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Lapalud P, Rothschild C, Mathieu-Dupas E, Balicchi J, Gruel Y, Laune D, Molina F, Schved JF, Granier C, Lavigne-Lissalde G. Anti-A2 and anti-A1 domain antibodies are potential predictors of immune tolerance induction outcome in children with hemophilia A. J Thromb Haemost 2015; 13:540-7. [PMID: 25603934 DOI: 10.1111/jth.12846] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Accepted: 12/03/2014] [Indexed: 11/30/2022]
Abstract
BACKGROUND Hemophilia A (HA) is a congenital bleeding disorder resulting from factor VIII deficiency. The most serious complication of HA management is the appearance of inhibitory antibodies (Abs) against injected FVIII concentrates. To eradicate inhibitors, immune tolerance induction (ITI) is usually attempted, but it fails in up to 30% of cases. Currently, no undisputed predictive marker of ITI outcome is available to facilitate the clinical decision. OBJECTIVES To identify predictive markers of ITI efficacy. METHODS The isotypic and epitopic repertoires of inhibitory Abs were analyzed in plasma samples collected before ITI initiation from 15 children with severe HA and high-titer inhibitors, and their levels were compared in the two outcome groups (ITI success [n = 7] and ITI failure [n = 8]). The predictive value of these candidate biomarkers and of the currently used indicators (inhibitor titer and age at ITI initiation, highest inhibitor titer before ITI, and interval between inhibitor diagnosis and ITI initiation) was then compared by statistical analysis (Wilcoxon test and receiver receiver operating characteristic [ROC] curve analysis). RESULTS Whereas current indicators seemed to fail in discriminating patients in the two outcome groups (ITI success or failure), anti-A1 and anti-A2 Ab levels before ITI initiation appeared to be good potential predictive markers of ITI outcome (P < 0.018). ROC analysis showed that anti-A1 and anti-A2 Abs were the best at discriminating between outcome groups (area under the ROC curve of > 0.875). CONCLUSION Anti-A1 and anti-A2 Abs could represent new promising tools for the development of ITI outcome prediction tests for children with severe HA.
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Affiliation(s)
- P Lapalud
- UMR3145 CNRS/BioRad, SysDiag, Montpellier, France
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Role of B Cells in Breaking and Maintaining Tolerance to Clotting Factor VIII in Congenital and Acquired Hemophilia A. Antibodies (Basel) 2014. [DOI: 10.3390/antib3020192] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
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Lewis KB, Hughes RJ, Epstein MS, Josephson NC, Kempton CL, Kessler CM, Key NS, Howard TE, Kruse-Jarres R, Lusher JM, Walsh CE, Watts RG, Ettinger RA, Pratt KP. Phenotypes of allo- and autoimmune antibody responses to FVIII characterized by surface plasmon resonance. PLoS One 2013; 8:e61120. [PMID: 23667433 PMCID: PMC3648518 DOI: 10.1371/journal.pone.0061120] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2012] [Accepted: 03/06/2013] [Indexed: 11/19/2022] Open
Abstract
Evidence of antibody isotype/subtype switching may provide prognostic value regarding the state of immune responses to therapeutic proteins, e.g. anti-factor VIII (FVIII) antibodies that develop in many hemophilia A patients, clinically termed “inhibitors”. A sensitive, high- information-content surface plasmon resonance (SPR) assay has been developed to quantify IgG subtype distributions and the domain specificity of anti-drug antibodies. Plasma samples from 22 subjects with an allo- or auto-immune reaction to FVIII were analyzed. Pre-analytical treatment protocols were developed to minimize non-specific binding and specific matrix interference due to von Willebrand factor-FVIII interactions. The dynamic range for IgG quantification was 0.2–5 µg/ml (∼1–33 nM), allowing characterization of inhibitor-positive samples. Subtype-specific monoclonal antibodies were used to quantify the IgG subtype distribution of FVIII-specific antibodies. Most samples obtained from multiply-infused inhibitor subjects contained IgG4 antibodies. Several distinct phenotypes were assigned based on the IgG subtype distribution: IgG1, IgG4, IgG1 & IgG4, and IgG1, IgG2 & IgG4. An IgG1-only response was found in mild/moderate HA subjects during early FVIII infusions, and analysis of serial samples followed antibody class switching as several subjects’ immune responses developed. Competition studies utilizing a recombinant FVIII-C2 domain indicated 40–80% of FVIII-specific antibodies in most samples were directed against this domain.
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Affiliation(s)
- Kenneth B. Lewis
- Puget Sound Blood Center Research Institute, Seattle, Washington, United States of America
| | - Richard J. Hughes
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California, United States of America
| | - Melinda S. Epstein
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California, United States of America
| | - Neil C. Josephson
- Puget Sound Blood Center Research Institute, Seattle, Washington, United States of America
- Division of Hematology, University of Washington, Seattle, Washington, United States of America
| | | | | | - Nigel S. Key
- University of North Carolina, Chapel Hill, North Carolina, United States of America
| | - Tom E. Howard
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California, United States of America
- Division of Hematology and Oncology, Department of Medicine, David Geffen School of Medicine at UCLA and Department of Pathology and Laboratory Medicine, Keck School of Medicine at USC, Los Angeles, California, United States of America
| | | | - Jeanne M. Lusher
- Wayne State University, Detroit, Michigan, United States of America
| | | | - Raymond G. Watts
- University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Ruth A. Ettinger
- Puget Sound Blood Center Research Institute, Seattle, Washington, United States of America
| | - Kathleen P. Pratt
- Puget Sound Blood Center Research Institute, Seattle, Washington, United States of America
- Division of Hematology, University of Washington, Seattle, Washington, United States of America
- * E-mail:
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Lapalud P, Ali T, Cayzac C, Mathieu-Dupas E, Levesque H, Pfeiffer C, Balicchi J, Gruel Y, Borg JY, Schved JF, Granier C, Lavigne-Lissalde G. The IgG autoimmune response in postpartum acquired hemophilia A targets mainly the A1a1 domain of FVIII. J Thromb Haemost 2012; 10:1814-22. [PMID: 22784315 DOI: 10.1111/j.1538-7836.2012.04850.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Acquired hemophilia A (AHA) is a severe life-threatening autoimmune disease due to the development of autoantibodies that neutralize the procoagulant activity of factor VIII (FVIII). In rare cases, AHA occurs in the postpartum period as a serious complication of an otherwise normal pregnancy and delivery. Due to its rarity, little is known about the features of the antibody response to FVIII in AHA. OBJECTIVES Our study wanted to (i) determine the epitope specificity and the immunoglobulin (Ig) subclasses of anti-FVIII autoantibodies in plasma samples from a large cohort of AHA patients, and (ii) compare the epitope specificity of anti-FVIII autoantibodies in plasma samples from postpartum AHA and other AHA patients. PATIENTS/METHODS Seventy-three plasma samples from patients with postpartum AHA (n = 10) or associated with malignancies (n = 16) or autoimmune diseases (n = 11) or without underlying disease (n = 36) were analyzed with three multiplexed assays. RESULTS AND CONCLUSIONS Our results showed a stronger response against the A1a1-A2a2-B fragments of FVIII and more specifically against the A1a1 domain in patients with postpartum AHA than in the other AHA groups (P < 0.01). Moreover, although IgG4 was the predominant IgG subclass in all groups, anti-A1a1-A2a2-B and anti-A1a1 domain autoantibodies of the IgG(1) and IgG3 subclasses were more frequently detected in postpartum AHA than in the other AHA groups. These findings support the involvement of the Th1-driven response in the generation of autoantibodies in women with postpartum AHA compared with the other groups of AHA patients in whom production of Th2-driven IgG4 was predominant.
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Affiliation(s)
- P Lapalud
- SysDiag, UMR3145 CNRS/BioRad, Montpellier, France.
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Griffiths AE, Wang W, Hagen FK, Fay PJ. Use of affinity-directed liquid chromatography-mass spectrometry to map the epitopes of a factor VIII inhibitor antibody fraction. J Thromb Haemost 2011; 9:1534-40. [PMID: 21668738 PMCID: PMC3154976 DOI: 10.1111/j.1538-7836.2011.04397.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Neutralizing factor (F) VIII antibodies develop in approximately 30% of individuals with hemophilia A and show specificity to multiple sites in the FVIII protein. METHODS Reactive epitopes to an immobilized IgG fraction prepared from a high-titer, FVIII inhibitor plasma were determined after immuno-precipitation (IP) of tryptic and chymotryptic peptides derived from digests of the A1 and A2 subunits of FVIIIa and FVIII light chain. Peptides were detected and identified using highly sensitive liquid chromatography-mass spectrometry (LC-MS). RESULTS Coverage maps of the A1 subunit, A2 subunit and light chain represented 79%, 69% and 90%, respectively, of the protein sequences. Dot blots indicated that the inhibitor IgG reacted with epitopes contained within each subunit of FVIIIa. IP coupled with LC-MS identified 19 peptides representing epitopes from all FVIII A and C domains. The majority of peptides (10) were derived from the A2 domain. Three peptides mapped to the C2 domain, while two mapped to the A1 and A3 domains, and single peptides mapped to the a1 segment and C1 domain. Epitopes were typically defined by peptide sequences of < 12 residues. CONCLUSIONS IP coupled with LC-MS identified extensive antibody reactivity at high resolution over the entire functional FVIII molecule and yielded sequence lengths of < 15 residues. A number of the peptides identified mapped to known sequences involved in functionally important protein-protein and protein-membrane interactions.
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Affiliation(s)
- Amy E. Griffiths
- Department of Biochemistry and Biophysics, University of Rochester School of Medicine, Rochester, NY 14642 USA
| | - Wensheng Wang
- Department of Biochemistry and Biophysics, University of Rochester School of Medicine, Rochester, NY 14642 USA
| | - Fred K. Hagen
- Proteomics Center, University of Rochester School of Medicine, Rochester, NY 14642 USA
| | - Philip J. Fay
- Department of Biochemistry and Biophysics, University of Rochester School of Medicine, Rochester, NY 14642 USA
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Characteristics, mechanisms of action, and epitope mapping of anti-factor VIII antibodies. Clin Rev Allergy Immunol 2009; 37:67-79. [PMID: 19172415 DOI: 10.1007/s12016-009-8119-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The development of anti-factor VIII (FVIII) antibodies (Abs), also called inhibitors, is currently one of the most serious complications arising during the treatment of hemophilia A patients. Improved prevention and eradication of these Abs remain a challenge both for clinicians and scientists. Numerous studies in the literature have reported on their epitope specificity, on their mechanism of FVIII inactivation, as well as on the methods used for their detection. In this review, we summarize the current knowledge on the nature (isotypes, kinetic properties), epitope properties, and mechanisms of action of anti-FVIII Abs. Furthermore, we present methods for detection and epitope characterization of anti-FVIII Abs with emphasis on the Luminex technique susceptible to facilitate the monitoring of changes in the epitope specificity of these Abs.
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Pratt KP, Thompson AR. B-Cell and T-Cell Epitopes in Anti-factor VIII Immune Responses. Clin Rev Allergy Immunol 2009; 37:80-95. [DOI: 10.1007/s12016-009-8120-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Persistent factor VIII-dependent factor X activation on endothelial cells is independent of von Willebrand factor. Blood Coagul Fibrinolysis 2008; 19:190-6. [PMID: 18388497 DOI: 10.1097/mbc.0b013e3282faa8c1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Endothelial cells are able to support the activation of coagulation factor X by activated factor IX in the presence of its cofactor, factor VIII. We have previously reported that this reaction is persistent on endothelial cells, but transient on activated platelets and phospholipid vesicles when activated factor X (Xa) is used as activator of factor VIII. Aim of the present study was to explore the influence of von Willebrand factor and that of the factor VIII activator, either factor Xa or thrombin, on the decay of factor X activation on the endothelial cell surface. Kinetics of factor X activation on human umbilical vein endothelial cells was compared with that on phospholipid vesicles employing purified coagulation factors from plasma as well as recombinant factor VIII variants. Employing factor Xa as factor VIII activator, rate constants for decay of membrane-bound factor X activation were consistently low on endothelial cells (0.02 min) as compared with phospholipid vesicles (0.2 min). Activation of factor VIII by thrombin resulted in two-fold increased decay rates. In the presence of excess of von Willebrand factor over factor VIII, decay rates were not significantly changed. Factor VIII variants with and without a Tyr to Phe substitution, which abolishes high-affinity binding to von Willebrand factor, displayed the same factor X activation decay kinetics. Although previous studies have shown that von Willebrand factor modulates factor VIII activation and stabilisation, this apparently does not affect the progression of factor X activation at the endothelium.
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Chaves DG, Velloso-Rodrigues C, Moreau V, Nguyen C, Villard S, Belisário AR, Granier C, Santoro MM. Reactivity profile of anti-factor VIII antibodies with designed synthetic peptides mimicking epitopes of the C2 and a1 domains. Br J Haematol 2008; 141:708-15. [PMID: 18422780 DOI: 10.1111/j.1365-2141.2008.07043.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Antibodies (Abs) that block factor VIII (FVIII) activity occur in hemophilia A patients treated with FVIII replacement therapy and severely impair treatment. In this work, we designed and synthesized ten peptides whose sequences are found in putative epitopes at the surface of a1 and C2 domains of the FVIII molecule. These peptides were screened for their ability to inhibit the binding of anti-FVIII Abs from plasmas of hemophilia A patients to FVIII. All peptides were efficient in inhibiting anti-FVIII Abs in plasma from patients with inhibitors, with however different efficiencies. It was found that each tested patient's plasma had a different profile of reactivity with peptides, consistent with an individual anti-FVIII Ab specificity. The profile of recognized peptides was also changing during the treatment of the patients. Three peptides were used in an affinity chromatography assay to attempt to remove anti-FVIII Abs from patients' plasma. Anti-FVIII IgGs were significantly captured by the peptide-Sepharose affinity matrixes as assessed by enzyme-linked immunosorbent assay. However, due to the low level of Abs in the plasma samples, other methods (Chromogenic and Bethesda assays) were not sensitive enough to properly detect the reduction of inhibitors.
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Affiliation(s)
- D G Chaves
- Department of Biochemistry and Immunology, Institute of Biological Science, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil.
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10
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Astermark J. Basic aspects of inhibitors to factors VIII and IX and the influence of non-genetic risk factors. Haemophilia 2007; 12 Suppl 6:8-13; discussion 13-4. [PMID: 17123388 DOI: 10.1111/j.1365-2516.2006.01360.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
The appearance of polyclonal antibodies inhibiting the function of exogenous factors VIII (FVIII) and IX (FIX) continues to be a major challenge in the treatment of patients with congenital haemophilia. Why these inhibitors develop in 10-20% of patients with haemophilia A, and in 1-5% of patients with haemophilia B, remains largely unexplained. The antibodies, however, are characterized by several features that may have implications for the immune process by which they occur. The FVIII antibodies are mainly directed towards the A2, A3 and C2 domains, thereby interfering with the function of the factor Xase complex, the binding of FVIII to von Willebrand factor, and the binding of FVIII to phospholipid membranes. The FIX epitopes are localized to the NH(2)-terminal gamma-carboxyglutamic acid region and the serine protease domain. Genetic risk factors are known to be of importance in the development of inhibitors, whereas the impact of non-genetic factors is less clear. However, based on studies of related subjects, it is obvious that non-genetic factors are of importance as well. Putative factors currently debated include age at the start of treatment, treatment in association with immune challenges, the type of product, and the mode of administration. Most of the findings reported to date, however, derive from small cohorts that have not been sufficiently well characterized with respect to genetic risk profile. Therefore, additional studies are required to quantify the impact of non-genetic factors on the pathophysiologic process of inhibitor development.
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Affiliation(s)
- J Astermark
- Department for Coagulation Disorders, Malmö University Hospital, Malmö, Sweden.
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Abstract
PURPOSE OF REVIEW Extracorporeal immunoadsorption is being increasingly applied in a variety of disorders. This approach is particularly suited to removal of antibodies or inhibitors to coagulation factor VIII and may be particularly useful before the administration of large amounts of expensive replacement or bypass therapy for patients with hemophilia who are bleeding, or patients undergoing immune tolerance therapy. RECENT FINDINGS In patients with inhibitors to factor VIII, several types of immunoadsorption therapy have been used, although reports are mainly anecdotal, consisting of relatively small numbers of persons. Nonetheless, the findings suggest that immunoadsorption may be clinically effective and cost-effective and should be considered early in the treatment of appropriate patients. New immunoadsorption technologies are being described for a variety of disorders, including hemophilia, and a new synthetic matrix of polystyrene beads functionalized with sulfonate and tyrosyl methylester groups for immunoadsorption removal of factor VIII inhibitors is intriguing. SUMMARY Although immunoadsorption was shown to be clinically effective in patients with inhibitors to factor VIII more than two decades ago, recent papers have emphasized the desirability of early implementation of the modality in the treatment plan. Immunoadsorption is relatively easy to perform with few adverse effects, but specialized equipment is required, and it should be performed in an experienced setting. Although potentially less costly than other (bypass) therapies, immunoadsorption is itself not inexpensive, and its comparative effectiveness with plasmapheresis and other management options for the dangerously bleeding patient with antibodies to factor VIII should be determined by multicenter randomized controlled trials. Interesting recent novel technical developments in the field may facilitate increased use of the procedure.
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Affiliation(s)
- John Freedman
- St. Michael's Hospital, University of Toronto, Toronto, Canada.
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Abstract
PURPOSE OF REVIEW The development of an inhibitory response to factor VIII (FVIII) remains a puzzling challenge both for clinicians and scientists, not to mention the difficulties of maintaining hemostasis in patients producing inhibitors. RECENT FINDINGS Three main research lines have been explored in recent months. The mechanisms by which an anti-FVIII antibody response is elicited in patients has been examined at both the B- and T-cell levels, with particular emphasis on the generation of specific B- and T-cell clones. The hemophilia A mouse model has served to confirm the main characteristics of the anti-FVIII immune response in terms of T-cell dependency and memorization of the response. Novel strategies for the prevention and downregulation of inhibitors have emerged, with special interest in antigen-specific approaches. SUMMARY Although the ultimate goal, preventing or suppressing inhibitor formation in patients, is not yet achieved, the research activity developed over the past months brings us forward in that direction.
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Affiliation(s)
- Marc G Jacquemin
- Center for Molecular and Vascular Biology, University of Leuven, Campus Gasthuisberg, Herestraat 49, 3000 Leuven, Belgium
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