Frequency of T Regulatory Cells Subpopulations in Hemophilia A Patients with Inhibitors

Abstract

Hemophilia A is a hemorrhagic disease caused by a quantitative/qualitative deficiency of factor VIII. It is classified as severe, moderate, or mild based on its residual procoagulant activity. Long-term administration of FVIII promotes the development of neutralizing antibodies (inhibitors) in almost 30% of patients with the severe form of the disease. Currently, the role of regulatory T cells in the development of these antibodies is conflicting. Accordingly, the aim of this study was to determine the percentage of regulatory T cells subpopulations by flow cytometry in 10 healthy subjects, 15 patients with severe hemophilia without inhibitors, and 8 with inhibitors. No significant differences in the frequency of regulatory T cells subpopulations were found between hemophilia A patients with inhibitors versus hemophilia A patients without inhibitors or healthy subjects. Our results suggest that the role of the regulatory T cells populations on the development of inhibitors in adult patients with hemophilia A is questionable. However, further analysis of the etiological relevance of these cells requires future research.

Keywords

hemophilia - inhibitors - regulatory T cells

Publikationsverlauf

Eingereicht: 22. Dezember 2024

Angenommen: 27. August 2025

Artikel online veröffentlicht:
02. Februar 2026

• References

• 1 García-Chávez J, Majluf-Cruz A. Hemofilia. Gac Med Mex 2013; 149 (03) 308-321
• 2 Santagostino E, Dougall A, Jackson M. et al. Chapter 2: Comprehensive care of hemophilia. WFH Guidelines for the Management of Hemophilia, 3rd edition. Haemophilia 2020; 26 (Suppl 6): 19-34
• 3 Ragni MV, Berntorp E, Carcao M. et al. Chapter 8: Inhibitors to clotting factor. Haemophilia 2020; 26 (Suppl. 06) 95-107
• 4 Green D. Factor VIII inhibitors: a 50-year perspective. Haemophilia 2011; 17 (06) 831-838
• 5 Lacroix-Desmazes S, Moreau A, Sooryanarayana. et al. Catalytic activity of antibodies against factor VIII in patients with hemophilia A. Nat Med 1999; 5 (09) 1044-1047
• 6 Astermark J. Basic aspects of inhibitors to factors VIII and IX and the influence of non-genetic risk factors. Haemophilia 2006; 12 (Suppl. 06) 8-13 , discussion 13–14
• 7 Lacroix-Desmazes S, Navarrete AM, André S, Bayry J, Kaveri SV, Dasgupta S. Dynamics of factor VIII interactions determine its immunologic fate in hemophilia A. Blood 2008; 112 (02) 240-249
• 8 Gershon RK, Kondo K. Cell interactions in the induction of tolerance: the role of thymic lymphocytes. Immunology 1970; 18 (05) 723-737
• 9 Sakaguchi S, Sakaguchi N, Asano M, Itoh M, Toda M. Immunologic self-tolerance maintained by activated T cells expressing IL-2 receptor alpha-chains (CD25). Breakdown of a single mechanism of self-tolerance causes various autoimmune diseases. J Immunol 1995; 155 (03) 1151-1164
• 10 Bodor J, Bopp T, Vaeth M. et al. Cyclic AMP underpins suppression by regulatory T cells. Eur J Immunol 2012; 42 (06) 1375-1384
• 11 Wardell CM, MacDonald KN, Levings MK, Cook L. Cross talk between human regulatory T cells and antigen-presenting cells: lessons for clinical applications. Eur J Immunol 2021; 51 (01) 27-38
• 12 Vignali DAA, Collison LW, Workman CJ. How regulatory T cells work. Nat Rev Immunol 2008; 8 (07) 523-532
• 13 Ding KY, Ji WC, Wu JS, Li T, Sheng YY. Higher frequency of CD4(+)CD25(high) Treg cells in hemophilia patients with factor VIII inhibitor. Genet Mol Res 2014; 13 (01) 1774-1781
• 14 El-Asrar MA, Hamed Ael-S, Darwish YW, Ismail EAR, Ismail NA. Assessment of the frequency of regulatory T cells (CD4+CD25+CD127-) in children with hemophilia A: relation to factor VIII inhibitors and disease severity. Blood Coagul Fibrinolysis 2016; 27 (01) 42-46
• 15 Schep SJ, Schutgens REG, Fischer K, Voorberg J, Boes M. Role of regulatory cells in immune tolerance induction in hemophilia A. HemaSphere 2021; 5 (05) e557
• 16 Arandi N, Zekavat OR, Shokrgozar N, Shahsavani A, Golmoghaddam H, Kalani M. Altered frequency of FOXP3⁺ regulatory T cells is associated with development of inhibitors in patients with severe hemophilia A. Int J Lab Hematol 2023; 45 (06) 953-960
• 17 Kleinewietfeld M, Starke M, Di Mitri D. et al. CD49d provides access to “untouched” human Foxp3+ Treg free of contaminating effector cells. Blood 2009; 113 (04) 827-836
• 18 Santegoets SJAM, Dijkgraaf EM, Battaglia A. et al. Monitoring regulatory T cells in clinical samples: consensus on an essential marker set and gating strategy for regulatory T cell analysis by flow cytometry. Cancer Immunol Immunother 2015; 64 (10) 1271-1286
• 19 Zong Y, Deng K, Chong WP. Regulation of Treg cells by cytokine signaling and co-stimulatory molecules. Front Immunol 2024; 15: 1387975
• 20 Witmer C, Young G. Factor VIII inhibitors in hemophilia A: rationale and latest evidence. Ther Adv Hematol 2013; 4 (01) 59-72
• 21 Salminen A. Activation of immunosuppressive network in the aging process. Ageing Res Rev 2020; 57 (Jan): 100998
• 22 Chien CH, Chiang BL. Regulatory T cells induced by B cells: a novel subpopulation of regulatory T cells. J Biomed Sci 2017; 24 (01) 86
• 23 Roncarolo MG, Gregori S, Bacchetta R, Battaglia M, Gagliani N. The biology of T regulatory type 1 cells and their therapeutic application in immune-mediated diseases. Immunity 2018; 49 (06) 1004-1019
• 24 Gandhi R, Farez MF, Wang Y, Kozoriz D, Quintana FJ, Weiner HL. Cutting edge: human latency-associated peptide+ T cells: a novel regulatory T cell subset. J Immunol 2010; 184 (09) 4620-4624
• 25 Long SA, Buckner JH. CD4+FOXP3+ T regulatory cells in human autoimmunity: more than a numbers game. J Immunol 2011; 187 (05) 2061-2066
• 26 Gouw SC, van den Berg HM, Fischer K. et al; PedNet and Research of Determinants of INhibitor development (RODIN) Study Group. Intensity of factor VIII treatment and inhibitor development in children with severe hemophilia A: the RODIN study. Blood 2013; 121 (20) 4046-4055
• 27 Kmieciak M, Gowda M, Graham L. et al. Human T cells express CD25 and Foxp3 upon activation and exhibit effector/memory phenotypes without any regulatory/suppressor function. J Transl Med 2009; 7: 89
• 28 Zerra PE, Cox C, Baldwin WH. et al. Marginal zone B cells are critical to factor VIII inhibitor formation in mice with hemophilia A. Blood 2017; 130 (23) 2559-2568
• 29 Navarrete A, Dasgupta S, Delignat S. et al. Splenic marginal zone antigen-presenting cells are critical for the primary allo-immune response to therapeutic factor VIII in hemophilia A. J Thromb Haemost 2009; 7 (11) 1816-1823
• 30 Li C, Muñoz-Rojas AR, Wang G, Mann AO, Benoist C, Mathis D. PPARγ marks splenic precursors of multiple nonlymphoid-tissue Treg compartments. Proc Natl Acad Sci U S A 2021; 118 (13) e2025197118
• 31 Dhaeze T, Peelen E, Hombrouck A. et al. Circulating follicular regulatory T cells are defective in multiple sclerosis. J Immunol 2015; 195 (03) 832-840
• 32 Zhang A-H, Yoon J, Kim YC, Scott DW. Targeting antigen-specific B cells using antigen-expressing transduced regulatory T cells. J Immunol 2018; 201 (05) 1434-1441
• 33 Pohl AP, Venkatesha SH, Zhang AH, Scott DW. Suppression of FVIII-specific memory B cells by chimeric BAR receptor-engineered natural regulatory T cells. Front Immunol 2020; 11 (April): 693
• 34 Parvathaneni K, Scott DW. Engineered FVIII-expressing cytotoxic T cells target and kill FVIII-specific B cells in vitro and in vivo. Blood Adv 2018; 2 (18) 2332-2340
• 35 Boulassel MR, Al-Ghonimi M, Al-Balushi B. et al. Regulatory B cells are functionally impaired in patients having hemophilia A with inhibitors. Clin Appl Thromb Hemost 2018; 24 (04) 618-624