/2022]
Abstract
Acquired factor V inhibitor (AFVI) results from the formation of autoantibodies to coagulation factor V (FV), and the clinical phenotype can range from asymptomatic laboratory abnormalities to life-threatening bleeds. We describe a 74-year-old man who developed AFVI along with a massive subcutaneous hematoma. He was initially treated with prednisolone (PSL), but AFVI recurred when the dose was reduced after a short period. We subsequently increased the PSL dose and added cyclophosphamide (CY), which resulted in a complete response. We then gradually tapered PSL and stopped CY, and the patient has since remained free of recurrent AFVI symptoms. We monitored FV activity, antigen concentrations, and inhibitor titers of this patient throughout the clinical course. The ratio of FV activity to antigen concentration was low at diagnosis and gradually increased along with the patient's improvement. This ratio might be a useful parameter for evaluating the effects of immunosuppressive therapy in patients with AFVI.
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Affiliation(s)
- Masahiro Mihara
- Department of Hematology, Gunma University Graduate School of Medicine, Maebashi, Japan
- Department of Internal Medicine, Kiboukan Hospital, Takasaki, Japan
| | - Yoshiyuki Ogawa
- Department of Hematology, Gunma University Graduate School of Medicine, Maebashi, Japan,
| | - Motoo Nagasaka
- Department of Internal Medicine, Kiboukan Hospital, Takasaki, Japan
| | - Nobuhiko Kobayashi
- Department of Hematology, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Hiroaki Shimizu
- Department of Hematology, Gunma University Graduate School of Medicine, Maebashi, Japan
- Department of Internal Medicine, Kiboukan Hospital, Takasaki, Japan
| | - Keiko Shinozawa
- Department of Molecular Genetics of Coagulation Disorders, Tokyo Medical University, Tokyo, Japan
| | - Katsuyuki Fukutake
- Department of Molecular Genetics of Coagulation Disorders, Tokyo Medical University, Tokyo, Japan
- Department of Laboratory Medicine, Tokyo Medical University, Tokyo, Japan
| | - Madoka Inoue
- Department of Clinical Laboratory, Gunma University Hospital, Maebashi, Japan
| | - Masami Murakami
- Department of Clinical Laboratory Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Hiroshi Handa
- Department of Hematology, Gunma University Graduate School of Medicine, Maebashi, Japan
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8
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Sakatoku K, Takakuwa T, Miura A, Araki T, Fujitani Y, Yamamura R. Acquired Factor V Inhibitor with Hemorrhagic Symptoms after Prasugrel Hydrochloride Treatment. Acta Haematol 2019; 143:478-480. [PMID: 31522179 DOI: 10.1159/000502406] [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] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 07/29/2019] [Indexed: 11/19/2022]
Abstract
Acquired factor V inhibitor (AFVI) is a rare coagulopathy. It may be triggered by specific antigens such as antibiotics. We herein report the first case of AFVI after treatment with prasugrel hydrochloride (prasugrel) in an 80-year-old male who underwent percutaneous coronary intervention because of angina pectoris 6 years ago and was initiated on aspirin and ticlopidine hydrochloride. He was switched from ticlopidine hydrochloride to prasugrel before undergoing percutaneous coronary intervention for myocardial infarction. Fifteen days later, he developed sudden nasal hemorrhage, hematuria, and systemic purpura. Coagulation tests revealed prolonged prothrombin time-international normalized ratio (11.35) and activated partial thromboplastin time (170 s). The coagulation factor profile revealed a decreased FV activity (1%). The Bethesda assay for FV inhibitor was positive. AFVI was diagnosed; prasugrel was immediately discontinued, and administration of recombinant activated factor VII and prednisolone were initiated. Hemorrhagic symptoms immediately disappeared; FV activity improved, and the FV inhibitor titer was normalized.
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Affiliation(s)
- Kazuki Sakatoku
- Department of Hematology, Graduate School of Medicine, Osaka City University, Osaka, Japan,
- Department of Hematology, Osaka Saiseikai Nakatsu Hospital, Osaka, Japan,
| | - Teruhito Takakuwa
- Department of Hematology, Osaka Saiseikai Nakatsu Hospital, Osaka, Japan
| | - Akiko Miura
- Department of Hematology, Osaka Saiseikai Nakatsu Hospital, Osaka, Japan
| | - Taku Araki
- Department of Hematology, Osaka Saiseikai Nakatsu Hospital, Osaka, Japan
| | - Yotaro Fujitani
- Department of Hematology, Osaka Saiseikai Nakatsu Hospital, Osaka, Japan
| | - Ryosuke Yamamura
- Department of Hematology, Osaka Saiseikai Nakatsu Hospital, Osaka, Japan
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9
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Wyatt KD, Coon LM, Rusk DN, Rodriguez V, Warad DM. Case Report: Development of Factor VIII Inhibitor in a Patient with an Uncommon de novo Mutation in the Factor VIII Gene. Acta Haematol 2019; 141:129-134. [PMID: 30783064 DOI: 10.1159/000495559] [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] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 11/15/2018] [Indexed: 11/19/2022]
Abstract
The development of factor VIII inhibitors remains a significant clinical challenge in the management of hemophilia A. We present a patient of mixed ethnicity with severe hemophilia A who was found to have a F8 gene hemizygous c.5815G>T mutation resulting in an Ala1939Ser substitution (Ala1920Ser in legacy nomenclature) and possible splice site change that has been reported in only 1 patient previously. He developed an inhibitor shortly after starting replacement recombinant factor VIII (Advate®; Baxalta, Bannockburn, IL, USA) and was successfully treated with immune tolerance therapy. Our report describes the second patient reported to have severe hemophilia due to this mutation and the only case of a factor VIII inhibitor associated with this mutation.
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Affiliation(s)
- Kirk D Wyatt
- Division of Pediatric Hematology/Oncology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Lea M Coon
- Division of Hematopathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Dawn N Rusk
- Hemophilia Treatment Center, Department of Hematology/Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Vilmarie Rodriguez
- Division of Pediatric Hematology/Oncology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Deepti M Warad
- Division of Pediatric Hematology/Oncology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, USA,
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10
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Li F, Shu K, Liu J, Shen C, Wang X, Zhang Z, Jiang M. Acquired Factor V Inhibitor with Symptoms and Titer of Inhibitor Differences: Report of Two Cases. Acta Haematol 2019; 141:148-150. [PMID: 30783058 DOI: 10.1159/000496080] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 12/07/2018] [Indexed: 11/19/2022]
Affiliation(s)
- Fanfan Li
- Clinical Laboratory Center, The second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Kuangyi Shu
- Clinical Laboratory Center, The second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Jie Liu
- Clinical Laboratory Center, The second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Chenfang Shen
- Clinical Laboratory Center, The second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xiaoou Wang
- Clinical Laboratory Center, The second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Zhaohua Zhang
- Clinical Laboratory Center, The second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Minghua Jiang
- Clinical Laboratory Center, The second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China,
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11
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Santagostino E, Young G, Escuriola Ettingshausen C, Jimenez-Yuste V, Carcao M. Inhibitors: A Need for Eradication? Acta Haematol 2019; 141:151-155. [PMID: 30783066 DOI: 10.1159/000495454] [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] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 11/14/2018] [Indexed: 01/19/2023]
Abstract
The development of inhibitors against factor VIII (FVIII) concentrates represents a significant treatment complication for hemophilia. Immune tolerance induction (ITI) therapy eradicates inhibitors in 60-80% of patients, resulting in a normal FVIII response. This article, based on presentations at the 6th International Coagulation Meeting, held in Barcelona, Spain, in September 2017, provides an overview of management approaches for patients with inhibitors and briefly tabulates four cases of ITI therapy (first-line or rescue ITI therapy in pediatric and adult patients) with successful outcomes. Switching FVIII product from recombinant FVIII to plasma-derived FVIII/VWF concentrate may be helpful in eradicating inhibitors. The rate of decline of inhibitor titer in the initial stages of ITI therapy is a good indicator of the success or failure of therapy, although prognostic biomarkers are needed. The development of the bispecific monoclonal antibody emicizumab, which was recently shown to reduce bleeding in inhibitor patients, offers a potential alternative therapeutic option. However, the benefits of inhibitor eradication, including a wider choice of cheaper therapeutic products for preventing and treating bleeds, suggest that at least one attempt of ITI therapy should be offered to patients who develop inhibitors.
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Affiliation(s)
- Elena Santagostino
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy,
| | - Guy Young
- Hemostasis and Thrombosis Center, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | | | - Victor Jimenez-Yuste
- Hematology Department, Hospital Universitario La Paz, Autónoma University, IdiPaz, Madrid, Spain
| | - Manuel Carcao
- Division of Hematology/Oncology, Department of Pediatrics and Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
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12
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Abstract
PURPOSE OF REVIEW Hemophilia is an X-linked blood coagulation genetic disorder, which can cause significant disability. Replacement therapy for coagulation factor VIII (hemophilia A) or factor IX (hemophilia B) may result in the development of high-affinity alloantibodies ('inhibitors') to the replacement therapy, thus making it ineffective. Therefore, there is interest in directing immunological responses towards tolerance to infused factors. RECENT FINDINGS In this review, we will discuss latest advancements in the development of potentially less immunogenic replacement clotting factors, optimization of current tolerance induction protocols (ITI), preclinical and clinical data of pharmacological immune modulation, hepatic gene therapy, and the rapidly advancing field of cell therapies. We will also evaluate publications reporting data from preclinical studies on oral tolerance induction using chloroplast-transgenic (transplastomic) plants. SUMMARY Until now, no clinical prophylactic immune modulatory protocol exists to prevent inhibitor formation to infused clotting factors. Recent innovative technologies provide hope for improved eradication and perhaps even prevention of inhibitors.
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Affiliation(s)
- Alexandra Sherman
- Department Pediatrics, Indiana University, Indianapolis, Indiana, USA
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Kadohira Y, Yamada S, Hayashi T, Morishita E, Asakura H, Ichinose A. A discrepancy between prothrombin time and Normotest (Hepaplastintest) results is useful for diagnosis of acquired factor V inhibitors. Int J Hematol 2018; 108:145-150. [PMID: 29611057 DOI: 10.1007/s12185-018-2453-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Revised: 03/27/2018] [Accepted: 03/28/2018] [Indexed: 11/27/2022]
Abstract
Acquired coagulation factor inhibitors are rare. Among them, coagulation factor V (FV) inhibitor is particularly uncommon and presents with variable clinical manifestations. Certain acquired FV inhibitor patients have only mild bleeding or, in select cases, no symptoms at all, leading to spontaneous recovery. Others have life-threatening bleeding that requires medical attention. Thus, a prompt decision regarding diagnosis and clinical intervention is crucial for such patients. In five acquired FV inhibitor cases treated in our facility, each patient had a malignancy as an underlying disease and all unexpectedly showed prolongation of both prothrombin time (PT) and activated partial thromboplastin time (APTT). They all also displayed a discrepancy between PT and Normotest (Hepaplastintest, HPT) results. All but one patient experienced no bleeding at the time of diagnosis and achieved spontaneous recovery in 1-3 weeks. The patient with bleeding symptoms received plasma exchanges and a platelet transfusion. Useful markers in diagnosing the presence of an acquired FV inhibitor were a sudden prolongation of PT and APTT, and a discrepancy between the PT/APTT and HPT assays. Spontaneous recovery can be expected for patients with only minor bleeding.
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Affiliation(s)
- Yasuko Kadohira
- Department of Hematology, Kanazawa University Hospital, 13-1 Takaramachi, Kanazawa, Ishikawa, 920-8641, Japan.
| | - Shinya Yamada
- Department of Hematology, Kanazawa University Hospital, 13-1 Takaramachi, Kanazawa, Ishikawa, 920-8641, Japan
| | - Tomoe Hayashi
- Department of Hematology, Kanazawa University Hospital, 13-1 Takaramachi, Kanazawa, Ishikawa, 920-8641, Japan
| | - Eriko Morishita
- Department of Hematology, Kanazawa University Hospital, 13-1 Takaramachi, Kanazawa, Ishikawa, 920-8641, Japan
| | - Hidesaku Asakura
- Department of Hematology, Kanazawa University Hospital, 13-1 Takaramachi, Kanazawa, Ishikawa, 920-8641, Japan
- Japanese Collaborative Research Group on Autoimmune Haemorrhaphilia Supported by the Japanese Ministry of Health, Labor and Welfare, Yamagata, Japan
| | - Akitada Ichinose
- Japanese Collaborative Research Group on Autoimmune Haemorrhaphilia Supported by the Japanese Ministry of Health, Labor and Welfare, Yamagata, Japan
- Department of Molecular Patho-Biochemistry and Patho-Biology, Yamagata University School, Yamagata, Japan
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14
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Nakata K, Ueda S, Matsunaga H, Mima F, Ueda H, Yoshioka A, Kaneko S, Maruo K, Morris S, Yonemoto S, Hayashi D, Fujii N, Narahara H, Inui Y, Kawata S. High Titer of Acquired Factor V Inhibitor Presenting with a Pseudo-deficiency of Multiple Coagulation Factors. Intern Med 2018; 57:393-397. [PMID: 29093398 PMCID: PMC5827322 DOI: 10.2169/internalmedicine.9150-17] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Acquired coagulation factor inhibitor is a rare coagulation disorder. We herein report a patient with acquired factor V inhibitor showing a decrease in multiple coagulation factor activities. A high titer of factor V inhibitor presumably led to a marked inhibition of factor V activity in the specific factor-deficient plasma used in coagulation factor activity assays based on either an activated partial thromboplastin time (APTT) or prothrombin time (PT) clotting assay, resulting in false low values of the coagulation activity. We re-examined the coagulation factor activity using several dilutions of the patient's plasma and confirmed that the high factor V inhibitor titer had caused an apparent decrease in multiple coagulation factor activities.
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Affiliation(s)
- Keiichi Nakata
- Department of Internal Medicine, Hyogo Prefectural Nishinomiya Hospital, Japan
| | - Shuji Ueda
- Department of Internal Medicine, Hyogo Prefectural Nishinomiya Hospital, Japan
| | - Hitomi Matsunaga
- Department of Internal Medicine, Hyogo Prefectural Nishinomiya Hospital, Japan
| | - Fuka Mima
- Department of Internal Medicine, Hyogo Prefectural Nishinomiya Hospital, Japan
| | - Hiroki Ueda
- Department of Internal Medicine, Hyogo Prefectural Nishinomiya Hospital, Japan
| | - Aya Yoshioka
- Department of Clinical Laboratory, Hyogo Prefectural Nishinomiya Hospital, Japan
| | - Sayoko Kaneko
- Department of Clinical Laboratory, Hyogo Prefectural Nishinomiya Hospital, Japan
| | - Kazushi Maruo
- Department of Medical Engineering, Hyogo Prefectural Nishinomiya Hospital, Japan
| | - Shayne Morris
- Department of Neurosurgery, Hyogo Prefectural Nishinomiya Hospital, Japan
| | - Sayoko Yonemoto
- Department of Internal Medicine, Hyogo Prefectural Nishinomiya Hospital, Japan
| | - Daisuke Hayashi
- Department of Internal Medicine, Hyogo Prefectural Nishinomiya Hospital, Japan
| | - Naohiko Fujii
- Department of Internal Medicine, Hyogo Prefectural Nishinomiya Hospital, Japan
| | - Hiroyuki Narahara
- Department of Internal Medicine, Hyogo Prefectural Nishinomiya Hospital, Japan
| | - Yoshiaki Inui
- Department of Internal Medicine, Hyogo Prefectural Nishinomiya Hospital, Japan
| | - Sumio Kawata
- Department of Internal Medicine, Hyogo Prefectural Nishinomiya Hospital, Japan
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15
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Messori A, Peyvandi F, Trippoli S, Palla R, Rosendaal FR, Mannucci PM. High-titre inhibitors in previously untreated patients with severe haemophilia A receiving recombinant or plasma-derived factor VIII: a budget-impact analysis. Blood Transfus 2018; 16:215-220. [PMID: 28686156 PMCID: PMC5839620 DOI: 10.2450/2017.0352-16] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 12/10/2016] [Accepted: 03/29/2017] [Indexed: 11/21/2022]
Affiliation(s)
- Andrea Messori
- HTA Unit, ESTAR, Regional Health Service, Florence, Italy
| | - Flora Peyvandi
- ”A. Bianchi Bonomi” Haemophilia and Thrombosis Centre, “Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico”, Milan, Italy
- ”Luigi Villa” Foundation, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | | | - Roberta Palla
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Frits R. Rosendaal
- Department of Clinical Epidemiology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Pier Mannuccio Mannucci
- ”A. Bianchi Bonomi” Haemophilia and Thrombosis Centre, “Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico”, Milan, Italy
- ”Luigi Villa” Foundation, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
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16
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Abstract
Inhibitor formation is among the most severe complications of hemophilia treatment. With a cumulative incidence of ∼30% in those with severe hemophilia A and ∼3% in those with severe hemophilia B, inhibitors are caused by a T-cell response directed against infused coagulation factor; these inhibitors neutralize factor VIII or IX activity and disrupt normal hemostasis. Inhibitor patients become unresponsive to standard factor treatment and, as an alternative, use bypass treatment (eg, recombinant factor VIIa or factor VIII inhibitor bypass activity). However, response to bypass agents is poorer and the burden of disease is higher, with greater morbidity, hospitalization, cost, and mortality, than in noninhibitor patients. Furthermore, inhibitor formation interferes with prophylaxis to prevent bleeding episodes and is a contraindication to gene therapy. Thus, more effective therapies for inhibitor patients are greatly needed. In the last several years, there has been an explosion of novel alternative hemostatic agents for hemophilia patients with and without inhibitors. These agents take advantage of technologic manipulation of coagulation factors and natural anticoagulants to promote hemostasis. The approaches include the following: (1) mutants or mimics of coagulation factors, rendering them resistant to natural anticoagulants; or (2) knock-down or disruption of natural anticoagulants, preventing degradation of coagulation factors. The purpose of this article was to review these novel alternative hemostatic agents and their mechanisms of action, as well as the preliminary pharmacokinetic, safety, and efficacy data available from early-phase clinical trials.
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Affiliation(s)
- Margaret V Ragni
- Department of Medicine, Division Hematology/Oncology, University of Pittsburgh, and Hemophilia Center of Western Pennsylvania, Pittsburgh, PA
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17
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Meeks SL, Batsuli G. Hemophilia and inhibitors: current treatment options and potential new therapeutic approaches. Hematology Am Soc Hematol Educ Program 2016; 2016:657-662. [PMID: 27913543 PMCID: PMC6142469 DOI: 10.1182/asheducation-2016.1.657] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
The immune response to infused factor concentrates remains a major source of morbidity and mortality in the treatment of patients with hemophilia A and B. This review focuses on current treatment options and novel therapies currently in clinical trials. After a brief review of immune tolerance regimens, the focus of the discussion is on preventing bleeding in patients with hemophilia and inhibitors. Recombinant factor VIIa and activated prothrombin complex concentrates are the mainstays in treating bleeds in patients with inhibitors. Both agents have been shown to reduce bleeding episodes to a similar degree when infused prophylactically; however, individual patients may respond better to one agent over the other at any given time. The international immune tolerance trial revealed that a high-dose factor VIII regimen provided significantly better bleeding protection than the low-dose regimen. Given the high cost of treatment and the potential for a high-dose immune tolerance regimen to prevent bleeding in some patients, we discuss how we treat patients to maximize the prevention of bleeds while minimizing cost. Novel approaches to treatment of these patients are in development. These include agents that mimic factor VIII or augment thrombin generation by bypassing the inhibitor, as well as agents that inhibit the natural anticoagulants.
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Affiliation(s)
- Shannon L Meeks
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Emory University, Atlanta, GA
| | - Glaivy Batsuli
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Emory University, Atlanta, GA
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18
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Jetty V, Glueck CJ, Freiberg RA, Wang P. Venous Thromboembolism After Knee Arthroscopy in Undiagnosed Familial Thrombophilia. Orthopedics 2016; 39:e1052-e1057. [PMID: 27459142 DOI: 10.3928/01477447-20160719-02] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Accepted: 05/27/2016] [Indexed: 02/03/2023]
Abstract
Venous thromboembolism is uncommon after knee arthroscopy, and there are no guidelines for thromboprophylaxis in elective routine knee arthroscopy. Preoperative evaluation of common thrombophilias should provide guidance for postarthroscopy thromboprophylaxis in otherwise healthy patients who are at high risk for venous thromboembolism. This study assessed 10 patients with venous thromboembolism after total hip or knee arthroplasty. Patients were assessed if venous thromboembolism occurred within 6 months after knee arthroscopy (n=10) or total hip or knee arthroplasty (n=21). This study assessed gene mutations (factor V Leiden, prothrombin G20210A, plasminogen activator inhibitor, methylenetetrahydrofolate reductase) and serologic thrombophilias (high levels of factors VIII and XI, homocysteine, anticardiolipin immunoglobulin G and immunoglobulin M antibodies, and lupus anticoagulant; low antigenic protein C, S, and free S; and antithrombin III deficiency). The same coagulation data were obtained for normal subjects (n=110). The major thrombophilias in the arthroscopy group were factor V Leiden heterozygosity (40%), high factor VIII level (50%), and high homocysteine (30%). The respective values in control subjects were 2% (P=.0004), 7% (P=.0011), and 5% (P=.02). When the arthroscopy group was compared with the 21 patients who had venous thromboembolism after total hip or knee arthroplasty, the sole difference was factor V Leiden heterozygosity, which was 40% vs 0%, respectively (P=.007). Although venous thromboembolism after knee arthroscopy is uncommon, to identify high-risk patients and guide postoperative thromboprophylaxis, the authors suggest routine preoperative measurement of 3 common familial thrombophilias: factor V Leiden, factor VIII, and homocysteine. [Orthopedics. 2016; 39(6):e1052-e1057.].
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19
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Rief P, Hackl G, Hafner F, Raggam RB, Wölfler A, Brodmann M, Gary T. Venous thromboembolism in a patient with persistent inhibitor to coagulation factor V - a case report. Clin Chem Lab Med 2016; 54:e269-71. [PMID: 26910745 DOI: 10.1515/cclm-2015-1103] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Accepted: 01/07/2016] [Indexed: 11/15/2022]
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20
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Miller CH, Rice AS, Boylan B, Payne AB, Kelly FM, Escobar MA, Gill J, Leissinger C, Soucie JM. Characteristics of hemophilia patients with factor VIII inhibitors detected by prospective screening. Am J Hematol 2015; 90:871-6. [PMID: 26147783 PMCID: PMC4642843 DOI: 10.1002/ajh.24104] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Revised: 06/03/2015] [Accepted: 07/01/2015] [Indexed: 11/11/2022]
Abstract
Characteristics of inhibitors identified by prospective screening may differ from those detected clinically. In a prospective study at 17 hemophilia centers with central inhibitor measurement by Nijmegen-Bethesda assay, 23 (2.8%) of 824 hemophilia A patients had new inhibitors detected: nine high-titer inhibitors (HTI: 7 ≥ 5.0 NBU plus 2 of 2.6 and 3.4 NBU at immune tolerance induction initiation) and 14 low-titer inhibitors (LTI: 0.5-1.9 NBU). HTI occurred at an earlier age (median 2 years, range 1-18, vs. median 11 years, range 2-61, P = 0.016). Both HTI (22%) and LTI (43%) occurred in non-severe patients. All HTI, but only 64% of LTI, were found to be FVIII-specific by chromogenic Bethesda assay or fluorescence immunoassay (FLI), indicating a high rate of false-positive LTI. Repeat specimens confirmed all HTI, 7/9 LTI, and 7/7 FVIII-specific LTI. FLI results were similar between HTI and FVIII-specific LTI; all included IgG1 and IgG4 subclasses. A comparable prospective study conducted from 1975 to 1979 at 13 U.S. centers found 31 (2.4%) new inhibitors among 1,306 patients. In both studies, one-third of inhibitors occurred in non-severe patients and one-quarter after 150 exposure days (ED). Significant differences were seen in the age at which inhibitors occurred (median 16 years in the older study vs. 5 years currently, P = 0.024) and in ED before inhibitor development, 10% in the older study and 43% currently study occurring within 20 ED, suggesting a temporal change in inhibitor development. Prospective screening detects inhibitors in patients of all severities, ages, and ED. Some LTI, however, are false positives.
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Affiliation(s)
- Connie H. Miller
- Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Anne S. Rice
- Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Brian Boylan
- Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Amanda B. Payne
- Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Fiona M. Kelly
- Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | - Joan Gill
- Comprehensive Center for Bleeding Disorders, Blood Center of Wisconsin and Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Cindy Leissinger
- Louisiana Center for Bleeding and Clotting Disorders, New Orleans, Louisiana
| | - J. Michael Soucie
- Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
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21
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Sarachana T, Dahiya N, Simhadri VL, Pandey GS, Saini S, Guelcher C, Guerrera MF, Kimchi-Sarfaty C, Sauna ZE, Atreya CD. Small ncRNA Expression-Profiling of Blood from Hemophilia A Patients Identifies miR-1246 as a Potential Regulator of Factor 8 Gene. PLoS One 2015; 10:e0132433. [PMID: 26176629 PMCID: PMC4503767 DOI: 10.1371/journal.pone.0132433] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Accepted: 06/16/2015] [Indexed: 11/18/2022]
Abstract
Hemophilia A (HA) is a bleeding disorder caused by deficiency of functional plasma clotting factor VIII (FVIII). Genetic mutations in the gene encoding FVIII (F8) have been extensively studied. Over a thousand different mutations have been reported in the F8 gene. These span a diverse range of mutation types, namely, missense, splice-site, deletions of single and multiple exons, inversions, etc. There is nonetheless evidence that other molecular mechanisms, in addition to mutations in the gene encoding the FVIII protein, may be involved in the pathobiology of HA. In this study, global small ncRNA expression profiling analysis of whole blood from HA patients, and controls, was performed using high-throughput ncRNA microarrays. Patients were further sub-divided into those that developed neutralizing-anti-FVIII antibodies (inhibitors) and those that did not. Selected differentially expressed ncRNAs were validated by quantitative reverse transcription-polymerase chain reaction (qRT-PCR) analysis. We identified several ncRNAs, and among them hsa-miR-1246 was significantly up-regulated in HA patients. In addition, miR-1246 showed a six-fold higher expression in HA patients without inhibitors. We have identified an miR-1246 target site in the noncoding region of F8 mRNA and were able to confirm the suppressory role of hsa-miR-1246 on F8 expression in a stable lymphoblastoid cell line expressing FVIII. These findings suggest several testable hypotheses vis-à-vis the role of nc-RNAs in the regulation of F8 expression. These hypotheses have not been exhaustively tested in this study as they require carefully curated clinical samples.
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Affiliation(s)
- Tewarit Sarachana
- Laboratory of Cellular Hematology, Division of Hematology Research and Review, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland 20993, United States of America
- Department of Clinical Chemistry, Faculty of Allied Health Sciences, Chulalongkorn University, Bangkok, 10330, Thailand
| | - Neetu Dahiya
- Laboratory of Cellular Hematology, Division of Hematology Research and Review, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland 20993, United States of America
| | - Vijaya L. Simhadri
- Laboratory of Hemostasis, Division of Hematology Research and Review, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland 20993, United States of America
| | - Gouri Shankar Pandey
- Laboratory of Hemostasis, Division of Hematology Research and Review, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland 20993, United States of America
| | - Surbhi Saini
- Laboratory of Hemostasis, Division of Hematology Research and Review, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland 20993, United States of America
- Center for Cancer and Blood Disorders, Children’s National Medical Center, Washington, D. C. 20010, United States of America
| | - Christine Guelcher
- Center for Cancer and Blood Disorders, Children’s National Medical Center, Washington, D. C. 20010, United States of America
| | - Michael F. Guerrera
- Center for Cancer and Blood Disorders, Children’s National Medical Center, Washington, D. C. 20010, United States of America
- School of Medicine and Health Sciences, George Washington University, Washington, D. C. 20037, United States of America
| | - Chava Kimchi-Sarfaty
- Laboratory of Hemostasis, Division of Hematology Research and Review, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland 20993, United States of America
| | - Zuben E. Sauna
- Laboratory of Hemostasis, Division of Hematology Research and Review, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland 20993, United States of America
- * E-mail: (ZES); (CDA)
| | - Chintamani D. Atreya
- Laboratory of Cellular Hematology, Division of Hematology Research and Review, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland 20993, United States of America
- * E-mail: (ZES); (CDA)
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22
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Kinjo Y, Yoshimura K, Suzuki T, Shinozawa K, Nakasone K, Yoshimata T, Nishihira M, Henzan E. [Development of asymptomatic acquired factor V inhibitor after the administration of antibiotics]. Rinsho Ketsueki 2014; 55:2311-2315. [PMID: 25501413] [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] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Acquired factor V (FV) inhibitor is a rare coagulation disorder, the causes and clinical symptoms of which are known to vary widely. Acquired FV inhibitor mostly occurs with exposure to fibrin glues during surgical procedures. We experienced a case with asymptomatic acquired FV inhibitor caused by antibiotic therapy for aspiration pneumonia.A man in his eighties had been treated for chronic atrial fibrillation, cerebral infarction and spinal canal stenosis. He was admitted after antibiotic therapy for aspiration pneumonia in a previous hospital. On admission, the screening test for blood coagulation revealed extreme prolongation of both prothrombin time (PT) and activated partial thromboplastin time (APTT). Vitamin K was administered intravenously after cessation of warfarin, but neither PT nor APTT showed any improvement. Subsequently, a cross mixing test was performed and showed an inhibitor pattern. Furthermore, a high titer of FV inhibitor was detected by the Bethesda method and an acquired FV inhibitor was thus diagnosed. Despite the presence of FV inhibitor, the patient showed no bleeding symptoms. Eight months later, both PT and APTT had diminished to normal clotting time values without immunosuppressive therapies.
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Affiliation(s)
- Yasuyuki Kinjo
- Department of Internal Medicine, Nanbu Tokushukai Hospital
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23
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Affiliation(s)
- P C Moorehead
- Section of Pediatric Hematology/Oncology, Janeway Children's Health and Rehabilitation Centre, St. John's, NL, Canada
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24
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Nair PS, Shetty SD, Chandrakala S, Ghosh K. Mutations in intron 1 and intron 22 inversion negative haemophilia A patients from Western India. PLoS One 2014; 9:e97337. [PMID: 24845853 PMCID: PMC4028251 DOI: 10.1371/journal.pone.0097337] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/18/2013] [Accepted: 04/19/2014] [Indexed: 11/18/2022]
Abstract
Despite increased awareness and diagnostic facilities, 70-80% of the haemophilia A (HA) patients still remain undiagnosed in India. Very little data is available on prevalent mutations in HA from this country. We report fifty mutations in seventy one Indian HA patients, of which twenty were novel. Ten novel missense mutations [p.Leu11Pro (p.Leu-8Pro), p.Tyr155Ser (p.Tyr136Ser), p.Ile405Thr (p.Ile386Thr), p.Gly582Val (p.Gly563Val) p.Thr696Ile (p.Thr677Ile), p.Tyr737Cys (p.Tyr718Cys), p.Pro1999Arg (p.Pro1980Arg), p.Ser2082Thr (p.Ser2063Thr), p.Leu2197Trp (p.Leu2178Trp), p.Asp2317Glu (p.Asp2298Glu)] two nonsense [p.Lys396* (p.Lys377*), p.Ser2205* (p.Ser2186*)], one insertion [p.Glu1268_Asp1269ins (p.Glu1249_Asp1250)] and seven deletions [p.Leu882del (p.Leu863del), p.Met701del (p.Met682del), p.Leu1223del (p.Leu1204del), p.Trp1961_Tyr1962del (p.Trp1942_Tyr1943del) p.Glu1988del (p.Glu1969del), p.His1841del (p.His1822del), p.Ser2205del (p.Ser2186del)] were identified. Double mutations (p.Asp2317Glu; p.Thr696Ile) were observed in a moderate HA case. Mutations [p. Arg612Cys (p.Arg593Cys), p.Arg2326Gln (p.Arg2307Gln)] known to be predisposing to inhibitors to factor VIII (FVIII) were identified in two patients. 4.6% of the cases were found to be cross reacting material positive (CRM+ve). A wide heterogeneity in the nature of mutations was seen in the present study which has been successfully used for carrier detection and antenatal diagnosis in 10 families affected with severe to moderate HA.
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Affiliation(s)
- Preethi S. Nair
- Department of Thrombosis and Haemostasis, National Institute of Immunohaematology (ICMR), Mumbai, Maharashtra, India
| | - Shrimati D. Shetty
- Department of Thrombosis and Haemostasis, National Institute of Immunohaematology (ICMR), Mumbai, Maharashtra, India
| | - S. Chandrakala
- Department of Haematology, King Edward Memorial Hospital, Mumbai, Maharashtra, India
| | - Kanjaksha Ghosh
- Department of Thrombosis and Haemostasis, National Institute of Immunohaematology (ICMR), Mumbai, Maharashtra, India
- * E-mail:
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25
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Wei Q, Li G, Tang L, Chen Z, Zhen Y, Wu X, Zhang N, Zhang J, Yu G, Wu R. [A cross-sectional survey of coagulation factor VIII inhibitor in children with hemophilia A]. Zhonghua Er Ke Za Zhi 2014; 52:99-102. [PMID: 24739719] [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] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
OBJECTIVE To study the current situation of coagulation factor VIII (FVIII) inhibitor development in children with hemophilia A (HA) through a cross-sectional survey, and to explore the risk factors of inhibitor development in order to provide evidence for further prevention and management strategies. METHOD The clinical data of outpatients with hemophilia A in Beijing Children's Hospital seen from November 2012 to May 2013 were collected, FVIII inhibitor was screened and analyzed its risk factors. RESULT A total of 102 HA children were enrolled, 5 were mild cases, 32 were moderate, and 65 were severe cases; the median age on enrollment was 55.5 (3.0-200.0) months:19(18.6%) of patients had inhibitors and 9 (8.8%) had low-titer inhibitors, 10 (9.8%) had high-titer inhibitors. Receiving FVIII treatment for life-threatening bleeding (P = 0.03) ,OR 4.10 (95%CI:1.17-14.32) was a risk factor for inhibitor generation and patients within 20 exposure days have more chances of inhibitor development (P = 0.04) ,OR 3.32 (95%CI:1.02-10.86) . High and intense FVIII exposure within short term was the risk factor for high titer inhibitor development (P = 0.01) ,OR 5.25 (95%CI:1.45-21.92) . CONCLUSION Intense FVIII exposure for severe hemorrhage was the risk factor of inhibitors development especially of high titer inhibitors.
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Affiliation(s)
- Qiqi Wei
- Beijing Children's Hospital Affiliated to Capital Medical University, Beijing 100045, China
| | - Gang Li
- Beijing Children's Hospital Affiliated to Capital Medical University, Beijing 100045, China
| | - Ling Tang
- Beijing Children's Hospital Affiliated to Capital Medical University, Beijing 100045, China
| | - Zhenping Chen
- Beijing Children's Hospital Affiliated to Capital Medical University, Beijing 100045, China
| | - Yingzi Zhen
- Beijing Children's Hospital Affiliated to Capital Medical University, Beijing 100045, China
| | - Xinyi Wu
- Beijing Children's Hospital Affiliated to Capital Medical University, Beijing 100045, China
| | - Ningning Zhang
- Beijing Children's Hospital Affiliated to Capital Medical University, Beijing 100045, China
| | - Jishui Zhang
- Beijing Children's Hospital Affiliated to Capital Medical University, Beijing 100045, China
| | - Guoxia Yu
- Beijing Children's Hospital Affiliated to Capital Medical University, Beijing 100045, China
| | - Runhui Wu
- Beijing Children's Hospital Affiliated to Capital Medical University, Beijing 100045, China?
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26
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Batra S, Sharathkumar A, Glaubach T, Gamerman S, Green D. Autoimmune haemophilia in a teenager. Haemophilia 2013; 19:e386-e388. [PMID: 23992250 DOI: 10.1111/hae.12251] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/10/2013] [Indexed: 06/02/2023]
Affiliation(s)
- S Batra
- Ann & Robert H. Lurie Children's Hospital of Chicago, Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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27
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Wu RH, Wei QQ. [Development of inhibitor against hemophilia and prevention and management strategies forpatients with hemophilia]. Zhonghua Er Ke Za Zhi 2013; 51:631-634. [PMID: 24225299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
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Klukowska A, Komrska V, Jansen M, Laguna P. Response to the letter to the editor by Ewenstein BM and Reininger AJ. Haemophilia 2013; 19:e257-e258. [PMID: 23600976 DOI: 10.1111/hae.12154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/20/2013] [Indexed: 06/02/2023]
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Grangl G, Gallistl S, Leschnik B, Muntean W. Port-A-Cath infection causes inhibitor recurrence after initial successful ITI. Haemophilia 2013; 19:e174-5. [PMID: 23465092 DOI: 10.1111/hae.12103] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/19/2013] [Indexed: 01/27/2023]
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Abstract
Outcomes for patients with hemophilia have improved dramatically over the past 50 years. With the increased availability of safe clotting factor concentrates, the primary focus in clinical management is now the prevention of long-term complications, most notably the debilitating hemophilic arthropathy that is associated with severe disease. This article reviews evidence-based approaches for managing both children and adults with hemophilia. Definitive evidence of improved clinical results from primary prophylaxis started in young patients with severe hemophilia A and a minimal bleeding history is presented. Furthermore, recent studies showing benefits for initiating prophylaxis in older adolescents and adults with established joint disease are examined. Inhibitors to factor VIII are the most problematic complication of factor replacement therapy. Patient-specific and treatment-related factors that contribute to the risk of inhibitor formation are discussed and controversies and clinical evidence related to approaches for tolerance induction are reviewed.
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Abstract
VWF is a multimeric plasma glycoprotein that specifically recruits platelets to sites of vessel injury. VWF multimeric size is central to this function, with larger multimers being more hemostatically active. Regulation of VWF multimeric size is mediated by the plasma metalloprotease ADAMTS13 (A Disintegrin And Metalloproteinase with ThromboSpondin type 1 motifs, member 13). This enzyme can only recognize and cleave VWF when it is unraveled by rheological shear forces of the flowing blood. After the exposure of cryptic exosites, VWF recognition by ADAMTS13 involves multiple interactions that enable the protease to cleave VWF. Loss of VWF multimer size regulation caused by severe ADAMTS13 deficiency (either inherited or acquired) is associated with the microvascular thrombotic disorder thrombotic thrombocytopenic purpura (TTP). The sequelae associated with TTP are widely thought to be linked to hyperreactive circulating VWF that cause unwanted platelet aggregation in the high shear environment of the microvasculature. Diagnosis of TTP is primarily made through a combination of symptoms, analysis of plasma ADAMTS13 activity, and detection of inhibitory anti-ADAMTS13 antibodies. Current frontline treatments for TTP include plasma exchange, which serves to remove inhibitory antibodies (in acquired TTP) and provide a source of functional ADAMTS13, and steroids to treat the autoimmune component of acquired TTP. The use of anti-CD20 therapy has also exhibited encouraging results in the treatment of acquired TTP. Newer therapeutic strategies that are currently being explored or are in development include recombinant ADAMTS13, a hyperreactive ADAMTS13 variant, and anti-VWF therapy. This review discusses the basic biochemistry of VWF and ADAMTS13, their dysfunction in TTP, and therapeutic approaches for the amelioration of TTP.
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Affiliation(s)
- James T B Crawley
- 1Centre for Haematology, Imperial College London, London, United Kingdom; and
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Motwani P, Howard L, Ali SS. Successful management of a possible antibiotic-related acquired factor V inhibitor: a case report and review of the literature. Acta Haematol 2012; 129:182-4. [PMID: 23257771 DOI: 10.1159/000345244] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2012] [Accepted: 10/03/2012] [Indexed: 12/26/2022]
Abstract
Acquired factor inhibitors are rare. We report a case of an elderly male who presented with a bleeding diathesis associated with an elevated prothrombin time and an activated partial thromboplastin time. Work-up revealed undetectable factor V activity and a factor V inhibitor level of >50 Bethesda units. The inhibitor may have been triggered by antibiotics. With a multimodality approach using steroids, platelet transfusions, intravenous immunoglobulin, factor VIII inhibitor bypass activity agent and cyclophosphamide, we successfully eliminated the inhibitor and controlled the bleeding.
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Affiliation(s)
- Pooja Motwani
- Baystate Medical Center, Western Campus of Tuft’s University, School of Medicine, Springfield, MA 01107, USA.
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33
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Paschal RD, Meeks SL, Neff AT. Development of factor VIII inhibitors in two patients with moderate haemophilia A. Haemophilia 2012; 19:e55-7. [PMID: 23171275 DOI: 10.1111/hae.12057] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/16/2012] [Indexed: 11/30/2022]
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34
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Perez Botero J, Burns D, Thompson CA, Pruthi RK. Successful treatment with thalidomide of a patient with congenital factor V deficiency and factor V inhibitor with recurrent gastrointestinal bleeding from small bowel arteriovenous malformations. Haemophilia 2012; 19:e59-61. [PMID: 23171429 DOI: 10.1111/hae.12066] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/24/2012] [Indexed: 12/22/2022]
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35
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Pergantou H, Xafaki P, Adamtziki E, Koletsi P, Komitopoulou A, Platokouki H. The challenging management of a child with type 3 von Willebrand disease and antibodies to von Willebrand factor. Haemophilia 2012; 18:e66-7. [PMID: 22531022 DOI: 10.1111/j.1365-2516.2012.02799.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Navarrete MA, van der Meer FJM, Damiani G, Diaz A, Eikenboom J. The use of rituximab therapy in patients with acquired factor V inhibitors. Am J Hematol 2012; 87:826-7. [PMID: 22641484 DOI: 10.1002/ajh.23241] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- M A Navarrete
- Department of Hematology, Alvarez General Hospital, Buenos Aires, Argentina.
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Zhang X, Guo J, Guo X, Pan J. Successful treatment of acquired haemophilia in a patient with bullous pemphigoid with single-dosing regimen of rituximab. Haemophilia 2012; 18:e393-5. [PMID: 22823057 DOI: 10.1111/j.1365-2516.2012.02917.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/22/2012] [Indexed: 01/20/2023]
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Zehnder J, Price E, Jin J. Controversies in heparin monitoring. Am J Hematol 2012; 87 Suppl 1:S137-40. [PMID: 22495972 DOI: 10.1002/ajh.23210] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2012] [Revised: 03/07/2012] [Accepted: 03/07/2012] [Indexed: 11/09/2022]
Affiliation(s)
- James Zehnder
- Departments of Pathology and Medicine, Hematology, Stanford University School of Medicine, California 94305, USA.
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Leissinger CA. The literature on inhibitors: articles that influence my management of patients with hemophilia A and high-titer inhibitors. Am J Hematol 2012; 87 Suppl 1:S23-6. [PMID: 22473571 DOI: 10.1002/ajh.23191] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2012] [Revised: 02/29/2012] [Accepted: 03/01/2012] [Indexed: 11/11/2022]
Abstract
High-titer inhibitors represent the greatest management challenge faced by clinicians who treat patients with hemophilia A, as bleeding episodes no longer respond to standard factor VIII replacement therapy. Over the last seven decades, major strides have been made in inhibitor treatment. This article focuses on the seminal clinical observations and studies that provided the foundation for these advances in hemophilia care.
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Affiliation(s)
- Cindy A Leissinger
- Louisiana Center for Bleeding and Clotting Disorders, Tulane University Medical Center, New Orleans, Louisiana 70112, USA.
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Rodriguez-Merchan EC, Gomez-Cardero P, Jimenez-Yuste V, Rico-Nieto A. A complex case of infected total knee arthroplasty in a haemophilic patient with inhibitor. Haemophilia 2012; 18:e357-9. [PMID: 22536792 DOI: 10.1111/j.1365-2516.2012.02815.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Holstein K, Marx G, Lentz B, Bokemeyer C, Langer F. Successful eradication of a FVIII inhibitor in a 60-year-old patient with mild haemophilia A using single-agent prednisolone. Hamostaseologie 2012; 32 Suppl 1:S48-S51. [PMID: 22960877] [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] [Subscribe] [Scholar Register] [Received: 03/01/2012] [Accepted: 06/13/2012] [Indexed: 06/01/2023]
Abstract
BACKGROUND Development of FVIII inhibitors represents a major challenge in patients with mild haemophilia A (HA), because they tend to occur at an older age and classical immune tolerance induction appears to be less effective. CASE REPORT A man (age: 60 years) with mild HA due to the missense mutation, Leu1929Arg, received a single dose of rFVIII at 35 IU/kg prior to routine colonoscopy, totalling 25 lifetime exposure days. Two months later, rFVIII was infused for a traumatic hip haematoma. However, FVIII recovery was inappropriate, and a FVIII inhibitor of 19 BU with type-2 kinetics was detected, resulting in FVIII:C of <1%. Two weeks later, the patient experienced spontaneous iliopsoas bleeding. Parallel to bypassing therapy, we started single-agent immunosuppression with prednisolone at 1.5mg/kg. FVIII:C "normalized" at 10.2% after four weeks. After five months, the inhibitor titre fell to <0.4 BU with sustained remission after one year of follow-up. CONCLUSION In mild HA, FVIII inhibitors may share characteristic features with FVIII autoantibodies commonly observed in acquired HA. Therefore, immunosuppressive therapy alone could be successful at least in a subset of patients.
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Affiliation(s)
- K Holstein
- II Medizinische Klinik und Poliklinik, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany.
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42
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Gao Y, Liu S, Ma G, Lv L, Su Y. Efficacy of low-dose rituximab in a refractory acquired factor VIII inhibitor case secondary to pemphigus. Acta Haematol 2012; 127:20-2. [PMID: 21996575 DOI: 10.1159/000330951] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/07/2011] [Accepted: 07/18/2011] [Indexed: 11/19/2022]
Abstract
Acquired factor VIII (FVIII) inhibitor induces a bleeding disorder caused by specific antibodies to FVIII. The cause of approximately one fifth of cases can be attributed to autoimmune disorders, such as pemphigus. Here, we describe a case of refractory acquired FVIII inhibitor in a patient with primary pemphigus and its successful treatment with low-dose rituximab. Coagulation studies revealed a prolonged activated partial thromboplastin time, which could not be corrected with the mixing test. At the same time, the FVIII activity level was significantly reduced, and the FVIII inhibitor titer was elevated. A treatment regimen with prednisolone/cyclophosphamide followed by prednisolone/cyclosporine was used. The patient temporarily responded but then became resistant to these medicines. However, subsequent treatment with low-dose rituximab achieved considerable clinical and laboratory improvement in the same patient. Follow-up at 6 months revealed a low level of residual FVIII inhibitor activity with normal coagulation functions. No drug-related side effects were detected. In conclusion, our results indicate that low-dose rituximab might be an effective and safe treatment for patients with acquired FVIII inhibitor.
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Affiliation(s)
- Yujuan Gao
- Department of Hematology, The First Affiliated Hospital, Harbin Medical University, China
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Wermes C, Niekrens C, Sykora KW. Successful long-time treatment with mycophenolate-mofetil in a child with acquired factor VIII inhibitor. Hamostaseologie 2012; 32 Suppl 1:S75-S78. [PMID: 22961096] [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] [Subscribe] [Scholar Register] [Received: 03/01/2012] [Accepted: 07/02/2012] [Indexed: 06/01/2023]
Abstract
UNLABELLED Here, we report about a boy (age: 18 years) who developed an acquired factor VIII inhibitor at the age of 9 years. He presented with bleeding in his right ankle, multiple haematomas and a high-titer factor VIII type II inhibitor (400 BU). THERAPY He received treatment with MMF (CellCept®), dexamethasone-immunoglobulin pulses, and rituximab together with high dose FVIII (Hannover protocol). His inhibitor titer decreased rapidly, and half-life and recovery normalized. Inhibitor titres increased after reduction of the factor VIII dose, and increased further after MMF was stopped. A second treatment course with MMF again resulted in reduction of the titre, improvement in half life and recovery, and no more bleedings. Inhibitor reappeared with MMF dose reduction, again accompanied by severe bleeding. Additional rituximab stopped the bleedings, and treatment with MMF has been continued since. CONCLUSION Although the laboratory parameters showed no complete remission, severe bleedings and expensive factor replacement could be avoided by long-term treatment with MMF.
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Affiliation(s)
- C Wermes
- Department of Paediatric Haematology and Oncology, Medical School Hannover, Hannover, Germany.
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Kocher S, Asmelash G, Makki V, Müller S, Krekeler S, Alesci S, Miesbach W. [Inhibitor development after changing FVIII/IX products in patients with haemophilia]. Hamostaseologie 2012; 32 Suppl 1:S39-S42. [PMID: 22961330] [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] [Subscribe] [Scholar Register] [Received: 03/30/2012] [Accepted: 06/11/2012] [Indexed: 06/01/2023]
Abstract
UNLABELLED The retrospective observational study surveys the relationship between development of inhibitors in the treatment of haemophilia patients and risk factors such as changing FVIII products. A total of 119 patients were included in this study, 198 changes of FVIII products were evaluated. RESULTS During the observation period of 12 months none of the patients developed an inhibitor, which was temporally associated with a change of FVIII products. A frequent change of FVIII products didn't lead to an increase in inhibitor risk. The change between plasmatic and recombinant preparations could not be confirmed as a risk factor. Furthermore, no correlation between treatment regimens, severity, patient age and comorbidities of the patients could be found.
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Affiliation(s)
- S Kocher
- Hämophiliezentrum, Medizinische Klinik III, Institut für Transfusionsmedizin, JW-Goethe-Universitätsklinikum, Frankfurt am Main
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Deal EN, Hollands JM, Riney JN, Skrupky LP, Smith JR, Reichley RM. Evaluation of therapeutic anticoagulation with enoxaparin and associated anti-Xa monitoring in patients with morbid obesity: a case series. J Thromb Thrombolysis 2011; 32:188-94. [PMID: 21465129 DOI: 10.1007/s11239-011-0584-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Our purpose was to describe anti-Xa levels, dosage requirements, and complications associated with enoxaparin treatment doses in patients with morbid obesity. Inpatients with a BMI >40 kg/m(2) at an academic medical center prescribed therapeutic enoxaparin from 2004 to 2010 who also had an associated anti-Xa level were included in this retrospective evaluation. Twenty-six patients were identified having median weight of 162 kg (range 106-243), median BMI of 49.5 kg/m(2) (range 40.1-98.1), and median enoxaparin duration of 4 days (range 1-32). Venous thromboembolism was the most common reason for anticoagulation (n = 19, 73%). The median starting dose was 0.8 mg/kg actual body weight (range 0.51-1; absolute dose 80-150 mg) every 12 h. Twelve patients (46%) achieved a goal anti-Xa level, 10 (38%) were above goal and 4 (15%) were uninterpretable. Among the 10 patients with anti-Xa levels above goal, the median initial dose was 0.85 mg/kg (range 0.75-1) versus 0.74 mg/kg (range 0.51-1) for patients at goal with similar median peak serum creatinine (PSCr) values between these two groups (P > 0.05). No bleeding events occurred in patients achieving goal anticoagulation versus 4/10 (40%) with high anti-Xa levels (P = 0.033) with similar median PSCr between these groups. No thrombotic events occurred while on therapy. The majority in this cohort with morbid obesity achieved anti-Xa levels at or above goal at doses less than the recommended 1 mg/kg every 12 h. Bleeding events were more frequent among patients with anti-Xa levels above goal, despite similar PSCr values.
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Affiliation(s)
- Eli N Deal
- Internal Medicine, Barnes-Jewish Hospital, 216 S. Kingshighway Blvd, St. Louis, MO 63110, USA.
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Wieland I, Wermes C, Eifrig B, Holstein K, Pollmann H, Siegmund B, Eberl W, Kemkes-Matthes B, Bidlingmaier C, Kurnik K, Lischetzki G, Nimtz-Talaska A, Eisert R, Bogdanova N, Doerk T, Sykora KW. Inhibitor-immunology-study. Evaluation of inhibitor development in haemophilia B. Hamostaseologie 2011; 31 Suppl 1:S57-S60. [PMID: 22057736] [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] [Subscribe] [Scholar Register] [Received: 03/15/2011] [Accepted: 05/13/2011] [Indexed: 05/31/2023]
Abstract
UNLABELLED The development of inhibitors in haemophilia B is one of the most important complications of replacement therapy, affecting mortality and morbidity. Inhibitor development is based on complex immunological factors, and to date, only little is known about its underlying mechanisms. Here, we present first results of the haemophilia B group of our Inhibitor-Immunology study. PATIENTS, METHODS So far we have analysed 15 patients with haemophilia B. Four of them developed a high titre inhibitor; the remaining 11 had no inhibitor. We evaluated 9 SNPs in 8 genes (CD40, CTLA-4 , IL-1β, IL-10, TLR2 , TLR4, TLR9, TNF-α). We compared the distribution of these alleles between inhibitor and non-inhibitor haemophilia B patients and between haemophilia B patients and a normal male control population. HLA typing was performed in all patients. Results, discussion: There appears to be a trend towards a skewed distribution of TLR 9, IL-10 and CTLA4 alleles in haemophilia B patients. Due to the limited number these differences are, however, not statistically significant. The t-test of all patients with inhibitor versus without inhibitor was significant for HLA-A*03 and DPB1*0401 and borderline for DRB1*0201.
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Affiliation(s)
- I Wieland
- Pädiatrische Hämatologie & Onkologie, MHH Hannover.
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Serban M, Mihailov D, Pop L, Ionita H, Ursu E, Talpos-Niculescu S, Ritli L, Baghiu D, Uscatescu V, Petrovanu C, Stancu P, Savescu D, Cucuianu A, Schramm W. Development of inhibitors in haemophilia. Ongoing epidemiological study. Hamostaseologie 2011; 31 Suppl 1:S20-S23. [PMID: 22057218] [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] [Subscribe] [Scholar Register] [Received: 02/28/2011] [Accepted: 05/13/2011] [Indexed: 05/31/2023]
Abstract
A number of 513 consecutive patients (494-haemophilia A and 19-haemophilia B) from eight haemophilia treatment centers have been investigated with Bethesda assay for the presence of factor VIII or IX inhibitors. The overall prevalence of inhibitors was 15.20%, 18.48% in severe, 5.60% in moderate and 12.24% in mild forms. The prevalence was higher than reported in most of the western countries. The age at start of substitution (p = 0.9775), the frequent switching of factor concentrates (p = 0.8931) were not relevant factors for the development of inhibitors. It is worth to be mentioned the unexpectedly occurrence of inhibitors in prior inhibitor negative (6/72) patients (during surgical interventions) probably due to their previous scarce substitution, occurrence which seems not being connected with the continuous infusion modality of factor VIII administration (p = 0.8341). In controversial situations, in the field of low titer (≤ 1 BU/ml) inhibitors for a reliable interpretation of the results the performance of recovery index and half-life time assessment of FVIII/IX was undertaken.
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Affiliation(s)
- M Serban
- University of Medicine and Pharmacy Victor Babes Timisoara, Rumänien.
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Tokgoz H, Caliskan U, Lavigne-Lissalde G, Giansily-Blaizot M. Successful prophylactic use of recombinant activated factor VII (rFVIIa) in a patient with congenital FVII deficiency and inhibitors to FVII. Haemophilia 2011; 18:e25-7. [PMID: 21973016 DOI: 10.1111/j.1365-2516.2011.02666.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Celkan T, Ozdemir N. Reduced early prophylaxis of children with haemophilia in a developing country, Turkey. Haemophilia 2011; 17:e840-e841. [PMID: 21682819 DOI: 10.1111/j.1365-2516.2011.02581.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
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50
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Ewenstein BM, Reininger AJ. Re: low incidence of factor VIII inhibitors in PUPs during prophylaxis, on-demand treatment and surgical procedures, with Octanate®: interim report from an ongoing prospective clinical study. Haemophilia 2011; 17:e847-e848. [PMID: 21752157 DOI: 10.1111/j.1365-2516.2011.02605.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
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