Effect of the First Factor VIII Infusions on Immunological Biomarkers in Previously Untreated Patients with Hemophilia A from the HEMFIL StudyFunding This study was funded by FAPEMIG (CDS – APQ-04185–10 and CDS – PPM-00205–14), CAPES (grant number 88881.068041/2014–01), and CNPq (grant number 456080/2014–7).
Hemophilia A (HA) is an inherited bleeding disorder which requires continuous replacement with factor (F) VIII concentrate. The main complication of HA is the development of neutralizing alloantibodies which inhibit FVIII activity (inhibitors). The objective of this study was to investigate the effect of the first FVIII infusions on immunological biomarkers in previously untreated patients with HA. Plasma samples were collected at enrollment before any FVIII infusion (T0) and at inhibitor development (INB +/T1) or up to 35 exposure days without inhibitors (INB −/T1). Anti-FVIII antibodies (immunoglobulin M, immunoglobulin G [IgG] 1, IgG3, and IgG4), chemokines (CCL2, CCL5, CXCL8, CXCL9, and CXCL10), and cytokines (interleukin [IL]-2, IL-4, IL-6, IL-10, interferon-γ, tumor necrosis factor, and IL-17) were assessed. A total of 71 children with severe HA were included, of whom 28 (39.4%) developed inhibitors. Plasma levels of anti-FVIII IgG4, IL-6, and CXCL8 were higher at INB +/T1 when compared with INB −/T1. This group presented a mixed cytokine profile and higher plasma levels of CXCL9 and CXL10 when compared with INB +/T1. We conclude that exposure to FVIII triggers a proinflammatory response mediated by IL-6 and CXCL8 in patients with HA who developed inhibitors. Regardless of inhibitor status, the immune system of all HA patients is stimulated after infusions of FVIII.
L.M.M.O. and L.L.J. performed the research, analyzed the data, and wrote the manuscript; M.P.S., M.H.C., C.S.L., and V.K.B.F. selected the patients and collected the clinical data; L.W.Z. performed the molecular tests; D.G.C. and S.M.R. designed the research, contributed to data analysis, and wrote the manuscript. All authors revised and approved the final version of the manuscript.
* These authors contributed equally to the work.
Eingereicht: 19. August 2020
Angenommen: 21. November 2020
10. Januar 2021 (online)
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- 1 Rizza CR, Spooner RJ. Treatment of haemophilia and related disorders in Britain and Northern Ireland during 1976-80: report on behalf of the directors of haemophilia centres in the United Kingdom. Br Med J (Clin Res Ed) 1983; 286 (6369): 929-933
- 2 Mahlangu J, Cerquiera M, Srivastava A. Emerging therapies for haemophilia - global perspective. Haemophilia 2018; 24 (Suppl. 06) 15-21
- 3 Peters R, Harris T. Advances and innovations in haemophilia treatment. Nat Rev Drug Discov 2018; 17 (07) 493-508
- 4 Hu G, Guo D, Key NS, Conti-Fine BM. Cytokine production by CD4+ T cells specific for coagulation factor VIII in healthy subjects and haemophilia A patients. Thromb Haemost 2007; 97 (05) 788-794
- 5 Chaves DG, Velloso-Rodrigues C, Oliveira CA, Teixeira-Carvalho A, Santoro MM, Martins-Filho OA. A shift towards a T cell cytokine deficiency along with an anti-inflammatory/regulatory microenvironment may enable the synthesis of anti-FVIII inhibitors in haemophilia A patients. Clin Exp Immunol 2010; 162 (03) 425-437
- 6 Oliveira CA, Velloso-Rodrigues C, Machado FC. et al. Cytokine profile and FVIII inhibitors development in haemophilia A. Haemophilia 2013; 19 (03) e139-e142
- 7 Jardim LL, Chaves DG, Silveira-Cassette ACO. et al. Immune status of patients with haemophilia A before exposure to factor VIII: first results from the HEMFIL study. Br J Haematol 2017; 178 (06) 971-978
- 8 Verbruggen B, van Heerde W, Novákovà I, Lillicrap D, Giles A. A 4% solution of bovine serum albumin may be used in place of factor VIII:C deficient plasma in the control sample in the Nijmegen Modification of the Bethesda factor VIII:C inhibitor assay. Thromb Haemost 2002; 88 (02) 362-364
- 9 Rossetti LC, Radic CP, Larripa IB, De Brasi CD. Developing a new generation of tests for genotyping hemophilia-causative rearrangements involving int22h and int1h hotspots in the factor VIII gene. J Thromb Haemost 2008; 6 (05) 830-836
- 10 Pio SF, Mühle C, De Oliveira GC, Rezende SM. Detection of int1h-related inversion of the factor VIII gene. Haemophilia 2011; 17 (02) 313-314
- 11 Rosendaal FR, Palla R, Garagiola I, Mannucci PM, Peyvandi F. SIPPET Study Group. Genetic risk stratification to reduce inhibitor development in the early treatment of hemophilia A: a SIPPET analysis. Blood 2017; 130 (15) 1757-1759
- 12 Taylor R. Interpretation of the correlation coefficient: a basic review. J Diagn Med Sonogr 1990; 1: 35-39
- 13 Tanaka T, Narazaki M, Kishimoto T. IL-6 in inflammation, immunity, and disease. Cold Spring Harb Perspect Biol 2014; 6 (10) a016295
- 14 Lin E, Calvano SE, Lowry SF. Inflammatory cytokines and cell response in surgery. Surgery 2000; 127 (02) 117-126
- 15 Charo IF, Ransohoff RM. The many roles of chemokines and chemokine receptors in inflammation. N Engl J Med 2006; 354 (06) 610-621
- 16 Delignat S, Rayes J, Russick J, Kaveri SV, Lacroix-Desmazes S. ABIRISK consortium. Inhibitor formation in congenital hemophilia A: an immunological perspective. Semin Thromb Hemost 2018; 44 (06) 517-530
- 17 Harada A, Sekido N, Akahoshi T, Wada T, Mukaida N, Matsushima K. Essential involvement of interleukin-8 (IL-8) in acute inflammation. J Leukoc Biol 1994; 56 (05) 559-564
- 18 Luster AD. Chemokines--chemotactic cytokines that mediate inflammation. N Engl J Med 1998; 338 (07) 436-445
- 19 Ragni MV, Wu W, Liang X, Hsieh CC, Cortese-Hassett A, Lu L. Factor VIII-pulsed dendritic cells reduce anti-factor VIII antibody formation in the hemophilia A mouse model. Exp Hematol 2009; 37 (06) 744-754
- 20 Gaitonde P, Peng A, Straubinger RM, Bankert RB, Balu-Iyer SV. Downregulation of CD40 signal and induction of TGF-β by phosphatidylinositol mediates reduction in immunogenicity against recombinant human Factor VIII. J Pharm Sci 2012; 101 (01) 48-55
- 21 Sun J, Yuan Z, Abajas YL. et al. A retrospective study of the cytokine profile changes in mice with FVIII inhibitor development after adeno-associated virus–mediated gene therapy in a hemophilia A mouse model. Hum Gene Ther 2018; 29 (03) 381-389
- 22 Qadura M, Waters B, Burnett E. et al. Immunoglobulin isotypes and functional anti-FVIII antibodies in response to FVIII treatment in Balb/c and C57BL/6 haemophilia A mice. Haemophilia 2011; 17 (02) 288-295
- 23 van Helden PMW, van den Berg HM, Gouw SC. et al. IgG subclasses of anti-FVIII antibodies during immune tolerance induction in patients with hemophilia A. Br J Haematol 2008; 142 (04) 644-652
- 24 Boylan B, Rice AS, Dunn AL. et al; Hemophilia Inhibitor Research Study Investigators, Hemophilia Inhibitor Research Study Investigators. Characterization of the anti-factor VIII immunoglobulin profile in patients with hemophilia A by use of a fluorescence-based immunoassay. J Thromb Haemost 2015; 13 (01) 47-53
- 25 Montalvão SAL, Tucunduva AC, Siqueira LH, Sambo AL, Medina SS, Ozelo MC. A longitudinal evaluation of anti-FVIII antibodies demonstrated IgG4 subclass is mainly correlated with high-titre inhibitor in haemophilia A patients. Haemophilia 2015; 21 (05) 686-692
- 26 Whelan SFJ, Hofbauer CJ, Horling FM. et al. Distinct characteristics of antibody responses against factor VIII in healthy individuals and in different cohorts of hemophilia A patients. Blood 2013; 121 (06) 1039-1048
- 27 Lazarchick J, Hoyer LW. The properties of immune complexes formed by human antibodies to factor VIII. J Clin Invest 1977; 60 (05) 1070-1079
- 28 Hartholt RB, Wroblewska A, Herczenik E. et al. Enhanced uptake of blood coagulation factor VIII containing immune complexes by antigen presenting cells. J Thromb Haemost 2017; 15 (02) 329-340
- 29 Varthaman A, Lacroix-Desmazes S. Pathogenic immune response to therapeutic factor VIII: exacerbated response or failed induction of tolerance?. Haematologica 2019; 104 (02) 236-244