1
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Tóth G, Zátroch I, Kiss D, Fazakas J. [Rapid diagnosis of acquired hemophilia A with ClotPro viscoelastometry analyser]. Orv Hetil 2023; 164:1600-1604. [PMID: 37987694 DOI: 10.1556/650.2023.32874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 07/13/2023] [Indexed: 11/22/2023]
Abstract
Acquired hemophilia A is a rare condition with the capability of bringing about life-threatening bleeding in the perioperative period, posing a significant challenge for the caregiver anesthetist to identify the underlying cause. However, a quick diagnosis might be supported by viscoelastometry by raising the suspicion of severe and isolated deficiency of the intrinsic coagulation pathway, requiring a prompt consultation with a hematology center. Special laboratory tests of hemostasis are helpful in the differential diagnosis of the detected coagulation disorder. Nevertheless, bypassing agents have gained a crucial role in the treatment of major perioperative blood losses by bypassing Factor VIII inactivated by autoantibodies and thus, initiating coagulation. Early goal-directed supplementation of depleted coagulation factors must also be kept in the focus of the therapy. Orv Hetil. 2023; 164(40): 1600-1604.
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Affiliation(s)
- Gyöngyi Tóth
- 1 Budapesti Uzsoki Utcai Kórház, Központi Aneszteziológiai és Intenzív Terápiás Osztály Budapest Magyarország
| | - István Zátroch
- 1 Budapesti Uzsoki Utcai Kórház, Központi Aneszteziológiai és Intenzív Terápiás Osztály Budapest Magyarország
| | - Dániel Kiss
- 2 Budapesti Uzsoki Utcai Kórház, Ortopéd-Traumatológiai Osztály Budapest Magyarország
| | - János Fazakas
- 3 Semmelweis Egyetem, Általános Orvostudományi Kar, Aneszteziológiai és Intenzív Terápiás Klinika Budapest, Pf. 2, 1428 Magyarország
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2
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Laney IV DF, Houle M, Deshotels L, Ferral H. Portal Hypertension in Patients with Hemophilia. Semin Intervent Radiol 2023; 40:389-392. [PMID: 37575345 PMCID: PMC10415051 DOI: 10.1055/s-0043-1771039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/15/2023]
Affiliation(s)
- Dan F. Laney IV
- Section of Interventional Radiology, Department of Radiology, Louisiana State University Health Sciences Center, New Orleans, Louisiana
| | - Matthew Houle
- Department of Internal Medicine, Tulane University School of Medicine, New Orleans, Louisiana
| | - Leigh Deshotels
- Department of Hematology and Medical Oncology, Tulane University School of Medicine, New Orleans, Louisiana
| | - Hector Ferral
- Section of Interventional Radiology, Department of Radiology, Louisiana State University Health Sciences Center, New Orleans, Louisiana
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Albattat S, Alabdultaif A, Albattat F, Albattat B. Cerebellar hematoma in severe hemophilia with inhibitor on emicizumab prophylaxis: a case report. J Med Case Rep 2023; 17:63. [PMID: 36814352 PMCID: PMC9948523 DOI: 10.1186/s13256-023-03783-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 01/19/2023] [Indexed: 02/24/2023] Open
Abstract
BACKGROUND Emicizumab is a novel prophylactic medication used to treat patients with hemophilia A. It is indicated to minimize the frequency of bleeding episodes and the severity of serious bleeding in patients with hemophilia A utilizing inhibitors. However, some cases of bleeding episodes have been reported, and more data are needed regarding their management and expected outcomes. CASE PRESENTATION We report a case of a 4-year-old Saudi Arabian boy with severe hemophilia A who presented with a post-traumatic cerebral hemorrhage. The patient, with high titer inhibitors, was on emicizumab prophylaxis therapy. On hospital admission, he received tranexamic acid (10 mg intravenously, every 6 hours), and recombinant activated factor VII 120 µg/kg every 2 hours for 2 days then every 4 hours for 4 days. On follow-up, the patient showed no signs of neurological deficit. There was no need for emergency neurosurgical intervention since the bleeding had been controlled throughout the first 2 days. There were no recorded thrombotic sequelae or neurological complications, with complete resolution within 10 days. CONCLUSIONS This case implies that low-dose recombinant activated factor VII might be used safely and effectively with patients with hemophilia A on emicizumab prophylaxis, to reduce the risk of cerebral hemorrhage or another episode of serious bleeding along with its long-term complications.
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Affiliation(s)
- Sami Albattat
- Pediatric Department, Maternity and Children's Hospital, Alhassa, Ministry of Health, Najran, Saudi Arabia.
| | - Abbas Alabdultaif
- grid.415696.90000 0004 0573 9824Pediatric Department, Maternity and Children’s Hospital, Alhassa, Ministry of Health, Najran, Saudi Arabia
| | - Fatimah Albattat
- grid.412140.20000 0004 1755 9687King Faisal University, Alhassa, Saudi Arabia
| | - Batla Albattat
- grid.412140.20000 0004 1755 9687King Faisal University, Alhassa, Saudi Arabia
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4
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Phenotypic variation in severe hemophilia A is related to endogenous thrombin potential and plasma levels of factor VII. Blood Coagul Fibrinolysis 2022; 33:463-467. [DOI: 10.1097/mbc.0000000000001176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Sun J, Chen X, Chai Z, Niu H, Dobbins AL, Nichols TC, Li C. Adeno-associated virus-mediated expression of activated factor V (FVa) for hemophilia phenotypic correction. Front Med (Lausanne) 2022; 9:880763. [PMID: 35991645 PMCID: PMC9388760 DOI: 10.3389/fmed.2022.880763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 07/14/2022] [Indexed: 12/04/2022] Open
Abstract
Adeno-associated virus (AAV) gene therapy has been successfully applied in hemophilia patients excluding patients with inhibitors. During the coagulation pathway, activated factor V (FVa) functions downstream as a cofactor of activated factor X (FXa) to amplify thrombin generation. We hypothesize that the expression of FVa via gene therapy can improve hemostasis of both factor IX and FVIII deficiencies, regardless of clotting factor inhibitor. A human FVa (hFVa) expression cassette was constructed, and AAV8 vectors encoding hFVa (AAV8/TTR-hFVa) were intravenously administrated into mice with hemophilia A and B with or without FVIII inhibitors. Hemostasis, including hFVa level, activated partial thromboplastin time (aPTT), tail clip, and the saphenous vein bleeding assay (SVBA), was evaluated. In hemophilia B mice, a dose of 4 × 1013 vg/kg AAV8/TTR-hFVa vectors achieved a complete phenotypic correction over 28 weeks. In hemophilia A mice, hemostasis improvement was also achieved, regardless of FVIII inhibitor development. In vivo hemostasis efficacy was confirmed by tail clip and SVBA. Interestingly, while minimal shortening of aPTT was observed at a lower dose of AAV8 vectors, hemostasis improvement was still achieved via in vivo bleeding assays. Collectively, FVa-based AAV gene therapy shows promise for hemostasis correction in hemophilia, regardless of inhibitor development and no potential risk for thrombosis.
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Affiliation(s)
- Junjiang Sun
- Division of Pharmacoengineering and Molecular Pharmaceutics, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Gene Therapy Center, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Xiaojing Chen
- Gene Therapy Center, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Zheng Chai
- Gene Therapy Center, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Hongqian Niu
- Gene Therapy Center, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Amanda L. Dobbins
- Gene Therapy Center, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Timothy C. Nichols
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Chengwen Li
- Gene Therapy Center, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
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6
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Das K, Pendurthi UR, Manco-Johnson M, Martin EJ, Brophy DF, Rao LVM. Factor VIIa treatment increases circulating extracellular vesicles in hemophilia patients: Implications for the therapeutic hemostatic effect of FVIIa. J Thromb Haemost 2022; 20:1928-1933. [PMID: 35608928 PMCID: PMC9846311 DOI: 10.1111/jth.15768] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 03/22/2022] [Indexed: 01/21/2023]
Affiliation(s)
- Kaushik Das
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler, Tyler, Texas, USA
| | - Usha R. Pendurthi
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler, Tyler, Texas, USA
| | | | - Erika J. Martin
- Department of Pharmacotherapy & Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond, Virginia, USA
| | - Donald F. Brophy
- Department of Pharmacotherapy & Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond, Virginia, USA
| | - L. Vijaya Mohan Rao
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler, Tyler, Texas, USA
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7
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Schultz NH, Glosli H, Bjørnsen S, Holme PA. The effect of emicizumab and bypassing agents in patients with hemophilia - An in vitro study. Res Pract Thromb Haemost 2021; 5:e12561. [PMID: 34263107 PMCID: PMC8268661 DOI: 10.1002/rth2.12561] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 05/22/2021] [Accepted: 06/09/2021] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Emicizumab is a nonfactor replacement therapy for hemophilia A (HA) and is a bispecific monoclonal antibody mimicking factor VIII by binding both factors IXa and X. Although it reduces the frequency of bleeding episodes, there is still need for bypassing agents in case of breakthrough bleeds or need for surgery. The HAVEN-1 study showed an increased risk of thrombotic events and episodes of thrombotic microangiopathic hemolytic anemia with simultaneous treatment with emicizumab and activated prothrombin complex concentrate (aPCC) in high doses (>100 U/kg daily) for more than 1 day, and it is suspected that these drugs have a synergistic hemostatic effect. OBJECTIVES To evaluate and compare the hemostatic effect of bypassing agents in vitro in people with HA before and after starting treatment with emicizumab to investigate if dosing should be adjusted to optimize treatment. PATIENTS/METHODS Blood collected before and after start of treatment with emicizumab was spiked with aPCC and recombinant factor VIIa (rFVIIa) at different concentrations. The effect of aPCC and rFVIIa was assessed by thrombin generation assay and thromboelastometry. RESULTS Six people with HA were included. The response to aPCC in thrombin generation after starting emicizumab was significantly stronger than before. This synergistic effect was less pronounced for emicizumab and rFVIIa. Furthermore, aPCC shortened thromboelastometry clotting time more effectively after starting emicizumab than before starting this treatment. CONCLUSIONS We demonstrated a strong synergistic effect of emicizumab and aPCC and a similar but less pronounced effect of rFVIIa in people treated with emicizumab.
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Affiliation(s)
- Nina Haagenrud Schultz
- Department of HaematologyOslo University HospitalOsloNorway
- Research Institute of Internal MedicineOslo University HospitalOsloNorway
- Department of HaematologyAkershus University HospitalLørenskogNorway
| | - Heidi Glosli
- Division of Paediatric and Adolescent MedicineCentre for Rare DisordersOslo University HospitalOsloNorway
- Division of Paediatric and Adolescent MedicineDepartment of Paediatric ResearchOslo University HospitalOsloNorway
| | - Stine Bjørnsen
- Research Institute of Internal MedicineOslo University HospitalOsloNorway
| | - Pål Andre Holme
- Department of HaematologyOslo University HospitalOsloNorway
- Research Institute of Internal MedicineOslo University HospitalOsloNorway
- Institute of Clinical MedicineUniversity of OsloOsloNorway
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8
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Avenick D, Kidd L, Istvan S, Dong F, Richter K, Edwards N, Hisada Y, Posma JJN, Massih CA, Mackman N. Effects of storage and leukocyte reduction on the concentration and procoagulant activity of extracellular vesicles in canine packed red cells. J Vet Emerg Crit Care (San Antonio) 2021; 31:221-230. [PMID: 33751799 DOI: 10.1111/vec.13050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 06/01/2019] [Accepted: 06/24/2019] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To characterize the size and procoagulant activity of extracellular vesicles (EV) that accumulate in canine packed red blood cells (pRBCs) over time and the effect of leukocyte reduction on these characteristics. DESIGN Prospective cohort study. SETTING Private small animal specialty referral hospital and university research laboratories. ANIMALS Ten healthy blood donor dogs. INTERVENTIONS Five pRBCs units were obtained according to standard protocols, and 5 were leukocyte-reduced prior to processing. Platelet-free supernatant from the pRBC units was collected on days 0, 10, 20, 32, and 42. MEASUREMENTS AND MAIN RESULTS Nanoparticle tracking analysis was performed to determine the size and concentration of EVs. Thrombin generation associated with phosphatidylserine-positive EVs was determined using a capture assay. Factor Xa generation associated with phosphatidylserine-positive EVs and tissue factor-positive EVs was measured in a subset of EVs isolated by centrifugation of the supernatant at 20,000 × g. R package nparLD and the Mann-Whitney U-test were used to determine the effect of duration of storage and the effect of leukocyte reduction, respectively. Small (mean < 125 nm) procoagulant EVs accumulated over time, with significant increases occurring on or after day 20 in both non-leukocyte reduced and leukocyte-reduced units. The procoagulant activity of the EVs was due to phosphatidylserine, not tissue factor. Increases in EV concentration and procoagulant activity occurred earlier in non-leukocyte reduced units. Extracellular vesicle accumulation and procoagulant activity were not decreased at any individual time point by leukocyte reduction. CONCLUSIONS Further studies characterizing and determining the clinical relevance of small procoagulant EVs in pRBCs are warranted.
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Affiliation(s)
| | - Linda Kidd
- College of Veterinary Medicine, Western University of Health Sciences, Pomona, California
| | | | - Fanglong Dong
- Graduate College of Biomedical Sciences, Western University of Health Sciences, Pomona, California
| | - Keith Richter
- Veterinary Specialty Hospital, San Diego, California
| | | | - Yohei Hisada
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Jens J N Posma
- Departments of Internal Medicine and Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Cherein Abdel Massih
- College of Veterinary Medicine, Western University of Health Sciences, Pomona, California
| | - Nigel Mackman
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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9
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Malik A, Rehman FU, Shah KU, Naz SS, Qaisar S. Hemostatic strategies for uncontrolled bleeding: A comprehensive update. J Biomed Mater Res B Appl Biomater 2021; 109:1465-1477. [PMID: 33511753 DOI: 10.1002/jbm.b.34806] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Revised: 12/31/2020] [Accepted: 01/14/2021] [Indexed: 11/10/2022]
Abstract
Uncontrolled bleeding remains the leading cause of morbidity and mortality across the entire macrocosm. It refers to excessive loss of blood that occurs inside of body, due to unsuccessful platelet plug formation at the injury site. It is not only limited to the battlefield, but remains the second leading cause of death amongst the civilians, as a result of traumatic injury. Startlingly, there are no effective treatments currently available, to cater the issue of internal bleeding, even though early intervention is of utmost significance in minimizing the mortality rates associated with it. The fatal issue of uncontrolled bleeding is ineffectively being dealt with the use of pressure dressings, tourniquet, and surgical procedures. This is not a practical approach in combat arenas or in emergency situations, where the traumatic injury inflicted is deep inside the body, and cannot be addressed externally, by the application of topical dressings. This review focuses on the traditional hemostatic agents that are used to augment the process of hemostasis, such as mineral zeolites, chitosan based products, biologically active agents, anti-fibrinolytics, absorbable agents, and albumin and glutaraldehyde, as well as the micro- and nano-based hemostatic agents such as synthocytes, thromboerythrocytes, thrombosomes, and the synthetic platelets.
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Affiliation(s)
- Annum Malik
- Nanosciences and Technology Department, National Centre for Physics, Quaid-i-Azam University Campus, Islamabad, Pakistan.,Department of Pharmacy, Quaid-i-Azam University, Islamabad, Pakistan
| | - Fiza Ur Rehman
- Nanosciences and Technology Department, National Centre for Physics, Quaid-i-Azam University Campus, Islamabad, Pakistan.,Department of Pharmacy, Quaid-i-Azam University, Islamabad, Pakistan
| | | | - Syeda Sohaila Naz
- Nanosciences and Technology Department, National Centre for Physics, Quaid-i-Azam University Campus, Islamabad, Pakistan
| | - Sara Qaisar
- Nanosciences and Technology Department, National Centre for Physics, Quaid-i-Azam University Campus, Islamabad, Pakistan
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10
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Peyron I, Kizlik‐Masson C, Dubois M, Atsou S, Ferrière S, Denis CV, Lenting PJ, Casari C, Christophe OD. Camelid-derived single-chain antibodies in hemostasis: Mechanistic, diagnostic, and therapeutic applications. Res Pract Thromb Haemost 2020; 4:1087-1110. [PMID: 33134775 PMCID: PMC7590285 DOI: 10.1002/rth2.12420] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 07/03/2020] [Accepted: 07/12/2020] [Indexed: 12/16/2022] Open
Abstract
Hemostasis is a complex process involving the concerted action of molecular and vascular components. Its basic understanding as well as diagnostic and therapeutic aspects have greatly benefited from the use of monoclonal antibodies. Interestingly, camelid-derived single-domain antibodies (sdAbs), also known as VHH or nanobodies, have become available during the previous 2 decades as alternative tools in this regard. Compared to classic antibodies, sdAbs are easier to produce and their small size facilitates their engineering and functionalization. It is not surprising, therefore, that sdAbs are increasingly used in hemostasis-related research. In addition, they have the capacity to recognize unique epitopes unavailable to full monoclonal antibodies. This property can be used to develop novel diagnostic tests identifying conformational variants of hemostatic proteins. Examples include sdAbs that bind active but not globular von Willebrand factor or free factor VIIa but not tissue factor-bound factor VIIa. Finally, sdAbs have a high therapeutic potential, exemplified by caplacizumab, a homodimeric sdAb targeting von Willebrand factor that is approved for the treatment of thrombotic thrombocytopenic purpura. In this review, the various applications of sdAbs in thrombosis and hemostasis-related research, diagnostics, and therapeutic strategies will be discussed.
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Affiliation(s)
- Ivan Peyron
- HIThUMR_S1176INSERMUniversité Paris‐SaclayLe Kremlin‐BicêtreFrance
| | | | - Marie‐Daniéla Dubois
- HIThUMR_S1176INSERMUniversité Paris‐SaclayLe Kremlin‐BicêtreFrance
- EA 7525 VPMCUniversité des AntillesSchoelcherMartiniqueFrance
| | - Sénadé Atsou
- HIThUMR_S1176INSERMUniversité Paris‐SaclayLe Kremlin‐BicêtreFrance
| | - Stephen Ferrière
- HIThUMR_S1176INSERMUniversité Paris‐SaclayLe Kremlin‐BicêtreFrance
| | - Cécile V. Denis
- HIThUMR_S1176INSERMUniversité Paris‐SaclayLe Kremlin‐BicêtreFrance
| | - Peter J. Lenting
- HIThUMR_S1176INSERMUniversité Paris‐SaclayLe Kremlin‐BicêtreFrance
| | - Caterina Casari
- HIThUMR_S1176INSERMUniversité Paris‐SaclayLe Kremlin‐BicêtreFrance
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11
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Ferrière S, Kawecki C, Ottavi JF, Denis CV, Kauskot A, Christophe OD, Lenting PJ. A single-domain antibody that blocks factor VIIa activity in the absence but not presence of tissue factor. J Thromb Haemost 2019; 17:2035-2046. [PMID: 31423724 DOI: 10.1111/jth.14615] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 08/12/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Activated factor VII (FVIIa) is pertinent to the initiation of blood coagulation. Proteolytic and amidolytic activity of FVIIa are greatly enhanced by its cofactor, tissue factor (TF). OBJECTIVE We aimed to generate a single-domain antibody (sdAb) that recognizes free FVIIa rather than TF-bound FVIIa. METHODS A llama-derived phage library was used to screen for anti-FVIIa sdAbs. RESULTS One sdAb, KB-FVIIa-004, bound to FVIIa, but not to its precursor FVII or to homologous proteins (prothrombin, factor X, or their activated derivatives). FVIIa amidolytic activity was inhibited by KB-FVIIa-004 (Ki = 28-45 nM) in a competitive manner. KB-FVIIa-004 also inhibited FVIIa-mediated FX activation (Ki = 26 nM). In contrast, KB-FVIIa-004 was inefficient in prolonging the clotting time of the prothrombin time-test, which was prolonged by a maximum of 10 s at high sdAb concentrations (10 μM). Furthermore, FVIIa/TF amidolytic activity or FVIIa/TF-mediated FX activation remained unaffected up to a 50-fold to 1000-fold molar excess of KB-FVIIa-004. These data suggest that KB-FVIIa-004 loses its inhibitory activity in the presence of TF. A KB-FVIIa-004/albumin fusion-protein (004-HSA) was generated for in vivo testing. By using 004-HSA, we observed that this sdAb blocked the therapeutic capacity of FVIIa to correct bleeding in FVIII-deficient mice. DISCUSSION This observation is compatible with the view that FVIIa functions independently of TF under these conditions. In conclusion, we have generated a sdAb that specifically blocks TF-independent activity of FVIIa. This antibody can be used to gain insight into the roles of TF-bound and TF-free FVIIa.
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Affiliation(s)
- Stephen Ferrière
- Laboratory of Hemostasis-Inflammation-Thrombosis, Institut National de la Santé et de la Recherche Médicale, UMR_S 1176, Univ. Paris-Sud, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Charlotte Kawecki
- Laboratory of Hemostasis-Inflammation-Thrombosis, Institut National de la Santé et de la Recherche Médicale, UMR_S 1176, Univ. Paris-Sud, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | | | - Cécile V Denis
- Laboratory of Hemostasis-Inflammation-Thrombosis, Institut National de la Santé et de la Recherche Médicale, UMR_S 1176, Univ. Paris-Sud, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Alexandre Kauskot
- Laboratory of Hemostasis-Inflammation-Thrombosis, Institut National de la Santé et de la Recherche Médicale, UMR_S 1176, Univ. Paris-Sud, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Olivier D Christophe
- Laboratory of Hemostasis-Inflammation-Thrombosis, Institut National de la Santé et de la Recherche Médicale, UMR_S 1176, Univ. Paris-Sud, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Peter J Lenting
- Laboratory of Hemostasis-Inflammation-Thrombosis, Institut National de la Santé et de la Recherche Médicale, UMR_S 1176, Univ. Paris-Sud, Université Paris-Saclay, Le Kremlin-Bicêtre, France
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12
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Anti-tissue factor pathway inhibitor (TFPI) therapy: a novel approach to the treatment of haemophilia. Int J Hematol 2018; 111:42-50. [PMID: 30302740 DOI: 10.1007/s12185-018-2548-6] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Accepted: 10/04/2018] [Indexed: 02/07/2023]
Abstract
Novel approaches to the treatment of haemophilia are needed due to the limitations of the current standard of care, factor replacement therapy. Aspirations include lessening the treatment burden and effectively preventing joint damage. Treating haemophilia by restoring thrombin generation may be an effective approach. A promising target for restoring thrombin generation is tissue factor pathway inhibitor (TFPI), a multivalent Kunitz-type serine protease inhibitor that regulates tissue factor-induced coagulation via factor Xa-dependent feedback inhibition of the tissue factor-factor VIIa complex. Inhibition of TFPI reverts the coagulation process to a more primitive state evolutionarily, whilst regulation by other natural inhibitors is preserved. An aptamer and three monoclonal antibodies directed against TFPI have been investigated in clinical trials. As well as improving thrombin generation in the range associated with mild haemophilia, anti-TFPI therapies have the advantage of subcutaneous administration. However, the therapeutic window needs to be defined along with the potential for complications due to the novel mechanism of action. This review provides an overview of TFPI, its role in normal coagulation, the rationale for TFPI inhibition, and a summary of anti-TFPI therapies, previously or currently in development.
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13
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Chowdary P. Inhibition of Tissue Factor Pathway Inhibitor (TFPI) as a Treatment for Haemophilia: Rationale with Focus on Concizumab. Drugs 2018; 78:881-890. [PMID: 29845491 PMCID: PMC6013504 DOI: 10.1007/s40265-018-0922-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Replacement therapy with missing factor (F) VIII or IX in haemophilia patients for bleed management and preventative treatment or prophylaxis is standard of care. Restoration of thrombin generation through novel mechanisms has become the focus of innovation to overcome limitations imposed by protein replacement therapy. Tissue factor pathway inhibitor (TFPI) is a multivalent Kunitz-type serine protease inhibitor that regulates tissue factor (TF)-induced coagulation through a FXa-dependent feedback inhibition of the TF.FVIIa complex in plasma and on endothelial surfaces. Concizumab is a monoclonal, humanised antibody, specific for the second Kunitz domain of TFPI that binds and inhibits FXa, abolishing the inhibitory effect of TFPI. Concizumab restored thrombin generation in FVIII and FIX deficient plasmas and decreased blood loss in a rabbit haemophilia model. Phase 1 single and multiple dose escalation studies in haemophilia patients demonstrated a dose dependent decrease in TFPI levels and a pro-coagulant effect with increasing d-dimers and prothrombin fragment 1 + 2. A dose dependent increase in peak thrombin and endogenous thrombin potential was observed with values in the normal range when plasma TFPI levels were nearly undetectable. A few haemophilia patients in the highest dose cohorts with complete inhibition of plasma TFPI showed a decreased fibrinogen concentration with normal levels of anti-thrombin and platelets and no evidence of thrombosis. Pharmacokinetic parameters were influenced by binding to the target (TFPI), demonstrating target mediated drug disposition. A trend towards decreasing bleeding tendency was observed and this preventative effect is being studied in Phase 2 studies with additional data gathered to improve our understanding of the therapeutic window and potential for thrombosis.
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Affiliation(s)
- Pratima Chowdary
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, Pond Street, London, NW3 2 QG, UK.
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14
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Tolerogenic properties of the Fc portion of IgG and its relevance to the treatment and management of hemophilia. Blood 2018; 131:2205-2214. [PMID: 29588277 DOI: 10.1182/blood-2017-12-822908] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 03/15/2018] [Indexed: 12/14/2022] Open
Abstract
Hemophilia, or inherited genetic deficiencies in coagulation factors, results in uncontrolled bleeding requiring replacement therapy with recombinant proteins given preventively or on demand. However, a major problem with these approaches is the potential for development of immune responses to the administered proteins due to the underlying genetic deficiency of the factor(s) throughout life. As such, there is great interest in developing strategies that avoid immunogenicity and induce immune tolerance. Recently, recombinant factor VIII (rFVIII) and rFIX fused to the crystallizable fragment (Fc) domain of immunoglobulin G (IgG) have been developed as therapeutic agents for hemophilia A and B, respectively. Although it is well known that the possession of an Fc domain confers IgG's longer-lasting circulating half-life, it is not generally appreciated that the Fc domain also confers immunoregulatory properties that are associated with the induction of tolerance. Here, we review some of the latest advances in our understanding of the tolerogenic abilities of IgG Fc and the impact of Fc-fusion proteins of rFVIII on the treatment of hemophilia.
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