1
|
Sun J, Li Z, Li G, Liu G, Yao W, Zhen Y, Chen Z, Wu R. Early immune tolerance induction is a unique predictor of favorable outcomes in hemophilia A children with intron 22 inversion and high-responding inhibitors. Thromb Res 2023; 226:56-60. [PMID: 37121012 DOI: 10.1016/j.thromres.2023.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 02/21/2023] [Accepted: 04/04/2023] [Indexed: 05/02/2023]
Abstract
BACKGROUND The predictors of immune tolerance induction (ITI) outcomes in hemophilia A (HA) patients with the same F8 genetic background have not yet been evaluated, although the F8 genotype is strongly associated with ITI response. This study aims to explore the predictors of ITI outcomes in the same F8 genetic background by focusing on intron 22 inversion (Inv22) patients with high-responding inhibitors. METHODS HA children with Inv22 and high-responding inhibitors who received low-dose ITI therapy over 24 months were included in this study. ITI outcomes were centrally assessed at the 24th month of treatment. The predictive ability of clinical variables to identify ITI success was determined using the receiver operating characteristic (ROC) curve, and the predictor of ITI outcomes was analyzed on the multivariable Cox model. RESULTS Among the 32 patients investigated, 23 (71.9 %) achieved success. In univariate analysis, interval time from inhibitor diagnosis to ITI start (interval-time) was significantly associated with ITI success (P = 0.001); however, inhibitor titers showed no significance (P > 0.05). The interval-time demonstrated a good predictive value for ITI success with the area under the ROC curve of 0.855 (P = 0.002), and the cutoff value was 25.8 months (sensitivity, 87.0 %; specificity, 88.9 %). In the multivariable Cox model which considered success rate and time to success, interval-time was the only independent predictor (<25.8 months vs. ≥25.8 months, P = 0.002). CONCLUSIONS The interval-time was first identified as a unique predictor of ITI outcomes in HA patients with high-responding inhibitors under the same F8 genetic background (Inv22). An interval-time of <25.8 months was associated with increased ITI success and reduced time to success.
Collapse
Affiliation(s)
- Jie Sun
- Hemophilia Comprehensive Care Center, Hematology Center, Beijing Key Laboratory of Pediatric Hematology-Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, 100045, China; Hematologic Disease Laboratory, Hematology Center, Beijing Key Laboratory of Pediatric Hematology-Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, China 100045
| | - Zekun Li
- Hemophilia Comprehensive Care Center, Hematology Center, Beijing Key Laboratory of Pediatric Hematology-Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, 100045, China; Hematologic Disease Laboratory, Hematology Center, Beijing Key Laboratory of Pediatric Hematology-Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, China 100045
| | - Gang Li
- Hematologic Disease Laboratory, Hematology Center, Beijing Key Laboratory of Pediatric Hematology-Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, China 100045
| | - Guoqing Liu
- Hemophilia Comprehensive Care Center, Hematology Center, Beijing Key Laboratory of Pediatric Hematology-Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, 100045, China
| | - Wanru Yao
- Hemophilia Comprehensive Care Center, Hematology Center, Beijing Key Laboratory of Pediatric Hematology-Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, 100045, China
| | - Yingzi Zhen
- Hemophilia Comprehensive Care Center, Hematology Center, Beijing Key Laboratory of Pediatric Hematology-Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, 100045, China
| | - Zhenping Chen
- Hematologic Disease Laboratory, Hematology Center, Beijing Key Laboratory of Pediatric Hematology-Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, China 100045.
| | - Runhui Wu
- Hemophilia Comprehensive Care Center, Hematology Center, Beijing Key Laboratory of Pediatric Hematology-Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, 100045, China.
| |
Collapse
|
2
|
Low-dose immune tolerance induction therapy in severe hemophilia a children in China: Starting earlier resulted in better inhibitor eradication outcomes. Thromb Res 2023; 225:33-38. [PMID: 36934482 DOI: 10.1016/j.thromres.2023.02.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Revised: 01/15/2023] [Accepted: 02/28/2023] [Indexed: 03/07/2023]
Abstract
BACKGROUND Shorter interval-time from inhibitor detection to starting immune tolerance induction (ITI) might predict better ITI outcomes for severe Hemophilia A (SHA) patients with high-risk-inhibitors. However, the prediction-impact of interval-time for these patients on low-dose ITI strategy remained unclear. OBJECTIVES To explore the relationship between interval-time and low-dose ITI outcomes in Chinese SHA children with high-risk-inhibitors. METHODS This was a single-center, retrospective study on SHA children with high-risk-inhibitors (each with immediate pre-ITI inhibitor titer>10 Bethesda Units/mL) undergoing low-dose ITI strategy for ≥24 months. ITI outcomes and their predictive factors were evaluated at the 24th month treatment for each patient. The predictive ability of interval-time on ITI success was determined using receiver operating characteristic (ROC) curve. RESULTS Among 47 patients investigated, 34 (72.3 %) achieved success. Independent predictor for ITI-outcome on multivariate analysis included the interval-time (p = 0.007) and peak inhibitor-titer (p = 0.011). Shorter interval-time predicted ITI success [cut-off value = 22.3 months, area under ROC-curve (AUC) = 0.701] and early-ITI success within 12 month (cut-off value = 9.4 months AUC = 0.704). Linear regression analysis suggested each month interval-time delay delayed success by 0.1552 month. Unlike the interval-time, peak inhibitor-titer had no success-predictive value in high-peak inhibitor-titer patients on ITI with immunosuppressants. CONCLUSIONS Interval-time represented a strong predictive value for outcomes in our low-dose ITI strategy for SHA patients with high-risk-inhibitors. Shorter interval-time was associated with higher success rate and earlier success achievement. The respective interval-time cut-off values were 22.3 months for ITI success and 9.4 months for early-success.
Collapse
|
3
|
Oomen I, Camelo RM, Rezende SM, Voorberg J, Mancuso ME, Oldenburg J, Carcao M, Matino D, Lillicrap D, Fischer K, Fijnvandraat K, Gouw SC. Determinants of successful immune tolerance induction in hemophilia A: systematic review and meta-analysis. Res Pract Thromb Haemost 2023; 7:100020. [PMID: 36891524 PMCID: PMC9986104 DOI: 10.1016/j.rpth.2022.100020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 10/31/2022] [Accepted: 11/09/2022] [Indexed: 01/21/2023] Open
Abstract
Background Immune tolerance induction (ITI) aims to eradicate anti-factor VIII (FVIII) antibodies (inhibitors) in persons with hemophilia A. However, this burdensome treatment fails in 10% to 40%. To estimate the chance of ITI success in clinical decision making, it is important to identify the predictors of ITI success. Objectives We performed a systematic review and meta-analysis to summarize the current evidence on determinants of ITI outcome in persons with hemophilia A. Methods A literature search was conducted to identify randomized controlled trials, cohort, or case-control studies reporting on the predictors for ITI outcome in persons with hemophilia A. The main outcome was ITI success. Methodological quality was assessed using an adapted Joanna Briggs Institute checklist, rating as high if ≥11 of 13 criteria were met. Pooled odds ratios (ORs) for ITI success were calculated for each determinant. ITI success was defined as negative inhibitor titer (<0.6 BU/mL), FVIII recovery ≥66% of expected, and FVIII half-life ≥6 hours in 16 (59.3%) studies. Results We included 27 studies, involving 1,734 participants. Methodological quality of 6 (22.2%) studies (418 participants) was rated as high. Twenty different determinants were assessed. Historical peak titer ≤100 BU/mL (compared with >100 BU/mL, OR, 1.7; 95% CI, 1.4-2.1), pre-ITI titer ≤10 BU/mL (compared with >10 BU/mL, OR, 1.8; 95% CI, 1.4-2.3), and peak titer during ITI ≤100 BU/mL (compared with >100 BU/mL, OR, 2.7; 95% CI, 1.9-3.8) were associated with a higher chance of ITI success. Conclusion Our results suggest that determinants related to the inhibitor titer are associated with ITI success.
Collapse
Affiliation(s)
- Ilja Oomen
- Amsterdam University Medical Center location University of Amsterdam, Department of Pediatric Hematology, Meibergdreef 9, Amsterdam, The Netherlands.,Department of Molecular Hematology, Sanquin Research and Landsteiner Laboratory, Amsterdam, The Netherlands
| | - Ricardo M Camelo
- Department of Internal Medicine, Faculty of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil.,Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Suely Meireles Rezende
- Department of Internal Medicine, Faculty of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Jan Voorberg
- Department of Molecular Hematology, Sanquin Research and Landsteiner Laboratory, Amsterdam, The Netherlands
| | - Maria Elisa Mancuso
- Center for Thrombosis and Hemorrhagic Diseases, Instituto di Ricovero e Cura a Carattere Scientifico Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Johannes Oldenburg
- Department of Internal Medicine, University Clinic Bonn, University of Bonn, Bonn, Germany
| | - Manuel Carcao
- Division of Hematology/Oncology, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Davide Matino
- Department of Medicine, McMaster University, University of Hamilton, Hamilton, Canada
| | - David Lillicrap
- Department of Pathology and Molecular Medicine, Queen's University, Kingston, Canada
| | - Kathelijn Fischer
- Department of Hematology, Van Creveldkliniek, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Karin Fijnvandraat
- Amsterdam University Medical Center location University of Amsterdam, Department of Pediatric Hematology, Meibergdreef 9, Amsterdam, The Netherlands.,Department of Molecular Hematology, Sanquin Research and Landsteiner Laboratory, Amsterdam, The Netherlands
| | - Samantha C Gouw
- Amsterdam University Medical Center location University of Amsterdam, Department of Pediatric Hematology, Meibergdreef 9, Amsterdam, The Netherlands.,Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | | |
Collapse
|
4
|
CAR-T Regulatory (CAR-Treg) Cells: Engineering and Applications. Biomedicines 2022; 10:biomedicines10020287. [PMID: 35203496 PMCID: PMC8869296 DOI: 10.3390/biomedicines10020287] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 01/21/2022] [Accepted: 01/24/2022] [Indexed: 01/27/2023] Open
Abstract
Regulatory T cells are critical for maintaining immune tolerance. Recent studies have confirmed their therapeutic suppressive potential to modulate immune responses in organ transplant and autoimmune diseases. However, the unknown and nonspecific antigen recognition of polyclonal Tregs has impaired their therapeutic potency in initial clinical findings. To address this limitation, antigen specificity can be conferred to Tregs by engineering the expression of transgenic T-cell receptor (TCR) or chimeric antigen receptor (CAR). In contrast to TCR Tregs, CAR Tregs are major histocompatibility complex (MHC) independent and less dependent on interleukin-2 (IL-2). Furthermore, CAR Tregs maintain Treg phenotype and function, home to the target tissue and show enhanced suppressive efficacy compared to polyclonal Tregs. Additional development of engineered CAR Tregs is needed to increase Tregs’ suppressive function and stability, prevent CAR Treg exhaustion, and assess their safety profile. Further understanding of Tregs therapeutic potential will be necessary before moving to broader clinical applications. Here, we summarize recent studies utilizing CAR Tregs in modulating immune responses in autoimmune diseases, transplantation, and gene therapy and future clinical applications.
Collapse
|
5
|
Li Z, Chen Z, Liu G, Cheng X, Yao W, Huang K, Li G, Zhen Y, Wu X, Cai S, Poon M, Wu R. Low-dose immune tolerance induction alone or with immunosuppressants according to prognostic risk factors in Chinese children with hemophilia A inhibitors. Res Pract Thromb Haemost 2021; 5:e12562. [PMID: 34278191 PMCID: PMC8279128 DOI: 10.1002/rth2.12562] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 04/28/2021] [Accepted: 05/18/2021] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND In developing countries, children with hemophilia A (HA) with high-titer inhibitor and poor immune tolerance induction (ITI) prognostic risk(s) cannot afford the recommended high- or intermediate-dose ITI. OBJECTIVES To determine the efficacy of low-dose ITI (plasma-derived factor VIII [FVIII]/von Willebrand factor at 50 FVIII IU/kg every other day) by itself (ITI-alone) or combined with immunosuppressants rituximab and prednisone (ITI-IS) in children with HA with high-titer inhibitor. METHODS All enrolled patients had pre-ITI inhibitor ≥10 BU. We used ITI-alone if inhibitor titer was <40 BU pre-ITI and during ITI, and ITI-IS if titer was ≥100 BU (historic) or ≥40 BU (pre- or during ITI) or if the patient was nonresponsive on ITI-alone. RESULTS Fifty-six children were analyzable, with median historic peak inhibitor titer 48.0 BU and followed for median 31.4 months. Overall, 35 (62.5%) achieved phase 2 success with negative inhibitor and normal FVIII recovery. The phase 2 success rate was 95% for the 20 patients receiving ITI-alone. For the 36 patients receiving ITI-IS, the phase 2 success rate was 44.4%, but would increase to 63.6% if the 14 patients with historic peak inhibitor titer ≥100 BU (and having phase 2 success rate of only 14.3%) were excluded. One patient developed repeated infection after IS treatment. Relapse occurred in 11.4% (4/35) patients with phase 2 success associated with rapid ITI dose reduction or irregular post-ITI FVIII prophylaxis. Our strategy reduced the cost from high-dose ITI by 74% to 90%. CONCLUSION The use of low-dose ITI with or without immunosuppressants according to ITI prognostic risk(s) is a clinically and economically feasible strategy for eradicating inhibitors in children with HA, particularly for those with historic peak inhibitor titer <100 BU.
Collapse
Affiliation(s)
- Zekun Li
- Hemophilia Comprehensive Care CenterHematology CenterBeijing Key Laboratory of Pediatric Hematology OncologyNational Key Discipline of Pediatrics (Capital Medical University)Key Laboratory of Major Diseases in ChildrenMinistry of EducationBeijing Children's HospitalNational Center for Children’s HealthCapital Medical UniversityBeijingChina
- Hematologic Disease LaboratoryHematology CenterBeijing Key Laboratory of Pediatric Hematology OncologyNational Key Discipline of Pediatrics (Capital Medical University)Key Laboratory of Major Diseases in ChildrenMinistry of EducationBeijing Pediatric Research InstituteBeijing Children’s HospitalNational Center for Children’s HealthCapital Medical UniversityBeijingChina
| | - Zhenping Chen
- Hematologic Disease LaboratoryHematology CenterBeijing Key Laboratory of Pediatric Hematology OncologyNational Key Discipline of Pediatrics (Capital Medical University)Key Laboratory of Major Diseases in ChildrenMinistry of EducationBeijing Pediatric Research InstituteBeijing Children’s HospitalNational Center for Children’s HealthCapital Medical UniversityBeijingChina
| | - Guoqing Liu
- Hemophilia Comprehensive Care CenterHematology CenterBeijing Key Laboratory of Pediatric Hematology OncologyNational Key Discipline of Pediatrics (Capital Medical University)Key Laboratory of Major Diseases in ChildrenMinistry of EducationBeijing Children's HospitalNational Center for Children’s HealthCapital Medical UniversityBeijingChina
| | - Xiaoling Cheng
- Department of Pharmacy, Beijing Children’s Hospital, National Center for Children’s HealthCapital Medical UniversityBeijingChina
| | - Wanru Yao
- Hemophilia Comprehensive Care CenterHematology CenterBeijing Key Laboratory of Pediatric Hematology OncologyNational Key Discipline of Pediatrics (Capital Medical University)Key Laboratory of Major Diseases in ChildrenMinistry of EducationBeijing Children's HospitalNational Center for Children’s HealthCapital Medical UniversityBeijingChina
| | - Kun Huang
- Hemophilia Comprehensive Care CenterHematology CenterBeijing Key Laboratory of Pediatric Hematology OncologyNational Key Discipline of Pediatrics (Capital Medical University)Key Laboratory of Major Diseases in ChildrenMinistry of EducationBeijing Children's HospitalNational Center for Children’s HealthCapital Medical UniversityBeijingChina
- Hematologic Disease LaboratoryHematology CenterBeijing Key Laboratory of Pediatric Hematology OncologyNational Key Discipline of Pediatrics (Capital Medical University)Key Laboratory of Major Diseases in ChildrenMinistry of EducationBeijing Pediatric Research InstituteBeijing Children’s HospitalNational Center for Children’s HealthCapital Medical UniversityBeijingChina
| | - Gang Li
- Hematologic Disease LaboratoryHematology CenterBeijing Key Laboratory of Pediatric Hematology OncologyNational Key Discipline of Pediatrics (Capital Medical University)Key Laboratory of Major Diseases in ChildrenMinistry of EducationBeijing Pediatric Research InstituteBeijing Children’s HospitalNational Center for Children’s HealthCapital Medical UniversityBeijingChina
| | - Yingzi Zhen
- Hemophilia Comprehensive Care CenterHematology CenterBeijing Key Laboratory of Pediatric Hematology OncologyNational Key Discipline of Pediatrics (Capital Medical University)Key Laboratory of Major Diseases in ChildrenMinistry of EducationBeijing Children's HospitalNational Center for Children’s HealthCapital Medical UniversityBeijingChina
| | - Xinyi Wu
- Hemophilia Comprehensive Care CenterHematology CenterBeijing Key Laboratory of Pediatric Hematology OncologyNational Key Discipline of Pediatrics (Capital Medical University)Key Laboratory of Major Diseases in ChildrenMinistry of EducationBeijing Children's HospitalNational Center for Children’s HealthCapital Medical UniversityBeijingChina
| | - Siyu Cai
- Center for Clinical Epidemiology and Evidence‐based MedicineCapital Medical UniversityBeijingChina
| | - Man‐Chiu Poon
- Departments of Medicine, Pediatrics and OncologySouthern Alberta Rare Blood and Bleeding Disorders Comprehensive Care ProgramFoothills HospitalAlberta Health ServicesUniversity of Calgary Cumming School of MedicineCalgaryABCanada
| | - Runhui Wu
- Hemophilia Comprehensive Care CenterHematology CenterBeijing Key Laboratory of Pediatric Hematology OncologyNational Key Discipline of Pediatrics (Capital Medical University)Key Laboratory of Major Diseases in ChildrenMinistry of EducationBeijing Children's HospitalNational Center for Children’s HealthCapital Medical UniversityBeijingChina
| |
Collapse
|
6
|
Fu RY, Chen AC, Lyle MJ, Chen CY, Liu CL, Miao CH. CD4 + T cells engineered with FVIII-CAR and murine Foxp3 suppress anti-factor VIII immune responses in hemophilia a mice. Cell Immunol 2020; 358:104216. [PMID: 32987195 DOI: 10.1016/j.cellimm.2020.104216] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 09/01/2020] [Accepted: 09/11/2020] [Indexed: 02/06/2023]
Abstract
Although protein replacement therapy provides effective treatment for hemophilia A patients, about a third of severe patients develop neutralizing inhibitor antibodies to factor VIII. Adoptive transfer of regulatory T cells (Tregs) has shown promise in treating unwanted immune responses. In previous studies, transferred polyclonal Tregs ameliorated the anti-factor VIII immune responses in hemophilia A mice. In addition, factor VIII-primed Tregs demonstrated increased suppressive function. However, antigen-specific Tregs are a small fraction of the total lymphocyte population. To generate large numbers of factor VIII-specific Tregs, the more abundant murine primary CD4+ T cells were lentivirally transduced ex vivo to express Foxp3 and a chimeric antigen receptor specific to factor VIII (F8CAR). Transduced cells significantly inhibited the proliferation of factor VIII-specific effector T cells in suppression assays. To monitor the suppressive function of the transduced chimeric antigen receptor expressing T cells in vivo, engineered CD4+CD25+Foxp3+F8CAR-Tregs were sorted and adoptively transferred into hemophilia A mice that are treated with hydrodynamically injected factor VIII plasmid. Mice receiving engineered F8CAR-Tregs showed maintenance of factor VIII clotting activity and did not develop anti-factor VIII inhibitors, while control CD4+T cell or PBS recipient mice developed inhibitors and had a sharp decrease in factor VIII activity. These results show that CD4+ cells lentivirally transduced to express Foxp3 and F8CAR can promote factor VIII tolerance in a murine model. With further development and testing, this approach could potentially be applied to human hemophilia patients.
Collapse
Affiliation(s)
- Richard Y Fu
- Center for Immunity and Immunotherapies, Seattle Children's Research Institute, Seattle, WA, USA
| | - Alex C Chen
- Center for Immunity and Immunotherapies, Seattle Children's Research Institute, Seattle, WA, USA
| | - Meghan J Lyle
- Center for Immunity and Immunotherapies, Seattle Children's Research Institute, Seattle, WA, USA
| | - Chun-Yu Chen
- Center for Immunity and Immunotherapies, Seattle Children's Research Institute, Seattle, WA, USA
| | - Chao Lien Liu
- Center for Immunity and Immunotherapies, Seattle Children's Research Institute, Seattle, WA, USA
| | - Carol H Miao
- Center for Immunity and Immunotherapies, Seattle Children's Research Institute, Seattle, WA, USA; Department of Pediatrics, University of Washington, Seattle, WA, USA.
| |
Collapse
|
7
|
Chen AC, Cai X, Li C, Khoryati L, Gavin MA, Miao CH. A Treg-Selective IL-2 Mutein Prevents the Formation of Factor VIII Inhibitors in Hemophilia Mice Treated With Factor VIII Gene Therapy. Front Immunol 2020; 11:638. [PMID: 32411127 PMCID: PMC7198749 DOI: 10.3389/fimmu.2020.00638] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 03/20/2020] [Indexed: 12/15/2022] Open
Abstract
Hemophilia A is a genetic disorder that results in the deficiency of functional factor VIII protein, which plays a key role in blood coagulation. Currently, the majority of hemophilia A patients are treated with repeated infusions of factor VIII protein. Approximately 30% of severe hemophilia A patients develop neutralizing antibodies to factor VIII (known as factor VIII inhibitors) due to treatment, rendering factor VIII protein infusions ineffective. Previously, mice receiving murine IL-2 complexed with α-murine IL-2 mAbs (JES6-1A12) showed a lack of factor VIII inhibitor formation after factor VIII treatment, which was associated with the proliferation and the activation of factor VIII-specific regulatory T cells (Tregs). In this paper, we evaluated if an Fc-fused mutated protein analog of mouse IL-2, named Fc.Mut24, engineered to selectively promote the expansion of Tregs in vivo can modulate factor VIII-specific immune responses. The mice received one intraperitoneal injection of Fc.Mut24. When the regulatory T cell population reached its highest frequency and peak activation, the mice received a hydrodynamic injection of factor VIII plasmid (day 4) followed by a second Fc.Mut24 dose (day 7). Peripheral blood was collected weekly. Flow cytometry was used to characterize the peripheral blood cell populations, while ELISA and Bethesda assays were used to assess the inhibitor concentrations and the functional titers in plasma. The activated partial thromboplastin time assay was used to assess the functional activities of factor VIII in blood. The mice receiving Fc.Mut24 showed a dramatic and transient increase in the population of activated Tregs after Fc.Mut24 injection. Factor VIII gene therapy via hydrodynamic injection resulted in high anti-factor VIII inhibitor concentrations in control PBS-injected mice, whereas the mice treated with Fc.Mut24 produced no inhibitors. Most significantly, there were no inhibitors generated after a second hydrodynamic injection of factor VIII plasmid administered at 19 weeks after the first injection in Fc.Mut24-treated mice. The mice receiving Fc.Mut24 maintained high levels of factor VIII activity throughout the experiment, while the control mice had the factor VIII activity dropped to undetectable levels a few weeks after the first factor VIII plasmid injection. Our data show that human therapies analogous to Fc.Mut24 could potentially provide a method to prevent inhibitor formation and induce long-term immune tolerance to factor VIII in hemophilia patients.
Collapse
Affiliation(s)
- Alex C. Chen
- Center for Immunity and Immunotherapies, Seattle Children’s Research Institute, Seattle, WA, United States
| | - Xiaohe Cai
- Center for Immunity and Immunotherapies, Seattle Children’s Research Institute, Seattle, WA, United States
| | - Chong Li
- Center for Immunity and Immunotherapies, Seattle Children’s Research Institute, Seattle, WA, United States
| | - Liliane Khoryati
- Translational Research Program, Benaroya Research Institute, Seattle, WA, United States
| | - Marc A. Gavin
- Translational Research Program, Benaroya Research Institute, Seattle, WA, United States
| | - Carol H. Miao
- Center for Immunity and Immunotherapies, Seattle Children’s Research Institute, Seattle, WA, United States
| |
Collapse
|
8
|
Smith BM, Lyle MJ, Chen AC, Miao CH. Antigen-specific in vitro expansion of factor VIII-specific regulatory T cells induces tolerance in hemophilia A mice. J Thromb Haemost 2020; 18:328-340. [PMID: 31609041 PMCID: PMC6994379 DOI: 10.1111/jth.14659] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 09/25/2019] [Accepted: 10/07/2019] [Indexed: 12/27/2022]
Abstract
BACKGROUND Following protein replacement therapy, one-third of severe hemophilia A patients develop antibodies to factor VIII (FVIII), which also hinders the efficacy of gene therapy. Regulatory T cells (Tregs) have a naturally suppressive function that potentially reduces the immune response to FVIII therapy. Furthermore, antigen-specific Tregs are functionally much more potent than polyclonal cells. Adoptive transfer of antigen-specific Tregs can effectively suppress anti-FVIII antibody responses. OBJECTIVE Develop a clinically feasible protocol to enrich and expand Tregs specific to FVIII for suppressing anti-FVIII immune responses. METHODS Regulatory T cells are isolated from FVIII-sensitized mice, sorted on CD25high markers, and expanded specifically with FVIII, antigen-presenting cells, and interleukin 2 (IL 2). Subsequently, Tregs are further cultured with anti-CD3/anti-CD28 beads, anti-Crry antibodies, and IL 2 to achieve 10-fold to 20-fold expansion. Expanded Tregs are characterized and tested for their suppressive activity in vitro and in vivo. RESULTS In vitro FVIII-specific suppressive assays indicate that FVIII specifically expanded Tregs are more suppressive than non-specifically expanded and naive Tregs. Adoptive transfer of expanded Tregs into HemA mice showed that FVIII-specifically expanded Tregs are significantly more potent in suppressing anti-FVIII immune responses in FVIII plasmid-treated HemA mice. Moreover, the FVIII-specific immune tolerance is maintained after a secondary challenge with FVIII plasmid. CONCLUSIONS Our results demonstrate that the FVIII-specific sensitization and expansion protocol yields more potent Tregs to suppress anti-FVIII antibody responses and induce long-term tolerance to FVIII, increasing the potential for adoptive Treg cell therapy to modulate anti-FVIII immune responses.
Collapse
Affiliation(s)
- Bryn M Smith
- Center for Immunity and Immunotherapies, Seattle Children's Research Institute, Seattle, Washington
| | - Meghan J Lyle
- Center for Immunity and Immunotherapies, Seattle Children's Research Institute, Seattle, Washington
| | - Alex C Chen
- Center for Immunity and Immunotherapies, Seattle Children's Research Institute, Seattle, Washington
| | - Carol H Miao
- Center for Immunity and Immunotherapies, Seattle Children's Research Institute, Seattle, Washington
- Department of Pediatrics, University of Washington, Seattle, Washington
| |
Collapse
|
9
|
Zanon E, Pasca S, Pollio B, Santagostino E, Linari S, Tagliaferri A, Santoro C, Rocino A, Marino R, Aru B, Borchiellini A, Siragusa S, Coppola A. Immune tolerance induction with moroctocog-alpha (Refacto/Refacto AF) in a population of Italian haemophilia A patients with high-titre inhibitors: Data from REF.IT Registry. Haemophilia 2019; 25:1003-1010. [PMID: 31603594 DOI: 10.1111/hae.13859] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 09/20/2019] [Accepted: 09/23/2019] [Indexed: 01/14/2023]
Abstract
BACKGROUND The appearance of inhibitors is the most serious complication in haemophilia A (HA) patients. The primary objective is their eradication. Up to date, immune tolerance induction (ITI) was the only therapeutic option to achieve this. AIM To assess the efficacy of moroctocog-alpha as an ITI regimen in a population of HA patients with high-titre inhibitors. METHODS The REF.IT Registry is a retrospective-prospective study that collected data on all patients with HA and high-titre inhibitors treated with moroctocog-alpha as an ITI regimen at twelve Italian Haemophilia Centres. RESULTS We enrolled 27 patients, 85.2% were children. All patients were high responders, 88.9% had severe HA. We found 69.3% of them had one or more risk factors for poor ITI prognosis, 14.8% were ITI rescue. Overall 59.3% achieved a complete/partial success (complete in 51.9%). ITI failed in 11 patients, 63.6% of them with poor-prognosis risk factors. Inhibitors appeared after a mean of 27 exposure days. Mean historical peak was 78.8 BU/mL. The primary ITIs started on average 20.2 months after the diagnosis. A partial or complete success after a mean of 15 months of treatment was achieved in 56.6% of the children while the same result was obtained by 75.0% adults after 22 months from ITI onset. Patients who were treated with high-dose moroctocog-alpha (200 UI/kg/day) were 63.0%. CONCLUSION Our Registry showed that the use of moroctocog-alpha in the setting of ITI was effective and safe also in a population of patients with high-titre inhibitors, presenting one or more risk factors for poor ITI prognosis.
Collapse
Affiliation(s)
- Ezio Zanon
- Hemophilia Center, University Hospital of Padua, Padua, Italy
| | - Samantha Pasca
- Hemophilia Center, University Hospital of Padua, Padua, Italy
| | | | - Elena Santagostino
- Hemophilia Center, Angelo Bianchi Bonomi Center, IRCCS Ca 'Granda Foundation, Maggiore University Hospital of Milan, Milan, Italy
| | - Silvia Linari
- Centre for Bleeding Disorders, Careggi University Hospital of Florence, Florence, Italy
| | - Annarita Tagliaferri
- Regional Reference Centre for Inherited Bleeding Disorders, University Hospital of Parma, Parma, Italy
| | - Cristina Santoro
- Cellular Biotecnology and Hematology Department, Umberto I University Hospital of Rome, Rome, Italy
| | - Angiola Rocino
- Hemophilia and Thrombosis Center, S.Giovanni Bosco Hospital of Neaples, Neaples, Italy
| | - Renato Marino
- Haemophilia and Thrombosis Center, Giovanni XXIII Hospital of Bari, Bari, Italy
| | - Brigida Aru
- Pediatric Onco-Haematology Center, Microcitemico Hospital of Cagliari, Cagliari, Italy
| | | | - Sergio Siragusa
- Hematology Department, Center of Hemorrhagic and Thrombotic Diseases, University of Palermo, Palermo, Italy
| | - Antonio Coppola
- Regional Reference Centre for Inherited Bleeding Disorders, University Hospital of Parma, Parma, Italy
| |
Collapse
|
10
|
Nakar C, Shapiro A. Hemophilia A with inhibitor: Immune tolerance induction (ITI) in the mirror of time. Transfus Apher Sci 2019; 58:578-589. [PMID: 31447396 DOI: 10.1016/j.transci.2019.08.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Inhibitor (neutralizing antibodies) development remains the most significant complication in patients with severe congenital hemophilia A receiving exogenous factor VIII (FVIII). Although our understanding of the pathophysiology of inhibitor development has advanced, the knowledge gained has not yet translated into a robust decline in incidence, with the overall risk remaining at ∼30%. Immune Tolerance Induction (ITI) is the only current method to successfully eradicate an inhibitor and achieve long-term tolerance. Although current practice utilizes a wide variety of ITI regimens, identification of an optimal regimen has not emerged. Over the last decade, the number of replacement products available in hemophilia has greatly expanded. The cumulative evidence with each product for use in ITI is often lacking. Most recently emicizumab, a humanized monoclonal bi-specific antibody that substitutes for the scaffolding effect of FVIIIa was approved; this agent prevents bleeding in both inhibitor and non-inhibitor patients. The use of emicizumab will bring about a new era in care that will require clinicians to challenge current practice paradigms including use and administration of ITI. This review will summarize the main clinical ITI data and practices for patients with severe congenital hemophilia A with inhibitors (CHAwI) over the last four decades and will highlight current studies in the field, with attention to open questions.
Collapse
Affiliation(s)
- Charles Nakar
- The Indiana Hemophilia and Thrombosis Center (IHTC), Indianapolis, IN, USA.
| | - Amy Shapiro
- The Indiana Hemophilia and Thrombosis Center (IHTC), Indianapolis, IN, USA
| |
Collapse
|
11
|
Haya S, Solano C, Cid AR, Argilés B, Hervás D, Querol F, Bonanad S, Casaña P. Predictive factors of immune tolerance treatment response in severe haemophilia A patients with inhibitors: A real‐world report from a single centre, mixed retrospective‐prospective long‐term study. Haemophilia 2019; 25:e97-e100. [PMID: 30604912 PMCID: PMC7078961 DOI: 10.1111/hae.13660] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Saturnino Haya
- Hemostasis and Thrombosis Unit, Hematology Service Hospital Universitari i Politècnic La Fe Valencia Spain
| | - Carlos Solano
- Hematology Service Hospital Clínico de Valencia Valencia Spain
- Department of Medicine Universidad de Valencia Valencia Spain
| | - Ana Rosa Cid
- Hemostasis and Thrombosis Unit, Hematology Service Hospital Universitari i Politècnic La Fe Valencia Spain
| | - Bienvenida Argilés
- Pediatric Hematology Unit Hospital Universitari i Politècnic La Fe Valencia Spain
| | - David Hervás
- Unit of Data Science, Biostatistics and Bioinformatics Instituto de Investigación Sanitaria La Fe Valencia Spain
| | - Felipe Querol
- Hemostasis and Thrombosis Unit, Hematology Service Hospital Universitari i Politècnic La Fe Valencia Spain
- Departament of Physiotherapy Universidad de Valencia Valencia Spain
| | - Santiago Bonanad
- Hemostasis and Thrombosis Unit, Hematology Service Hospital Universitari i Politècnic La Fe Valencia Spain
| | - Pilar Casaña
- Hemostasis and Thrombosis Unit, Hematology Service Hospital Universitari i Politècnic La Fe Valencia Spain
| |
Collapse
|
12
|
Harper P, Favaloro EJ, Curtin J, Barnes C, Dunkley S. Human plasma-derived FVIII/VWD concentrate (Biostate): a review of experimental and clinical pharmacokinetic, efficacy and safety data. Drugs Context 2016; 5:212292. [PMID: 27114741 PMCID: PMC4831637 DOI: 10.7573/dic.212292] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Indexed: 11/28/2022] Open
Abstract
Human plasma-derived factor VIII/von Willebrand factor complex concentrates are used to control bleeding in patients with von Willebrand disease (VWD) or haemophilia A (HA). The properties of these haemostatic factor concentrates vary widely, which can have significant clinical implications. This review provides an extensive overview of the molecular properties, in addition to pharmacokinetic, efficacy and safety data, and case studies of clinical experience of one such concentrate, Biostate. These data are discussed in the context of various therapeutic applications and compared with other factor concentrate products. Data are presented from data on file from the manufacturer; product information and published experimental and clinical pharmacokinetic, safety and efficacy study data; and example case studies of clinical experience. The data discussed herein demonstrate that Biostate has well-established efficacy profiles in the treatment of patients with VWD or HA, with the control of bleeding rated as ‘excellent’, ‘good’ or ‘moderate’ in >90% of patients. In an immune-tolerance induction setting, 73% of patients achieved a complete response following treatment with Biostate. Biostate was generally well tolerated in patients with HA or VWD, with infrequent minor adverse events reported and no reported cases of clinically relevant thrombosis.
Collapse
Affiliation(s)
- Paul Harper
- Palmerston North Hospital, 50 Ruahine Street, Private Bag 11036, Palmerston North, New Zealand
| | - Emmanuel J Favaloro
- Institute of Clinical Pathology and Medical Research (ICPMR), Cnr Hawkesbury Road and Darcy Road, Westmead, NSW 2145, Australia
| | - Julie Curtin
- The Children's Hospital, Cnr Hawkesbury Road and Hainsworth Street, Westmead, NSW 2145, Australia
| | - Chris Barnes
- Royal Children's Hospital, 50 Flemington Road, Parkville, VIC 3052, Australia
| | - Scott Dunkley
- Royal Prince Alfred Hospital, Missenden Road, Camperdown, NSW 2050, Australia
| |
Collapse
|
13
|
Principles of treatment and update of recommendations for the management of haemophilia and congenital bleeding disorders in Italy. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2015; 12:575-98. [PMID: 25350962 DOI: 10.2450/2014.0223-14] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
|
14
|
Nakar C, Manco-Johnson MJ, Lail A, Donfield S, Maahs J, Chong Y, Blades T, Shapiro A. Prompt immune tolerance induction at inhibitor diagnosis regardless of titre may increase overall success in haemophilia A complicated by inhibitors: experience of two US centres. Haemophilia 2015; 21:365-373. [DOI: 10.1111/hae.12608] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/10/2014] [Indexed: 01/19/2023]
Affiliation(s)
- C. Nakar
- The Indiana Hemophilia and Thrombosis Center (IHTC); Indianapolis IN USA
| | - M. J. Manco-Johnson
- The University of Colorado Hemophilia & Thrombosis Center (UCHTC); Aurora CO USA
| | - A. Lail
- Rho, Inc.; Chapel Hill NC USA
| | | | - J. Maahs
- The Indiana Hemophilia and Thrombosis Center (IHTC); Indianapolis IN USA
| | - Y. Chong
- The Indiana Hemophilia and Thrombosis Center (IHTC); Indianapolis IN USA
| | - T. Blades
- The University of Colorado Hemophilia & Thrombosis Center (UCHTC); Aurora CO USA
| | - A. Shapiro
- The Indiana Hemophilia and Thrombosis Center (IHTC); Indianapolis IN USA
| |
Collapse
|
15
|
van Velzen AS, Peters M, van der Bom JG, Fijnvandraat K. Effect of von Willebrand factor on inhibitor eradication in patients with severe haemophilia A: a systematic review. Br J Haematol 2014; 166:485-95. [DOI: 10.1111/bjh.12942] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Accepted: 03/31/2014] [Indexed: 01/19/2023]
Affiliation(s)
- Alice S. van Velzen
- Department of Pediatric Haematology; Emma Children's Hospital; Academic Medical Center; Amsterdam The Netherlands
| | - Marjolein Peters
- Department of Pediatric Haematology; Emma Children's Hospital; Academic Medical Center; Amsterdam The Netherlands
| | - Johanna G. van der Bom
- Centre for Clinical Transfusion Research; Sanquin Research; Leiden the Netherlands
- Department of Clinical Epidemiology; Leiden University Medical Centre; Leiden the Netherlands
| | - Karin Fijnvandraat
- Department of Pediatric Haematology; Emma Children's Hospital; Academic Medical Center; Amsterdam The Netherlands
| |
Collapse
|