Sensitization of CD4⁺ T Cells to Coagulation Factor VIII: Response in Congenital and Acquired Hemophilia Patients and in Healthy Subjects

Summary

Antibodies (Ab) that inhibit factor VIII (fVIII) may develop in patients with hemophilia A and rarely in individuals without congenital fVIII deficiency (acquired hemophilia). Synthesis of fVIII inhibitors requires CD4⁺ T cells. We investigated the proliferative response of blood CD4⁺ cells from 11 patients with congenital or acquired hemophilia and 12 healthy subjects, to recombinant human fVIII, and to pools of overlapping synthetic peptides spanning the sequences of individual fVIII domains. All patients had CD4⁺ cells that responded to fVIII. The intensity of the responses fluctuated over time: several patients had brief periods when they did not respond to fVIII. All healthy subjects had transient CD4⁺ responses to fVIII, that were significantly lower than those of hemophilia patients. Also, healthy subjects responded to fVIII less frequently and for shorter periods than hemophilia patients. All patients and healthy subjects recognized several fVIII domains: the A3 domain was recognized most strongly and frequently. The transient sensitization of CD4⁺ cells to fVIII in healthy subjects suggests that inadequate tolerization of CD4⁺ cells to fVIII, due to lack of endogenous fVIII, is an important factor in the development of clinically significant anti-fVIII antibodies in hemophilia A.

Key words

Immune response - T cells - factor VIII - inhibitors

⁴ Previously known as Bianca M. Conti-Tronconi

• References

• 1 Vehar GA, Keyt B, Eaton D, Rodriguez H, O’Brien DP, Rotblat F, Oppermann H, Keck R, Wood WI, Harkins RN, Tuddenham EGD, Lawn RM, Capon DJ. Structure of human factor VIII. Nature 1984; 312: 337-42.
• 2 Hoyer LW. Hemophilia A. N Engl J Med 1994; 330: 38-47.
• 3 Hoyer LW. The incidence of factor VIII inhibitors in patients with severe hemophilia A. In: Aledort LM, Hoyer LW, Lusher JM, Reisner HM, White GC. eds. Inhibitors to Coagulation Factors. Adv Exp Med Biol. 1995. 386 35-45.
• 4 Cohen AJ, Kessler CM. Acquired inhibitors. Baillieres Clin Haematol 1996; 09: 331-54.
• 5 Lollar P. Characterization of factor VIII B-cell Inhibitory epitopes. Thromb Haemost 1999; 82: 505-8.
• 6 Nilsson IM, Berntorp E, Zettervall O, Dahlback B. Noncoagulation inhibitory factor VIII antibody after induction of tolerance to factor VIII in hemophilia A patients. Blood 1990; 75: 378-83.
• 7 Gilles JGG, Arnout J, Vermylen J, Saint-Remy J-MR. Anti-factor VIII antibodies of hemophiliac patients are frequently directed towards nonfunctional determinants and do not exhibit isotypic restriction. Blood 1993; 82: 2452-61.
• 8 Bray GL, Kroner BL, Arkin S, Aledort LW, Hilgartner MW, Etster ME, Ragni MV, Goedert JJ. Loss of high-responder inhibitors in patients with severe hemophilia A and human immunodeficiency virus type 1 infection: A report from the multi-center hemophilia cohort study. Am J Hematol 1993; 42: 375-9.
• 9 Qian J, Collins M, Hoyer LW. Prevention of factor VIII inhibitors in murine hemophilia. Blood 1998; 92: 709a.
• 10 Batlle J, Gomez E, Rendal E, Torea J, Loures E, Couselo M, Vila P, Sedano C, Tusell X, Magallon M, Quintana M, Gonzalez-Boullosa R, Lopez-Fernandez MF. Ab to factor VIII in plasma of patients with hemophilia A and normal subjects. Ann Hematol 1996; 72: 321-6.
• 11 Gilles JG, Saint-Remy J-MR. Healthy subjects produce both anti-factor VIII and specific anti-idiotypic antibodies. J Clin Invest 1994; 94: 1496-505.
• 12 Algiman M, Dietrich G, Nydegger UE, Boieldieu D, Sultan Y, Kazatchkine MD. Natural Ab to factor VIII (anti-hemophilic factor) in healthy individuals. Proc Natl Acad Sci USA 1992; 89: 3795-9.
• 13 Burns J, Rosenzweig A, Zweiman B, Lisak RP. Isolation of myelin basic protein-reactive T-cell lines from normal human blood. Cell Immunol 1983; 81: 435-40.
• 14 Morel-Kopp MC, Tchernia G, Lambert T, Verdy E, Schlegel N, Dreyfus M, Chateauvieux L, Kaplan C. AutoAb directed against the platelet GP complex Ib-IX in normal individuals. Blood 1992; 80: 49a.
• 15 Ito Y, Nieda M, Uchigata Y, Nishimura M, Tokunaga K, Kuwata S, Obata F, Tadokoro K, Hirata Y, Omori Y, Juji T. Recognition of human insulin in the context of HLA-DRB1*0406 products by T cells of insulin autoimmune syndrome patients and healthy donors. J Immunol 1993; 151: 5770-6.
• 16 Hoffman RW, Takeda Y, Sharp GC, Lee DR, Hill DL, Kaneoka H, Caldwell CW. Human T cell clones reactive against U-small nuclear ribonucleoprotein autoantigens from connective tissue disease patients and healthy individuals. J Immunol 1993; 151: 6460-9.
• 17 Moiola L, Karachunski P, Protti M, Howard J, Conti-Tronconi BM. Epitopes on the β subunit of muscle acetylcholine receptor recognized by CD4⁺ cells of myasthenia patients and healthy subjects. J Clin Invest 1994; 93: 1020-8.
• 18 Kuwana M, Medsger Jr TA, Wright TM. T cell proliferative response induced by DNA topoisomerase I in patients with systemic sclerosis and healthy donors. J Clin Invest 1995; 96: 586-96.
• 19 Matzinger P. Tolerance, danger, and the extended family. Ann Rev Immunol 1994; 12: 991-1045.
• 20 Reding MT, Wu H, Krampf M, Okita DK, Diethelm-Okita BM, Key NS, Conti-Fine BM. CD4⁺ T cell response to factor VIII in hemophilia A, acquired hemophilia, and healthy subjects. Thromb Haemost 1999; 82: 509-15.
• 21 Houghten RA. General method for the rapid solid-phase synthesis of large numbers of peptides: Specificity of antigen-antibody interaction at the level of individual amino acids. Proc Natl Acad Sci USA 1985; 82: 5131-5.
• 22 Stern LJ, Brown JH, Jardetzky TS, Gorga JC, Urban RG, Strominger JL, Wiley DC. Crystal structure of the human class II MHC protein HLA-DR1 complexed with an influenza virus peptide. Nature 1994; 368: 215-21.
• 23 Manfredi AA, Protti MP, Dalton MWM, Howard Jr JF, Conti-Tronconi BM. Myasthenia Gravis: T helper repertoire on the γ and δ subunits of human muscle acetylcholine receptor. J Clin Invest 1993; 92: 1055-67.
• 24 Raju R, Navaneetham D, Okita DK, Diethelm-Okita B, McCormick D, Conti-Fine BM. Epitopes for human CD4⁺ T cells on diphtheria toxin: structural features of sequence segments forming epitopes recognized by most subjects. Eur J Immunol 1995; 25: 3207-14.
• 25 Diethelm-Okita B, Okita DK, Banaszak LJ, Conti-Fine BM. Universal epitopes for human CD4⁺ cells on tetanus and diphtheria toxins. J Infect Dis 2000; 181: 1001-9.
• 26 Wang ZY, Okita DK, Howard JF, Conti-Fine BM. Differential T cell recognition of the muscle acetylcholine receptor subunits in generalized and ocular myasthenia gravis. Neurology 1998; 50: 1045-54.
• 27 Verbruggen B, Novakova I, Wessels H, Boezman J, van den Berg M, Mauser-Bunschoten E. The Nijmegen modification of the Bethesda assay for FVIII:C inhibitors: improved specificity and reliability. Thromb Haemost 1995; 73: 247-51.
• 28 Pemberton S, Lindley P, Zaitsev V, Card G, Tuddenham EG, Kemball-Cook G. A molecular model for the triplicated A domains of human factor VIII based on the crystal structure of human ceruloplasmin. Blood 1997; 89: 2413-21.
• 29 Mason D. A very high level of crossreactivity is an essential feature of the T cell receptor. Immunol Today 1998; 19: 395-404.
• 30 Newton-Nash DK, Gill JC, Foster PA. Cellular immune responses to coagulant factor VIII in F.VIII inhibitor patients. In: Aledort LM, Hoyer LW, Lusher JM, Reisner HM, White GC. eds. Inhibitors to Coagulation Factors. Adv Exp Med Biol. 1995. 386 285.
• 31 Singer ST, Addiego Jr JE, Reason DC, Lucas A. T lymphocyte proliferative responses induced by recombinant factor VIII in hemophilia A patients with inhibitors. Thromb Haemost 1996; 76: 17-22.
• 32 Johnson JG, Jenkins MK. The role of anergy in peripheral T cell unresponsiveness. Life Sci 1994; 55: 1767-80.
• 33 Schwartz RH. Models of T cell anergy: Is there a common molecular mechanism?. J Exp Med 1996; 184: 1-8.
• 34 Herzog RW, Yang EY, Couto LB, Hagstrom JN, Elwell D, Fields PA, Burton M, Bellinger DA, Read MS, Brinkhous KM, Podsakoff GM, Nichols TC, Kurtzman GJ, High KA. Long-term correction of canine hemophilia B by gene transfer of blood coagulation factor IX mediated by adeno-associated viral vector. Nat Med 1999; 05: 56-63.
• 35 Snyder RO, Miao C, Meuse L, Tubb J, Donahue BA, Lin H-F, Stafford DW, Patel S, Thompson AR, Nichols T, Read MS, Bellinger DA, Brinkhous KM, Kay MA. Correction of hemophilia B in canine and murine models using recombinant adeno-associated viral vectors. Nat Med 1999; 05: 64-70.
• 36 Herzog RW, Fields PA, Arruda VR, Elwell D, Nichols TC, Couto LB, Hagstrom JN, High KA. Characterization of immune responses to factor IX in small and large animal models for gene therapy. Blood 1998; 92: 689a.
• 37 Lozier JN, High KA. Molecular basis of hemophilia. Hematologic Pathology 1990; 04: 1-26.
• 38 Evans JP, Brinkhous KM, Brayer GD, Reisner HM, High KA. Canine hemophilia B resulting from a point mutation with unusual consequences. Proc Natl Acad Sci USA 1989; 86: 10095-9.
• 39 Chicz RM, Urban RG, Gorga JC, Vignali DAA, Lane WS, Strominger JL. Specificity and promiscuity among naturally processed peptides bound to HLA-DR alleles. J Exp Med 1993; 178: 27-47.
• 40 Karachunski P, Ostlie N, Okita D, Conti-Fine BM. Protection from experimental myasthenia gravis in C57Bl/6 mice by sniffing of synthetic CD4⁺ T cells epitopes. J Clin Invest 1997; 100: 3027-35.
• 41 Karachunski PI, Ostlie NS, Okita DK, Garman R, Conti-Fine BM. Subcutaneous administration of T epitope sequences of the acetylcholine receptor prevents experimental myasthenia gravis. J Neuroimmunol 1999; 93: 108-21.