Clinical experience with polyelectrolyte-fractionated porcine factor VIII concentrate in the treatment of hemophiliacs with antibodies to factor VIII

Abstract Circulating antibodies to factor VIII (anti-VIII, “inhibitors”) occurring in patients with hemophilia neutralize porcine factor VIII less readily than human factor VIII in vitro. Over an 18-mo period, 8 patients with anti-VIII were treated with 45 courses (297 infusions) of polyelectrolyte-fractionated porcine factor VIII concentrate (PE porcine VIII). Where no anti-PE porcine VIII was detectable, mean post- infusion rise in plasma factor VIII was 1.29 U/dl/units infused/kg. Above 13 Old Oxford units of anti-PE porcine VIII and 48 Bethesda units of anti-human VIII, there were no postinfusion rises in plasma factor VIII. Where postinfusion rises were detected, clinical responses were good and conventional methods could be used to guide dosage. Ten percent of infusions were followed by febrile reactions, but these were usually mild and decreased in frequency and severity with increasing exposure. Multiple and prolonged courses of therapy were given to some patients without evidence of loss of clinical or laboratory efficacy. PE porcine VIII could provoke anamnestic rises of anti-VIII in susceptible patients, but appeared to have a lower immunogenic potential than human VIII. PE porcine VIII is a rational and effective therapeutic alternative for patients with anti-VIII, particularly those with intermediate level inhibitors who cannot be managed effectively using human factor VIII.

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Clinical experience with polyelectrolyte-fractionated porcine factor VIII concentrate in the treatment of hemophiliacs with antibodies to factor VIII

Blood ◽

10.1182/blood.v63.1.31.bloodjournal63131 ◽

1984 ◽

Vol 63 (1) ◽

pp. 31-41 ◽

Cited By ~ 1

Author(s):

PB Kernoff ◽

ND Thomas ◽

PA Lilley ◽

KB Matthews ◽

E Goldman ◽

...

Keyword(s):

Factor Viii ◽

Clinical Experience ◽

Human Factor ◽

Intermediate Level ◽

Human Factor Viii ◽

Plasma Factor ◽

Post Infusion ◽

Clinical Responses ◽

Circulating Antibodies

Circulating antibodies to factor VIII (anti-VIII, “inhibitors”) occurring in patients with hemophilia neutralize porcine factor VIII less readily than human factor VIII in vitro. Over an 18-mo period, 8 patients with anti-VIII were treated with 45 courses (297 infusions) of polyelectrolyte-fractionated porcine factor VIII concentrate (PE porcine VIII). Where no anti-PE porcine VIII was detectable, mean post- infusion rise in plasma factor VIII was 1.29 U/dl/units infused/kg. Above 13 Old Oxford units of anti-PE porcine VIII and 48 Bethesda units of anti-human VIII, there were no postinfusion rises in plasma factor VIII. Where postinfusion rises were detected, clinical responses were good and conventional methods could be used to guide dosage. Ten percent of infusions were followed by febrile reactions, but these were usually mild and decreased in frequency and severity with increasing exposure. Multiple and prolonged courses of therapy were given to some patients without evidence of loss of clinical or laboratory efficacy. PE porcine VIII could provoke anamnestic rises of anti-VIII in susceptible patients, but appeared to have a lower immunogenic potential than human VIII. PE porcine VIII is a rational and effective therapeutic alternative for patients with anti-VIII, particularly those with intermediate level inhibitors who cannot be managed effectively using human factor VIII.

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Localization of epitopes for human factor VIII inhibitor antibodies by immunoblotting and antibody neutralization

Blood ◽

10.1182/blood.v74.5.1618.bloodjournal7451618 ◽

1989 ◽

Vol 74 (5) ◽

pp. 1618-1626 ◽

Cited By ~ 1

Author(s):

D Scandella ◽

M Mattingly ◽

S de Graaf ◽

CA Fulcher

Keyword(s):

Factor Viii ◽

Human Factor ◽

Factor Viii Inhibitor ◽

Type I ◽

Protein Fragments ◽

Human Factor Viii ◽

Circulating Antibodies ◽

A1 Domain ◽

A2 Domain

Human factor VIII(FVIII) inhibitors are pathologic, circulating antibodies that inactivate FVIII. We have examined the location of epitopes on the FVIII protein for inhibitors from hemophilia A and nonhemophilic individuals. The inhibitors were of type I or type II in the kinetics of their inactivation of FVIII. A cDNA clone of human FVIII was used to express defined FVIII protein fragments in Escherichia coli for immunoblotting with inhibitor plasma. An epitope for 18 heavy-chain inhibitors was localized to the aminoterminal 18.3 Kd of the A2 domain. Two of these inhibitors also recognized an epitope located between A1 and A2 domains. Similarly, an epitope for 23 light- chain inhibitors was localized to the C2 domain. Weaker epitopes for 13 of the same inhibitors within the C1 and C2 domains were also observed. Four of the 23 inhibitors in addition bound strongly to the A3 domain. Most inhibitors (22 of 23) were neutralized in vitro only by the FVIII fragments to which they bound on immunoblots; however, one inhibitor that was neutralized by a fragment containing the A1 domain did not bind to it on immunoblots. Conversely, 3 of 3 inhibitors that bound to the A3 domain and 5 of 15 that bound to the A2 domain were not neutralized by the corresponding fragments. The epitope specificity of an inhibitor did not depend on its source or type. Our results show that FVIII inhibitors bind to limited areas within the heavy and light chains of FVIII. Some inhibitor plasmas contain additional antibodies that may not be inhibitory.

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Polyelectrolyte Fractionated Porcine Factor VIII Concentrate In The Treatment Of Haemophiliacs With Antibodies To Factor VIII: C

10.1055/s-0038-1652541 ◽

1981 ◽

Cited By ~ 2

Author(s):

P B A Kernoff ◽

N D Thomas ◽

P A Lilley ◽

E G D Tuddenham

Keyword(s):

Factor Viii ◽

Adverse Reactions ◽

Human Factor ◽

High Plasma ◽

Major Drawback ◽

Therapeutic Value ◽

Human Factor Viii ◽

Clinical Responses ◽

Bleeding Episodes

Antibodies to procoagulant factor VIII (anti-VIII:C) occurring in patients with haemophilia neutralise porcine factor VIII:C less readily than human factor VIII: C in vitro. Porcine factor VIII concentrate (porcine VIII) therefore has potential advantages in the treatment of such patients. Polyelectrolyte-fractionated porcine VIII (PE porcine VIII) lacks a major drawback of earlier preparations of porcine VIII in that it contains negligible quantities of platelet aggregating factor (PAF). The purpose of this study was to make a preliminary clinical assessment of the therapeutic value of PE porcine VIII. Over 6 months, 12 courses of treatment were given to four patients with circulating anti-VIII: C. Bleeding episodes treated ranged from the potentially lethal to moderately severe joint and muscle haemorrhages. Duration of courses was from 24 hrs. to more than 3 weeks. Clinical responses were strikingly good and no patient developed thrombocytopenia. Occasional mild pyrogenic-type transfusion reactions were encountered, but these were easily controlled. Dose- response relationships were most favourable in patients with low pre-infusion levels of anti-VIII: C activity against PE porcine VIII but excellent clinical responses could be obtained without achieving high plasma VIII: C levels. Multiple courses of therapy (up to 6) were given to individual patients without evidence of loss of clinical or laboratory efficacy, or an increased tendency to adverse reactions. There was no evidence of resistance in the patient who was treated daily for more than 3 weeks. Only 1 course of therapy was followed by a classical anamnestic rise in anti-VIII: C, and this course had included human factor VIII. PE porcine VIII appears to have a low immunogenic potential, and is a rational and effective therapeutic alternative for patients with anti-VIII: C.

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Human Factor VIII Concentrates in Hemophiliac Dogs

10.1055/s-0039-1682593 ◽

1977 ◽

Author(s):

Jessica H. Lewis ◽

Ute Hasiba ◽

Joel A. Spero

Keyword(s):

Factor Viii ◽

Human Factor ◽

Rapid Development ◽

The Third ◽

Human Factor Viii ◽

Post Infusion ◽

Factor Viii Concentrates ◽

In Vitro Effects

Human factor VIII corrects the clotting defect in dog hemophilic plasma in vitro. The present studies were undertaken to see if this happened in vivo and to look for and document the development of an inhibitor. Four hemophiliac dogs were infused with factor VIII concentrates, the first two on five occasions, the others three times. Factor VIII:C, VIIIR:Ag (defined with antibody to human VIII) and VIIIR:vW were followed at pre, 10 minutes, 2 and 24 hours post infusion. The pre-infusion VIII:C (assayed with human substrate) averaged 0.23 U/ml compared to 6.93 U/ml for normal dogs; VIIIR:Ag was absent in both. VIIIR:vW was low but variable. Following the first injection, all four dogs responded in VIII:C about as calculated. The amounts of VIIIR:Ag and vW were much greater than VIII:C in the concentrates and in the post-first infusion samples from the dogs. On subsequent infusions rises in VIIIR:Ag were not detected and increases in VIII:C and VIIIR:vW were minimal. Precipitating anti-human VIII was found on the third infusion and thereafter. After the first infusion reactions were marked. Vomiting and diarrhea occurred in all, and one dog died in anaphylactic shock about one hour after the third infusion. Lack of response in VIIIR:Ag occurred before anti-VIII could be demonstrated in vitro. This rapid development of an inhibitor suggests that prolonged cross-species VIII therapy will not be successful. The ability of the precipitating anti-VIII elicited in the dogs to destroy VIII:C, VIIIR:Ag and VIIIR:vW is analagous to the in vitro effects of heterologous anti-VIIIs (rabbit and goat).

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Localization of epitopes for human factor VIII inhibitor antibodies by immunoblotting and antibody neutralization

Blood ◽

10.1182/blood.v74.5.1618.1618 ◽

1989 ◽

Vol 74 (5) ◽

pp. 1618-1626 ◽

Cited By ~ 92

Author(s):

D Scandella ◽

M Mattingly ◽

S de Graaf ◽

CA Fulcher

Keyword(s):

Factor Viii ◽

Human Factor ◽

Factor Viii Inhibitor ◽

Type I ◽

Protein Fragments ◽

Human Factor Viii ◽

Circulating Antibodies ◽

A1 Domain ◽

A2 Domain

Abstract Human factor VIII(FVIII) inhibitors are pathologic, circulating antibodies that inactivate FVIII. We have examined the location of epitopes on the FVIII protein for inhibitors from hemophilia A and nonhemophilic individuals. The inhibitors were of type I or type II in the kinetics of their inactivation of FVIII. A cDNA clone of human FVIII was used to express defined FVIII protein fragments in Escherichia coli for immunoblotting with inhibitor plasma. An epitope for 18 heavy-chain inhibitors was localized to the aminoterminal 18.3 Kd of the A2 domain. Two of these inhibitors also recognized an epitope located between A1 and A2 domains. Similarly, an epitope for 23 light- chain inhibitors was localized to the C2 domain. Weaker epitopes for 13 of the same inhibitors within the C1 and C2 domains were also observed. Four of the 23 inhibitors in addition bound strongly to the A3 domain. Most inhibitors (22 of 23) were neutralized in vitro only by the FVIII fragments to which they bound on immunoblots; however, one inhibitor that was neutralized by a fragment containing the A1 domain did not bind to it on immunoblots. Conversely, 3 of 3 inhibitors that bound to the A3 domain and 5 of 15 that bound to the A2 domain were not neutralized by the corresponding fragments. The epitope specificity of an inhibitor did not depend on its source or type. Our results show that FVIII inhibitors bind to limited areas within the heavy and light chains of FVIII. Some inhibitor plasmas contain additional antibodies that may not be inhibitory.

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The Fractionation Properties of Human Factor VIII (Antihaemophilic Factor)

Thrombosis and Haemostasis ◽

10.1055/s-0038-1654503 ◽

1960 ◽

Vol 04 (02) ◽

pp. 253-260 ◽

Cited By ~ 1

Author(s):

Franco Gobbi

Keyword(s):

Factor Viii ◽

Human Factor ◽

Maximum Yield ◽

Factor Vii ◽

Precipitation Method ◽

Salting Out ◽

Human Factor Viii ◽

Plasma Factor ◽

Two Factors ◽

Thromboplastic Activity

SummaryThe fractionation properties of human Factor VIII (antihaemophilic factor, AHF, antihaemophilic globulin) have been studied using a plasma of congenital afibrinogenaemia as a starting material.From a fibrinogen-free plasma, Factor VIII does not precipitate with ethanol at a final concentration of 8%; on the contrary the maximum yield is reached at an ethanol concentration of 25%.With a precipitation method carried out by a one to ten dilution of plasma with distilled water and acidification by N/10 hydrochloric acid to a pFI 5.2, Factor VIII does not precipitate with the euglobulin fraction; when normal plasma is used, such a precipitation is almost complete.With the salting-out fractionation method by ammonium sulphate, Factor VIII precipitates at a concentration between 25 and 33% of saturation either from fibrinogen-free and from normal human plasma.A non-specific thromboplastic activity appears in the fractions prepared by every method. This activity, which is probably due to the activation of seric accelerators, is easily removed by Al(OH)s adsorption. Thus, in order to insure the specificity of Factor VIII assays, the preliminary adsorption of the fractions is indispensable before testing their antihaemophilic activity.Fibrinogen and Factor VIII have different and definite precipitation patterns. When these two factors are associated the fractionation properties of AHF appear quite modified, showing a close similarity to those of fibrinogen. This fact can explain the technical difficulties encountered in the attempt to purify the antihaemophilic factor, and the lack of reproducible procedures for removing fibrinogen without affecting Factor VII.

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Impaired Prothrombin Consumption in Bernard-Soulier Syndrome Is Corrected In Vitro by Human Factor VIII

Thrombosis and Haemostasis ◽

10.1055/s-0038-1655972 ◽

1997 ◽

Vol 77 (02) ◽

pp. 383-386 ◽

Cited By ~ 8

Author(s):

S Bellucci ◽

J P Girma ◽

M Lozano ◽

D Meyer ◽

J P Caen

Keyword(s):

Factor Viii ◽

Human Factor ◽

Platelet Membrane ◽

Giant Platelets ◽

Prolonged Bleeding Time ◽

Human Factor Viii ◽

Von Willebrand ◽

Willebrand Factor ◽

Bernard Soulier Syndrome

SummaryThe Bernard-Soulier syndrome (BSS) is characterized by thrombocytopenia with giant platelets, a prolonged bleeding time with defective platelet adhesion to the subendothelium related to a defect in platelet membrane glycoprotein lb (GPIb) and a decreased prothrombin consumption. The mechanism of the latter abnormality remains unknown. In this study, we showed that this defect was corrected by the addition of purified human factor VIII (FVIII) to blood from four patients with BSS. The correction of prothrombin consumption was almost complete at concentrations between 1.5 and 3 IU/ml of FVIII procoagulant activity (VIII.'C) and partially abolished by a monoclonal antibody which neutralizes VIII:C. This correction was specific for FVIII and was not observed after addition of purified human FIX. It was obtained, in the same magnitude range, with FVIII complexed to von Willebrand factor (vWF) but not with free vWF. These data provide a new insight into the knowledge of the physiological interaction between the platelet membrane and the vWF-FVIII complex facilitating plasma coagulation activation and may lead to helpful therapeutic advances.

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Factor VIII/von Willebrand factor in subendothelium mediates platelet adhesion

Blood ◽

10.1182/blood.v65.4.823.bloodjournal654823 ◽

1985 ◽

Vol 65 (4) ◽

pp. 823-831 ◽

Cited By ~ 2

Author(s):

VT Turitto ◽

HJ Weiss ◽

TS Zimmerman ◽

II Sussman

Keyword(s):

Factor Viii ◽

Von Willebrand Factor ◽

Vessel Wall ◽

Platelet Adhesion ◽

Human Factor ◽

Rabbit Aorta ◽

Human Factor Viii ◽

Plasma Factor ◽

Von Willebrand ◽

Willebrand Factor

The present studies were undertaken to determine whether factor VIII/von Willebrand factor (vWF) present in the vessel wall (in addition to that in plasma) may mediate the attachment of platelets to subendothelium. Subendothelium from everted rabbit aorta was exposed to human citrated blood flowing through an annular perfusion chamber at 40 mL/min (wall shear rate of 2,600 s-1 for five minutes). The vessel segments were incubated at 37 degrees C for one hour with various dilutions of either goat-anti-rabbit factor VIII/vWF serum or an IgG fraction prepared from the serum. Control segments were incubated with serum or IgG from a nonimmunized goat. Values of platelet contact (C), platelet adhesion (C + S), and thrombus formation (T) on the subendothelium were evaluated by a morphometric technique. Compared with vessels incubated with fractions prepared from a normal goat, a significant decrease in platelet adhesion (C + S), ranging from 45% to 65%, was observed on vessels incubated with various dilutions (1:5 to 1:50) of either serum or IgG fractions of goat-anti-rabbit factor VIII/vWF. A similar decrease in platelet adhesion was observed with vessels incubated with an F(ab')2 fragment against rabbit factor VIII/vWF prepared in the goat. When goat-anti-rabbit factor VIII/vWF IgG was added to rabbit blood (1:75 dilution), platelet adhesion was reduced to the same extent (65%) on normal rabbit vessels and on vessels pre-incubated with goat-anti-rabbit factor VIII/vWF. Immunofluorescence studies revealed the presence of rabbit factor VIII/vWF in the subendothelium of rabbit aorta and the continued binding of the goat-anti-factor VIII/vWF antibodies on subendothelium during the perfusion studies. No uptake of human factor VIII/vWF on the rabbit subendothelium was observed by this immunologic technique; human factor VIII/vWF was found to be entirely associated with the attached human platelets. Thus, factor VIII/vWF in the vessel wall may mediate platelet attachment to subendothelium in a manner similar to that of plasma factor VIII/vWF.

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Use of porcine factor VIII in the treatment of patients with acquired hemophilia

Blood ◽

10.1182/blood.v81.6.1513.1513 ◽

1993 ◽

Vol 81 (6) ◽

pp. 1513-1520 ◽

Cited By ~ 166

Author(s):

AE Morrison ◽

CA Ludlam ◽

C Kessler

Keyword(s):

Factor Viii ◽

Acquired Hemophilia ◽

First Line Therapy ◽

Human Factor Viii ◽

Plasma Factor ◽

Inhibitor Level ◽

Clinical Responses ◽

Bleeding Episodes ◽

Antibody Levels ◽

Auto Antibody

Abstract Data have been collected from 47 centers in Europe and North America on the treatment with porcine factor VIII concentrate of 74 acute bleeding episodes in 65 patients with acquired hemophilia. The median initial anti-human factor VIII auto-antibody inhibitor level was 38 Bethesda unit (BU)/mL (range 1.2 to 1,024) whereas that against porcine was 1 BU/mL (range 0 to 15). The mean initial dose of porcine factor VIII infused was 84 IU/kg, which increased the plasma factor VIII:C activity by 0.85 IU/mL. Therapy was continued for a mean of 8.5 days during which time the average number of infusions was 11. Objective clinical responses were rated as good or excellent in 78% of recipients. Side effects were uncommon; only one patient experienced a severe anaphylactic reaction necessitating the discontinuation of porcine FVIII therapy. After therapy, no increase in the median level of anti- human FVIII or anti-porcine antibody was noted in the group as a whole, although 13 patients showed individual increases in either anti-human or anti-porcine antibody levels or both of more than 10 BU/mL. Of the 7 patients who subsequently rebled, 5 were successfully re-treated and 2 did not respond to further porcine factor VIII treatment. Porcine factor VIII is safe and clinically effective treatment for bleeding episodes associated with acquired hemophilia and should be considered as first-line therapy for patients whose acquired anti-factor VIII:C antibody cross-reacts with porcine factor VIII:C at low levels.

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