1
|
Arandi N, Zekavat OR, Shokrgozar N, Shahsavani A, Golmoghaddam H, Kalani M. Altered frequency of FOXP3 + regulatory T cells is associated with development of inhibitors in patients with severe hemophilia A. Int J Lab Hematol 2023; 45:953-960. [PMID: 37488961 DOI: 10.1111/ijlh.14139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Accepted: 07/09/2023] [Indexed: 07/26/2023]
Abstract
INTRODUCTION The development of anti-factor VIII (FVIII) antibodies or "inhibitors" is a major complication following FVIII replacement therapy in patients with severe hemophilia A (HA), rendering the treatment inefficient. Data on the role of regulatory T cells (Tregs) in inhibitor formation in these patients are rare. Herein, we aimed to investigate whether a difference in the FOXP3+ Tregs is linked to the formation of the inhibitors in severe HA patients. METHODS In this cross-sectional study, 32 patients with severe HA (8 patients with inhibitors and 24 without inhibitors) and 24 healthy controls were enrolled. The frequency of FOXP3+ Tregs was determined using multicolor flow cytometry method. RESULTS Our results showed that the median level of CD4+ CD25+ FOXP3+ Tregs did not significantly differ between HA patients and healthy controls and between HA patients with and without inhibitors (P > 0.05). However, patients with inhibitors had significantly lower amounts of CD4+ CD25- FOXP3+ Tregs compared to those without inhibitors as well as healthy controls (*P = 0.012 and *P = 0.004, respectively). The frequency of CD4+ CD25+ T cells was significantly higher in HA patients who developed inhibitors compared to the inhibitor-negative ones whereas they were lower in inhibitor-negative patients compared to the healthy controls (*P = 0.013 and *P = *0.029, respectively). The percentages of CD4+ CD25+ T cells were positively correlated with the levels of inhibitors in HA patients (r = 0.45, *P = 0.021). CONCLUSION Our data demonstrated for the first time that the CD4+ CD25- FOXP3+ Tregs might be implicated in the prevention of inhibitor formation in severe HA patients.
Collapse
Affiliation(s)
- Nargess Arandi
- Hematology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Omid Reza Zekavat
- Hematology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Negin Shokrgozar
- Hematology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Amin Shahsavani
- Hematology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Hossein Golmoghaddam
- Department of Immunology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mehdi Kalani
- Department of Immunology, Professor Alborzi Clinical Microbiology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| |
Collapse
|
2
|
De Pablo-Moreno JA, Miguel-Batuecas A, Rodríguez-Merchán EC, Liras A. Treatment of congenital coagulopathies, from biologic to biotechnological drugs: The relevance of gene editing (CRISPR/Cas). Thromb Res 2023; 231:99-111. [PMID: 37839151 DOI: 10.1016/j.thromres.2023.10.001] [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: 07/17/2023] [Revised: 09/09/2023] [Accepted: 10/02/2023] [Indexed: 10/17/2023]
Abstract
Congenital coagulopathies have, throughout the history of medicine, been a focus of scientific study and of great interest as they constitute an alteration of one of the most important and conserved pathways of evolution. The first therapeutic strategies developed to address them were aimed at restoring the blood components lost during hemorrhage by administering whole blood or plasma. Later on, the use of cryoprecipitates was a significant breakthrough as it made it possible to decrease the volumes of blood infused. In the 1970' and 80', clotting factor concentrates became the treatment and, from the 1990's to the present day, recombinant factors -with increasingly longer half-lives- have taken over as the treatment of choice for certain coagulopathies in a seamless yet momentous transition from biological to biotechnological drugs. The beginning of this century, however, saw the emergence of new advanced (gene and cell) treatments, which are currently transforming the therapeutic landscape. The possibility to use cells and viruses as well as specific or bispecific antibodies as medicines is likely to spark a revolution in the world of pharmacology where therapies will be individualized and have long-term effects. Specifically, attention is nowadays focused on the development of gene editing strategies, chiefly those based on CRISPR/Cas technology. Rare coagulopathies such as hemophilia A and B, or even ultra-rare ones such as factor V deficiency, could be among those deriving the greatest benefit from these new developments.
Collapse
Affiliation(s)
- Juan A De Pablo-Moreno
- Department of Genetic, Physiology and Microbiology, Biology School, Complutense University of Madrid, Spain
| | - Andrea Miguel-Batuecas
- Department of Genetic, Physiology and Microbiology, Biology School, Complutense University of Madrid, Spain
| | - E Carlos Rodríguez-Merchán
- Osteoarticular Surgery Research, Hospital La Paz Institute for Health Research-IdiPAZ (La Paz University Hospital-Autonomous University of Madrid), Spain
| | - Antonio Liras
- Department of Genetic, Physiology and Microbiology, Biology School, Complutense University of Madrid, Spain.
| |
Collapse
|
3
|
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.
Collapse
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
| |
Collapse
|
4
|
Roman G, Stavik B, Lauritzen KH, Sandset PM, Harrison SP, Sullivan GJ, Chollet ME. "iPSC-derived liver organoids and inherited bleeding disorders: Potential and future perspectives". Front Physiol 2023; 14:1094249. [PMID: 36711019 PMCID: PMC9880334 DOI: 10.3389/fphys.2023.1094249] [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: 11/09/2022] [Accepted: 01/02/2023] [Indexed: 01/15/2023] Open
Abstract
The bleeding phenotype of hereditary coagulation disorders is caused by the low or undetectable activity of the proteins involved in hemostasis, due to a broad spectrum of genetic alterations. Most of the affected coagulation factors are produced in the liver. Therefore, two-dimensional (2D) cultures of primary human hepatocytes and recombinant overexpression of the factors in non-human cell lines have been primarily used to mimic disease pathogenesis and as a model for innovative therapeutic strategies. However, neither human nor animal cells fully represent the hepatocellular biology and do not harbor the exact genetic background of the patient. As a result, the inability of the current in vitro models in recapitulating the in vivo situation has limited the studies of these inherited coagulation disorders. Induced Pluripotent Stem Cell (iPSC) technology offers a possible solution to overcome these limitations by reprogramming patient somatic cells into an embryonic-like pluripotent state, thus giving the possibility of generating an unlimited number of liver cells needed for modeling or therapeutic purposes. By combining this potential and the recent advances in the Clustered Regularly Interspaced Short Palindromic Repeats (CRISPR)/Cas9 technology, it allows for the generation of autologous and gene corrected liver cells in the form of three-dimensional (3D) liver organoids. The organoids recapitulate cellular composition and organization of the liver, providing a more physiological model to study the biology of coagulation proteins and modeling hereditary coagulation disorders. This advanced methodology can pave the way for the development of cell-based therapeutic approaches to treat inherited coagulation disorders. In this review we will explore the use of liver organoids as a state-of-the-art methodology for modeling coagulation factors disorders and the possibilities of using organoid technology to treat the disease.
Collapse
Affiliation(s)
- Giacomo Roman
- Department of Hematology, Oslo University Hospital, Oslo, Norway
- Research Institute of Internal Medicine, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Benedicte Stavik
- Department of Hematology, Oslo University Hospital, Oslo, Norway
- Research Institute of Internal Medicine, Oslo University Hospital, Oslo, Norway
| | - Knut H. Lauritzen
- Department of Hematology, Oslo University Hospital, Oslo, Norway
- Research Institute of Internal Medicine, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Per Morten Sandset
- Department of Hematology, Oslo University Hospital, Oslo, Norway
- Research Institute of Internal Medicine, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Sean P. Harrison
- Department of Pediatric Research, Oslo University Hospital, Oslo, Norway
| | - Gareth J. Sullivan
- Department of Pediatric Research, Oslo University Hospital, Oslo, Norway
- Department of Immunology, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Maria Eugenia Chollet
- Department of Hematology, Oslo University Hospital, Oslo, Norway
- Research Institute of Internal Medicine, Oslo University Hospital, Oslo, Norway
| |
Collapse
|
5
|
Luo L, Zheng Q, Chen Z, Huang M, Fu L, Hu J, Shi Q, Chen Y. Hemophilia a patients with inhibitors: Mechanistic insights and novel therapeutic implications. Front Immunol 2022; 13:1019275. [PMID: 36569839 PMCID: PMC9774473 DOI: 10.3389/fimmu.2022.1019275] [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: 08/14/2022] [Accepted: 11/09/2022] [Indexed: 12/14/2022] Open
Abstract
The development of coagulation factor VIII (FVIII) inhibitory antibodies is a serious complication in hemophilia A (HA) patients after FVIII replacement therapy. Inhibitors render regular prophylaxis ineffective and increase the risk of morbidity and mortality. Immune tolerance induction (ITI) regimens have become the only clinically proven therapy for eradicating these inhibitors. However, this is a lengthy and costly strategy. For HA patients with high titer inhibitors, bypassing or new hemostatic agents must be used in clinical prophylaxis due to the ineffective ITI regimens. Since multiple genetic and environmental factors are involved in the pathogenesis of inhibitor generation, understanding the mechanisms by which inhibitors develop could help identify critical targets that can be exploited to prevent or eradicate inhibitors. In this review, we provide a comprehensive overview of the recent advances related to mechanistic insights into anti-FVIII antibody development and discuss novel therapeutic approaches for HA patients with inhibitors.
Collapse
Affiliation(s)
- Liping Luo
- Department of Hematology, Fujian Provincial Key Laboratory of Hematology, Fujian Institute of Hematology, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Qiaoyun Zheng
- Department of Hematology, Fujian Provincial Key Laboratory of Hematology, Fujian Institute of Hematology, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Zhenyu Chen
- Department of Hematology, Fujian Provincial Key Laboratory of Hematology, Fujian Institute of Hematology, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
- Medical Technology and Engineering College of Fujian Medical University, Fuzhou, Fujian, China
| | - Meijuan Huang
- Department of Hematology, Fujian Provincial Key Laboratory of Hematology, Fujian Institute of Hematology, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Lin Fu
- Department of Hematology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Jianda Hu
- Department of Hematology, Fujian Provincial Key Laboratory of Hematology, Fujian Institute of Hematology, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Qizhen Shi
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, United States
- Blood Research Institute, Versiti, Milwaukee, WI, United States
- Children’s Research Institute, Children’s Wisconsin, Milwaukee, WI, United States
- Midwest Athletes Against Childhood Cancer (MACC) Fund Research Center, Milwaukee, WI, United States
| | - Yingyu Chen
- Department of Hematology, Fujian Provincial Key Laboratory of Hematology, Fujian Institute of Hematology, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| |
Collapse
|
6
|
Risk Factors for Amputation in the Surgical Treatment of Hemophilic Osteoarthropathy: A 20-Year Single-Center Report. Pain Res Manag 2022; 2022:1512616. [PMID: 35386858 PMCID: PMC8979685 DOI: 10.1155/2022/1512616] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 01/28/2022] [Accepted: 02/23/2022] [Indexed: 12/19/2022]
Abstract
Purpose Hemophilic osteoarthropathy (HO) is a common cause of spontaneous bleeding in hemophiliacs. Surgical procedures are necessary for patients with severe HO. As a last resort, amputation is sometimes needed to treat complex HO cases. This study aimed to review the existing records of patients who underwent amputations in HO surgical treatment, summarize the risk factors, and provide relevant references for surgeons. Methods We retrospectively reviewed the records of hemophilic patients received surgeries at Peking Union Medical College Hospital between 2000 and 2020. The amputation patients without neoplasm or acute trauma were screened out. Patient information was extracted from medical records. A literature retrieval of hemophilic amputation cases was conducted via PubMed. The risk factors of amputation were summarized and analyzed via descriptive statistics and Fisher's precision probability test. Results Four male hemophilia A patients out of 201 patients underwent lower limb amputation. The reasons of amputation contained severe pseudotumor with factor inhibitor and large bone defects, recurrent pathological fracture with pseudotumor, skin ulcer with chronic osteomyelitis, and pseudotumor with systematic infection. In cases reported in retrieved literature, severe pseudotumor with complications, bacterial infection and factor inhibitor were common factors. Discussion. As the first study on amputations in HO patients, we found that severe hemophilic pseudotumor, chronic bacterial infection, and coagulation factor inhibitor was potential risk factors for amputation. Sufficient factor replacement therapy is fundamental in the prevention of amputation. The early diagnosis and specially designed surgical techniques could improve the rate of limb salvage.
Collapse
|
7
|
Abstract
Efmoroctocog alfa (Elocta®, Eloctate®, Eloctate™), an extended half-life (EHL) recombinant factor VIII (rFVIII)-Fc fusion protein, is approved for the treatment and prophylaxis of bleeding in patients with haemophilia A. The efficacy of efmoroctocog alfa in the prevention and treatment of bleeding in previously treated patients (PTPs) and previously untreated patients (PUPs) with severe haemophilia A has been demonstrated in phase III studies; this includes its use in the perioperative setting (in PTPs). Furthermore, the effectiveness of efmoroctocog alfa in clinical practice has been confirmed in numerous real-world studies; compared with conventional, standard half-life (SHL) FVIII products, prophylaxis with this EHL FVIII product achieved similar or reduced bleeding rates with fewer injections. Efmoroctocog alfa was generally well tolerated; inhibitors occurred in approximately one-third of PUPs in a phase III study. Efmoroctocog alfa is an established and effective EHL FVIII replacement therapy for the management of haemophilia A. Compared with SHL FVIII products, EHL FVIII products such as efmoroctocog alfa have the potential to optimise prophylactic outcomes by decreasing the burden of treatment or increasing the level of bleed protection.
Collapse
Affiliation(s)
- James E Frampton
- Springer Nature, Private Bag 65901, Mairangi Bay, Auckland, 0754, New Zealand.
| |
Collapse
|