Chromogenic Assay Research Articles

Evaluation of proteolytic activity and serine proteases distribution in plasma from patients with bladder cancer.

Bladder cancer (BC) is an aggressive disease with a poor prognosis. A bladder tumor, like other malignant neoplasms, is characterized by the presence of both cancer cells and stromal cells which secrete cytokines, chemokines, growth factors, and proteolytic enzymes. One such class of proteolytic enzymes are serine proteases, which take part in the tumor microenvironment formation via supporting and contributing to tumor progression. This study aims to evaluate the proteolytic activity and serine protease contribution in plasma from BC patients. The research involved patients of Alexandrovsky city clinical hospital aged 52-76 with transitional cell carcinoma of the bladder. All examined patients were divided into five groups: the control group included conditionally healthy donors, while other patients were grouped according to their tumor stage (I, II, III and IV). Plasma plasminogen levels were determined by enzyme-linked immunosorbent assay, and the potential activity was measured by chromogenic plasminogen assay. Serine proteases fractions were obtained by the affinity chromatography method, and enzyme concentration in the selected fractions were determined by the Bradford method. Serine proteases distribution was investigated by electrophoresis in a polyacrylamide gel. It was determined that the concentration, potential activity of plasminogen, and the total amount of serine proteases in plasma from BC patients were greater than the values of the corresponding indicators in healthy donors. This could be one of the factors contributing to increased proteolysis seen in the process of carcinogenesis. Plasminogen concentration in BC patients with stage IV disease; however, displayed a tendency to be reduced compared to earlier stages, and the potential activity of plasminogen was significantly lower in patients with stages III - IV BC. Futhermore, a tumor stage specific gradual decline in the serine protease plasma content was shown. The results of electrophoretic analysis established a significant diminishment in the percentage of high molecular weight components (under non-reducing conditions) and their complete disappearance (under reducing conditions) in plasma serine protease fractions from BC patients. A decline in the percentage of heavy and light plasmin chains in BC patients was also observed. Additionally, a rise in the degraded forms of plasminogen/plasmin content was seen in BC samples, as well as the presence of fractions corresponding to trypsin and NE (under non-reducing conditions) that were absent in the control samples. The results indicate significant changes in the proteolytic activity of plasma, from BC patients when compared to healthy controls, which is accompanied by alterations in serine protease distribution caused by tumor microenvironment pecularlities at the different stages of oncopathology.

AAV-Mediated Expression of a Single-Chain FVIII Mimetic Antibody Efficiently Corrects Bleeding in Haemophilia a Mice

Background: The recent approval of gene therapy for haemophilia A (HA) using adeno-associated viruses (AAVs) marks an important and long-awaited landmark as it is associated with markedly reduced bleeding events whilst overcoming the demands of regular life-long administration of factor concentrates or antibodies with FVIII mimetic activity. However, the benefits of AAV gene therapy in severely affected HA patients are likely to be short-lived as clinical data from most of the advanced trials show a gradual decline in transgenic Factor VIII (FVIII) levels over time. The reasons for this decline in expression remain unexplained but may be due in part to the packaging of an oversized FVIII expression cassette into AAV vectors. This hypothesis is supported by the fact that such decline in transgene expression has not been observed in other gene therapy approaches in clinic where the transgene expression cassette is within the packaging limits of AAV vectors. Therefore, we explored an alternative therapy approach for HA that utilises an expression cassette encoding a novel FVIII mimetic bispecific antibody (Bi8) that remains within the packaging constrains of AAV vectors, thus potentially improving the prospects of long-term control of the bleeding diathesis in severely affected HA subjects. . Methods: Bi8, is a small 54kDa single-chain bispecific antibody designed as a tandem of single-chain fragment variables (scFvs) targeting Factors IXa (FIXa) and X (FX). FVIII mimetic activity of recombinant Bi8 protein was evaluated in vitro using (1) the catalytic conversion of purified FX into FXa in a chromogenic assay, and (2) factor XIa (FXIa)-triggered thrombin generation assay (TGA) and activated partial thromboplastin time (aPTT) using spiked human HA plasma. Bi8 sequences were cloned in an AAV expression cassette downstream of a strong liver-specific promoter, pseudotyped with AAV serotype 8 capsid and evaluated in vitro as well as in vivo, including in FVIIIKO mice to assess potency in a tail vein transection assay, kinetics of Bi8 expression and the occurrence of anti-drug antibodies (ADAs). Results: In preliminary experiments, we demonstrated that the single-chain format used for Bi8 retained haemostatic functions. When tested in a chromogenic assay, recombinant Bi8 protein showed kinetics of FXa formation identical to that of emicizumab. Furthermore, Bi8 spiked in human HA plasma at 350nM corrected the clotting time (17.2 sec) in an aPTT assay to levels observed with emicizumab (22.7 sec). TGA with recombinant Bi8 and emicizumab showed comparable efficacy with peaks of thrombin generation at 354.2 and 358.4nM respectively. Next, human hepatocyte HuH7 cells were transduced with AAV8 encoding Bi8 (AAV8_Bi8) vectors in vitro, leading to the expression of a fully functional bispecific antibody with an activity/antigen ratio of 0.99 when compared to the recombinant Bi8 protein. Three doses of AAV8_Bi8 vector were then evaluated in 6-8 weeks old, male FVIIIKO mice, with a single intravenous infusion of 4e 11; 4e 12 and 1.2e 13 vector genome (vg) per kilo. Expression of the bispecific antibody was detectable in plasma for all 3 doses and peaked 2 weeks post-infusion with respective concentrations of 4.5; 47.4 and 178.8nM (Panel A). Transgenic expression was then stably maintained for 12 weeks and ADAs were not detected in any of the treated animals. When challenged in a bleeding assay, haemostasis was secured in all cohorts of mice infused with AAV-Bi8 vectors, including at the lowest dose of 4e 11 vg/kg where the average total blood loss was reduced to 401.2μL (median 406.2μL) compared to 760.4μL (median 773.1μL) in non-treated FVIIIKO mice (Panel B). Conclusion: This study establishes the feasibility of using AAV vectors to deliver an expression cassette encoding Bi8, a novel FVIII mimetic antibody formatted as a single-chain tandem-scFv, leading to circulating concentrations of bispecific antibody at levels that can secure haemostasis and reduce blood loss in a murine model of HA. This non FVIII-based expression cassette meets the packaging capacity of AAVs and therefore provides an alternative approach for AAV-mediated gene therapy for HA that may be better suited for stable long-term expression than FVIII transgenes.

Transplacental Transfer of Emicizumab: Experience with Emicizumab in a Pregnant Female with Severe Hemophilia Α and an Inhibitor

Introduction: Severe hemophilia A (HA) in females is incredibly rare particularly if complicated by a high-titer factor VIII (FVIII) inhibitor. We report, to the best of our knowledge, the first-of-its-kind use of emicizumab (emi) ante/post-partum, its effect on the newborn, and its excretion in breast milk. Baseline details: 29-year-old-female was diagnosed with severe HA at age 1 following prolonged bleeding from a venipuncture site. She had no family history of HA. One stage FVIII activity (OSA) was less than 1%. She was compound heterozygous for F8 type 1 and type 2 intron 22 inversions. At 21 months of age, she developed a high-titer inhibitor (peak: 35 Bethesda unit[BU]). She was not treated with immune tolerance induction and had remained on factor eight inhibitor bypassing activity (FEIBA) as prophylaxis until transferring to our center. She was transitioned to monthly emi prophylaxis and recombinant FVIIa (rFVIIa, NovoSeven) for breakthrough bleeding at age 26. She was medically advised against pregnancy due to unclear safety profile of emi in pregnancy and theoretical concerns for an increased risk of bleeding and thrombotic complications associated with the use of bypassing agents in the peripartum setting. Nevertheless, she desired pregnancy and continued on emi prophylaxis every 4 weeks during her pregnancy. Clinical course in pregnancy: She had an uncomplicated antepartum course and did not require rFVIIa for breakthrough bleeds. Blood emi levels and FVIII inhibitor levels were measured in each trimester of pregnancy (Table 1). Her labor was induced with oxytocin while on rFVIIa and tranexamic acid (TXA) support. She had a spontaneous, unassisted vaginal delivery immediately complicated by post-partum hemorrhage resulting in estimated blood loss of 1100cc. She did not require blood transfusion. She continued on 90 mcg/kg rFVIIa support every 2 hours, gradually prolonging the dosing interval by 2 hours every 24 hours (q2, q4, q6, etc.), and experienced no further in-hospital bleeding. She delivered a healthy female newborn. The infant developed cephalhematoma but transcranial ultrasound was negative for intracranial bleeding. Cord blood was collected at the time of delivery and sent for emi level, FVIII activity and FVIII inhibitor titer (Table 2). FVIII inhibitor assay with bovine reagent (CBU) was performed using chromogenic substrate assay (CSA) after pre-analytical heat-inactivation of patient plasma. The infant's CSA FVIII level was measured using a bovine chromogenic FVIII assay, and FVIII was also assayed using a one-stage APTT-based assay. Mother opted to breast-feed the infant. Emi level was measured in breast milk (Table 1). Conclusion: In this highly unusual case, we demonstrate that emi crossed the placenta and is excreted in breast milk. We also demonstrate that the maternal FVIII inhibitor did not cross the placenta into the newborn. Drawing conclusions on the safety of emi despite placental and breast milk transmission and transmissibility of inhibitor based on a single case would be premature. The conglomeration of several rarities in a single case renders our report unique and insightful and provides a baseline experience for future cases.

Descriptive and Epidemiological Study of Joint Damage in Non-Severe Hemophilia: Update of the Damage Study of the Mediterranean Group

Introduction: There is growing evidence indicating joint damage (JD) in non-severe hemophilia (nSH) patients. Although age and baseline factor (F) VIII/FIX levels have been proposed as good predictors of JD in mild hemophilia (MiH), data are scarce and in moderate hemophilia (MoH) are lacking. Besides, global hemostatic capacity (GHC) in this population and its contribution to JD has not been assessed. Methods: We designed a cross-sectional, observational and multicenter study carried out in 12 Spanish hospitals (Mediterranean Group). We evaluated JD in nSH patients and its correlation with age, baseline FVIII/FIX and GHC. JD was defined as a HEAD-US score >0. Baseline FVIII (chromogenic assay), FIX (clotting assay) and GHC (assessed by thrombin generation test, TGT, Genesia ®, Stago) were evaluated in a central laboratory. Results were expressed as median (25 th-75 th percentiles). Categorical variables were expressed with percentage. A p value<0.05 was considered statistically significant. Results: A total of 98 nSH patients were included: 10 (10.2%) MoH (9 HA: age= 35.6 [21.7-45.0] years old (YO); FVIII = 4.0 [4.0-5.0] IU/dL; 1 HB: FIX= 2 IU/dL) and 88 MiH (84 HA: age= 38.6 [19.0-52.1 YO]; FVIII= 15.5 [11.0-24.0] IU/dL; 4 HB: FIX= 30.0 [16.8-35.4] IU/dL). Target joints were observed in patients with MiH (7/88: 8.6% of the MiH patients). HEAD-US score was obtained in 73 patients (74.5% of the total participating patients): nine MoH patients presented a HEAD-US= 1 (0-6) (age: 32.7 [21.7-42.9] YO) while 64 MiH patients presented a HEAD-US= 0 (0-3) (age: 37.9 [17.8-48.7] YO) (comparison between MoH and MiH patients: HEAD-US: p=0.427, age: p= 0.614). Only 55.5% (5/9) MoH patients and 45.3% (29/64) MiH patients, presented JD (p=0.725). Baseline FVIII/FIX was 13.0 (7.0-20.0) IU/dL and 16.0 (11.0-22.5) IU/dL in patients with or without JD respectively (p= 0.311). These mild difference of number of patients with JD and degree of JD between MiH and MoH were corroborated by not detecting correlation between baseline FVIII/FIX levels and JD (r= -0.095; p= 0.426) (Figure 1). JD increased with age (r= 0.380; p= 0.001) reinforcing previous findings. GHC correlated with baseline FVIII/FIX (Table 1) but not with the degree of JD, suggesting that thrombin generation, with the used conditions, might not be helpful to predict JD in this population. Conclusions: Around 50% of patients with nSH presented JD. This JD increased with age, supporting previous data. Although there was a correlation between baseline FVIII/FIX levels and thrombin generation, none of the TGT parameters were predictive of the degree of JD, enhancing that other variables might be influencing the development of JD in nSH patients. Of note, MiH individuals may develop severe JD due to presence of target joints. In summary, our results highlight the importance of evaluating JD in nSH in order to determine whether new protocols are required for the diagnosis, prevention, and treatment of JD in nSH patients.

Pharmacodynamic Biomarkers in Infants with Hemophilia A Receiving Emicizumab in HAVEN 7

Background: Emicizumab, a bispecific antibody that mimics the cofactor function of activated factor (F)VIII, demonstrated a favorable safety and efficacy profile in infants with severe hemophilia A (HA) without FVIII inhibitors in HAVEN 7 (NCT04431726; Pipe et al. Blood 2022, 140[S1]: 457-459). It is known that some coagulation factors including FIX and FX, the binding targets of emicizumab, have lower plasma levels during the first 6 months of life. This research investigates whether the developing coagulation system impacts the pharmacodynamics (PD) of emicizumab prophylaxis in infants with HA enrolled to HAVEN 7 from birth to ≤ 12 months of age. Methods: Informed consent from the parents/legally authorized representative and ethics approval were obtained. PD was assessed by activated partial thromboplastin time (aPTT), FVIII activity using a chromogenic assay containing human FIX and FX (considered FVIII-like activity), and by FXIa-triggered thrombin generation (TG) assay. Plasma antigen levels of FIX and FX were determined using immunoassays. Plasma samples from 110 healthy infants (HIs; n=42, 0-3 months old; n=68, >3-24 months old) collected separately were also measured to generate age matched reference ranges. Results: In HAVEN 7, PD biomarkers, and FIX and FX plasma levels were assessed in 55 participants during the first 52 weeks of emicizumab exposure (data cut-off May 22, 2023). At baseline, mean FVIII activity was <1 IU/dL, mean TG peak height was zero, and aPTT was prolonged as expected due to the deficiency of FVIII. By the first post-baseline visit (Week 3), aPTT was normalized to the age matched reference range in most participants and was then generally maintained in the normal range throughout the treatment period. Mean (SD) FVIII-like activity increased to 22.52 (6.05) U/dL at Week 5 after the four loading doses of emicizumab and was sustained at 21-26 U/dL thereafter. Mean (SD) TG peak height increased to 67.37 (27.21) nM at Week 5 and was sustained at 67-88 nM throughout the treatment period. Mean plasma FIX and FX concentrations were not affected by emicizumab treatment. The PD biomarkers, and FIX and FX plasma levels were also analyzed as a function of age group. The loading period (first 4 weeks) was excluded and only “steady state” measurements were considered for the PD markers. All measurements were considered for FIX and FX plasma levels. Mean (SD) FVIII-like activity of 18.14 (5.40) U/dL in the youngest participants (1-2 months old) increased to 23.57 (7.64) U/dL at 3-4 months old and was similar (23-28 U/dL) in the older age groups. Age did not have a significant impact on mean TG peak height. There was no age effect on aPTT. Mean (SD) plasma FIX and FX antigen concentrations were 4.40 (1.09) µg/mL and 6.24 (1.29) µg/mL in the <1 month old participants, increased progressively with age until about 9 months old, and then stayed around 9-10 µg/mL for both FIX and FX. Lower plasma levels of FIX and FX, as well as FVIII activity were also observed in the HIs ≤3 months vs. >3 months of age. There was no significant difference in TG between ≤ 3 months vs. >3 months of age in HIs. FVIII-like activity increased with increasing emicizumab concentrations in a linear fashion up to emicizumab concentrations of 100 µg/mL. Hence, the lower FVIII-like activity in the youngest participants could be partially explained by lower mean “steady state” trough emicizumab concentrations of 48.3 µg/mL at 1 month of age, which then increased to approx. 60 µg/mL at 4-5 months of age and older. TG peak height increased with increasing emicizumab concentrations but showed large variability. Lower FIX and FX plasma levels during the first 9 months of age may also have an impact on the PD results. Even though the levels were lower in the youngest participants, increases in FVIII-like activity and TG were seen at “steady state” emicizumab in all age groups as expected based on previous studies of emicizumab. The sample sizes were small in some of the age groups analyzed. Conclusions: FVIII-like activity and thrombin generation increased, and aPTT was normalized after starting emicizumab prophylaxis in HAVEN 7. Increase with age was seen on FVIII-like activity as well as FIX and FX levels. The PD profiles of emicizumab in infants with HA were consistent with those previously observed in older children and adults with HA. Hence, even with lower levels of FIX and FX observed at the youngest participants, emicizumab showed the expected PD response.

Immunogenicity of a Plasma-Derived Von Willebrand Factor/Factor VIII Concentrate during the Wil-31 Prophylaxis Study in Patients with Von Willebrand Disease

Background: Long-term prophylaxis with a von Willebrand factor (VWF) concentrate is recommended in people with von Willebrand disease (VWD) with a history of frequent and severe bleeds. The WIL-31 study demonstrated the efficacy of prophylaxis with a plasma-derived VWF/factor VIII (pdVWF/FVIII) concentrate containing VWF and FVIII in a 1:1 activity ratio (wilate ®) in adults and children with VWD of all types. The primary endpoint was met, showing a decrease in mean total annualized bleeding rate (ABR) of 84% compared with prior on-demand treatment. Aim: To assess the immunogenicity of pdVWF/FVIII when used during the WIL-31 study in children and adults with VWD of all types. Methods: WIL-31 (NCT04052698) was a prospective, non-controlled, international, multicenter phase 3 trial that enrolled male/female patients aged ≥6 years with VWD type 1 (VWF: RCo <30 IU/dL), type 2 (except 2N) or type 3. Prior to entering the WIL-31 study, all patients had received on-demand treatment with a VWF-containing product during a 6-month, prospective, observational, run-in study (WIL-29); patients who experienced at least 6 bleeding episodes (BEs), excluding menstrual bleeds, of which ≥2 were treated with a VWF-containing product, were eligible to enter WIL-31. During WIL-31, patients received regular pdVWF/FVIII (containing VWF and FVIII in a 1:1 activity ratio) prophylaxis 2-3 times per week at a dose of 20-40 IU/kg for 12 months. FVIII (chromogenic and one-stage assays) and VWF (VWF:RCo assay) activities were assessed at baseline and throughout the study. Retention samples were collected at screening and baseline visits for possible later inhibitor testing (to be performed at a central laboratory using the Nijmegen-Bethesda assay for FVIII inhibitors and the mixing study based on VWF:RCo for VWF inhibitors). Inhibitor testing was also performed if inhibitor development was suspected. Results: Inhibitor testing was performed in 2 of 33 patients because of unusual pharmacokinetic results at the 6-month visits, even though neither patient had any clinical signs of an inhibitor. The VWF inhibitors were detected in samples from two brothers taken at their 6-month visits. However, when retained blood samples from the screening visits of both boys were tested, both samples tested inhibitor-positive, demonstrating that both boys had developed the inhibitors prior to starting prophylaxis during WIL-31. During and before the WIL-29 run-in study, both boys had been treated on demand with another pdVWF/FVIII concentrate. The boys had both been diagnosed with VWD shortly after birth, and it was suspected that they had type 2A based on family history and were 15 (patient A) and 11 years old (patient B) at the start of WIL-31. They had a family history of VWD (both parents were diagnosed with VWD), but no family history of inhibitors. After the completion of WIL-31, both patients were reclassified to type 3 VWD following further investigation including next-generation sequencing. Baseline VWF activity indicated low VWF:RCo levels (Patient A: 0.092 IU/mL and Patient B: 0.65 IU/mL; Figure 1). The boys received 38 (patient A) and 34 IU/kg (patient B) pdVWF/FVIII respectively, twice weekly during WIL-31, and their mean total ABRs decreased by 85% and 91%, respectively, during WIL-31 compared with WIL-29. All bleeding episodes during WIL-31 were spontaneous nose bleeds. Both boys continued the same prophylactic regimen until the end of WIL-31. In one patient the inhibitor titer was negative by the end of the study. Conclusion: VWF inhibitors were detected in 2 of the 33 patients on prophylaxis with pdVWF/FVIII in the WIL-31 study and subsequent investigation revealed that both patients were already positive for VWF inhibitors prior to the study start. In one of the patients, the inhibitor resolved during continued prophylaxis. Despite the inhibitors, prophylaxis was effective in both patients with an ≥85% reduction in ABR compared to on demand treatment.

Childhood Treatment with Adeno-Associated Viral Gene Therapy Results in Stable FVIII Expression and Improved Bleeding Phenotype in Adult Severe Hemophilia A Dogs

Introduction: In patients with severe hemophilia A, adeno-associated virus (AAV)-mediated factor VIII (FVIII) gene therapy is associated with reduced bleeding compared with FVIII prophylaxis. AAV5-FVIII gene therapy is approved in the U.S. and conditionally approved in Europe for the treatment of adults with severe hemophilia A. Gene therapy during childhood could potentially prevent the development of arthropathy and improve quality of life. However, there are unknowns regarding long-term safety and whether the predominant episomal nature of AAV persistence would lead to loss of transgene expression with hepatocyte divisions and liver expansion during childhood. The inflammatory response to AAV gene therapy in children is also largely uncharacterized. We have previously reported the treatment of five neonatal or infant dogs with a single vector infusion of a codon-optimized AAV5-B-domain deleted canine FVIII (cFVIII) construct with a hybrid liver promoter (AAV5-cFVIII). Dogs treated at 2 weeks of age demonstrated improved whole blood clot time (WBCT) over a 6-month period despite minimal cFVIII expression (<3%). Dogs treated at 2 months of age demonstrated stable cFVIII expression measured over a 6-month period and decreased WBCT. Aims: To describe the early inflammatory response to AAV5-cFVIII in infant and neonatal dogs, and to provide an update on the safety and efficacy of AAV5-cFVIII in these animals 12-16 months post-treatment. Methods: Hemophilia A dogs were treated with a single vector infusion (dose=2.0e14 vg/kg) of AAV5-cFVIII at 2 weeks (n=2) or 2 months (n=3) of age. Epigenomic data suggests that 2 months of age in dogs is equivalent to 9 months in humans. Liver volume was measured by magnetic resonance imaging at baseline, 3, 6, and 12 months post-AAV5-cFVIII treatment. Plasma cytokine levels were measured using a cytokine array pre-treatment (day 0) and post-treatment (days 2-28). Percutaneous liver biopsy samples were obtained at 2 weeks, 6 months, and 12 months post-treatment. Results: Cytokine array analyses of samples demonstrated that one dog who received AAV5-cFVIII at 2 weeks experienced transient post-treatment plasma elevation of IL-6, KC-like, MCP-1, TGFβ-1, and TGFβ-2 that returned to baseline levels by day 18. Two dogs treated at 2 months experienced a transient increase in GMC-SF, IL-2, IL-6, IL-7, IL-15, and IL-18 that returned to baseline levels by day 21. No changes in levels of IFNγ, IL-8, IL-10, IP-10, TNFα, or TGFβ-3 were observed. Changes in plasma cytokine levels were not associated with an elevation in plasma alanine transaminase levels. Hemophilia A dogs treated with AAV5-cFVIII at 2 weeks of age maintained an improved WBCT 12 to 16 months post-treatment, although cFVIII expression as measured by one-stage (OSA) and chromogenic substrate assays (CSA) remained minimal (<3%). Body weight and liver volume increased by 10.6-fold (measured at 16 months) and 12-fold (measured at 12 months) respectively. Dogs treated with AAV5-cFVIII at 2 months of age demonstrated sustained cFVIII expression by OSA and CSA after 12 to 16 months (8.9-13.39% measured at 16 months by OSA), despite a 3.2-fold increase in body weight (measured at 16 months), and a 3.9-fold increase in liver volume (measured at 12 months). This was associated with improved WBCT observed over the 12 to 16-month period for all three dogs. Overall, a reduction in bleeding events (BEs) was observed in all dogs. No BEs were recorded prior to AAV5-cFVIII treatment for dogs treated at 2 weeks of age. During the 16 months post-treatment, one dog experienced two spontaneous BEs, while no BEs were observed for the second dog. The dogs treated at 2 months experienced 4 (3 spontaneous and 1 traumatic) BEs prior to AAV5-cFVIII treatment, and 1 traumatic BE 48 hours post-treatment prior to the detection of FVIII expression. For the remaining 16 months post-treatment, no BEs were observed in this group. Conclusions: Treatment using AAV5-cFVIII at 2 months of age in a hemophilia A dog model resulted in stable FVIII expression into adult life despite significant liver expansion. For some dogs, AAV-cFVIII treatment resulted in an early transient increase in plasma proinflammatory cytokine levels with no evidence of transaminitis that resolved within three weeks.Further studies on liver biopsy samples are ongoing to evaluate cellular implications, vector genome distribution, and mechanisms of AAV persistence.

Effect of emicizumab-neutralizing antibodies on activated partial thromboplastin time–based clotting time test results in patients treated with emicizumab

BackgroundEmicizumab is a bispecific humanized monoclonal antibody that shortens the activated partial thromboplastin time (aPTT), making aPTT-based tests unreliable. ObjectivesTo evaluate the efficacy of a mixture of 2 anti-idiotype monoclonal antibodies (anti-emi) in neutralizing emicizumab in samples from persons with hemophilia A treated with emicizumab. MethodsFifty samples from persons with hemophilia A treated with emicizumab were analyzed for aPTT and factor VIII procoagulant activity; FVIII inhibitor titer was measured using Nijmegen-Bethesda assay in 50 plasma samples of additional patients (positive for FVIII inhibitor) treated with emicizumab. FVIII procoagulant activity and inhibitor titer were measured using 1-stage (Actin FS, Siemens) and chromogenic assays with bovine regents (Factor VIII Chromogenic Assay, Siemens). Emicizumab concentration was measured by modified a 1-stage assay calibrated with a drug-specific calibrator (r2 Diagnostics Inc). All the tests were performed on Sysmex CS-2400 (Sysmex) before and after the addition of anti-emi (Chugai Pharmaceutical). ResultsEmicizumab concentrations measured after neutralization were <1.6 μg/mL in all samples. FVIII levels were >480 IU/dL with an aPTT of <30.8 seconds in all samples before neutralization and were <1 IU/dL with an aPTT of >70 seconds after adding anti-emi. FVIII inhibitor resulted in a false negative result in 44 of 50 samples measured with the 1-stage assay before neutralization. A good correlation (r = 0.98) was found between inhibitor titer measured using the chromogenic (insensitive to emicizumab) and 1-stage assays after neutralization. ConclusionThe anti-emi antibodies were shown to completely neutralize emicizumab, making samples pretreated with anti-emi analyzable with the 1-stage assay.

A global comparative field study to evaluate the factor VIII activity of efanesoctocog alfa by one-stage clotting and chromogenic substrate assays at clinical haemostasis laboratories.

Structural and chemical modifications of factor VIII (FVIII) products may influence their behaviour in FVIII activity assays. Hence, it is important to assess the performance of FVIII products in these assays. Efanesoctocog alfa is a new class of FVIII replacement therapy designed to provide both high sustained factor activity levels and prolonged plasma half-life. Evaluate the accuracy of measuring efanesoctocog alfa FVIII activity in one-stage clotting assays (OSAs) and chromogenic substrate assays (CSAs). Human plasma with no detectable FVIII activity was spiked with efanesoctocog alfa or a full-length recombinant FVIII product comparator, octocog alfa, at nominal concentrations of 0.80 IU/mL, 0.20 IU/mL, or 0.05 IU/mL, based on labelled potency. Clinical haemostasis laboratories (N=35) tested blinded samples using in-house assays. Data from 51 OSAs (14 activated partial thromboplastin time [aPTT] reagents) and 42 CSAs (eight kits) were analyzed. Efanesoctocog alfa activity was reliably (±25% of nominal activity) measured across all concentrations using OSAs with Actin FSL and multiple other aPTT reagents. Under- and overestimation of FVIII activity occurred with some reagents. No specific trend was observed for any class of aPTT activators. A two- to three-fold overestimation was consistently observed using CSAs and the OSA with Actin FS as the aPTT reagent across evaluated concentrations. Under- or overestimation occurred with some specific OSAs and most CSAs, which has been previously observed with other modified FVIII replacement products. Efanesoctocog alfa FVIII activity was measured with acceptable accuracy and reliability using several OSA methods and commercial plasma standards.

Giroctocogene fitelparvovec gene therapy for severe hemophilia A: 104-week analysis of the phase 1/2 Alta study

AbstractPatients with hemophilia A require exogenous factor VIII (FVIII) or nonfactor hemostatic agents to prevent spontaneous bleeding events. Adeno-associated virus (AAV) vector–based gene therapy is under clinical investigation to enable endogenous FVIII production. Giroctocogene fitelparvovec is a recombinant AAV serotype 6 vector containing the coding sequence for the B-domain–deleted human F8 gene. In the ongoing phase 1/2, dose-ranging Alta study, 4 sequential cohorts of male participants with severe hemophilia A received a single IV dose of giroctocogene fitelparvovec. The primary end points are safety and changes in circulating FVIII activity. Interim results up to 214 weeks after treatment for all participants are presented. Eleven participants were dosed. Increases in alanine and aspartate aminotransferases were the most common treatment-related adverse events (AEs), which resolved with corticosteroid administration. Two treatment-related serious AEs (hypotension and pyrexia) were reported in 1 participant within 6 hours of infusion and resolved within 24 hours after infusion. At the highest dose level (3 × 1013 vg/kg; n = 5), the mean circulating FVIII activity level at week 52 was 42.6% (range, 7.8%-122.3%), and at week 104 it was 25.4% (range, 0.9%-71.6%) based on a chromogenic assay. No liver masses, thrombotic events, or confirmed inhibitors were detected in any participant. These interim 104-week data suggest that giroctocogene fitelparvovec is generally well tolerated with appropriate clinical management and has the potential to provide clinically meaningful FVIII activity levels, as indicated by the low rate of bleeding events in the highest dose cohort. This trial was registered at www.clinicaltrials.gov as #NCT03061201.

Artemisia brevifolia Wall. Ex DC Enhances Cefixime Susceptibility by Reforming Antimicrobial Resistance.

(1) Background: A possible solution to antimicrobial resistance (AMR) is synergism with plants like Artemisia brevifolia Wall. ex DC. (2) Methods: Phytochemical quantification of extracts (n-hexane (NH), ethyl acetate (EA), methanol (M), and aqueous (Aq)) was performed using RP-HPLC and chromogenic assays. Extracts were screened against resistant clinical isolates via disc diffusion, broth dilution, the checkerboard method, time-kill, and protein quantification assays. (3) Results: M extract had the maximum phenolic (15.98 ± 0.1 μg GAE/mgE) and flavonoid contents (9.93 ± 0.5 μg QE/mgE). RP-HPLC displayed the maximum polyphenols in the M extract. Secondary metabolite determination showed M extract to have the highest glycosides, alkaloids, and tannins. Preliminary resistance profiling indicated that selected isolates were resistant to cefixime (MIC 20-40 µg/mL). Extracts showed moderate antibacterial activity (MIC 60-100 µg/mL). The checkerboard method revealed a total synergy between EA extract and cefixime with 10-fold reductions in cefixime dose against resistant P. aeruginosa and MRSA. Moreover, A. brevifolia extracts potentiated the antibacterial effect of cefixime after 6 and 9 h. The synergistic combination was non- to slightly hemolytic and could inhibit bacterial protein in addition to cefixime disrupting the cell wall, thus making it difficult for bacteria to survive. (4) Conclusion: A. brevifolia in combination with cefixime has the potential to inhibit AMR.

Chromogenic detection of telomere lengths in situ aids the identification of precancerous lesions in the prostate.

Telomeres are terminal chromosomal elements that are essential for the maintenance of genomic integrity. The measurement of telomere content provides useful diagnostic and prognostic information, and fluorescent methods have been developed for this purpose. However, fluorescent-based tissue assays are cumbersome for investigators to undertake, both in research and clinical settings. A robust chromogenic in situ hybridization (CISH) approach was developed to visualize and quantify telomere content at single cell resolution in human prostate tissues, both frozen and formalin-fixed, paraffin-embedded (FFPE). This new assay (telomere chromogenic in situ hybridization ["Telo-CISH"]) produces permanently stained slides that are viewable with a standard light microscope, thus avoiding the need for specialized equipment and storage. The assay is compatible with standard immunohistochemistry, thereby allowing simultaneous assessment of histomorphology, identification of specific cell types, and assessment of telomere status. In addition, Telo-CISH eliminates the problem of autofluorescent interference that frequently occurs with fluorescent-based methods. Using this new assay, we demonstrate successful application of Telo-CISH to help identify precancerous lesions in the prostate by the presence of markedly short telomeres specifically in the luminal epithelial cells. In summary, with fewer restrictions on the types of tissues that can be tested, and increased histologic information provided, the advantages presented by this novel chromogenic assay should extend the applicability of tissue-based telomere length assessment in research and clinical settings.

A next generation FVIII mimetic bispecific antibody, Mim8, the impact on non-factor VIII related haemostasis assays.

Mim8 is a next generation bispecific antibody developed for the treatment of haemophilia A (HA). Mim8 has an increased potency compared to first generation molecules. The impact on Mim8 on non-FVIII measuring haemostasis assays was assessed in plasma containing Mim8. Congenital severe HA plasma was spiked with increasing concentrations of Mim8 (0-20μg/mL). 28 routine and specialist haemostasis assays were used to measure activities. These included tests for prothrombin time (PT), fibrinogen, thrombin, D-dimer, anti-Xa, heparin induced thrombocytopenia (HIT), clotting factors II-XII, factor XIII, von Willebrand factor (VWF), thrombophilia and DRVVT. Less than 10 % difference was calculated between plasma without Mim8 and plasma spiked to 15μg/mL Mim8 in all assays except thrombin time (-10.5%), APTT-based factor IX, XI and XII, Werfen VWF:RCo (10.6%) and Siemens LA1 (-26.4%) and LA2 (-16.9%). At the expected therapeutic steady state levels of Mim8 (5-8μg/mL), less than 10% difference was calculated for thrombin time and Werfen VWF:RCo. APTT-based assays of FIX, XI and XII are significantly elevated in the presence of Mim8 and should not be performed. A chromogenic FIX assay could be used to accurately measure FIX activity in the presence of Mim8. There was some interference in the DRVVT method we used so local assessment of other DRVVT methods is advised. Differences in all other tests would not be predicted to affect patient management.

Chromogenic and Clot-Based Bivalirudin Assays for Monitoring Anticoagulation.

Direct thrombin inhibitors (DTIs) are usually monitored with the activated partial thromboplastin time (aPTT) or activated clotting time (ACT). Both are complex assays with multiple enzymatic steps, and performance may be influenced by physiologic and pathologic factors unrelated to the DTI. Simpler systems, such as clot-based dilute thrombin time (dTT) and chromogenic anti-factor IIa assays, have been developed for monitoring DTIs, but there is limited data on their performance in clinical settings. Medical records of patients who received bivalirudin between March 2020 and April 2022 at a single institution were reviewed for demographic data and adverse outcomes. Plasma samples drawn for aPTT testing were analyzed with chromogenic anti-IIa and dTT bivalirudin assays. Results were compared to bivalirudin dosing. Results of aPTT assays from 32 patients were compared with the chromogenic (n = 136) and dTT (n = 120) bivalirudin assays. Correlations between the aPTT and the chromogenic and dTT assays were poor (Spearman coefficients 0.55 and 0.62, respectively). There was a stronger correlation when results of the chromogenic and dTT assays were compared to each other (Spearman coefficient 0.92). When assay results were compared to bivalirudin dose, there were stronger correlations with the chromogenic and dTT assays than with the aPTT (Spearman coefficients 0.51, 0.63 and 0.22, respectively). There was considerable variation between results of specific bivalirudin assays and the aPTT. While bivalirudin assay results correlated better with administered drug dose, suggesting improving reliability, more studies are needed to determine if there is correlation between testing and clinical outcomes.

Agreement between one stage and chromogenic assays in samples from patients receiving recombinant porcine FVIII (Obizur, Susoctocog-alfa).

Recombinant porcine FVIII (rpFVIII) (Obizur, Susoctcog-alfa, Takeda, Japan) is licensed for the treatment of bleeding in acquired Haemophilia A (AHA). The summary of product characteristics state that monitoring should be by one stage assay (OSA) rather than chromogenic assay (CSA). CSA have been shown to underestimate activity when rpFVIII is added to plasma in vitro. Samples from three AHA patients (n = 21) (pre- and post rpFVIII) were assessed using FVIII:C assays; OSA methods: Actin, Actin FS, Actin FSL and Pathromtin SL performed on CS5100i (Sysmex, Kobe, Japan); APTT-SP, SynthASil and SynthAFax performed on ACL TOP (Werfen, Barcelona, Spain). CSA methods on CS5100i: Siemens Chromogenic Assay, Biophen FVIII:C, Technochrom FVIII:C; on ACL TOP: Rox Factor VIII, Coamatic Factor VIII and CRYOcheck Factor VIII. OSA and CSA varied according to reagent used median OSA 61 IU/dL (range 41.5-81 IU/dL (ANOVA p < 0.0001)) median CSA 46.5 IU/dL (range of method specific medians 36.5-84 IU/dL (ANOVA p < 0.0001)). Amongst OSA, Actin FS was associated with the highest FVIII:C, APTT-SP was associated with the lowest. Variation in CSA results by different methods was also seen with highest FVIII:C levels obtained using the Technochrom FVIII:C and the lowest levels obtained with Siemens Assay. The relationship between OSA and CSA was not consistent between method or patient. Previously there has been reports of underestimation by CSA in in vitro spiked samples. Investigation into concentration of phospholipids in the APTT reagents may explain some of these variations.

PB1112 UK National External Quality Assessment Scheme for Blood Coagulation (UK NEQAS BC) Emicizumab Programme, Survey July 2022 Results for Modified One-Stage Assay and Chromogenic Assay

PB1112 UK National External Quality Assessment Scheme for Blood Coagulation (UK NEQAS BC) Emicizumab Programme, Survey July 2022 Results for Modified One-Stage Assay and Chromogenic Assay

The Evaluation of Clot Waveform Analyses for Assessing Hypercoagulability in Patients Treated with Factor VIII Concentrate.

Regular prophylactic therapy has become an increasingly common treatment for severe hemophilia. Therefore, hypercoagulability-a potential risk factor of thrombosis-is a cause for concern in hemophilic patients treated with a high dose of FVIII concentrate. In clot waveform analysis (CWA)-thrombin time (TT), a small amount of thrombin activates clotting factor VIII (FVIII) instead of fibrinogen, resulting in FVIII measurements using CWA-TT with a small amount of thrombin. The coagulation ability of patients treated with FVIII concentrate or emicizumab was evaluated using activated partial thromboplastin time (APTT), TT and a small amount of tissue factor-induced FIX activation assay (sTF/FIXa) using CWA. The FVIII activity based on CWA-TT was significantly greater than that based on the CWA-APTT or chromogenic assay. FVIII or FVIII-like activities based on the three assays in plasma without emicizumab were closely correlated; those in plasma with emicizumab based on CWA-TT and chromogenic assays were also closely correlated. CWA-APTT and CWA-TT showed different patterns in patients treated with FVIII concentrates compared to those treated with emicizumab. In particular, CWA-TT in patients treated with FVIII concentrate showed markedly higher peaks in platelet-rich plasma than in platelet-poor plasma. CWA-APTT showed lower coagulability in hemophilic patients treated with FVIII concentrate than in healthy volunteers, whereas CWA-sTF/FIXa did not. In contrast, CWA-TT showed hypercoagulability in hemophilic patients treated with FVIII concentrate. CWA-TT can be used to evaluate the thrombin bursts that cause hypercoagulability in patients treated with emicizumab. Although routine APTT evaluations demonstrated low coagulation ability in patients treated with FVIII concentrate, CWA-TT showed hypercoagulability in these patients, suggesting that the evaluation of coagulation ability may be useful when using multiple assays.

A-160 Factor VIII Chromogenic Low Activity Sample Analysis in a Low Calibration Curve Model

Abstract Background Adequate laboratorial diagnostics of hemophilia is essential and could be done by chromogenic and one-stage assays based on APTT methodologies. Adverse effects of medications became less severe recently, but it remains important to be aware of to ensure that treatment is effective and ensure the best possible conditions for affected individuals. Classification of hemophilia according to FVIII activity: mild 25%–5%; moderate, 5%–1% and severe &amp;lt;1%. For new therapies such as emicizumab and some drugs with an extended half-life, the World Federation of Hemophilia recommends the use of a chromogenic assay of FVIII containing bovine FX for monitoring factor FVIII activity. Objetive: evaluate the applicability of a low calibration curve (LCC) in the chromogenic factor VIII (FVIII-Chr) assay by standardizing the dilution of the standard (calibrator) and thus ensuring the accuracy of the analyses in the lower values like severe hemophilia range. Methods The samples were obtained from H&amp;H LAB SAS, which guarantees all requirements. Sysmex® CS 2100i Siemens Healthineers. Calibration was performed with Standard Human Plasma (SHP), together with FVIII-Chr. Quality Control (QC); the accuracy of the LCC was checked. Results Preparation of the LCC: SHP reconstitution, followed by 1:10 dilution between the SHP and the plasma deficient in FVIII. The curve was named FVIII-Chr Low. QC was performed through pathological control (PC) with 2 dilutions: 1) identical to the formation of the low curve, i.e., dilution 1:10 (2.3%–3.9%). 2) dilution 1:30 (0.2%–2%) to accommodate the range of activity comprising severe hemophilia. The values found confirms the curve’s quality. Discussion This study sought to develop a way to detect FVIII activities &amp;lt;1.5% in a reproductive manner, even with a reduced “N” number of samples for severe state. The chromogenic test presents a limit of detection for the optical density of D.O. 0.0080 reporting &amp;lt;0,3% FVIII-Chr activity, which is very close to the most diluted point of the LCC. Conclusion QC performance with PC 1/10 and 1/30 showed excellent reproducibility. With the protocol FVIII Low and LCC (SHP + PDF) it is possible to obtain results of FVIII-Chr &amp;lt;1.0% compatible patients with severe hemophilia clinical condition.

Functional determination of emicizumab in presence of factor VIII activity

BackgroundAccurate measurement of emicizumab in the presence of factor (F) VIII is required in patients with severe hemophilia A treated with emicizumab, as well as additional need for FVIII substitution or emicizumab prophylaxis in patients with acquired or moderate to mild hemophilia A. However, the presence of FVIII potentially biases the results. ObjectivesTo assess the impact of plasma FVIII activity on determined emicizumab levels and evaluate different strategies for correction for or preanalytical inhibition of FVIII. MethodsEvaluated strategies comprised of the following: (1) calculation of actual emicizumab plasma levels based on measured FVIII activities and FVIII-affected emicizumab values, (2) preanalytical heat treatment (56 °C for 40 minutes), and (3) neutralization of FVIII activity using FVIII inhibitors. Emicizumab levels and FVIII activities were measured using a modified FVIII one-stage clotting assay and a chromogenic FVIII assay based on bovine factors, respectively. ResultsSpiking experiments revealed a consistent linear association between FVIII activities and determined (FVIII-affected) emicizumab results at different emicizumab input levels (∼0.12 μg/mL per IU/dL of FVIII). This principally allowed for mathematical correction of measured emicizumab levels in the presence of FVIII. While a 40% to 50% activity loss of intrinsic plasma emicizumab through heat treatment was observed in patient samples, emicizumab spiked into FVIII-deficient plasma was not or only marginally affected. Application of inhibitor-based FVIII neutralization led to good agreement of results when compared with direct quantification of emicizumab by liquid chromatography-tandem mass spectrometry. ConclusionInhibitor-based FVIII neutralization appears to be a feasible strategy for accurate measurement of plasma emicizumab levels in the presence of FVIII activity.

Clinical Implications of Discrepancy between One-Stage Clotting and Chromogenic Factor IX Activity in Hemophilia B.

Discrepancy in factor IX activity (FIX:C) between one-stage assay (OSA) and chromogenic substrate assay (CSA) in patients with hemophilia B (PwHB) introduces challenges for clinical management. To study the differences in FIX:C using OSA and CSA in moderate and mild hemophilia B (HB), their impact on classification of severity, and correlation with genotype. Single-center study including 21 genotyped and clinically characterized PwHB. FIX:C by OSA was measured using ActinFSL (Siemens) and CSA by Biophen (Hyphen). In addition, in vitro experiments with wild-type FIX were performed. Reproducibility of CSA was assessed between three European coagulation laboratories. FIX:C by CSA was consistently lower than by OSA, with 10/17 PwHB having a more severe hemophilia type by CSA. OSA displayed a more accurate description of the clinical bleeding severity, compared with CSA. A twofold difference between OSA:CSA FIX:C was present in 12/17 PwHB; all patients had genetic missense variants in the FIX serine protease domain. Discrepancy was also observed with diluted normal plasma, most significant for values below 0.10 IU/mL. Assessment of samples with low FIX:C showed excellent reproducibility of the CSA results between the laboratories. FIX:C was consistently higher by OSA compared with the CSA. Assessing FIX:C by CSA alone would have led to diagnosis of a more severe hemophilia type in a significant proportion of patients. Our study suggests using both OSA and CSA FIX:C together with genotyping to classify HB severity and provide essential information for clinical management.