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Christopherson PA, Tijet N, Haberichter SL, Flood VH, Ross J, Notley C, Rawley O, Montgomery RR, James PD, Lillicrap D. The common VWF variant p.Y1584C: detailed pathogenic examination of an enigmatic sequence change. J Thromb Haemost 2024; 22:666-675. [PMID: 38040335 PMCID: PMC10922911 DOI: 10.1016/j.jtha.2023.11.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 10/26/2023] [Accepted: 11/13/2023] [Indexed: 12/03/2023]
Abstract
BACKGROUND As knowledge of the human genome has advanced, so too has the recognition that interpretation of the pathogenic nature of sequence variants can be challenging. The von Willebrand factor (VWF) gene exhibits a significant degree of sequence variability, and the first VWF variant associated with type 1 von Willebrand disease (VWD), c.4751 A>G, p.Y1584C, was described in 2003. However, since that time, the pathogenic nature of this variant has remained unclear, being assigned properties ranging from a risk factor to a pathogenic variant. OBJECTIVES To provide additional evaluation on the interpretation of pathogenicity for this common VWF variant. METHODS Fifty-eight subjects with only the p.Y1584C variant were recruited from 2 cohort studies (the Zimmerman Program and the Canadian type 1 VWD study). Clinical and laboratory phenotypes were assessed. RESULTS The prevalence of the p.Y1584C variant in our cohorts was 23- to 27-fold higher than that in large normal population databases. Significantly more p.Y1584C subjects had an abnormal bleeding score when compared to Y1584 individuals. In comparison with a group of 35 subjects without the p.Y1584C variant, subjects with the variant had lower mean VWF:antigen and VWF:ristocetin cofactor values and significantly higher VWF propeptide/VWF:antigen ratios suggestive of enhanced clearance. CONCLUSION Collectively, the results of this analysis suggest that p.Y1584C is likely pathogenic, however, due to influences such as incomplete penetrance, variable expressivity, and other genetic modifiers like ABO blood group, the straightforward assignment of pathogenicity to this variant is inevitably challenging.
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Affiliation(s)
| | - Nathalie Tijet
- Department of Pathology and Molecular Medicine, Richardson Laboratory, Queen's University, Kingston, Ontario, Canada
| | | | | | - Justyne Ross
- University of North Carolina, Chapel Hill, North Carolina
| | - Colleen Notley
- Department of Pathology and Molecular Medicine, Richardson Laboratory, Queen's University, Kingston, Ontario, Canada
| | - Orla Rawley
- Department of Pathology and Molecular Medicine, Richardson Laboratory, Queen's University, Kingston, Ontario, Canada
| | | | - Paula D James
- Department of Medicine, Queen's University, Kingston, ON, Canada
| | - David Lillicrap
- Department of Pathology and Molecular Medicine, Richardson Laboratory, Queen's University, Kingston, Ontario, Canada.
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Roberts JC, Christopherson PA, Tarantino MD, Gonzales SE, Morateck PA, Perry CL, Flood VH, Abshire TC, Montgomery RR. Von Willebrand Factor (VWF) multiplex activity assay differentiation of type 1 von Willebrand Disease (VWD) and variant VWD. Haemophilia 2024; 30:161-168. [PMID: 38013388 PMCID: PMC10842138 DOI: 10.1111/hae.14901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 10/10/2023] [Accepted: 11/12/2023] [Indexed: 11/29/2023]
Abstract
INTRODUCTION VWD diagnosis is challenging requiring multiple VWF activity tests using many individual assays. We have developed an ELISA-based VWF Multiplex Activity Assay (VWF-MAA) to address this concern; however, the ability of the VWF-MAA to discriminate between type 1 VWD, variant VWD, and normal subjects has not been evaluated. AIM To evaluate the VWF-MAA and its ability to differentiate between type 1 VWD, variant VWD and normal subjects in individuals undergoing an initial laboratory evaluation for bleeding. METHODS A total of 177 plasma samples from the Zimmerman Program: Comparative Effectiveness in the Diagnosis of VWD were evaluated from 11 centres across the US and Canada. The VWF-MAA was compared to Versiti Blood Research Institute (VBRI) and Local Center (LC) assigned VWD diagnosis. RESULTS Overall, 129/177 (72.9%) were correctly assigned as normal (non-VWD), type 1, or variant VWD compared to the VBRI assigned diagnosis. VWF-MAA assigned non-VWD accurately in 29/57 (50.9%) samples, and type 1 VWD accurately in 93/110 (84.6%) samples. Considering LC diagnosis where there was agreement with VWF-MAA and not VBRI diagnosis, type 1 VWD was accurate in 105/110 (95.5%) samples. Bland-Altman analysis demonstrated good correlation between laboratory methods. VWD, types 2A, 2B, 1C VWD were also assigned by the VWF-MAA. CONCLUSIONS We demonstrate that the VWF-MAA has utility in differentiating type 1 VWD, variant VWD and normal subjects in individuals undergoing an initial laboratory evaluation for bleeding.
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Affiliation(s)
- Jonathan C Roberts
- Bleeding & Clotting Disorders Institute (BCDI), Peoria, Illinois, USA
- Departments of Pediatrics and Medicine, University of Illinois College of Medicine at Peoria, Peoria, Illinois, USA
| | | | - Michael D Tarantino
- Bleeding & Clotting Disorders Institute (BCDI), Peoria, Illinois, USA
- Departments of Pediatrics and Medicine, University of Illinois College of Medicine at Peoria, Peoria, Illinois, USA
| | - Sarah E Gonzales
- Bleeding & Clotting Disorders Institute (BCDI), Peoria, Illinois, USA
| | - Patti A Morateck
- Versiti Blood Research Institute (VBRI), Milwaukee, Wisconsin, USA
| | - Crystal L Perry
- Versiti Blood Research Institute (VBRI), Milwaukee, Wisconsin, USA
| | - Veronica H Flood
- Versiti Blood Research Institute (VBRI), Milwaukee, Wisconsin, USA
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Thomas C Abshire
- Versiti Blood Research Institute (VBRI), Milwaukee, Wisconsin, USA
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Robert R Montgomery
- Versiti Blood Research Institute (VBRI), Milwaukee, Wisconsin, USA
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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Sadler B, Christopherson PA, Perry CL, Bellissimo DB, Haberichter SL, Haller G, Antunes L, Flood VH, Di Paola J, Montgomery RR. Characterization of copy-number variants in a large cohort of patients with von Willebrand disease reveals a relationship between disrupted regions and disease type. Res Pract Thromb Haemost 2023; 7:102232. [PMID: 38077814 PMCID: PMC10704516 DOI: 10.1016/j.rpth.2023.102232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 09/13/2023] [Accepted: 10/01/2023] [Indexed: 02/12/2024] Open
Abstract
Background Genetic analysis for von Willebrand disease (VWD) commonly utilizes DNA sequencing to identify variants in the von Willebrand factor (VWF) gene; however, this technique cannot always detect copy-number variants (CNVs). Additional mapping of CNVs in patients with VWD is needed. Objectives This study aimed to characterize CNVs in a large sample of VWF mutation-negative VWD patients. Methods To determine the role of CNVs in VWD, a VWF high-resolution comparative genomic hybridization array was custom-designed to avoid multiple sequence variations, repeated sequences, and the VWF pseudogene. This was performed on 204 mutation-negative subjects for whom clinical variables were also available. Results Among the 204 patients, 7 unique CNVs were found, with a total of 24 CNVs (12%). Of the 7 unique CNVs, 1 was novel, 1 was found in a VWF database, and 5 were previously reported. All patients with type 1C VWD and a CNV had the same exon 33 and 34 in-frame deletion. Certain clinical variables were also significantly different between those with and without CNVs. Conclusion The in-frame deletion in patients with type 1C VWD exactly matches the D4N module of the D4 domain, a region where mutations and deletions are known to affect clearance. We observed significantly higher VWF-to-ristocetin cofactor levels in patients with type 1C VWD and a CNV than in patients without a CNV, suggesting a relationship between CNVs and the increased clearance observed in patients with type 1C VWD. Glycoprotein IbM activity was significantly lower in patients with type 1 VWD and a CNV than in patients without a CNV, suggesting that platelet binding is more affected by CNVs than single base pair mutations. This work elucidates some of the underlying genetic mechanisms of CNVs in these patients.
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Affiliation(s)
- Brooke Sadler
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, USA
| | | | | | - Daniel B. Bellissimo
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Sandra L. Haberichter
- Versiti Blood Research Institute, Milwaukee, Wisconsin, USA
- Division of Pediatric Hematology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Gabe Haller
- Department of Neurosurgery, Washington University, St. Louis, Missouri, USA
| | - Lilian Antunes
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Veronica H. Flood
- Versiti Blood Research Institute, Milwaukee, Wisconsin, USA
- Division of Pediatric Hematology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Jorge Di Paola
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Robert R. Montgomery
- Versiti Blood Research Institute, Milwaukee, Wisconsin, USA
- Division of Pediatric Hematology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Zimmerman Program Investigators
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, USA
- Versiti Blood Research Institute, Milwaukee, Wisconsin, USA
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Division of Pediatric Hematology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
- Department of Neurosurgery, Washington University, St. Louis, Missouri, USA
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Doherty D, Grabell J, Christopherson PA, Montgomery RR, Coller BS, Lavin M, O'Donnell JS, James PD. Variability in International Society on Thrombosis and Haemostasis-Scientific and Standardization Committee endorsed Bleeding Assessment Tool (ISTH-BAT) score with normal aging in healthy females: contributory factors and clinical significance. J Thromb Haemost 2023; 21:880-886. [PMID: 36696194 PMCID: PMC11008594 DOI: 10.1016/j.jtha.2022.11.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 11/30/2022] [Accepted: 12/01/2022] [Indexed: 01/09/2023]
Abstract
BACKGROUND Bleeding assessment tools are key screening tests used in the evaluation of patients with suspected inherited bleeding disorders. The International Society on Thrombosis and Haemostasis-Scientific and Standardization Committee endorsed Bleeding Assessment Tool (ISTH-BAT) has differing reference ranges for adult males (0-3), adult females (0-5), and children (0-2), reflecting differing bleeding symptoms and exposure to hemostatic challenges in these healthy population subgroups. Age is known to markedly impact bleeding score in individuals with von Willebrand disease. However, the influence of age on bleeding score in healthy adult controls is poorly understood. OBJECTIVES We aimed to assess variability in ISTH-BAT score with age among healthy control females. METHODS We used the legacy "Merging Project" dataset of normal healthy controls upon which current ISTH-BAT normal ranges are based. We included women, totaling 646 individuals. The normal range (middle 95th percentile) of total ISTH-BAT and grouped subdomain scores between age quartiles was assessed. RESULTS The normal range of ISTH-BAT scores increased with age, ranging from 0 to 4 in the youngest quartile (age range, 18-30) to 0 to 6 in the oldest (age range, 52-88). This increased variability with aging was related both to high menorrhagia domain scores in older women and an increase in postprocedural bleeding with accumulated exposure to hemostatic challenges. CONCLUSIONS Cumulatively, our data highlight that normal aging leads to increased variability in bleeding scores in healthy adult females. Further refinement of the ISTH-BAT with age-adjusted reference ranges may improve the sensitivity and specificity of the tool among females.
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Affiliation(s)
- Dearbhla Doherty
- National Coagulation Centre, St James's Hospital, Dublin, Ireland; Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland.
| | - Julie Grabell
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | | | - Robert R Montgomery
- Blood Research Institute, Versiti, Milwaukee, WI, USA; Children's Research Institute, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Barry S Coller
- Allen and Frances Adler Laboratory of Blood and Vascular Biology, Rockefeller University, NY, USA
| | - Michelle Lavin
- National Coagulation Centre, St James's Hospital, Dublin, Ireland; Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - James S O'Donnell
- National Coagulation Centre, St James's Hospital, Dublin, Ireland; Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland; National Children's Research Centre, Our Lady's Children's Hospital Crumlin, Dublin, Ireland
| | - Paula D James
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
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Christopherson PA, Haberichter SL, Flood VH, Sicking UO, Abshire TC, Montgomery RR. Ristocetin dependent cofactor activity in von Willebrand disease diagnosis: Limitations of relying on a single measure. Res Pract Thromb Haemost 2022; 6:e12807. [PMID: 36381287 PMCID: PMC9637542 DOI: 10.1002/rth2.12807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 08/15/2022] [Accepted: 08/19/2022] [Indexed: 11/09/2022] Open
Abstract
Background Von Willebrand disease (VWD) is a common inherited bleeding disorder, however the diagnosis can be complicated by a subjective bleeding history and issues with some current von Willebrand factor (VWF) laboratory assays. Objectives In the Zimmerman Program, we sought to determine how often a type 1 diagnosis was based on a single low VWF ristocetin cofactor (VWF:RCo) level resulting from the common genetic variant p.D1472H or an isolated assay issue, if that low value was corroborated by the VWF glycoprotein-IbM (VWF:GPIbM) assay, and if retesting confirmed original levels. Methods New patients being evaluated for bleeding were consented. Analysis included VWF sequencing, bleeding scores, and comparisons of local VWF antigen (VWF:Ag) and VWF:RCo to central VWF:Ag and VWF:GPIbM. Results A total of 18% of VWD subjects had a low local VWF:RCo, but normal VWF:Ag and normal central testing including VWF:GPIbM. Seventy percent of the low VWF:RCo cohort had no pathogenic VWF variants; however, 33% carried p.D1472H. Low VWF:RCo subjects with follow-up local testing within 2 years showed those with p.D1472H continued to have low VWF:RCo and VWF:RCo/VWF:Ag ratio with normal VWF:GPIbM. Subjects without p.D1472H had an increase mean VWF:RCo, resulting in 59% with normal levels on repeat testing. Conclusions The diagnosis of VWD based on a single low VWF:RCo but normal VWF:Ag, was often attributed to p.D1472H or variability in VWF:RCo that was eliminated with VWF:GPIbM. Our study suggests that using VWF:RCo alone for diagnostic purposes may be insufficient while repeat VWF:RCo or VWF:GPIbM testing can be valuable in establishing a VWD diagnosis.
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Affiliation(s)
| | - Sandra L. Haberichter
- Versiti Blood Research InstituteMilwaukeeWisconsinUSA
- Division of Hematology/Oncology, Department of PediatricsMedical College of WisconsinMilwaukeeWisconsinUSA
- Children's Research Institute, Children's Hospital of WisconsinMilwaukeeWisconsinUSA
| | - Veronica H. Flood
- Versiti Blood Research InstituteMilwaukeeWisconsinUSA
- Division of Hematology/Oncology, Department of PediatricsMedical College of WisconsinMilwaukeeWisconsinUSA
- Children's Research Institute, Children's Hospital of WisconsinMilwaukeeWisconsinUSA
| | | | | | - Robert R. Montgomery
- Versiti Blood Research InstituteMilwaukeeWisconsinUSA
- Division of Hematology/Oncology, Department of PediatricsMedical College of WisconsinMilwaukeeWisconsinUSA
- Children's Research Institute, Children's Hospital of WisconsinMilwaukeeWisconsinUSA
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Lavin M, Christopherson P, Grabell J, Abshire T, Flood V, Haberichter SL, Lillicrap D, O’Donnell JS, Montgomery RR, James PD. Longitudinal bleeding assessment in von Willebrand disease utilizing an interim bleeding score. J Thromb Haemost 2022; 20:2246-2254. [PMID: 35780487 PMCID: PMC10193460 DOI: 10.1111/jth.15807] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 05/24/2022] [Accepted: 06/10/2022] [Indexed: 01/01/2023]
Abstract
BACKGROUND Assessment of bleeding phenotype is critically important in the diagnosis of von Willebrand disease (VWD). Despite advances in bleeding assessment tools (BATs), standardized tools to evaluate bleeding following diagnosis (interim bleeding) are lacking. OBJECTIVES We assessed the clinical utility of an interim bleeding protocol in a multicenter, international study involving patients with VWD. METHODS The enrolment ISTH BAT formed the original bleeding score (0 BS). At follow-up, the International Society on Thrombosis and Haemostasis BAT was repeated but included only interval bleeding (Interim BS, 1 BS). Both scores were annualized (0 BS/yr, 1 BS/yr). BS were analyzed by VWD subtype, plasma VWF level, sex, and age. RESULTS Interim BS discriminated by subtype, with significantly increased 0 BS and 1 BS in patients with type 3 VWD. In patients with type 1 VWD, a positive or negative 0 BS did not predict future bleeding, with similar 1 BS/yr (median 1.0 vs. 0.7, p = .2). Despite significantly higher 0 BS in females with type 1 VWD than males (median 7 vs. 5, p = .0012), 1 BS were not significantly different (median 4 vs. 4, p = .16). While 0 BS were lower in children than adults with type 1 VWD, interim BS were similar (median 5 vs. 3, p = .5; 1BS/yr, median 1 vs. 0.8, p = .7). Interestingly, in those with plasma von Willebrand factor:ristocetin cofactor levels >50 IU/dl, interim BS rates were similar to those 30-50 IU/dl (1 BS/yr 0.8 vs. 1.3, p = .5). CONCLUSION This study provides both a new approach to longitudinal bleeding assessment and insights into the evolution of bleeding in VWD.
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Affiliation(s)
- Michelle Lavin
- National Coagulation Centre, St. James’s Hospital, Dublin, Ireland
- Irish Centre for Vascular Biology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | | | - Julie Grabell
- Department of Medicine, Queen’s University, Kingston, Ontario, Canada
| | - Thomas Abshire
- Blood Research Institute, Versiti, Milwaukee, Wisconsin, USA
| | - Veronica Flood
- Blood Research Institute, Versiti, Milwaukee, Wisconsin, USA
| | | | - David Lillicrap
- Department of Pathology & Molecular Medicine, Queen’s University, Kingston, Ontario, Canada
| | - James S. O’Donnell
- National Coagulation Centre, St. James’s Hospital, Dublin, Ireland
- Irish Centre for Vascular Biology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | | | - Paula D. James
- Department of Medicine, Queen’s University, Kingston, Ontario, Canada
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Christopherson PA, Haberichter SL, Flood VH, Perry CL, Sadler BE, Bellissimo DB, Di Paola J, Montgomery RR. Molecular pathogenesis and heterogeneity in type 3 VWD families in U.S. Zimmerman program. J Thromb Haemost 2022; 20:1576-1588. [PMID: 35343054 DOI: 10.1111/jth.15713] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 03/15/2022] [Accepted: 03/22/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Type 3 von Willebrand Disease (VWD) is a rare and severe form of VWD characterized by the absence of von Willebrand factor (VWF). OBJECTIVES As part of the Zimmerman Program, we sought to explore the molecular pathogenesis, correlate bleeding phenotype and severity, and determine the inheritance pattern found in type 3 VWD families. PATIENTS/METHODS 62 index cases with a pre-existing diagnosis of type 3 VWD were analyzed. Central testing included FVIII, VWF:Ag, VWF:RCo, and VWFpp. Bleeding symptoms were quantified using the ISTH bleeding score. Genetic analysis included VWF sequencing, comparative genomic hybridization and predictive computational programs. RESULTS 75% of subjects (46) had central testing confirming type 3, while 25% were re-classified as type 1-Severe or type 1C. Candidate VWF variants were found in all subjects with 93% of expected alleles identified. The majority were null alleles including frameshift, nonsense, splice site, and large deletions, while 13% were missense variants. Additional studies on 119 family members, including 69 obligate carriers, revealed a wide range of heterogeneity in VWF levels and bleeding scores, even amongst those with the same variant. Co-dominant inheritance was present in 51% of families and recessive in 21%, however 28% were ambiguous. CONCLUSION This report represents a large cohort of VWD families in the U.S. with extensive phenotypic and genotypic data. While co-dominant inheritance was seen in approximately 50% of families, this study highlights the complexity of VWF genetics due to the heterogeneity found in both VWF levels and bleeding tendencies amongst families with type 3 VWD.
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Affiliation(s)
| | - Sandra L Haberichter
- Versiti Blood Research Institute, Milwaukee, Wisconsin, USA
- Division of Hematology/Oncology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
- Children's Research Institute, Children's Hospital of Wisconsin, Milwaukee, Wisconsin, USA
| | - Veronica H Flood
- Versiti Blood Research Institute, Milwaukee, Wisconsin, USA
- Division of Hematology/Oncology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
- Children's Research Institute, Children's Hospital of Wisconsin, Milwaukee, Wisconsin, USA
| | | | - Brooke E Sadler
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Daniel B Bellissimo
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jorge Di Paola
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Robert R Montgomery
- Versiti Blood Research Institute, Milwaukee, Wisconsin, USA
- Division of Hematology/Oncology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
- Children's Research Institute, Children's Hospital of Wisconsin, Milwaukee, Wisconsin, USA
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Kanaji S, Morodomi Y, Weiler H, Zarpellon A, Montgomery RR, Ruggeri ZM, Kanaji T. The impact of aberrant von Willebrand factor-GPIbα interaction on megakaryopoiesis and platelets in humanized type 2B von Willebrand disease model mouse. Haematologica 2022; 107:2133-2143. [PMID: 35142156 PMCID: PMC9425322 DOI: 10.3324/haematol.2021.280561] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Indexed: 11/24/2022] Open
Abstract
Type 2B von Willebrand disease (VWD) is caused by gain-of-function mutations in von Willebrand factor (VWF). Increased VWF affinity for GPIbα results in loss of high molecular weight multimers and enhanced platelet clearance, both contributing to the bleeding phenotype. Severity of the symptoms vary among type 2B VWD patients, with some developing thrombocytopenia only under stress conditions. Efforts have been made to study underlying pathophysiology for platelet abnormalities, but animal studies have been limited because of species specificity in the VWF-GPIbα interaction. Here, we generated a severe form of type 2B VWD (p.V1316M) knockin mice in the context of human VWF exon 28 (encoding A1 and A2 domains) and crossed them with human GPIbα transgenic strain. Heterozygous mutant mice recapitulated the phenotype of type 2B VWD in autosomal dominant manner and presented severe macrothrombocytopenia. Of note, platelets remaining in the circulation had extracytoplasmic GPIbα shed-off from the cell surface. Reciprocal bone marrow transplantation determined mutant VWF produced from endothelial cells as the major cause of the platelet phenotype in type 2B VWD mice. Moreover, altered megakaryocyte maturation in the bone marrow and enhanced extramedullary megakaryopoiesis in the spleen were observed. Interestingly, injection of anti-VWF A1 blocking antibody (NMC-4) not only ameliorated platelet count and GPIbα expression, but also reversed MK ploidy shift. In conclusion, we present a type 2B VWD mouse model with humanized VWF-GPIbα interaction which demonstrated direct influence of aberrant VWF-GPIbα binding on megakaryocytes.
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Affiliation(s)
- Sachiko Kanaji
- Department of Molecular Medicine, MERU-Roon Research Center on Vascular Biology, The Scripps Research Institute, La Jolla, CA; Blood Research Institute, Blood Center of Wisconsin, Versiti, Milwaukee.
| | - Yosuke Morodomi
- Department of Molecular Medicine, MERU-Roon Research Center on Vascular Biology, The Scripps Research Institute, La Jolla
| | - Hartmut Weiler
- Blood Research Institute, Blood Center of Wisconsin, Versiti, Milwaukee
| | - Alessandro Zarpellon
- Department of Molecular Medicine, MERU-Roon Research Center on Vascular Biology, The Scripps Research Institute, La Jolla, CA; MERU-VasImmune, Inc., San Diego
| | - Robert R Montgomery
- Blood Research Institute, Blood Center of Wisconsin, Versiti, Milwaukee, WI; Children's Research Institute, Children's Hospital of Wisconsin, Milwaukee, WI; Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI 53226
| | - Zaverio M Ruggeri
- Department of Molecular Medicine, MERU-Roon Research Center on Vascular Biology, The Scripps Research Institute, La Jolla, CA; MERU-VasImmune, Inc., San Diego
| | - Taisuke Kanaji
- Department of Molecular Medicine, MERU-Roon Research Center on Vascular Biology, The Scripps Research Institute, La Jolla, CA; Blood Research Institute, Blood Center of Wisconsin, Versiti, Milwaukee
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Digiandomenico S, Conley SF, Johnson VP, Christopherson PA, Haberichter SL, Zhang J, Simpson P, Abshire TC, Montgomery RR, Flood VH. Screening for von Willebrand disease does not impact posttonsillectomy bleeding in a low-risk population. Pediatr Blood Cancer 2021; 68:e29371. [PMID: 34606172 PMCID: PMC8919995 DOI: 10.1002/pbc.29371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 08/23/2021] [Accepted: 09/05/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND Bleeding is an important complication in children following tonsillectomy. Screening with coagulation tests prior to procedure is common to assess bleeding risk in the perioperative period, although ASH/ASPHO Choosing Wisely guidelines recommend against routine PT/PTT testing. Our aim was to compare von Willebrand factor antigen (VWF:Ag) and activity levels among patients with postoperative bleeding following tonsillectomy to evaluate for potential risk for bleeding. PROCEDURE Eligible subjects were aged 0-18 without significant personal or family history of major bleeding. Postoperative bleeding diaries were collected and symptoms measured using a postoperative bleeding score. Plasma VWF levels were drawn at time of anesthesia administration. RESULTS Postoperative bleeding occurred in 248 cases out of 1399 total subjects. Median VWF:Ag was 86 in patients with postoperative bleeding scores of 1-2, 86 for scores 3-4, 84 for scores 5-6, and 83 for scores >6, with no significant difference among groups (p = .98). Additionally, no difference was observed for subjects with multiple days of postoperative bleeding as compared to those with only 1 day of postoperative bleeding. Finally, no difference in VWF:Ag was observed for subjects whose first reported bleed occurred early in the postoperative course compared to those whose first reported bleed occurred later. VWF:Ag does not correlate with severity of bleeding, time of onset of first bleeding event, or recurrence of bleeding in healthy children with no personal or family history of bleeding who have postoperative bleeding following tonsillectomy. CONCLUSIONS This data does not support routine von Willebrand disease screening prior to tonsillectomy.
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Affiliation(s)
- Stefanie Digiandomenico
- Department of Pediatrics, Division of Hematology/Oncology, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI 53226
| | - Stephen F. Conley
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI 53226
| | - Victoria P. Johnson
- Versiti Blood Research Institute, 8727 Watertown Plank Rd, Milwaukee, WI 53226
| | | | - Sandra L. Haberichter
- Department of Pediatrics, Division of Hematology/Oncology, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI 53226,Versiti Blood Research Institute, 8727 Watertown Plank Rd, Milwaukee, WI 53226,Children’s Research Institute, Children’s Hospital of Wisconsin, Milwaukee, WI 53226
| | - Jian Zhang
- Department of Pediatrics, Division of Quantitative Health Sciences, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI 53226
| | - Pippa Simpson
- Department of Pediatrics, Division of Quantitative Health Sciences, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI 53226
| | - Thomas C. Abshire
- Department of Pediatrics, Division of Hematology/Oncology, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI 53226,Versiti Blood Research Institute, 8727 Watertown Plank Rd, Milwaukee, WI 53226,Children’s Research Institute, Children’s Hospital of Wisconsin, Milwaukee, WI 53226
| | - Robert R. Montgomery
- Department of Pediatrics, Division of Hematology/Oncology, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI 53226,Versiti Blood Research Institute, 8727 Watertown Plank Rd, Milwaukee, WI 53226,Children’s Research Institute, Children’s Hospital of Wisconsin, Milwaukee, WI 53226
| | - Veronica H. Flood
- Department of Pediatrics, Division of Hematology/Oncology, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI 53226,Versiti Blood Research Institute, 8727 Watertown Plank Rd, Milwaukee, WI 53226,Children’s Research Institute, Children’s Hospital of Wisconsin, Milwaukee, WI 53226
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10
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Schroeder JA, Kuether EA, Fang J, Jing W, Weiler H, Wilcox DA, Montgomery RR, Shi Q. Thromboelastometry assessment of hemostatic properties in various murine models with coagulopathy and the effect of factor VIII therapeutics. J Thromb Haemost 2021; 19:2417-2427. [PMID: 34245090 PMCID: PMC8865566 DOI: 10.1111/jth.15456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Accepted: 07/07/2021] [Indexed: 12/31/2022]
Abstract
BACKGROUND Rotational thromboelastometry (ROTEM) has been commonly used to assess the viscoelastic properties of the blood clotting process in the clinic for patients with a hemostatic or prothrombotic disorder. OBJECTIVE To evaluate the capability of ROTEM in assessing hemostatic properties in whole blood from various mouse models with genetic bleeding or clotting disease and the effect of factor VIII (FVIII) therapeutics in FVIIInull mice. METHODS Mice with a genetic deficiency in either a coagulation factor or a platelet glycoprotein were used in this study. The properties of platelet- or plasma-FVIII were also assessed. Citrated blood from mice was recalcified and used for ROTEM analysis. RESULTS We found that blood collected from the vena cava could generate reliable results from ROTEM analysis, but not blood collected from the tail vein, retro-orbital plexus, or submandibular vein. Age and sex did not significantly affect the hemostatic properties determined by ROTEM analysis. Clotting time (CT) and clot formation time (CFT) were significantly prolonged in FVIIInull (5- and 9-fold, respectively) and FIXnull (4- and 5.7-fold, respectively) mice compared to wild-type (WT)-C57BL/6J mice. Platelet glycoprotein (GP)IIIanull mice had significantly prolonged CFT (8.4-fold) compared to WT-C57BL/6J mice. CT and CFT in factor V (FV) Leiden mice were significantly shortened with an increased α-angle compared to WT-C57BL/6J mice. Using ROTEM analysis, we showed that FVIII expressed in platelets or infused into whole blood restored hemostasis of FVIIInull mice in a dose-dependent manner. CONCLUSION ROTEM is a reliable and sensitive assay for assessing therapeutics on hemostatic properties in mouse models with a bleeding or clotting disorder.
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Affiliation(s)
- Jocelyn A. Schroeder
- Blood Research Institute, Versiti Wisconsin, Milwaukee, Wisconsin, USA
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
- Children’s Research Institute, Children’s Wisconsin, Milwaukee, Wisconsin, USA
- MACC Fund Research Center, Milwaukee, Wisconsin, USA
| | - Erin A. Kuether
- Blood Research Institute, Versiti Wisconsin, Milwaukee, Wisconsin, USA
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
- Children’s Research Institute, Children’s Wisconsin, Milwaukee, Wisconsin, USA
- MACC Fund Research Center, Milwaukee, Wisconsin, USA
| | - Juan Fang
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
- MACC Fund Research Center, Milwaukee, Wisconsin, USA
| | - Weiqing Jing
- Blood Research Institute, Versiti Wisconsin, Milwaukee, Wisconsin, USA
| | - Hartmut Weiler
- Blood Research Institute, Versiti Wisconsin, Milwaukee, Wisconsin, USA
| | - David A. Wilcox
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
- Children’s Research Institute, Children’s Wisconsin, Milwaukee, Wisconsin, USA
- MACC Fund Research Center, Milwaukee, Wisconsin, USA
| | - Robert R. Montgomery
- Blood Research Institute, Versiti Wisconsin, Milwaukee, Wisconsin, USA
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
- Children’s Research Institute, Children’s Wisconsin, Milwaukee, Wisconsin, USA
- MACC Fund Research Center, Milwaukee, Wisconsin, USA
| | - Qizhen Shi
- Blood Research Institute, Versiti Wisconsin, Milwaukee, Wisconsin, USA
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
- Children’s Research Institute, Children’s Wisconsin, Milwaukee, Wisconsin, USA
- MACC Fund Research Center, Milwaukee, Wisconsin, USA
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11
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DiGiandomenico S, Christopherson PA, Haberichter SL, Abshire TC, Montgomery RR, Flood VH. Laboratory variability in the diagnosis of type 2 VWD variants. J Thromb Haemost 2021; 19:131-138. [PMID: 33049112 PMCID: PMC7790985 DOI: 10.1111/jth.15129] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 09/27/2020] [Accepted: 09/29/2020] [Indexed: 12/20/2022]
Abstract
Essentials Patients with von Willebrand disease were enrolled in our study. Type 2 VWD diagnoses were based on original test results. Repeat evaluation resulted in many patients receiving a different type 2 diagnosis. Some genetic variants were particularly likely to move type 2 subcategories. ABSTRACT: Introduction Type 2 von Willebrand disease (VWD) refers to patients with a qualitative defect in von Willebrand factor. Accurate diagnosis of type 2 VWD subtypes can be challenging. Aim of the study To compare the historical diagnosis of type 2 VWD with current laboratory testing. Methods Subjects were enrolled in the Zimmerman Program either because of a preexisting diagnosis of VWD (retrospective cohort) or from evaluation for bleeding symptoms or suspected VWD (prospective cohort). Original diagnosis was assigned by the local center and central diagnosis was based on central laboratory testing. Results Two hundred and seventeen index cases in the retrospective cohort and 35 subjects in the prospective cohort carried a local diagnosis of type 2 VWD (29% and 6% of enrolled index cases, respectively). In the retrospective cohort, the diagnosis was confirmed in 66% of cases with a preexisting diagnosis of 2A, 77% 2B, 54% 2M, and 72% 2N. In the prospective cohort, 31% were confirmed 2A, 60% 2B, 23% 2M, and 100% 2N. Several genetic variants were repeatedly implicated in subjects with changed diagnosis: p.M1304R, p.R1315C, p.R1374C, and p.R1374H. Conclusions Both the prospective and retrospective cohorts demonstrated consistent variation in subjects whose diagnosis changed between 2A, 2B, and 2M. The importance of accurately diagnosing type 2 VWD may be most significant in the 2B subtype given potential concerns with the use of desmopressin in type 2B VWD. Some genetic variants appear in multiple types of VWD, making specific diagnoses challenging.
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Affiliation(s)
- Stefanie DiGiandomenico
- Department of Pediatrics, Division of Hematology/Oncology, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI 53226
| | | | - Sandra L. Haberichter
- Department of Pediatrics, Division of Hematology/Oncology, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI 53226
- Versiti Blood Research Institute, 8727 Watertown Plank Rd, Milwaukee, WI 53226
| | - Thomas C. Abshire
- Department of Pediatrics, Division of Hematology/Oncology, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI 53226
- Versiti Blood Research Institute, 8727 Watertown Plank Rd, Milwaukee, WI 53226
| | - Robert R. Montgomery
- Department of Pediatrics, Division of Hematology/Oncology, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI 53226
- Versiti Blood Research Institute, 8727 Watertown Plank Rd, Milwaukee, WI 53226
| | - Veronica H. Flood
- Department of Pediatrics, Division of Hematology/Oncology, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI 53226
- Versiti Blood Research Institute, 8727 Watertown Plank Rd, Milwaukee, WI 53226
- Children’s Research Institute, Children’s Hospital of Wisconsin, Milwaukee, WI 53226
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12
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Garcia J, Flood VH, Haberichter SL, Fahs SA, Mattson JG, Geurts AM, Zogg M, Weiler H, Shi Q, Montgomery RR. A rat model of severe VWD by elimination of the VWF gene using CRISPR/Cas9. Res Pract Thromb Haemost 2020; 4:64-71. [PMID: 31989086 PMCID: PMC6971331 DOI: 10.1002/rth2.12280] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 10/02/2019] [Accepted: 10/06/2019] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Von Willebrand Disease (VWD) is the most common inherited bleeding disorder, caused by quantitative and qualitative changes in von Willebrand factor (VWF). The biology of VWD, studied in canine, porcine, and murine models, differ in species-specific biology of VWF and the amenability to experimental manipulations such as phlebotomy. The factor VIII (FVIII) levels in these models are higher than in humans with type 3 VWD, suggesting functional differences between FVIII and VWF.ObjectivesTo develop a VWF knock out (VWF-/-) rat by excision of all 52 exons of the VWF locus. METHODS The entire VWF gene was eliminated in Sprague-Dawley (Crl:SD) rats via CRISPR/Cas9-mediated gene editing. VWF antigen (VWF:Ag), VWF propeptide, and VWF collagen IV binding (VWF:CB4) levels were determined by ELISA assays and FVIII chromogenic activity (FVIII:C) levels by chromogenic FVIII assays. Lateral tail veins were transected to measure bleeding time. VWF-/- rats were infused with FVIII-/- rat platelet poor plasma (PPP) to determine response of plasma FVIII. RESULTS Breeding of VWF ± rats yielded VWF-/- offspring at normal Mendelian ratios. VWF:Ag, VWF propeptide, VWF:CB4, and FVIII:C plasma levels were undetectable in VWF-/- rats. VWF-/- rats bled longer and more than VWF+/- and VWF+/+ rats when challenged. Transfusion of FVIII-deficient platelet-poor plasma induced a rapid rise in endogenous FVIII:C in VWF-/- rats. CONCLUSION This rat model of severe VWD due to elimination of the entire VWF gene recapitulates the severe secondary deficiency of FVIII seen in human type 3 VWD and facilitates the study of VWF and FVIII and their interactions.
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Affiliation(s)
- Jessica Garcia
- Department of PediatricsDivision of Hematology/OncologyUT Southwestern Medical CenterDallasTXUSA
| | - Veronica H. Flood
- Department of PediatricsDivision of Hematology/OncologyMedical College of WisconsinMilwaukeeWIUSA
- Blood Research InstituteBloodCenter of WisconsinMilwaukeeWIUSA
| | | | - Scot A. Fahs
- Blood Research InstituteBloodCenter of WisconsinMilwaukeeWIUSA
| | | | - Aron M. Geurts
- Blood Research InstituteBloodCenter of WisconsinMilwaukeeWIUSA
| | - Mark Zogg
- Department of PhysiologyMedical College of WisconsinMilwaukeeWIUSA
| | - Hartmut Weiler
- Blood Research InstituteBloodCenter of WisconsinMilwaukeeWIUSA
| | - Qizhen Shi
- Department of PediatricsDivision of Hematology/OncologyMedical College of WisconsinMilwaukeeWIUSA
- Blood Research InstituteBloodCenter of WisconsinMilwaukeeWIUSA
| | - Robert R. Montgomery
- Department of PediatricsDivision of Hematology/OncologyMedical College of WisconsinMilwaukeeWIUSA
- Blood Research InstituteBloodCenter of WisconsinMilwaukeeWIUSA
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13
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Thornburg CD, Montgomery RR, Pipe SW. How we approach: Training pediatric coagulationists. Pediatr Blood Cancer 2019; 66:e27982. [PMID: 31486588 DOI: 10.1002/pbc.27982] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 08/15/2019] [Accepted: 08/18/2019] [Indexed: 11/09/2022]
Abstract
Unique expertise is required for the care of children, adolescents, and young adults with bleeding and clotting disorders. A number of Hemophilia Treatment Centers have developed pediatric hemostasis and thrombosis fellowship programs to facilitate subspecialty training and recruitment and retention in this field. This manuscript reviews an approach to training pediatric coagulationists including a description of current programs, sample curriculum, funding sources, and expected outcomes.
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Affiliation(s)
- Courtney D Thornburg
- Hemophilia and Thrombosis Treatment Center, Rady Children's Hospital San Diego, San Diego, California.,Department of Pediatrics, UC San Diego, La Jolla, California
| | - Robert R Montgomery
- Blood Research Institute, Versiti, Milwaukee, Wisconsin.,Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Steven W Pipe
- Departments of Pediatrics and Pathology, University of Michigan, Ann Arbor, Michigan
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14
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Chen J, Schroeder JA, Luo X, Montgomery RR, Shi Q. The impact of GPIbα on platelet-targeted FVIII gene therapy in hemophilia A mice with pre-existing anti-FVIII immunity. J Thromb Haemost 2019; 17:449-459. [PMID: 30609275 PMCID: PMC6397061 DOI: 10.1111/jth.14379] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Indexed: 01/13/2023]
Abstract
Essentials Platelet-specific FVIII gene therapy is effective in hemophilia A mice even with inhibitors. The impact of platelet adherence via VWF/GPIbα binding on platelet gene therapy was investigated. GPIbα does not significantly affect platelet gene therapy of hemophilia A with inhibitors. Platelet gene therapy induces immune tolerance in hemophilia A mice with pre-existing immunity. SUMMARY: Background We have previously demonstrated that von Willebrand factor (VWF) is essential in platelet-specific FVIII (2bF8) gene therapy of hemophilia A (HA) with inhibitory antibodies (inhibitors). At the site of injury, platelet adherence is initiated by VWF binding to the platelet GPIb complex. Objective To investigate the impact of GPIbα on platelet gene therapy of HA with inhibitors. Methods Platelet-FVIII expression was introduced by 2bF8 lentivirus (2bF8LV) transduction of hematopoietic stem cells (HSCs) from GPIbαnull (Ibnull ) mice or rhF8-primed FVIIInull (F8null ) mice followed by transplantation into lethally irradiated rhF8-primed F8null recipients. Animals were analyzed by flow cytometry, FVIII assays and the tail bleeding test. Results After transplantation, 99% of platelets were derived from donors. The macrothrombocytopenia phenotype was maintained in F8null mice that received 2bF8LV-transduced Ibnull HSCs (2bF8-Ibnull /F8null ). The platelet-FVIII expression level in 2bF8-Ibnull /F8null recipients was similar to that obtained from F8null mice that received 2bF8LV-transduced F8null HSCs (2bF8-F8null /F8null ). The tail bleeding test showed that the remaining hemoglobin level in the 2bF8-Ibnull /F8null group was significantly higher than in the F8null control group, but there was no significant difference between the 2bF8-Ibnull /F8null and 2bF8-F8null /F8null groups. The half-life of inhibitor disappearance time was comparable between the 2bF8-Ibnull /F8null and 2bF8-F8null /F8null groups. The rhF8 re-challenge did not elicit a memory immune response once inhibitor titers dropped to undetectable levels after 2bF8 gene therapy. Conclusion GPIbα does not significantly impact platelet gene therapy of HA with inhibitors. 2bF8 gene therapy restores hemostasis and promotes immune tolerance in HA mice with pre-existing immunity.
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Affiliation(s)
- Juan Chen
- Blood Research Institute, BloodCenter of Wisconsin, Milwaukee, WI, USA
| | - Jocelyn A. Schroeder
- Blood Research Institute, BloodCenter of Wisconsin, Milwaukee, WI, USA
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
- Children’s Research Institute, Children’s Hospital of Wisconsin, Milwaukee, Wisconsin, USA
- MACC Fund Research Center, Milwaukee, WI, USA
| | - Xiaofeng Luo
- Blood Research Institute, BloodCenter of Wisconsin, Milwaukee, WI, USA
| | - Robert R. Montgomery
- Blood Research Institute, BloodCenter of Wisconsin, Milwaukee, WI, USA
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
- Children’s Research Institute, Children’s Hospital of Wisconsin, Milwaukee, Wisconsin, USA
- MACC Fund Research Center, Milwaukee, WI, USA
| | - Qizhen Shi
- Blood Research Institute, BloodCenter of Wisconsin, Milwaukee, WI, USA
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
- Children’s Research Institute, Children’s Hospital of Wisconsin, Milwaukee, Wisconsin, USA
- MACC Fund Research Center, Milwaukee, WI, USA
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15
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Swystun LL, Lai JD, Notley C, Georgescu I, Paine AS, Mewburn J, Nesbitt K, Schledzewski K, Géraud C, Kzhyshkowska J, Goerdt S, Hopman W, Montgomery RR, James PD, Lillicrap D. The endothelial cell receptor stabilin-2 regulates VWF-FVIII complex half-life and immunogenicity. J Clin Invest 2018; 128:4057-4073. [PMID: 30124466 DOI: 10.1172/jci96400] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 07/03/2018] [Indexed: 11/17/2022] Open
Abstract
Quantitative abnormalities of the von Willebrand factor-factor VIII (VWF-FVIII) complex associate with inherited bleeding or thrombotic disorders. Receptor-mediated interactions between plasma VWF-FVIII and phagocytic or immune cells can influence their hemostatic and immunogenic activities. Genetic association studies have demonstrated that variants in the STAB2 gene, which encodes the scavenger receptor stabilin-2, associate with plasma levels of VWF-FVIII. However, the mechanistic basis and pathophysiological consequences of this association are unknown. We have demonstrated that stabilin-2-expressing cells bind and internalize human VWF and FVIII in a VWF-dependent manner, and stabilin-2-deficient mice displayed prolonged human VWF-FVIII half-life compared with controls. The stabilin-2 variant p.E2377K significantly decreased stabilin-2 expression and impaired VWF endocytosis in a heterologous expression system, and common STAB2 variants associated with plasma VWF levels in type 1 von Willebrand disease patients. STAB2-deficient mice displayed a decreased immunogenic response to human VWF-FVIII complex, while coinfusion of human VWF-FVIII with the stabilin-2 ligand hyaluronic acid attenuated the immune response to exogenous FVIII. Collectively, these data suggest that stabilin-2 functions as both a clearance and an immunoregulatory receptor for VWF-FVIII, making stabilin-2 a novel molecular target for modification of the half-life of VWF-FVIII and the immune response to VWF-FVIII concentrates.
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Affiliation(s)
| | - Jesse D Lai
- Department of Pathology and Molecular Medicine and
| | | | | | | | - Jeff Mewburn
- Division of Cancer Biology and Genetics, Queen's University, Kingston, Ontario, Canada
| | - Kate Nesbitt
- Department of Pathology and Molecular Medicine and
| | - Kai Schledzewski
- Department of Dermatology, Venereology and Allergology, University Medical Center and Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Cyrill Géraud
- Department of Dermatology, Venereology and Allergology, University Medical Center and Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Julia Kzhyshkowska
- Department of Dermatology, Venereology and Allergology, University Medical Center and Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Sergij Goerdt
- Department of Dermatology, Venereology and Allergology, University Medical Center and Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Wilma Hopman
- Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada
| | - Robert R Montgomery
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Paula D James
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
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16
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Affiliation(s)
- Richard A Marlar
- The Departments of Pediatrics, Biochemistry & Genetics, University of Colorado Health Sciences Center, Laboratory Services, Veterans Administration Medical Centel Denver, Colorado, USA
- The Blood Center of Southeastern Wisconsin, Milwaukee, Wisconsin, USA
| | | | - Andre W Broekmans
- The Leiden University Hospital, Hemostasis and Thrombosis Research Unit, Leiden, The Nethertands
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17
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Gill JC, Wheeler D, Menitove JE, Aster RH, Casper JT, Kirchner P, Montgomery RR. Persistence and Progression of Immunologic Abnormalities in Haemophilia. Thromb Haemost 2018. [DOI: 10.1055/s-0038-1661308] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
SummaryImmunologic parameters in 51 patients with haemophilia treated with cryoprecipitate from volunteer donors or with commercial lyophilized concentrate were studied on 2–7 occasions. Concentrate users had significantly decreased mean T4 (helper)/T8 (suppressor) lymphocyte ratios when the initial (1.5 ± .43) and most recent (1.25 ± .60) values were compared (p <.001), whereas in cryoprecipitate users mean values remained normal. Of the 22 concentrate users with initially normal T4/T8 ratios, 10 became abnormal during the study, an incidence of 45%. Fifteen of 28 (54%) patients with abnormal T4/T8 ratios had elevated circulating immune complexes (CIC), whereas all 16 patients with normal T4/T8 ratios had normal levels of CIC. Six patients have persistent lymphadenopathy.
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Affiliation(s)
- Joan C Gill
- The Blood Center of Southeastern Wisconsin, the Great Lakes Hemophilia Foundation, and the Departments of Pediatrics and Medicine, The Medical College of Wisconsin, Milwaukee, Wl, USA
| | - Dana Wheeler
- The Blood Center of Southeastern Wisconsin, the Great Lakes Hemophilia Foundation, and the Departments of Pediatrics and Medicine, The Medical College of Wisconsin, Milwaukee, Wl, USA
| | - Jay E Menitove
- The Blood Center of Southeastern Wisconsin, the Great Lakes Hemophilia Foundation, and the Departments of Pediatrics and Medicine, The Medical College of Wisconsin, Milwaukee, Wl, USA
| | - Richard H Aster
- The Blood Center of Southeastern Wisconsin, the Great Lakes Hemophilia Foundation, and the Departments of Pediatrics and Medicine, The Medical College of Wisconsin, Milwaukee, Wl, USA
| | - James T Casper
- The Blood Center of Southeastern Wisconsin, the Great Lakes Hemophilia Foundation, and the Departments of Pediatrics and Medicine, The Medical College of Wisconsin, Milwaukee, Wl, USA
| | - Phyllis Kirchner
- The Blood Center of Southeastern Wisconsin, the Great Lakes Hemophilia Foundation, and the Departments of Pediatrics and Medicine, The Medical College of Wisconsin, Milwaukee, Wl, USA
| | - Robert R Montgomery
- The Blood Center of Southeastern Wisconsin, the Great Lakes Hemophilia Foundation, and the Departments of Pediatrics and Medicine, The Medical College of Wisconsin, Milwaukee, Wl, USA
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18
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Kasper CK, Aronson DL, Davignon G, Foster P, Hillman-Wiseman C, Lusher JM, Manco-Johnson M, Meade JB, Montgomery RR, Rickies FR, White GC. Comparison of Six Commercial Plasma References for Factor VIII, Factor IX and von Willebrand Factor. Thromb Haemost 2018. [DOI: 10.1055/s-0038-1649860] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
SummarySix brands of normal reference plasma produced in the United States, with assigned assay values for factor VIII and IX and, in four instances, ristocetin cofactor and von Willebrand antigen, were assayed in nine coagulation laboratories in academic institutions in the same country. Differences in mean assays of reference plasmas, as a percent of labelled potency, were significant and were greater than differences among laboratories. Standard methods of assigning potency to commercial reference plasmas are recommended.
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Affiliation(s)
- Carol K Kasper
- The Orthopaedic Hospital University of Southern California, Los Angeles, California, USA
| | - David L Aronson
- The George Washington University Medical Center, Washington D.C., USA
| | | | - Paul Foster
- The Blood Center of Southeastern Wisconsin, Milwaukee, Wisconsin, USA
| | | | - Jeanne M Lusher
- The Children’s Hospital of Michigan, Wayne State University, Detroit, Michigan
| | | | - James B Meade
- The University of North Carolina Hospitals, Chapel Hill, North Carolina, USA
| | | | | | - Gilbert C White
- The University of North Carolina Hospitals, Chapel Hill, North Carolina, USA
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19
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Ginsburg D, Bockenstedt PL, Allen EA, Fox DA, Foster PA, Ruggeri ZM, Zimmerman TS, Montgomery RR, Bahou WF, Johnson TA, Yang AY. Fine Mapping of Monoclonal Antibody Epitopes on Human von Willebrand Factor Using a Recombinant Peptide Library. Thromb Haemost 2018. [DOI: 10.1055/s-0038-1648400] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
SummaryA recombinant human von Willebrand factor (vWF) cDNA fragment library was constructed in λgtll for the localization of anti-vWF monoclonal antibody epitopes. Twelve of 21 monoclonal antibodies screened identified epitopes expressed in λgtll as β-galactosidase fusion proteins. By sequence analysis, these antigenic determinants were localized to segments ranging from 17 to 105 amino acids in length. Four epitopes apparently shared by more than one antibody were identified, suggesting the presence of immuno-dominant epitopes within vWF. Monoclonal antibody C3, which blocks factor VIII (FVIII) binding to vWF, bound to the same epitope previously identified by a second monoclonal antibody which also blocks this function, suggesting that this region may be at or near the vWF/FVIII binding domain. Three antibodies recognize the same region within the vWF A2 repeat. Mutations near this region appear to be responsible for Type IIA von Willebrand’s disease. The co-localization of these antibodies suggests that this domain might be exposed on the surface of vWF, consistent with its apparent increased sensitivity to plasma proteases.
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Affiliation(s)
- David Ginsburg
- The Howard Hughes Medical Institute and Department of Human Genetics, University of Michigan Medical School, Ann Arbor, MI, USA
- The Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Paula L Bockenstedt
- The Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Elizabeth A Allen
- The Howard Hughes Medical Institute and Department of Human Genetics, University of Michigan Medical School, Ann Arbor, MI, USA
| | - David A Fox
- The Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Paul A Foster
- The Department of Molecular and Experimental Medicine and Committee on Vascular Biology, Scripps Clinic and Research Foundation, La Jolla, CA, USA
| | - Zaverio M Ruggeri
- The Department of Molecular and Experimental Medicine and Committee on Vascular Biology, Scripps Clinic and Research Foundation, La Jolla, CA, USA
| | - Theodore S Zimmerman
- The Department of Molecular and Experimental Medicine and Committee on Vascular Biology, Scripps Clinic and Research Foundation, La Jolla, CA, USA
| | - Robert R Montgomery
- The Blood Center of Southeastern Wisconsin and Medical College of Wisconsin, Milwaukee, WI, USA
| | - Wadie F Bahou
- The Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Timothy A Johnson
- The Howard Hughes Medical Institute and Department of Human Genetics, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Angela Y Yang
- The Howard Hughes Medical Institute and Department of Human Genetics, University of Michigan Medical School, Ann Arbor, MI, USA
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Flood VH, Johnsen JM, Kochelek C, Slobodianuk TL, Christopherson PA, Haberichter SL, Udani R, Bellissimo DB, Friedman KD, Montgomery RR. Common VWF sequence variants associated with higher VWF and FVIII are less frequent in subjects diagnosed with type 1 VWD. Res Pract Thromb Haemost 2018; 2:390-398. [PMID: 30046743 PMCID: PMC5974909 DOI: 10.1002/rth2.12077] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 12/19/2017] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Genetic variation in the VWF gene is associated with von Willebrand factor (VWF) and factor VIII (FVIII) levels in healthy individuals. OBJECTIVES We hypothesized that VWF sequence variants associated with higher VWF or FVIII could impact the diagnosis of type 1 von Willebrand disease (VWD). METHODS We examined VWF antigen (VWF:Ag), VWF ristocetin cofactor activity (VWF:RCo), VWF propeptide (VWFpp), and FVIII levels along with VWF gene sequencing in 256 healthy control and 97 type 1 VWD subjects as part of a cross-sectional study. RESULTS We found several VWF sequence variants (VWF c.2880G>A and VWF c.2365A>G(;)c.2385T>C, found in linkage disequilibrium) associated with higher VWF and FVIII levels in healthy controls (P < .001 for both variants). In addition, these variants were significantly more common in controls than in subjects diagnosed with type 1 VWD and VWF:Ag <30 (P < .005). The decreased variant frequencies in type 1 VWD was not seen in other VWD types. VWF:Ag, VWF:RCo, and FVIII were not statistically different in type 1 VWD subjects who had these VWF variants compared to type 1 VWD patients without them. There was no difference in ABO blood group, VWF propeptide levels (excluding subjects with known VWF clearance defects), or bleeding score using the ISTH bleeding assessment tool. CONCLUSIONS These data suggest that certain VWF sequence variants associated with elevated FVIII and VWF levels may protect against reduced VWF levels. These findings were independent of other pathogenic sequence variants in VWF, suggesting a possible independent effect of c.2880G>A and c.2365A>G(;)c.2385T>C on VWF levels.
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Affiliation(s)
- Veronica H. Flood
- Department of PediatricsDivision of Hematology/OncologyMedical College of WisconsinMilwaukeeWIUSA
- Children's Research InstituteChildren's Hospital of WisconsinMilwaukeeWIUSA
- Blood Research InstituteBloodCenter of WisconsinMilwaukeeWIUSA
| | - Jill M. Johnsen
- Research InstituteBloodWorks NWSeattleWAUSA
- Department of MedicineUniversity of WashingtonSeattleWAUSA
| | | | | | | | - Sandra L. Haberichter
- Department of PediatricsDivision of Hematology/OncologyMedical College of WisconsinMilwaukeeWIUSA
- Children's Research InstituteChildren's Hospital of WisconsinMilwaukeeWIUSA
- Blood Research InstituteBloodCenter of WisconsinMilwaukeeWIUSA
| | - Rupa Udani
- Diagnostic LaboratoriesBloodCenter of WisconsinMilwaukeeWIUSA
| | | | | | - Robert R. Montgomery
- Department of PediatricsDivision of Hematology/OncologyMedical College of WisconsinMilwaukeeWIUSA
- Children's Research InstituteChildren's Hospital of WisconsinMilwaukeeWIUSA
- Blood Research InstituteBloodCenter of WisconsinMilwaukeeWIUSA
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Carvajal-Hausdorf DE, Stanton KP, Patsenker J, Villarroel-Espindola F, Esch A, Montgomery RR, Psyrri A, Kalogeras KT, Kotoula V, Fountzilas G, Schalper KA, Kluger Y, Rimm DL. Abstract P2-09-18: Multiplexed (18-Plex) measurement of protein targets in trastuzumab-treated patients using imaging mass cytometry. Cancer Res 2018. [DOI: 10.1158/1538-7445.sabcs17-p2-09-18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Introduction: Recent studies have shown that the molecular heterogeneity of HER2 intracellular (ICD) and extracellular (ECD) domains, as well as overall immune infiltration, are associated with response to adjuvant trastuzumab. Traditional strategies for in situ measurement in the tumor microenvironment allow the combination of up to 6 targets, limiting our capability for in-depth interrogation of tissues. Imaging Mass Cytometry (IMC) uses metal-conjugated antibodies to provide multidimensional, objective measurement of protein targets. We used this high-throughput multiplexing platform to perform an 18-plex assessment of HER2 ICD/ECD, cytotoxic T cell infiltration and other structural and signaling proteins in a cohort of patients treated with trastuzumab.
Methods: An antibody panel for detection of 18 targets (Pancytokeratin, HER2 ICD, HER2 ECD, CD8, vimentin, cytokeratin 7, beta-catenin, HER3, MET, EGFR, ERK 1-2, MEK 1-2, PTEN, PI3K p110 alpha, Akt, mTOR, Ki67 and Histone H3) was conjugated to unique metals for detection in an IMC instrument (Fluidigm). All assays were objectively standardized and validated using quantitative immunofluoresce (QIF). Finally, the IMC technique was validated against HER2 single marker assays by QIF. We used a collection of trastuzumab-treated patients from the HeCOG 10/05 trial (n=180), and identified a case:control series using 5-year recurrence events (n=19), which were matched to controls (n=41) by age and TNM stage. Formalin-fixed, paraffin embedded tissues in tissue microarray format were ablated in the IMC attachment to the CyTOF flow cytometer for simultaneous detection of markers. Image visualization was conducted using MCD Viewer (Fluidigm). Statistical analyses were performed using a range of platforms.
Results: Patients that recurred after adjuvant treatment with trastuzumab showed a decreased fraction of HER2 ECD pixels over threshold in a compartment determined by CK and HER2 ICD compared to cases without recurrence (p=0.057). After exclusion of the lowest HER2 expressers (that would have fallen below the threshold for positive by current HER2 assays), 5-year recurrence events where associated with reduced total ECD/ ICD ratio intensity in tumor (p=0.044). Patients below the median for total ECD/ICD ratio showed a trend for decreased benefit from trastuzumab (p=0.066). Levels of cytotoxic T cell infiltration, depicted by total CD8 intensity, were lower in patients with recurrences (p=0.05).
Conclusion: Objective measurement of highly multiplexed protein targets in routine, fixed breast cancer tissues shows that a decreased ratio of HER2 ECD/ ICD is associated with 5-year recurrence after trastuzumab treatment. This observation is consistent with our previous work using QIF but represents the first time this has been done on identical cell content (on a single tissue section). Additionally, on the same section we found that lower levels of overall cytotoxic T cell infiltration were associated with worse outcome. Further analysis of the multiplexed data, including both correlative and distance-based analyses are underway.
Citation Format: Carvajal-Hausdorf DE, Stanton KP, Patsenker J, Villarroel-Espindola F, Esch A, Montgomery RR, Psyrri A, Kalogeras KT, Kotoula V, Fountzilas G, Schalper KA, Kluger Y, Rimm DL. Multiplexed (18-Plex) measurement of protein targets in trastuzumab-treated patients using imaging mass cytometry [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P2-09-18.
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Affiliation(s)
- DE Carvajal-Hausdorf
- Yale School of Medicine, New Haven, CT; Rensselaer Polytechnic Institute, Troy, NY; Fluidigm Corporation, Markham, ON, Canada; Attikon University Hospital, Athens, Greece; Aristotle University of Thessaloniki School of Medicine, Thessaloniki, Greece
| | - KP Stanton
- Yale School of Medicine, New Haven, CT; Rensselaer Polytechnic Institute, Troy, NY; Fluidigm Corporation, Markham, ON, Canada; Attikon University Hospital, Athens, Greece; Aristotle University of Thessaloniki School of Medicine, Thessaloniki, Greece
| | - J Patsenker
- Yale School of Medicine, New Haven, CT; Rensselaer Polytechnic Institute, Troy, NY; Fluidigm Corporation, Markham, ON, Canada; Attikon University Hospital, Athens, Greece; Aristotle University of Thessaloniki School of Medicine, Thessaloniki, Greece
| | - F Villarroel-Espindola
- Yale School of Medicine, New Haven, CT; Rensselaer Polytechnic Institute, Troy, NY; Fluidigm Corporation, Markham, ON, Canada; Attikon University Hospital, Athens, Greece; Aristotle University of Thessaloniki School of Medicine, Thessaloniki, Greece
| | - A Esch
- Yale School of Medicine, New Haven, CT; Rensselaer Polytechnic Institute, Troy, NY; Fluidigm Corporation, Markham, ON, Canada; Attikon University Hospital, Athens, Greece; Aristotle University of Thessaloniki School of Medicine, Thessaloniki, Greece
| | - RR Montgomery
- Yale School of Medicine, New Haven, CT; Rensselaer Polytechnic Institute, Troy, NY; Fluidigm Corporation, Markham, ON, Canada; Attikon University Hospital, Athens, Greece; Aristotle University of Thessaloniki School of Medicine, Thessaloniki, Greece
| | - A Psyrri
- Yale School of Medicine, New Haven, CT; Rensselaer Polytechnic Institute, Troy, NY; Fluidigm Corporation, Markham, ON, Canada; Attikon University Hospital, Athens, Greece; Aristotle University of Thessaloniki School of Medicine, Thessaloniki, Greece
| | - KT Kalogeras
- Yale School of Medicine, New Haven, CT; Rensselaer Polytechnic Institute, Troy, NY; Fluidigm Corporation, Markham, ON, Canada; Attikon University Hospital, Athens, Greece; Aristotle University of Thessaloniki School of Medicine, Thessaloniki, Greece
| | - V Kotoula
- Yale School of Medicine, New Haven, CT; Rensselaer Polytechnic Institute, Troy, NY; Fluidigm Corporation, Markham, ON, Canada; Attikon University Hospital, Athens, Greece; Aristotle University of Thessaloniki School of Medicine, Thessaloniki, Greece
| | - G Fountzilas
- Yale School of Medicine, New Haven, CT; Rensselaer Polytechnic Institute, Troy, NY; Fluidigm Corporation, Markham, ON, Canada; Attikon University Hospital, Athens, Greece; Aristotle University of Thessaloniki School of Medicine, Thessaloniki, Greece
| | - KA Schalper
- Yale School of Medicine, New Haven, CT; Rensselaer Polytechnic Institute, Troy, NY; Fluidigm Corporation, Markham, ON, Canada; Attikon University Hospital, Athens, Greece; Aristotle University of Thessaloniki School of Medicine, Thessaloniki, Greece
| | - Y Kluger
- Yale School of Medicine, New Haven, CT; Rensselaer Polytechnic Institute, Troy, NY; Fluidigm Corporation, Markham, ON, Canada; Attikon University Hospital, Athens, Greece; Aristotle University of Thessaloniki School of Medicine, Thessaloniki, Greece
| | - DL Rimm
- Yale School of Medicine, New Haven, CT; Rensselaer Polytechnic Institute, Troy, NY; Fluidigm Corporation, Markham, ON, Canada; Attikon University Hospital, Athens, Greece; Aristotle University of Thessaloniki School of Medicine, Thessaloniki, Greece
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Flood VH, Abshire TC, Christopherson PA, Friedman KD, Cox Gill J, Montgomery RR, Haberichter SL. Von Willebrand disease in the United States: perspective from the Zimmerman program. ACTA ACUST UNITED AC 2018; 3. [PMID: 30135959 DOI: 10.21037/aob.2017.12.05] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
This article will discuss the diagnosis and management of von Willebrand disease (VWD) in the United States and results from the Zimmerman Program, a national study of VWD. An algorithm is presented to show how we currently approach diagnostic testing for VWD, including the potential replacement of the ristocetin cofactor assay with a new von Willebrand factor (VWF)-GPIb binding assay. Results from the Zimmerman Program type 1 cohort are presented, including the findings that genetic defects in the VWF gene are most common with VWF levels <30 IU/dL, but bleeding symptoms were present across the entire cohort regardless of VWF level. Typical management of VWD patients is also discussed, including the use of desmopressin and VWF concentrates. Despite these advances, there remain several areas of VWD where more research is required to optimize treatment.
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Affiliation(s)
- Veronica H Flood
- Blood Research Institute, Blood Center of Wisconsin, Milwaukee, WI, USA.,Children's Research Institute, Children's Hospital of Wisconsin, Milwaukee, WI, USA.,Department of Pediatrics, Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Thomas C Abshire
- Blood Research Institute, Blood Center of Wisconsin, Milwaukee, WI, USA.,Children's Research Institute, Children's Hospital of Wisconsin, Milwaukee, WI, USA.,Department of Pediatrics, Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | | | - Kenneth D Friedman
- Blood Research Institute, Blood Center of Wisconsin, Milwaukee, WI, USA.,Children's Research Institute, Children's Hospital of Wisconsin, Milwaukee, WI, USA.,Department of Pediatrics, Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Joan Cox Gill
- Blood Research Institute, Blood Center of Wisconsin, Milwaukee, WI, USA.,Children's Research Institute, Children's Hospital of Wisconsin, Milwaukee, WI, USA.,Department of Pediatrics, Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Robert R Montgomery
- Blood Research Institute, Blood Center of Wisconsin, Milwaukee, WI, USA.,Children's Research Institute, Children's Hospital of Wisconsin, Milwaukee, WI, USA.,Department of Pediatrics, Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Sandra L Haberichter
- Blood Research Institute, Blood Center of Wisconsin, Milwaukee, WI, USA.,Children's Research Institute, Children's Hospital of Wisconsin, Milwaukee, WI, USA.,Department of Pediatrics, Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
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Doruelo AL, Haberichter SL, Christopherson PA, Boggio LN, Gupta S, Lentz SR, Shapiro AD, Montgomery RR, Flood VH. Clinical and laboratory phenotype variability in type 2M von Willebrand disease. J Thromb Haemost 2017; 15:1559-1566. [PMID: 28544236 PMCID: PMC5538962 DOI: 10.1111/jth.13742] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Indexed: 12/22/2022]
Abstract
Essentials The pathophysiology of type 2M von Willebrand disease (VWD) is poorly understood. Sequence variations in type 2M VWD subjects were characterized. A high degree of clinical and laboratory variability exists within type 2M VWD variants. Some type 2M variants may share features of type 2A VWD. SUMMARY Background von Willebrand factor (VWF) is a multimeric coagulation factor that tethers platelets to injured subendothelium. Type 2M von Willebrand disease (VWD) is characterized by a qualitative defect in VWF with preserved multimer distribution. Objectives Through the Zimmerman Program for the Molecular and Clinical Biology for VWD, five VWF sequence variations were studied in subjects diagnosed with type 2M VWD. Methods Bleeding phenotype was assessed using the ISTH bleeding assessment tool. Full-length VWF gene sequencing was performed for each subject. Each variant was placed into a recombinant VWF vector using site-directed mutagenesis and expressed in HEK293T cells as homozygous or heterozygous VWF. Variant expression, collagen binding and platelet GPIbα binding were studied through ELISA assays. Multimer analysis was performed by gel electrophoresis. Results Bleeding scores were elevated for all subjects except for the p.P1162L and p.R1374C variants. Although all had reduced VWF ristocetin cofactor activity/VWF antigen ratios on plasma testing, recombinant VWF did not show a classic type 2M phenotype for any of the five variants. Homozygous expression of variants p.D1283Y, p.R1349C, p.R1374C and p.I1453N was consistent with type 2A VWD, although all had normal expression as heterozygous recombinant VWF. Variant p.P1162L had normal VWF expression and function, consistent with the lack of bleeding symptoms. Conclusions Although originally classified as type 2M VWD, these homozygous recombinant VWF variants do not fulfill complete 2M VWD diagnostic criteria. A better classification schema and improved testing for putative type 2M variants is needed in order to effectively diagnose and treat affected patients.
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Affiliation(s)
- Ashley L. Doruelo
- Department of Pediatrics, Division of Hematology/Oncology, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI 53226
- Children’s Research Institute, Children’s Hospital of Wisconsin, Milwaukee, WI 53226
| | - Sandra L. Haberichter
- Department of Pediatrics, Division of Hematology/Oncology, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI 53226
- Children’s Research Institute, Children’s Hospital of Wisconsin, Milwaukee, WI 53226
- Blood Research Institute, BloodCenter of Wisconsin, 8727 Watertown Plank Rd, Milwaukee, WI 53226
| | - Pamela A. Christopherson
- Blood Research Institute, BloodCenter of Wisconsin, 8727 Watertown Plank Rd, Milwaukee, WI 53226
| | | | - Sweta Gupta
- Indiana Hemophilia & Thrombosis Center, Indianapolis, IN 46260
| | - Steven R. Lentz
- University of Iowa Carver College of Medicine, Iowa City, IA 52242
| | - Amy D. Shapiro
- Indiana Hemophilia & Thrombosis Center, Indianapolis, IN 46260
| | - Robert R. Montgomery
- Department of Pediatrics, Division of Hematology/Oncology, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI 53226
- Children’s Research Institute, Children’s Hospital of Wisconsin, Milwaukee, WI 53226
- Blood Research Institute, BloodCenter of Wisconsin, 8727 Watertown Plank Rd, Milwaukee, WI 53226
| | - Veronica H. Flood
- Department of Pediatrics, Division of Hematology/Oncology, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI 53226
- Children’s Research Institute, Children’s Hospital of Wisconsin, Milwaukee, WI 53226
- Blood Research Institute, BloodCenter of Wisconsin, 8727 Watertown Plank Rd, Milwaukee, WI 53226
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Baumgartner CK, Mattson JG, Weiler H, Shi Q, Montgomery RR. Targeting factor VIII expression to platelets for hemophilia A gene therapy does not induce an apparent thrombotic risk in mice. J Thromb Haemost 2017; 15:98-109. [PMID: 27496751 PMCID: PMC5280575 DOI: 10.1111/jth.13436] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Accepted: 07/12/2016] [Indexed: 01/08/2023]
Abstract
Essentials Platelet-Factor (F) VIII gene therapy is a promising treatment in hemophilia A. This study aims to evaluate if platelet-FVIII expression would increase the risk for thrombosis. Targeting FVIII expression to platelets does not induce or elevate thrombosis risk. Platelets expressing FVIII are neither hyper-activated nor hyper-responsive. SUMMARY Background Targeting factor (F) VIII expression to platelets is a promising gene therapy approach for hemophilia A, and is successful even in the presence of inhibitors. It is well known that platelets play important roles not only in hemostasis, but also in thrombosis and inflammation. Objective To evaluate whether platelet-FVIII expression might increase thrombotic risk and thereby compromise the safety of this approach. Methods In this study, platelet-FVIII-expressing transgenic mice were examined either in steady-state conditions or under prothrombotic conditions induced by inflammation or the FV Leiden mutation. Native whole blood thrombin generation assay, rotational thromboelastometry analysis and ferric chloride-induced vessel injury were used to evaluate the hemostatic properties. Various parameters associated with thrombosis risk, including D-dimer, thrombin-antithrombin complexes, fibrinogen, tissue fibrin deposition, platelet activation status and activatability, and platelet-leukocyte aggregates, were assessed. Results We generated a new line of transgenic mice that expressed 30-fold higher levels of platelet-expressed FVIII than are therapeutically required to restore hemostasis in hemophilic mice. Under both steady-state conditions and prothrombotic conditions induced by lipopolysaccharide-mediated inflammation or the FV Leiden mutation, supratherapeutic levels of platelet-expressed FVIII did not appear to be thrombogenic. Furthermore, FVIII-expressing platelets were neither hyperactivated nor hyperactivatable upon agonist activation. Conclusion We conclude that, in mice, more than 30-fold higher levels of platelet-expressed FVIII than are required for therapeutic efficacy in hemophilia A are not associated with a thrombotic predilection.
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Affiliation(s)
- C K Baumgartner
- Blood Research Institute, BloodCenter of Wisconsin, Milwaukee, WI, USA
| | - J G Mattson
- Blood Research Institute, BloodCenter of Wisconsin, Milwaukee, WI, USA
| | - H Weiler
- Blood Research Institute, BloodCenter of Wisconsin, Milwaukee, WI, USA
| | - Q Shi
- Blood Research Institute, BloodCenter of Wisconsin, Milwaukee, WI, USA
- Medical College of Wisconsin, Milwaukee, WI, USA
- Children's Research Institute, Children's Hospital of Wisconsin, Milwaukee, WI, USA
- MACC Fund Research Center, Milwaukee, WI, USA
| | - R R Montgomery
- Blood Research Institute, BloodCenter of Wisconsin, Milwaukee, WI, USA
- Medical College of Wisconsin, Milwaukee, WI, USA
- Children's Research Institute, Children's Hospital of Wisconsin, Milwaukee, WI, USA
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Abstract
Von Willebrand factor (VWF) is a critical regulator of hemostatic processes, including collagen binding, platelet adhesion, and platelet aggregation. It also serves as a carrier protein to normalize plasma factor VIII synthesis, release, and survival. While VWF protein measurements by immunoassay are reasonably comparable between institutions, the measurement of VWF ristocetin cofactor activity (VWF:RCo) has significant variability. Other tests of VWF function, including collagen binding or platelet glycoprotein IIb-IIIa binding, are not universally available, yet these functional defects may cause major bleeding even with normal VWF antigen (VWF:Ag) and VWF:RCo assays. This results in both the overdiagnosis and underdiagnosis of VWD. Newer assays of VWF function (using recombinant glycoprotein Ib rather than whole platelets) have been developed that may improve interlaboratory variability. Some of these tests are not uniformly available and may not be licensed in the United States. Large longitudinal studies of VWF in von Willebrand disease (VWD) patients are not available. Patients are sometimes diagnosed with a single diagnostic VWF panel. Plasma VWF levels increase with age, but it is not clear if this results in less bleeding or whether different normal ranges should be used to identify age-related decreases in VWF. In order to quantitatively compare bleeding symptoms in VWD patients and normal individuals, recent studies in the European Union, Canada, United Kingdom, Holland, and the United States have used semiquantitative bleeding assessment tools (BATs). Even with careful centralized testing, including functional assays of VWF, addition of a BAT does not solve all of the problems with VWD diagnosis. No matter where the line is drawn for diagnosis of VWD, VWF is still a continuous variable. Thus, VWD can be a severe hemorrhagic disease requiring frequent treatment or a mild condition that may not be clinically relevant. As will be discussed by Dr. Goodeve in her presentation, genetics has helped us to diagnose type 2 functional variants of VWD but has not been helpful for the many patients who are at the interface of normal and low VWF and carry the possible diagnosis of type 1 VWD. The hematologist's management of patients with reduced levels of VWF still requires both the art and science of clinical medicine.
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Affiliation(s)
- Robert R Montgomery
- Blood Research Institute, BloodCenter of Wisconsin and Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI
| | - Veronica H Flood
- Blood Research Institute, BloodCenter of Wisconsin and Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI
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Abstract
West Nile virus (WNV) is the most important causative agent of viral encephalitis worldwide and an important public health concern in the United States due to its high prevalence, severe disease, and the absence of effective treatments. Infection with WNV is mainly asymptomatic, but some individuals develop severe, possibly fatal, neurological disease. Individual host factors play a role in susceptibility to WNV infection, including genetic polymorphisms in key anti-viral immune genes, but age is the most well-defined risk factor for susceptibility to severe disease. Ageing is associated with distinct changes in immune cells and a decline in immune function leading to increased susceptibility to infection and reduced responses to vaccination. WNV is detected by pathogen recognition receptors including Toll-like receptors (TLRs), which show reduced expression and function in ageing. Neutrophils, monocyte/macrophages and dendritic cells, which first recognize and respond to infection, show age-related impairment of many functions relevant to anti-viral responses. Natural killer cells control many viral infections and show age-related changes in phenotype and functional responses. A role for the regulatory receptors Mertk and Axl in blood-brain barrier permeability and in facilitating viral uptake through phospholipid binding may be relevant for susceptibility to WNV, and age-related up-regulation of Axl has been noted previously in human dendritic cells. Understanding the specific immune parameters and mechanisms that influence susceptibility to symptomatic WNV may lead to a better understanding of increased susceptibility in elderly individuals and identify potential avenues for therapeutic approaches: an especially relevant goal, as the world's populating is ageing.
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Affiliation(s)
- R R Montgomery
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
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Obser T, Ledford-Kraemer M, Oyen F, Brehm MA, Denis CV, Marschalek R, Montgomery RR, Sadler JE, Schneppenheim S, Budde U, Schneppenheim R. Identification and characterization of the elusive mutation causing the historical von Willebrand Disease type IIC Miami. J Thromb Haemost 2016; 14:1725-35. [PMID: 27344059 PMCID: PMC5035592 DOI: 10.1111/jth.13398] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Accepted: 06/15/2016] [Indexed: 11/28/2022]
Abstract
UNLABELLED Essentials Von Willebrand disease IIC Miami features high von Willebrand factor (VWF) with reduced function. We aimed to identify and characterize the elusive underlying mutation in the original family. An inframe duplication of VWF exons 9-10 was identified and characterized. The mutation causes a defect in VWF multimerization and decreased VWF clearance from the circulation. SUMMARY Background A variant of von Willebrand disease (VWD) type 2A, phenotype IIC (VWD2AIIC), is characterized by recessive inheritance, low von Willebrand factor antigen (VWF:Ag), lack of VWF high-molecular-weight multimers, absence of VWF proteolytic fragments and mutations in the VWF propeptide. A family with dominantly inherited VWD2AIIC but markedly elevated VWF:Ag of > 2 U L(-1) was described as VWD type IIC Miami (VWD2AIIC-Miami) in 1993; however, the molecular defect remained elusive. Objectives To identify the molecular mechanism underlying the phenotype of the original VWD2AIIC-Miami. Patients and Methods We studied the original family with VWD2AIIC-Miami phenotypically and by genotyping. The identified mutation was recombinantly expressed and characterized by standard techniques, confocal imaging and in a mouse model, respectively. Results By Multiplex ligation-dependent probe amplification we identified an in-frame duplication of VWF exons 9-10 (c.998_1156dup; p.Glu333_385dup) in all patients. Recombinant mutant (rm)VWF only presented as a dimer. Co-expressed with wild-type VWF, the multimer pattern was indistinguishable from patients' plasma VWF. Immunofluorescence studies indicated retention of rmVWF in unusually large intracellular granules in the endoplasmic reticulum. ADAMTS-13 proteolysis of rmVWF under denaturing conditions was normal; however, an aberrant proteolytic fragment was apparent. A decreased ratio of VWF propeptide to VWF:Ag and a 1-desamino-8-d-arginine vasopressin (DDAVP) test in one patient indicated delayed VWF clearance, which was supported by clearance data after infusion of rmVWF into VWF(-/-) mice. Conclusion The unique phenotype of VWD2 type IIC-Miami results from dominant impairment of multimer assembly, an aberrant structure of mutant mature VWF and reduced clearance in vivo.
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Affiliation(s)
- T Obser
- Department of Pediatric Hematology and Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - F Oyen
- Department of Pediatric Hematology and Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - M A Brehm
- Department of Pediatric Hematology and Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - C V Denis
- INSERM UMR_S 1176, Université Paris-Sud, Université Paris-Saclay, Le Kremlin-Bicetre, France
| | - R Marschalek
- Institute of Pharmaceutical Biology/ZAFES/DCAL, Biocenter, Johann-Wolfgang-Goethe-University Frankfurt, Frankfurt/Main, Germany
| | - R R Montgomery
- Blood Research Institute of Blood Center of Wisconsin and Medical College of Wisconsin, Milwaukee, WI, USA
| | - J E Sadler
- Departments of Medicine and Biochemistry and Molecular Biophysics, Washington University School of Medicine, St. Louis, MO, USA
| | - S Schneppenheim
- Medilys Central Laboratory Coagulation, Asklepios Clinic Altona, Hamburg, Germany
| | - U Budde
- Medilys Central Laboratory Coagulation, Asklepios Clinic Altona, Hamburg, Germany
| | - R Schneppenheim
- Department of Pediatric Hematology and Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
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Baumgartner CK, Zhang G, Kuether EL, Weiler H, Shi Q, Montgomery RR. Comparison of platelet-derived and plasma factor VIII efficacy using a novel native whole blood thrombin generation assay. J Thromb Haemost 2015; 13:2210-9. [PMID: 26453193 PMCID: PMC4715732 DOI: 10.1111/jth.13169] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Accepted: 09/30/2015] [Indexed: 12/01/2022]
Abstract
BACKGROUND We have recently developed a successful gene therapy approach for hemophilia A in which factor VIII (FVIII) expression is targeted to platelets by the αIIb promoter. Levels of platelet-expressed FVIII (2bF8) achieved by gene therapy may vary between individuals due to differences in ex vivo transduction and gene expression efficiency. Accurate assays to evaluate 2bF8 efficacy are desirable. OBJECTIVE To compare the hemostatic efficacy of 2bF8 with replacement therapy over a wide therapeutic dose range. METHODS Efficacy of 2bF8 was assessed using a new transgenic mouse model expressing high 2bF8 levels (LV18(tg) ). Blood from LV18(tg) mice or FVIII(null) mice infused with recombinant FVIII was mixed with FVIII(null) blood at different ratios ex vivo to achieve several concentrations of 2bF8 or plasma FVIII. Samples were evaluated with a novel native whole blood thrombin generation assay that uses recalcified whole blood without the addition of tissue factor to initiate coagulation. RESULTS FVIII dose dependency was observed in all five thrombin generation parameters. While the total amount of thrombin generated was similar, 2bF8 significantly accelerated thrombin generation compared with plasma FVIII. Remarkably, a 10-fold lower dose of 2bF8 than plasma FVIII (0.2% vs. 2%) significantly shortened the onset and peak of thrombin generation compared with FVIII(null) blood. CONCLUSION Using a new transgenic mouse model, we showed that the novel native whole blood thrombin generation assay established here can be used to monitor platelet targeted FVIII gene therapy. The higher therapeutic efficacy of 2bF8 compared with factor replacement therapy seemed to be due to acceleration of thrombin generation.
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Affiliation(s)
- C K Baumgartner
- Blood Research Institute, BloodCenter of Wisconsin, Milwaukee, WI, USA
| | - G Zhang
- Blood Research Institute, BloodCenter of Wisconsin, Milwaukee, WI, USA
| | - E L Kuether
- Blood Research Institute, BloodCenter of Wisconsin, Milwaukee, WI, USA
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - H Weiler
- Blood Research Institute, BloodCenter of Wisconsin, Milwaukee, WI, USA
| | - Q Shi
- Blood Research Institute, BloodCenter of Wisconsin, Milwaukee, WI, USA
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
- Children's Research Institute, Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | - R R Montgomery
- Blood Research Institute, BloodCenter of Wisconsin, Milwaukee, WI, USA
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
- Children's Research Institute, Children's Hospital of Wisconsin, Milwaukee, WI, USA
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Shi Q, Schroeder JA, Kuether EL, Montgomery RR. The important role of von Willebrand factor in platelet-derived FVIII gene therapy for murine hemophilia A in the presence of inhibitory antibodies. J Thromb Haemost 2015; 13:1301-9. [PMID: 25955153 PMCID: PMC4496307 DOI: 10.1111/jth.13001] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Accepted: 04/16/2015] [Indexed: 12/01/2022]
Abstract
BACKGROUND Our previous studies have demonstrated that targeting FVIII expression to platelets results in FVIII storage together with von Willebrand factor (VWF) in platelet α-granules and that platelet-derived FVIII (2bF8) corrects the murine hemophilia A phenotype even in the presence of high-titer anti-FVIII inhibitory antibodies (inhibitors). OBJECTIVE To explore how VWF has an impact on platelet gene therapy for hemophilia A with inhibitors. METHODS 2bF8 transgenic mice in the FVIII(-/-) background (2bF8(tg+/-) F8(-/-) ) with varying VWF phenotypes were used in this study. Animals were analyzed by VWF ELISA, FVIII activity assay, Bethesda assay and tail clip survival test. RESULTS Only 18% of 2bF8(tg+/-) F8(-/-) VWF(-/-) animals, in which VWF was deficient, survived the tail clip challenge with inhibitor titers of 3-8000 BU mL(-1) . In contrast, 82% of 2bF8(tg+/-) F8(-/-) VWF(+/+) mice, which had normal VWF levels, survived tail clipping with inhibitor titers of 10-50,000 BU mL(-1) . All 2bF8(tg+/-) F8(-/-) VWF(-/-) mice without inhibitors survived tail clipping and no VWF(-/-) F8(-/-) mice survived this challenge. Because VWF is synthesized by endothelial cells and megakaryocytes and is distributed in both plasma and platelets in peripheral blood, we further investigated the effect of each compartment of VWF on platelet-FVIII gene therapy for hemophilia A with inhibitors. In the presence of inhibitors, 42% of animals survived tail clipping in the group with plasma-VWF and 50% survived in the platelet-VWF group. CONCLUSION VWF is essential for platelet gene therapy for hemophilia A with inhibitors. Both platelet-VWF and plasma-VWF are required for optimal platelet-derived FVIII gene therapy for hemophilia A in the presence of inhibitors.
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Affiliation(s)
- Q Shi
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
- Blood Research Institute, Blood Center of Wisconsin, Milwaukee, WI, USA
- Children's Research Institute, Children's Hospital of Wisconsin, Milwaukee, WI, USA
- MACC Fund Research Center, Milwaukee, WI, USA
| | - J A Schroeder
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
- Blood Research Institute, Blood Center of Wisconsin, Milwaukee, WI, USA
- Children's Research Institute, Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | - E L Kuether
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
- Blood Research Institute, Blood Center of Wisconsin, Milwaukee, WI, USA
- Children's Research Institute, Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | - R R Montgomery
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
- Blood Research Institute, Blood Center of Wisconsin, Milwaukee, WI, USA
- Children's Research Institute, Children's Hospital of Wisconsin, Milwaukee, WI, USA
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Kanaji S, Fahs SA, Ware J, Montgomery RR, Shi Q. Non-myeloablative conditioning with busulfan before hematopoietic stem cell transplantation leads to phenotypic correction of murine Bernard-Soulier syndrome. J Thromb Haemost 2014; 12:1726-32. [PMID: 25066812 PMCID: PMC4194147 DOI: 10.1111/jth.12673] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2014] [Accepted: 07/08/2014] [Indexed: 12/01/2022]
Abstract
BACKGROUND Bernard-Soulier syndrome (BSS) is an inherited bleeding disorder characterized by macrothrombocytopenia. Platelet transfusion is used for the management of bleeding, but repeated transfusion often results in alloimmunization. We have recently shown phenotypic correction of murine BSS (GPIbα(null) ) using lethal radiation conditioning followed by hematopoietic lentivirus-mediated gene transfer. OBJECTIVES For application of gene therapy to treatment of human patients, it is important to minimize treatment-related side effects. The objective of this study is to model a clinically relevant non-myeloablative hematopoietic stem cell (HSC) transplantation strategy. METHODS Using transplantation of bone marrow (BM) HSCs from transgenic mice that express hGPIbα (hGPIbα(tg+/+) ), we sought to (i) determine the percentage of hGPIbα(tg+/+) HSCs required for therapeutic benefit, (ii) evaluate the efficacy of non-myeloablative conditioning using busulfan, and (iii) test the ability of anti-thymocyte globulin (ATG) to prevent/reduce undesirable immune responses. RESULTS Transplantation of 10-20% hGPIbα(tg+/+) BM HSCs mixed with GPIbα(null) BM HSCs into irradiated GPIbα(null) mice was sufficient to correct bleeding time (n = 5). Transplantation of hGPIbα(tg+/+) BM HSCs into busulfan-conditioned GPIbα(null) mice corrected bleeding time in 21 of 27 recipients. Antibody response to hGPIbα and immune-mediated thrombocytopenia was documented in eight of 27 recipients, suggesting immunogenicity of hGPIbα in busulfan-conditioned GPIbα(null) mice. However, these antibodies disappeared without treatment within 30 weeks after transplantation. A combination of busulfan plus ATG conditioning successfully prevented antibody development and significantly increased therapeutic engraftment. CONCLUSION A conditioning regimen of busulfan in combination with ATG could potentially be used in non-myeloablative autologous gene therapy in human BSS.
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Affiliation(s)
- S Kanaji
- Blood Research Institute, Blood Center of Wisconsin, Milwaukee, WI, USA; The Scripps Research Institute, La Jolla, CA, USA
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Elbatarny M, Mollah S, Grabell J, Bae S, Deforest M, Tuttle A, Hopman W, Clark DS, Mauer AC, Bowman M, Riddel J, Christopherson PA, Montgomery RR, Rand ML, Coller B, James PD. Normal range of bleeding scores for the ISTH-BAT: adult and pediatric data from the merging project. Haemophilia 2014; 20:831-5. [PMID: 25196510 DOI: 10.1111/hae.12503] [Citation(s) in RCA: 191] [Impact Index Per Article: 19.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/18/2014] [Indexed: 10/24/2022]
Abstract
Bleeding Assessment Tools (BATs) have been developed to aid in the standardized evaluation of bleeding symptoms. The Vicenza Bleeding Questionnaire (BQ), published in 2005, established a common framework and scoring key that has undergone subsequent modification over the years, culminating in the publication of the ISTH-BAT in 2010. Understanding the normal range of bleeding scores is critical when assessing the utility of a BAT. Within the context of The Merging Project, a bioinformatics system was created to facilitate the merging of legacy data derived from four different (but all Vicenza-based) BATs; the MCMDM1-VWD BQ, the Condensed MCMDM-1VWD BQ, the Pediatric Bleeding Questionnaire and the ISTH-BAT. Data from 1040 normal adults and 328 children were included in the final analysis, which showed that the normal range is 0-3 for adult males, 0-5 for adult females and 0-2 in children for both males and females. Therefore, the cut-off for a positive or abnormal BS is ≥4 in adult males, ≥6 in adult females and ≥3 in children. This information can now be used to objectively assess bleeding symptoms as normal or abnormal in future studies.
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Affiliation(s)
- M Elbatarny
- Department of Medicine, Queen's University, Kingston, Canada
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Brott DA, Katein A, Thomas H, Lawton M, Montgomery RR, Richardson RJ, Louden CS. Evaluation of von Willebrand factor and von Willebrand factor propeptide in models of vascular endothelial cell activation, perturbation, and/or injury. Toxicol Pathol 2014; 42:672-83. [PMID: 24499802 DOI: 10.1177/0192623313518664] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Pharmacologically, vasoactive agents targeting endothelial and/or smooth muscle cells (SMC) are known to cause acute drug-induced vascular injury (DIVI) and the resulting pathology is due to endothelial cell (EC) perturbation, activation, and/or injury. Alteration in EC structure and/or function may be a critical event in vascular injury and, therefore, evaluation of the circulatory kinetic profile and secretory pattern of EC-specific proteins such as VWF and VWFpp could serve as acute vascular injury biomarkers. In rat and dog models of DIVI, this profile was determined using pharmacologically diverse agents associated with functional stimulation/perturbation (DDAVP), pathological activation (lipopolysaccharide [LPS]/endotoxin), and structural damage (fenoldopam [FD], dopamine [DA], and potassium channel opener (PCO) ZD6169). In rats, FD caused moderate DIVI and time-related increase in plasma VWF levels ∼33% while in control rats VWF increased ∼5%. In dogs, VWF levels transiently increased ∼30% when there was morphologic evidence of DIVI by DA or ZD6169. However, in dogs, VWFpp increased >60-fold (LPS) and >6-fold (DDAVP), respectively. This was in comparison to smaller dynamic 1.38-fold (LPS) and 0.54-fold (DDAVP) increases seen in plasma VWF. Furthermore, DA was associated with a dose-dependent increase in plasma VWFpp. In summary, VWF and VWFpp can discriminate between physiological and pathological perturbation, activation, and injury to ECs.
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Affiliation(s)
- David A Brott
- Global Safety Assessment, AstraZeneca Pharmaceuticals, Wilmington, Delaware, USA
| | - Anne Katein
- Global Safety Assessment, AstraZeneca Pharmaceuticals, Wilmington, Delaware, USA
| | - Heath Thomas
- Safety Assessment, Pathology, GlaxoSmithKline, King of Prussia, Pennsylvania, USA
| | - Michael Lawton
- Drug Safety Research & Development, Pfizer Worldwide Research & Development, Groton, Connecticut, USA
| | | | - Rudy J Richardson
- Department of Environmental Health Sciences, The University of Michigan, Ann Arbor, Michigan, USA
| | - Calvert S Louden
- Drug Safety Sciences, Janssen Pharmaceuticals, Spring House, Pennsylvania, USA
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Johansson MW, Kruger SJ, Schiebler ML, Evans MD, Sorkness RL, Denlinger LC, Busse WW, Jarjour NN, Montgomery RR, Mosher DF, Fain SB. Markers of vascular perturbation correlate with airway structural change in asthma. Am J Respir Crit Care Med 2013; 188:167-78. [PMID: 23855693 DOI: 10.1164/rccm.201301-0185oc] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
RATIONALE Air trapping and ventilation defects on imaging are characteristics of asthma. Airway wall thickening occurs in asthma and is associated with increased bronchial vascularity and vascular permeability. Vascular endothelial cell products have not been explored as a surrogate to mark structural airway changes in asthma. OBJECTIVES Determine whether reporters of vascular endothelial cell perturbation correlate with airway imaging metrics in patients with asthma of varying severity. METHODS Plasma from Severe Asthma Research Program subjects was analyzed by ELISAs for soluble von Willebrand factor mature protein (VWF:Ag) and propeptide (VWFpp), P-selectin, and platelet factor 4. Additional subjects were analyzed over 48 hours after whole-lung antigen challenge. We calculated ventilation defect volume by hyperpolarized helium-3 magnetic resonance imaging and areas of low signal density by multidetector computed tomography (less than -856 Hounsfield units [HU] at functional residual capacity and -950 HU at total lung capacity [TLC]). MEASUREMENTS AND MAIN RESULTS VWFpp and VWFpp/Ag ratio correlated with and predicted greater percentage defect volume on hyperpolarized helium-3 magnetic resonance imaging. P-selectin correlated with and predicted greater area of low density on chest multidetector computed tomography less than -950 HU at TLC. Platelet factor 4 did not correlate. Following whole-lung antigen challenge, variation in VWFpp, VWFpp/Ag, and P-selectin among time-points was less than that among subjects, indicating stability and repeatability of the measurements. CONCLUSIONS Plasma VWFpp and P-selectin may be useful as surrogates of functional and structural defects that are evident on imaging. The results raise important questions about why VWFpp and P-selectin are associated specifically with different imaging abnormalities.
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Affiliation(s)
- Mats W Johansson
- Department of Biomolecular Chemistry, University of Wisconsin, 4285A Medical Sciences Center, 1300 University Avenue, Madison, WI 53706, USA.
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Flood VH, Gill JC, Friedman KD, Christopherson PA, Jacobi PM, Hoffmann RG, Montgomery RR, Haberichter SL. Collagen binding provides a sensitive screen for variant von Willebrand disease. Clin Chem 2013; 59:684-91. [PMID: 23340442 DOI: 10.1373/clinchem.2012.199000] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND von Willebrand factor (VWF) is a multimeric protein that binds platelets and collagen, facilitating hemostasis at sites of vessel injury. Measurement of VWF multimer distribution is critical for diagnosis of variant von Willebrand disease (VWD), particularly types 2A and 2B, but the typical measurement by gel electrophoresis is technically difficult and time-consuming. A comparison of VWF collagen binding (VWF:CB) and VWF multimer distribution was performed to evaluate the utility of VWF:CB as a diagnostic test. METHODS Participants were enrolled in the Zimmerman Program for the Molecular and Clinical Biology of VWD. VWF:CB was analyzed with type III collagen and multimer distribution by agarose gel electrophoresis. The study population included 146 healthy controls, 351 individuals with type 1 VWD, and 77 with type 2 VWD. Differences between individuals with multimer group results within (controls) and outside the reference intervals were assessed with Mann-Whitney tests. RESULTS The mean VWF:CB/VWF antigen ratio was 1.10 for individuals with multimer distribution within the reference intervals and 0.51 for those with multimer distribution outside the reference intervals (P < 0.001). Sensitivity of VWF:CB for multimer abnormalities was 100% for healthy controls, 99% for patients with type 1, and 100% for patients with type 2A and type 2B VWD using a VWF:CB/VWF antigen cutoff ratio of 0.6, and decreased to 99% for all patients with a ratio of 0.7. With the exception of individuals with novel or unclassified mutations, the VWF:CB was able to correctly categorize participants with variant VWD. CONCLUSIONS These findings suggest that VWF:CB may substitute for multimer distribution in initial VWD testing, although further studies are needed to validate the clinical utility of VWF:CB.
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Affiliation(s)
- Veronica H Flood
- Department of Pediatrics, Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, WI, USA.
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Shi Q, Kuether EL, Schroeder JA, Perry CL, Fahs SA, Cox Gill J, Montgomery RR. Factor VIII inhibitors: von Willebrand factor makes a difference in vitro and in vivo. J Thromb Haemost 2012; 10:2328-37. [PMID: 22908929 PMCID: PMC3670966 DOI: 10.1111/j.1538-7836.2012.04902.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND The important association between von Willebrand factor (VWF) and factor VIII (FVIII) has been investigated for decades, but the effect of VWF on the reactivity of FVIII inhibitory antibodies, referred to as inhibitors, is still controversial. OBJECTIVE To investigate the interaction among VWF, FVIII and FVIII inhibitory antibodies. METHODS Three sources of inhibitors were used for in vitro studies, including the plasma from immunized VWF(null) FVIII(null) mice, purified plasma IgG from human inhibitor patients, or human monoclonal antibody from inhibitor patients' B-cell clones. Inhibitors were incubated with recombinant human FVIII (rhFVIII) either with or without VWF. The remaining FVIII activity was determined by chromogenic assay and inhibitor titers were determined. For in vivo studies, inhibitors and rhFVIII were infused into FVIII(null) or VWF(null) FVIII(null) mice followed by a tail clip survival test. RESULTS VWF has a dose-dependent protective effect on FVIII, limiting inhibitor inactivation of FVIII in both mouse and human samples. A preformed complex of VWF with FVIII provides more effective protection from inhibitors than competitive binding of antibodies and VWF to FVIII. The protective effect of VWF against FVIII inactivation by inhibitors was further confirmed in vivo by infusing inhibitors and FVIII into FVIII(null) or VWF(null) FVIII(null) mice followed by a tail clip survival test. CONCLUSION Our results demonstrate that VWF exerts a protective effect, reducing inhibitor inactivation of FVIII, both in vitro and in vivo.
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Affiliation(s)
- Q Shi
- Department of Pediatrics, Medical College of Wisconsin Blood Research Institute, BloodCenter of Wisconsin Children's Research Institute, Children's Hospital of Wisconsin, Milwaukee, WI, USA
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Abstract
BACKGROUND von Willebrand factor (VWF) is a glycoprotein that plays an important role in primary hemostasis. VWF is synthesized and stored in endothelial cells (ECs) and megakaryocytes/platelets. Plasma VWF is primarily derived from ECs and is generally believed to be essential for hemostasis. VWF synthesized in megakaryocytes is stored in platelet α-granules, from which it is released following platelet activation. The relative contribution of VWF stored in ECs or megakaryocytes/platelets or present in plasma to hemostasis is not clear. OBJECTIVES We investigated whether EC-derived VWF plays the major role in hemostasis while the contribution of platelet-derived VWF is negligible, or if platelet-derived VWF also significantly contributes to hemostasis. METHODS AND RESULTS Mice expressing VWF only in ECs (EC-VWF) or platelets (Plt-VWF) were created by reciprocal bone marrow transplantation between C57BL/6J (WT) and VWF knockout mice (VWF-/-). Plasma VWF levels in EC-VWF were similar to WT. Plt-VWF mice had a trace amount of VWF in their plasma while VWF levels in platelet lysate were comparable to WT. Tail bleeding time was normal in EC-VWF. Interestingly, Plt-VWF showed partially corrected bleeding time and significantly decreased blood loss volume compared with VWF-/-. Adhesion of platelets perfused over immobilized collagen under shear stress was significantly higher in both EC-VWF and Plt-VWF compared with VWF-/-. CONCLUSION VWF synthesized in ECs is sufficient to support hemostasis in VWF-/- mice, and VWF produced in megakaryocytes/platelets can also contribute to hemostasis in the absence of EC-derived VWF.
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Affiliation(s)
- S Kanaji
- Blood Research Institute, BloodCenter of Wisconsin, Department of Pediatrics, Medical College of Wisconsin, Children's Research Institute, Children's Hospital of Wisconsin, Milwaukee, WI 53226, USA.
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Kuether EL, Schroeder JA, Fahs SA, Cooley BC, Chen Y, Montgomery RR, Wilcox DA, Shi Q. Lentivirus-mediated platelet gene therapy of murine hemophilia A with pre-existing anti-factor VIII immunity. J Thromb Haemost 2012; 10:1570-80. [PMID: 22632092 PMCID: PMC3419807 DOI: 10.1111/j.1538-7836.2012.04791.x] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND The development of inhibitory antibodies, referred to as inhibitors, against exogenous factor VIII in a significant subset of patients with hemophilia A remains a persistent challenge to the efficacy of protein replacement therapy. Our previous studies using the transgenic approach provided proof-of-principle that platelet-specific expression could be successful in treating hemophilia A in the presence of inhibitory antibodies. OBJECTIVE To investigate a clinically translatable approach for platelet gene therapy of hemophilia A with pre-existing inhibitors. METHODS Platelet FVIII expression in preimmunized FVIII(null) mice was introduced by transplantation of lentivirus-transduced bone marrow or enriched hematopoietic stem cells. FVIII expression was determined with a chromogenic assay. The transgene copy number per cell was quantitated with real-time PCR. Inhibitor titer was measured with the Bethesda assay. Phenotypic correction was assessed by the tail clipping assay and an electrolytically induced venous injury model. Integration sites were analyzed with linear amplification-mediated PCR. RESULTS Therapeutic levels of platelet FVIII expression were sustained in the long term without evoking an anti-FVIII memory response in the transduced preimmunized recipients. The tail clip survival test and the electrolytic injury model confirmed that hemostasis was improved in the treated animals. Sequential bone marrow transplants showed sustained platelet FVIII expression resulting in phenotypic correction in preimmunized secondary and tertiary recipients. CONCLUSIONS Lentivirus-mediated platelet-specific gene transfer improves hemostasis in mice with hemophilia A with pre-existing inhibitors, indicating that this approach may be a promising strategy for gene therapy of hemophilia A even in the high-risk setting of pre-existing inhibitory antibodies.
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Affiliation(s)
- E L Kuether
- Department of Pediatrics, Medical College of Wisconsin, Blood Research Institute, BloodCenter of Wisconsin, Children's Research Institute, Children's Hospital of Wisconsin, Milwaukee, WI 53226, USA
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Flood VH, Gill JC, Christopherson PA, Wren JS, Friedman KD, Haberichter SL, Hoffmann RG, Montgomery RR. Comparison of type I, type III and type VI collagen binding assays in diagnosis of von Willebrand disease. J Thromb Haemost 2012; 10:1425-32. [PMID: 22507643 PMCID: PMC3809762 DOI: 10.1111/j.1538-7836.2012.04747.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND von Willebrand factor (VWF) plays a key role in coagulation by tethering platelets to injured subendothelium through binding sites for collagen and platelet GPIb. Collagen binding assays (VWF:CB), however, are not part of the routine work-up for von Willebrand disease (VWD). OBJECTIVES This study presents data on collagen binding for healthy controls and VWD subjects to compare three different collagens. PATIENTS/METHODS VWF antigen (VWF:Ag), VWF ristocetin cofactor activity and VWF:CB with types I, III and VI collagen were examined for samples obtained from the Zimmerman Program. RESULTS Mean VWF:CB in healthy controls was similar and highly correlated for types I, III and VI collagen. The mean VWF:CB/VWF:Ag ratios for types I, III and VI collagen were 1.31, 1.19 and 1.21, respectively. In type 1 VWD subjects, VWF:CB was similar to VWF:Ag with mean VWF:CB/VWF:Ag ratios for types I, III and VI collagen of 1.32, 1.08 and 1.1, respectively. For type 2A and 2B subjects, VWF:CB was uniformly low, with mean ratios of 0.62 and 0.7 for type I collagen, 0.38 and 0.4 for type III collagen, and 0.5 and 0.47 for type VI collagen. CONCLUSIONS Normal ranges for type I, III and VI collagen are correlated, but higher values were obtained with type I collagen as compared with types III and VI. The low VWF:CB in type 2A and 2B subjects suggests that VWF:CB may also supplement analysis of multimer distribution. However, these results reflect only one set of assay conditions per collagen type and therefore may not be generalizable to all collagen assays.
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Affiliation(s)
- V H Flood
- Department of Pediatrics, Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, WI, USA.
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Flood VH, Gill JC, Christopherson PA, Bellissimo DB, Friedman KD, Haberichter SL, Lentz SR, Montgomery RR. Critical von Willebrand factor A1 domain residues influence type VI collagen binding. J Thromb Haemost 2012; 10:1417-24. [PMID: 22507569 PMCID: PMC3809952 DOI: 10.1111/j.1538-7836.2012.04746.x] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND von Willebrand factor (VWF) binds to subendothelial collagen at sites of vascular injury. Laboratory testing for von Willebrand disease (VWD), however, does not always include collagen binding assays (VWF:CB) and standard VWF:CB assays use type I and/or type III collagen rather than type VI collagen. OBJECTIVES We report here on several mutations that exclusively alter binding to type VI collagen. PATIENTS/METHODS Healthy controls and index cases from the Zimmerman Program for the Molecular and Clinical Biology of VWD were analyzed for VWF antigen (VWF:Ag), VWF ristocetin cofactor activity and VWF:CB with types I, III and VI collagen. VWF gene sequencing was performed for all subjects. RESULTS Two healthy controls and one type 1 VWD subject were heterozygous for an A1 domain sequence variation, R1399H, and displayed a selective decreased binding to type VI collagen but not types I and III. Expression of recombinant 1399H VWF resulted in absent binding to type VI collagen. Two other VWF A1 domain mutations, S1387I and Q1402P, displayed diminished binding to type VI collagen. An 11 amino acid deletion in the A1 domain also abrogated binding to type VI collagen. CONCLUSIONS VWF:CB may be useful in diagnosis of VWD, as a decreased VWF:CB/VWF:Ag ratio may reflect specific loss of collagen binding ability. Mutations that exclusively affect type VI collagen binding may be associated with bleeding, yet missed by current VWF testing.
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Affiliation(s)
- V H Flood
- Department of Pediatrics, Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, WI 53201-2178, USA.
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Hubbard AR, Hamill M, Eikenboom HCJ, Montgomery RR, Mertens K, Haberichter S. Standardization of von Willebrand factor propeptide: value assignment to the WHO 6th IS Factor VIII/von Willebrand factor, plasma (07/316). J Thromb Haemost 2012; 10:959-60. [PMID: 22696769 PMCID: PMC4196679 DOI: 10.1111/j.1538-7836.2012.04672.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- A R Hubbard
- National Institute for Biological Standards and Control, Potters Bar, Hertfordshire, UK.
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Abstract
Hemostasis is achieved by the coordinate interaction of plasma, platelets, and vascular endothelium. Coagulation factors circulate in plasma with synthesis in liver and in endothelium. Interaction between Factor VIII (FVIII) and von Willebrand factor (VWF) in plasma is critically important, but there remains some question about whether this relationship is first established within the endothelial cell or in plasma. When FVIII is expressed with VWF in a cell that stores VWF, FVIII will also be stored and released. The manuscript will summarize some studies in which gene therapy exploits this relationship between VWF and FVIII to achieve hemostasis even in the presence of circulating inhibitory antibodies to FVIII. VWF is critical to this efficacy in the presence of inhibitors. Since FIX expression in platelets is effective for hemophilia B, efficacy in the presence of inhibitory antibodies to FIX was not achieved and emphasized the importance of VWF to the efficacy of platelet FVIII expression. These approaches have been studied in murine models but will need further study before this approach can be attempted clinically.
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Affiliation(s)
- Robert R Montgomery
- Blood Research Institute of BloodCenter of Wisconsin and Medical College of Wisconsin, Milwaukee, WI, USA.
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Kanaji S, Kuether EL, Fahs SA, Schroeder JA, Ware J, Montgomery RR, Shi Q. Correction of murine Bernard-Soulier syndrome by lentivirus-mediated gene therapy. Mol Ther 2012; 20:625-32. [PMID: 22044935 PMCID: PMC3293608 DOI: 10.1038/mt.2011.231] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2011] [Accepted: 09/28/2011] [Indexed: 12/29/2022] Open
Abstract
Bernard-Soulier syndrome (BSS) is an inherited bleeding disorder caused by a defect in the platelet glycoprotein (GP) Ib-IX-V complex. The main treatment for BSS is platelet transfusion but it is often limited to severe bleeding episodes or surgical interventions due to the risk of alloimmunization. We have previously reported successful expression of human GPIbα (hGPIbα) in human megakaryocytes using a lentiviral vector (LV) encoding human GP1BA under control of the platelet-specific integrin αIIb promoter (2bIbα). In this study, we examined the efficacy of this strategy for the gene therapy of BSS using GPIbα(null) as a murine model of BSS. GPIbα(null) hematopoietic stem cells (HSC) transduced with 2bIbα LV were transplanted into lethally irradiated GPIbα(null) littermates. Therapeutic levels of hGPIbα expression were achieved that corrected the tail bleeding time and improved the macrothrombocytopenia. Sequential bone marrow (BM) transplants showed sustained expression of hGPIbα with similar phenotypic correction. Antibody response to hGPIbα was documented in 1 of 17 total recipient mice but was tolerated without any further treatment. These results demonstrate that lentivirus-mediated gene transfer can provide sustained phenotypic correction of murine BSS, indicating that this approach may be a promising strategy for gene therapy of BSS patients.
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Affiliation(s)
- Sachiko Kanaji
- Blood Research Institute, Blood Center of Wisconsin, Milwaukee, Wisconsin, USA
| | - Erin L Kuether
- Blood Research Institute, Blood Center of Wisconsin, Milwaukee, Wisconsin, USA
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
- Children's Research Institute, Children's Hospital of Wisconsin, Milwaukee, Wisconsin, USA
| | - Scot A Fahs
- Blood Research Institute, Blood Center of Wisconsin, Milwaukee, Wisconsin, USA
| | - Jocelyn A Schroeder
- Blood Research Institute, Blood Center of Wisconsin, Milwaukee, Wisconsin, USA
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
- Children's Research Institute, Children's Hospital of Wisconsin, Milwaukee, Wisconsin, USA
| | - Jerry Ware
- Department of Physiology and Biophysics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Robert R Montgomery
- Blood Research Institute, Blood Center of Wisconsin, Milwaukee, Wisconsin, USA
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
- Children's Research Institute, Children's Hospital of Wisconsin, Milwaukee, Wisconsin, USA
| | - Qizhen Shi
- Blood Research Institute, Blood Center of Wisconsin, Milwaukee, Wisconsin, USA
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
- Children's Research Institute, Children's Hospital of Wisconsin, Milwaukee, Wisconsin, USA
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Shi Q, Kuether EL, Schroeder JA, Fahs SA, Montgomery RR. Intravascular recovery of VWF and FVIII following intraperitoneal injection and differences from intravenous and subcutaneous injection in mice. Haemophilia 2012; 18:639-46. [PMID: 22221819 DOI: 10.1111/j.1365-2516.2011.02735.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Intravenous infusion studies in humans suggest that both von Willebrand factor (VWF) and factor VIII (FVIII) remain intravascular in contrast to other coagulation proteins. We explored whether infusion of VWF and FVIII by either intraperitoneal (i.p.) or subcutaneous (s.c.) injection would result in efficient absorption of these large proteins into the vascular circulation. FVIII(null) or VWF(null) mice were infused with plasma-derived or recombinant VWF and/or FVIII by i.p., s.c., or intravenous (i.v.) injection. Both VWF and FVIII were absorbed into the blood circulation after i.p. injection with a peak between 2 and 4 h at levels similar to those observed in mice infused intravenously. In contrast, neither VWF nor FVIII was detected in the plasma following s.c. injection. Although i.v. injection achieved peak plasma levels quickly, both human VWF and FVIII rapidly decreased during the first 2 h following i.v. injection. Following both i.v. and i.p. infusion of VWF, the multimeric structure of circulating VWF was similar to that observed in the infusate. These results demonstrate that both VWF and FVIII can be efficiently absorbed into the blood circulation following i.p., but not s.c. injection, indicating that i.p. administration could be an alternative route for VWF or FVIII infusion.
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Affiliation(s)
- Q Shi
- Department of Pediatrics, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226, USA.
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Flood VH, Gill JC, Friedman KD, Bellissimo DB, Haberichter SL, Montgomery RR. Von Willebrand disease in the United States: a perspective from Wisconsin. Semin Thromb Hemost 2011; 37:528-34. [PMID: 22102196 DOI: 10.1055/s-0031-1281039] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
Von Willebrand disease (VWD) is a common bleeding disorder with prevalence in the United States of 0.01 to 1% and a prevalence in the region around Milwaukee, Wisconsin, of at least 0.025%. Care of local patients with VWD primarily occurs through our comprehensive treatment centers, although some patients are managed solely by their primary care physician or community hematologist. Type 1 VWD is the most common subtype, with more females carrying this diagnosis than males. Diagnosis and treatment in general follows guidelines outlined by the National Institutes of Health. An ongoing study, the Zimmerman Program for the Molecular and Clinical Biology of VWD, is currently enrolling patients with all VWD subtypes across the United States to better delineate the extent of VWD and correlate bleeding symptoms with laboratory findings and VWF ( Von Willebrand factor) sequence variations. Results so far have shown that VWF gene polymorphisms are common, particularly in African Americans, and may affect laboratory assays of VWF function.
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Affiliation(s)
- Veronica H Flood
- Division of Hematology/Oncology, Department of Pediatrics, Medical College of Wisconsin, Wisconsin 53201-2178, USA.
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Montgomery RR, Monahan PE, Ozelo MC. Unique strategies for therapeutic gene transfer in haemophilia A and haemophilia BWFH State-of-the-Art Session on Therapeutic Gene Transfer Buenos Aires, Argentina. Haemophilia 2011; 16 Suppl 5:29-34. [PMID: 20590853 DOI: 10.1111/j.1365-2516.2010.02290.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
SUMMARY Gene therapy of haemophilia has been initiated through a number of approaches including expression in muscle, liver and omental implanted fibroblasts, or i.v. injection of an expression construct under the control of a ubiquitous promoter. In all these approaches, the goal was to have factor VIII (FVIII) or factor IX (FIX) synthesized so that it restored the levels of the missing protein in blood. The three talks in this session are totally, or at least in part, directed at strategies that may be clinically effective even in the absence of correction of the missing plasma clotting factor, although the haematopoietic stem cell or blood outgrowth endothelial cell therapy could achieve plasma correction as well. Two of the approaches achieve localized coagulation factor expression without necessarily correcting the systemic defect--one is with synthesis of FVIII or FIX within the joint space and the other is with the local release of FVIII (or FIX) by platelets at the site of vascular injury. All of the three approaches have demonstrated efficacy in small animal models and are now the subject of larger animal studies. None has yet to progress to human trials.
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Castaman G, Montgomery RR, Meschengieser SS, Haberichter SL, Woods AI, Lazzari MA. von Willebrand's disease diagnosis and laboratory issues. Haemophilia 2011; 16 Suppl 5:67-73. [PMID: 20590859 DOI: 10.1111/j.1365-2516.2010.02296.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
SUMMARY In this paper, the recent developments in the diagnosis and laboratory issues of von Willebrand's disease (VWD) are presented. Dr. Castaman reviews the functional tests available for the diagnosis of VWD and their pathophysiological significance, focusing on which tests are best used in the diagnosis and classification of VWD. Dr Montgomery reviews an emerging issue that is accelerated clearance of von Willebrand factor (VWF) occurring in some variants of VWD. This phenotype can be suspected by the presence of an increased ratio between the VWF propeptide and the VWF antigen. These patients have typically a robust, but short-lived increase of FVIII and VWF after desmopressin. Dr Meschengieser reviews the determinants of bleeding after surgery in patients with VWD, emphasizing the role of bleeding history in predicting this risk.
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Affiliation(s)
- G Castaman
- Department of Cell Therapy and Hematology, Hemophilia and Thrombosis Center, San Bortolo Hospital, Vicenza, Italy.
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Shi Q, Montgomery RR. Platelets as delivery systems for disease treatments. Adv Drug Deliv Rev 2010; 62:1196-203. [PMID: 20619307 DOI: 10.1016/j.addr.2010.06.007] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2010] [Accepted: 06/29/2010] [Indexed: 12/23/2022]
Abstract
Platelets are small, anucleate, discoid shaped blood cells that play a fundamental role in hemostasis. Platelets contain a large number of biologically active molecules within cytoplasmic granules that are critical to normal platelet function. Because platelets circulate in blood through out the body, release biological molecules and mediators on demand and participate in hemostasis as well as many other pathophysiologic processes, targeting expression of proteins of interest to platelets and utilizing platelets as delivery systems for disease treatment would be a logical approach. This paper reviews the genetic therapy for inherited bleeding disorders utilizing platelets as delivery system, with a particular focus on platelet-derived FVIII for hemophilia A treatment.
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Flood VH, Lederman CA, Wren JS, Christopherson PA, Friedman KD, Hoffmann RG, Montgomery RR. Absent collagen binding in a VWF A3 domain mutant: utility of the VWF:CB in diagnosis of VWD. J Thromb Haemost 2010; 8:1431-3. [PMID: 20345715 PMCID: PMC3892206 DOI: 10.1111/j.1538-7836.2010.03869.x] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Veronica H. Flood
- Department of Pediatrics, Division of Hematology/Oncology, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI 53226
| | | | - Jeffrey S. Wren
- Blood Research Institute, BloodCenter of Wisconsin, 8727 Watertown Plank Rd, Milwaukee, WI 53226
| | - Pamela A. Christopherson
- Blood Research Institute, BloodCenter of Wisconsin, 8727 Watertown Plank Rd, Milwaukee, WI 53226
| | - Kenneth D. Friedman
- Blood Research Institute, BloodCenter of Wisconsin, 8727 Watertown Plank Rd, Milwaukee, WI 53226
| | - Raymond G. Hoffmann
- Department of Pediatrics, Division of Quantitative Health Sciences, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI 53226
| | - Robert R. Montgomery
- Department of Pediatrics, Division of Hematology/Oncology, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI 53226
- Blood Research Institute, BloodCenter of Wisconsin, 8727 Watertown Plank Rd, Milwaukee, WI 53226
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Abstract
Hemophilia A and B are monogenic disorders that were felt to be ideal targets for initiation of gene therapy. Although the first hemophilia gene therapy trial has been over 10 years ago, few trials are currently actively recruiting. Although preclinical studies in animals were promising, levels achieved in humans did not achieve long-term expression at adequate levels to achieve cures. Transplantation as a source of cellular replacement therapy for both hemophilia A and B have been successful following liver transplantation in which the recipient produces normal levels of either factor VIII (FVIII) or factor IX (FIX). Most of these transplants have been conducted for the treatment of liver failure rather than for "curing" hemophilia. There are a variety of new strategies for delivering the missing clotting factor through ectopic expression of the deficient protein. One approach uses hematopoietic stem cells using either a nonspecific promoter or using a lineage-specific promoter. An alternative strategy includes enhanced expression in endothelial cells or blood-outgrowth endothelial cells. An additional approach includes the expression of FVIII or FIX intraarticularly to mitigate the intraarticular bleeding that causes much of the disability for hemophilia patients. Because activated factor VII (FVIIa) can be used to treat patients with inhibitory antibodies to replacement clotting factors, preclinical gene therapy has been performed using platelet- or liver-targeted FVIIa expression. All of these newer approaches are just beginning to be explored in large animal models. Whereas improved recombinant replacement products continue to be the hallmark of hemophilia therapy, the frequency of replacement therapy is beginning to be addressed through longer-acting replacement products. A safe cure of hemophilia is still the desired goal, but many barriers must still be overcome.
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Affiliation(s)
- Robert R. Montgomery
- Blood Research Institute, BloodCenter of Wisconsin, and Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI
| | - Qizhen Shi
- Blood Research Institute, BloodCenter of Wisconsin, and Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI
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