Immune tolerance induction: What have we learned over time?

Development of inhibitory antibodies to infused factor VIII (FVIII) concentrates continues to be the most serious complication of haemophilia A management. Induction of immune tolerance by administering high doses of FVIII concentrate (antigen) and prothrombin complex concentrates to control bleeding was originated in the 1970s in Bonn, Germany, by Dr Hans-Hermann Brackmann, and became known as the Bonn protocol. ITI transformed the life of the index patient, who was 19 years of age when he began treatment, and dramatically improved the medical landscape for all patients with haemophilia and inhibitors. Over the past 40 years, variations to the Bonn protocol have been proposed. All protocols are effective although some are better suited than others for use in certain situations. The specific molecular defect in FVIII and the human leucocyte antigen (HLA) type of an individual with haemophilia are major codependent determinants to inhibitor development. Given the range of potential molecular defects and the staggering number of potential HLA types, it is likely that treatment arms of randomized studies in haemophilia represent highly diverse populations, which reduces the power of a study to demonstrate differences between treatments. Although available clinical guidelines and consensus recommendations for ITI therapy are not always in complete agreement, collectively the guidelines provide a reasonable level of guidance for administering ITI therapy under different clinical scenarios. Several studies of ITI therapy are ongoing with the aim of clarifying unresolved issues in haemophilia management including the role of von Willebrand factor in inhibitor eradication.

Rap1b is critical for glycoprotein VI-mediated but not ADP receptor-mediated alpha2beta1 activation.

BACKGROUND: The platelet alpha2beta1 integrin functions as both an adhesion and signaling receptor upon exposure to collagen. Recent studies have indicated that alpha2beta1 function can be activated via inside-out signaling, similar to the prototypical platelet integrin alphaIIbbeta3. However, signaling molecules that regulate alpha2beta1 activation in platelets are not well defined. A strong candidate molecule is the small GTPase Rap1b, the dominant platelet isoform of Rap1, which regulates alphaIIbbeta3 activation. OBJECTIVES: We hypothesized that Rap1b positively regulates alpha2beta1 during agonist-induced platelet activation. METHODS: To test whether Rap1b activates alpha2beta1 downstream of glycoprotein (GP)VI or other platelet receptors, we stimulated platelets purified from Rap1b-/- or wild-type mice with diverse agonists and measured alpha2beta1 activation using fluorescein isothiocyanate-labeled monomeric collagen. We also examined the role of Rap1b in outside-in signaling pathways by analyzing adhesion and spreading of Rap1b-/- or wild-type platelets on monomeric, immobilized collagen. Finally, we monitored the activation status of related Rap GTPases to detect changes in signaling pathways potentially associated with Rap1b-mediated events. RESULTS: Rap1b-/- platelets displayed comparable ADP-induced or thrombin-induced alpha2beta1 activation as wild-type platelets, but reduced convulxin-dependent alpha2beta1 activation. Rap1b-/- platelets exhibited increased spreading on immobilized collagen but similar adhesion to immobilized collagen compared to wild-type platelets. Rap1b-/- platelets also showed Rap1a and Rap2 activation upon agonist stimulation, possibly revealing functional compensation among Rap family members. CONCLUSIONS: Rap1b is required for maximal GPVI-induced but not ADP-induced activation of alpha2beta1 in murine platelets.

Breeding in high-elevation habitat results in shift to slower life-history strategy within a single species.

1. Elevational gradients create environmental variation that is hypothesized to promote variation in life-history strategies. We tested whether differences in life-history strategies were associated with elevation in a songbird, the dark-eyed junco (Junco hyemalis; Aves; A.O.U. 1998). 2. We monitored birds in four replicated sites per elevation, at 2000 m a.s.l. (high elevation) and 1000 m a.s.l. (low elevation), in the Rocky Mountains of Canada. 3. Over 5 years, we measured the following traits and vital rates: egg-laying schedules, morphological indicators of reproductive stage, seasonal reproductive success, indicators of competitive class (age, size, arrival time), and survival rates. 4. We found two main patterns: with an increase in breeding elevation, dark-eyed juncos delayed the development of structures necessary for reproduction (e.g. cloacal protuberance in males) and reduced the duration of their reproductive period to less than half of the time used by low-elevation birds; and 5. Juncos at high-elevation sites had 55-61% lower annual reproductive success and 15 to 20% higher survival rates. While adult juncos at high elevations produced fewer offspring, those offspring were in better condition. Proportions of age and size classes in high- compared to low-elevation populations were similar, suggesting that a life-history trade-off is present, rather than competition forcing inferior competitors to breed in a peripheral habitat. The apparent trade-off between reproduction and survival corresponded to a shorter period of favourable weather and available food in high- compared to low-elevation habitats. 6. Thus, elevation had a strong influence on life-history characteristics of a single species over a short spatial distance, suggesting a shift in life history from a high reproductive strategy at lower elevations to a high survivor strategy at high elevations. 7. This is the first paper to show a shift in avian life-history strategies along an elevational gradient (in both genders, of multiple age classes) when region (latitude) and phylogenetic histories are controlled for.

Cellular immune responses in hemophilia: why do inhibitors develop in some, but not all hemophiliacs?

Advances in molecular immunology over the past two decades permit a better understanding of why antibodies develop to peptide antigens like factor VIII and the events that lead to the development of these antibodies. Two important variables that are critical in antibody formation are (i) the molecular defect in FVIII and the consequences of that defect on translation and protein production, and (ii) the major histocompatibility complex (MHC) molecules which bind specific peptide sequences and present those peptides to CD4 T lymphocytes to initiate the cellular cascade leading to B-cell stimulation and differentiation, and ultimately to antibody formation. Inhibitors develop in hemophilia because transfused FVIII can be seen as a foreign protein and elicits an immune response in much the same way that any other foreign protein might elicit an immune response. However, not all hemophiliacs generate an immune response, either because they do not recognize FVIII as foreign or because their MHC phenotype is such that a cellular immune response is not initiated. In this model, it is the combination of molecular defect and MHC phenotype that determines inhibitor formation. The interplay of these two variables in the context of why some but not all hemophiliacs develop antibodies after treatment with replacement factor is reviewed.

B-domain deleted recombinant factor VIII preparations are bioequivalent to a monoclonal antibody purified plasma-derived factor VIII concentrate: a randomized, three-way crossover study.

BACKGROUND: Deletion of the B-domain of recombinant blood coagulation factor VIII (BDDrFVIII) increases the manufacturing yield of the product but does not impair in vitro or in vivo functionality. BDDrFVIII (ReFacto) has been developed with the additional benefit of being formulated without human albumin. OBJECTIVE: The primary objective of this three-way crossover-design study was to compare the pharmacokinetic (PK) parameters of two BDDrFVIII formulations (one reconstituted with 5 mL of sterile water, the other reconstituted with 4 mL sodium chloride 0.9% USP) with those of a plasma-derived, full-length FVIII preparation (Hemofil M) in patients with haemophilia A to determine bioequivalence. METHODS: A series of blood samples were collected over a period of 48 h after i.v. administration of each of the FVIII preparations. Plasma FVIII activity was determined using a validated chromogenic substrate assay. Plasma FVIII activity vs. time curves was characterized for a standard set of PK parameter estimates. Two parameter estimates, the maximum plasma concentration (Cmax) and the area under plasma concentration vs. time curves (AUCs), were used to evaluate bioequivalence. The two preparations were considered bioequivalent if the 90% confidence intervals for the ratio of geometric means for Cmax and AUCs fell within the bioequivalence window of 80% to 125%. RESULTS/CONCLUSION: Results show that each BDDrFVIII formulation is bioequivalent to Hemofil M and the two formulations of BDDrFVIII are bioequivalent to each other.

Phase I study of a novel recombinant human soluble thrombomodulin, ART-123.

BACKGROUND: Anticoagulants are often given for extended periods of time to patients at high risk for venous thromboembolism, such as after orthopedic surgery. Daily subcutaneous (sc) injections can be inconvenient to the patient. A long-acting anticoagulant requiring less frequent dosing could make treatment more acceptable. Thrombomodulin is a natural anticoagulant that activates protein C, which leads to inactivation of factor (F)Va and FVIIIa and decreased thrombin formation. Recombinant human thrombomodulin is a novel anticoagulant with a long half-life in animal models. METHODS AND RESULTS: This phase I study examined pharmacokinetics, pharmacodynamics, and safety of recombinant human soluble thrombomodulin (ART-123) after administration of doses between 0.02 and 0.06 mg kg(-1) body weight intravenously (iv), and between 0.02 and 0.45 mg kg(-1) sc in 55 healthy volunteers. The plasma half-life was 2-3 days after sc injection of various single doses. Plasma ART-123 levels estimated to be needed for prevention of thrombus formation in humans were maintained for at least 6 days after single sc injection of 0.30 and 0.45 mg kg(-1) ART-123. Antithrombotic activity with these doses was demonstrated by achieving prothrombinase inhibition of more than 80% for more than 6 days after administration. No major bleeding occurred. Pharmacodynamic modeling revealed that adequate antithrombotic ART-123 levels can be achieved for 6 days with one dose of 0.45 mg kg(-1) ART-123, and for 12 days with 2 doses of 0.30 mg kg(-1), given 5 days apart. CONCLUSIONS: Recombinant human soluble thrombomodulin (ART-123) has a long half-life after sc injection and is well tolerated, making it a suitable agent to be tested in clinical thromboprophylaxis trials.

Cranial pseudotumour in haemophilia.

Intracranial pseudotumour has rarely been reported in haemophilia. We present the fourth case describing this complication.

Induction of megakaryocytes to synthesize and store a releasable pool of human factor VIII.

von Willebrand factor (VWF) is a complex plasma glycoprotein that modulates platelet adhesion at the site of a vascular injury, and it also serves as a carrier protein for factor (F)VIII. As megakaryocytes are the only hematopoietic lineage to naturally synthesize and store VWF within alpha-granules, this study was performed to determine if expression of a FVIII transgene in megakaryocytes could lead to trafficking and storage of FVIII with VWF in platelet alpha-granules. Isolex selected CD34+ cells from human G-CSF mobilized peripheral blood cells (PBC) and murine bone marrow were transduced with a retrovirus encoding the B-domain deleted form of human FVIII (BDD-FVIII). Cells were then induced with cytokines to form a population of multiple lineages including megakaryocytes. Chromogenic analysis of culture supernatant from FVIII-transduced human cells demonstrated synthesis of functional FVIII. Treatment of cells with agonists of platelet activation (ADP, epinephrine, and thrombin receptor-activating peptide) resulted in the release of VWF antigen and active FVIII into the supernatant from transduced cells. Immunofluorescence analysis of cultured human and murine megakaryocytes revealed a punctate pattern of staining for FVIII that was consistent with staining for VWF. Electron microscopy of transduced megakaryocytes using immunogold-conjugated antibodies colocalized FVIII and VWF within the alpha-granules. FVIII retained its association with VWF in human platelets isolated from the peripheral blood of NOD/SCID mice at 2-6 weeks post-transplant of transduced human PBC. These results suggest feasibility for the development of a locally inducible secretory pool of FVIII in platelets of patients with hemophilia A.

Gene therapy for platelet disorders: studies with Glanzmann's thrombasthenia.

Current research aimed at correcting platelet defects are designed to further our knowledge in the use of hematopoietic stem cells for gene therapies of hemorrhagic disorders. Information gained from these studies may be directly applicable to treatment of disorders affecting platelets (e.g. Glanzmann's thrombasthenia, Bernard Soulier syndrome, gray platelet syndrome, and von Willebrand disease) as well as other disorders affecting distinct hematopoietic cell lineages. This work specifically addresses three questions: (i) can bone marrow stem cells be given sufficient genetic information to induce abnormal megakaryocytes to synthesize transgene products that help newly formed platelets to participate in normal hemostasis? (ii) can the newly synthesized receptor be maintained as a platelet-specific protein at therapeutic levels for a reasonable period of time? and (iii) will newly expressed proteins be tolerated by the immune system or become a target for B- and T-cell mediated immunity resulting in the premature destruction and clearing of the genetically altered megakaryocytes and platelets? Answers to these questions should indicate the feasibility of targeting platelets with genetic therapies that will in turn enable better management of patients with inherited bleeding disorders. The long-range benefit of this research will be an improved understanding of the regulation of protein expression during normal megakaryocytopoiesis, and the accumulation of additional scientific knowledge about normal platelet function and the way in which platelets and other cells recognize and interact with each other.

Identification of T-cell epitopes in clotting factor IX and lack of tolerance in inbred mice.

Immune responses to the factor IX protein pose problems for hemophilia B patients who develop antibodies against factor IX and for potential future treatment with gene therapy. To better define the response to human factor IX, we analyzed T-cell responses to human factor IX in factor IX knockout mice on BALB/c and C57BL/6 (B6) backgrounds, both strains having CD4+ T cells that proliferate in response to human factor IX. Surprisingly, wild-type mice have similar factor IX-recognizing CD4+ T cells. We defined a dominant CD4+ epitope for each strain (CVETGVKITVVAGEH for BALB/c and LLELDEPLVLNSYVTPIC for B6) that was recognized by both factor IX knockout and wild-type mice. While human factor IX did not cross-react with the mouse homologs of these epitopes, immunization with peptides from murine factor IX stimulated proliferation in factor IX knockout mice and wild-type mice, demonstrating a failure to delete murine factor IX-specific T cells in normal mice.

Use of recombinant factor IX in subjects with haemophilia B undergoing surgery.

Recombinant human FIX (rFIX) was evaluated in 28 subjects, including 26 with mild, moderate, or severe haemophilia B and two haemophilia B carriers undergoing 36 surgical procedures. Preoperative rFIX dose was highly correlated with postinfusion FIX activity, r=0.61, P=0.0158. Peri- and post-operative estimated blood loss was similar to that expected in non-haemophilic individuals, and haemostasis was rated as excellent or good in 34 of 35 (97.1%) of the operative procedures. Transfusions were required in five of 36 (13.9%) procedures, including one liver transplantation, and three knee and one hip arthroplasties. Adverse events occurred in 15 of 28 (53.6%) subjects, but there were no perioperative haemorrhages, thromboembolic events, coagulation activation, viral transmission, or inhibitor formation. A transient low-responding FIX inhibitor developed in one subject preoperatively, but required no change in treatment and resolved 15 months later. Thus, rFIX was found to be safe and effective in achieving haemostasis in subjects with FIX deficiency undergoing surgery.