Progression to AIDS in French haemophiliacs: association with HLA-B35.

OBJECTIVE: To evaluate whether HLA-B35 influences progression to AIDS in HIV-seropositive subjects with haemophilia. DESIGN: Retrospective (before 1985) and prospective (after 1985) follow-up of a group of French haemophiliacs. METHODS: We studied 144 seropositive patients with moderate or severe haemophilia A or B or von Willebrand's disease. Enzyme-linked immunosorbent assay was used to screen patient sera for total HIV antigen and core p24 antigen antibodies. All patients were typed for HLA A, B and C antigens in the same laboratory. Time of seroconversion was estimated to be the mid-point between the last seronegative test and the first seropositive test. AIDS-free survival curves were constructed using the Kaplan-Meier estimate and differences in survival analysed using the Mantel-Cox test. The Cox proportional hazards model was used to adjust for confounding variables. RESULTS: Median follow-up after seroconversion was 8.7 years (range, 3.5-10.7 years). By the end of the study, six HLA-B35-positive patients and 12 HLA-B35-negative patients had progressed to AIDS. Individuals with HLA-B35 showed a significantly faster rate of progression to AIDS over the follow-up period than HLA-B35-negative individuals (hazard ratio, 2.72; P = 0.037). After adjusting for type and severity of haemophilia, CD4 cell count at first seropositive test, age at seroconversion, and zidovudine treatment before AIDS, the hazard ratio was 2.74 (P = 0.045). CONCLUSION: HLA-B35 is a risk factor for more rapid progression to AIDS in subjects with haemophilia.

Twenty-four novel hemophilia B mutations revealed by rapid scanning of the whole factor IX gene in a French population sample.

Full scanning of the factor IX gene by means of denaturing gradient gel electrophoresis enabled us to determine the molecular defects in 48 out of 49 hemophiliacs and to evaluate the spectrum of factor IX mutations in the French population. Our results further document the high molecular heterogeneity of the disease and the efficiency of this rapid screening method for disease-causing mutations. This direct approach, which is based on computer-aided analysis of the whole coding, promoter and exon-flanking factor IX gene sequences, proved to be helpful for carrier detection and prenatal diagnosis in most hemophilia B families, including sporadic cases. Moreover, we were able to identify 24 novel molecular defects of various natures in the factor IX gene.

Sucrose formulated recombinant human antihemophilic factor VIII is safe and efficacious for treatment of hemophilia A in home therapy--International Kogenate-FS Study Group.

To add an increased level of safety to antihemophilic factor replacement therapy, a full-length, recombinant Factor VIII (rFVIII) product has been developed without human-derived plasma proteins during purification and formulation and using an additional solvent/detergent viral inactivation step. This first clinical trial of a sucrose-formulated full-length rFVIII (rFVIII-FS) was conducted in previously treated patients (> or = 100 prior exposure days) with severe (<2% FVIII) hemophilia A in North America (NA) and Europe (EU). Pharmacokinetic profiles for rFVIII-FS were compared with those of currently licensed rFVIII product (Kogenate) in 35 patients. Safety and efficacy during home therapy were evaluated in 71 patients. The new formulation displayed a pharmacokinetic profile similar to that of rFVIII. Patients on home therapy received a cumulative total of 11,867 exposure days, 12,546 infusions, and 22,443,694 IU of rFVIII-FS. Of 2585 bleeds, 93.5% were treated with 1-2 infusions and 80.5% of responses were rated as excellent or good. No evidence of de novo inhibitor formation was observed. Only 0.27% of infusions were associated with any drug-related adverse event. Except for an episode of intermittent chest pain with palpitations which ceased after treatment with analgesics, associated adverse events were mild or moderate. Overall, rFVIII-FS provided excellent hemostatic control, was well-tolerated, and caused no significant adverse effects, thus demonstrating safety and efficacy for treatment of bleeds in patients with hemophilia A.

French previously untreated patients with severe hemophilia A after exposure to recombinant factor VIII : incidence of inhibitor and evaluation of immune tolerance.

Fifty French previously untreated patients with severe hemophilia A (factor VIII < 1%), treated with only one brand of recombinant factor VIII (rFVIII), were evaluated for inhibitor development, assessment of risk factors and outcome of immune tolerance regimen. The median period on study was 32 months (range 9-74) since the first injection of rFVIII. Fourteen patients (28%) developed an inhibitor, four of whom (8%) with a high titer (> or = 10 BU). All inhibitor patients but one continued to receive rFVIII either for on-demand treatment or for immune tolerance regimen (ITR). Among these patients, inhibitor was transient in 2 (4%), became undetectable in 6 and was still present in 6. The prevalence of inhibitor was 12%. Presence of intron 22 inversion was found to be a risk factor for inhibitor development. Immune tolerance was difficult to achieve in our series despite a follow-up period of 16 to 30 months: immune tolerance was complete in only one out of the 3 patients undergoing low dose ITR and in one out of the 5 patients with high dose ITR.

[Neurological complications of hemophilia in children (author's transl)]. / Les accidents neurologiques de l'hémophilie chez l'enfant.

Although the treatment of hemophilia has greatly improved, the disease is still sometimes responsible for neurological or neurosurgical disorders. Such disorders were observed in the department of Neurosurgery at the "Hopital des ENFANTS MALADES' in twelve hemophiliacs, five of them having antifactor antibodies. Four main points results from this study: 1) A traumatic etiology was found only in one third of the cases. 2) CT Scan is the main investigation since it allows to find out what cases should be operated upon. The ratio of neurosurgical cases varies from one statistic to another from 40% to 70%. 3) The frequency of neurological disorders is correlated with the importance of the deficit in antihemophilic factors, which is usually less than 1%. 4) The death rate in this series was nil. Hemophiliacs without antifactor antibodies should receive a substitutive treatment as soon as possible. However, in hemophiliacs with antifactor antibodies, this treatment should only be given when surgery is required.

[Adenoidectomy and tonsillectomy in children with hemophilia and von Willebrand disease]. / Adénoïdectomies et amygdalectomies chez les enfants atteints d'hémophilie et de la maladie de Willebrand.

Hemophilia type A or B is due to deficiency in factor VIII C or IX C, but whatever the type and whether the affection is severe or attenuated the risk of hemorrhage after surgery is identical. Willebrand's disease is due to either a qualitative or quantitative anomaly of willebrand's factor. Between 1979 and 1984, 15 children with these diseases were operated upon for removal of tonsils and adenoids. Surgery was performed under cover of substituted therapy with frozen cryoprecipitate for Willebrand's disease, either frozen or dried cryoprecipitate together with F VIII concentrates for hemophilia A, and PPSB for hemophilia B. This treatment was continued pastoperatively for 7 days after adenoidectomy and 10 days after tonsillectomy. Follow up examinations enabling possible adjustment of transfusional needs included determination of CKT and assay of factors VIII C or IX C in the hemophiliac children, and assay of factors F VIII R, AG, F VIII RCF and F VIII C in those will willebrand's disease.

[Circulating anticoagulants with antiprothrombinase activity in systemic lupus erythematosus (author's transl)]. / Anticoagulants circulants d'activité antiprothrombinase au cours du lupus érythémateux disséminé.

Circulating anticoagulants with antiprothrombinase activity were detected in 14 out of 49 patients (i.e. 29%) presenting with severe forms of systemic lupus erythematosus (SLE) predominantly renal (29) or extrarenal (20). Nine of these 14 patients had thrombopenia and 8 had a falsely positive Wassermann test. The anticoagulants were more frequently encountered in patients with severe extrarenal manifestations (9/20 cases) than in patients with severe proliferative renal lesions (5/29 cases). They were found in 5 out of 10 patients with arterial and/or venous thrombosis. Anticoagulant levels paralleled the course of the disease during treatment. No haemorrhage was observed in 14 percutaneous renal biopsies performed on 11 patients free from outer coagulopathies. This suggests that the presence of antiprothrombinase anticoagulants in the blood of patients without thrombopenia or other coagulation disorders is compatible with surgery or biopsy of the kidney.

[Thromboembolic manifestations in systemic lupus erythematosus (author's transl)]. / Manifestations thromboemboliques au cours du lupus érythémateux disséminé.

Among 60 patients (56 females, 4 males) with severe forms of SLE, 13 developed thromboembolic arterial and/or venous manifestations, an overall incidence of 21.6 percent. Thrombophlebitis episodes, mainly affecting lower limbs, occurred in 8 patients, usually an initial or early manifestation of active lupus disease; thrombophlebitis was recurrent in two, and pulmonary embolism was proved in two patients. Arterial occlusion developed in 7 patients, early in the course of active SLE and mainly affecting peripheral arteries in 4, later and affecting coronary arteries in three. In two patients, both arterial and venous manifestations occurred simultaneously or successively. A circulating anticoagulant with antiprothrombinase activity was present in 8 (61 percent) of the 13 patients with thromboembolic manifestations, as compared to only 21 percent of those without such manifestations, a highly significant (p less than 0.001) difference.

A de novo intragenic deletion of the potential EGF domain of the factor IX gene in a family with severe hemophilia B.

We have studied a family of three patients who were severely afflicted with hemophilia B without inhibitor for their factor IX genes through the use of factor IX cDNA and genomic DNA probes. The patients had detectable (30% of normal) factor IX antigen. DNA hybridization analysis demonstrated that these patients had a partial intragenic deletion in their factor IX gene. This 2.8-kb deletion included exon d and the surrounding sequences. This exon codes for the amino acid sequence from No. 47 through 84 of the factor IX protein and contains its first potential EGF domain; the de novo occurrence of the mutation in the grandfather's germ cells was established by linkage analysis. This specific gene has been named F IXStrasbourg.

Transmission of non-A, non-B hepatitis by heat-treated factor VIII concentrate.

In-vitro and animal studies have shown that viral agents can be removed from or inactivated in clotting factor concentrates by physical or chemical treatment. However, clinical data have as yet not substantiated the results of these studies. 13 haemophilia A patients who had not been treated previously with blood or blood products were given a dry-heated factor VIII concentrate and were tested serologically over the next 12 months. Hepatitis developed in 11 patients (84%) and was invariably of type non-A, non-B. Morbidity was not related to the lot of the therapeutic material or to the number of infusions. The incubation period was either 5 or 8-11 weeks, and only 1 patient had symptoms. Aminotransferase elevation showed both monophasic and biphasic patterns. During the follow-up period signs of the disease disappeared in 10 patients (90%). These findings contrast with the absence of non-A, non-B hepatitis in chimpanzees given the same heated concentrate. Thus, clinical studies in first-exposure haemophiliacs are essential for the true evaluation of the safety of new "treated" concentrates.

Hereditary nephritis associated with May-Hegglin anomaly.

Hereditary nephritis associated with hematologic abnormalities seems to be an exceptional occurrence. We have observed a family which nephritis was combined with May-Hegglin anomaly. A girl and her father suffered from proteinuria; a paternal uncle received kidney graft; a paternal grand aunt died on periodic hemodialysis. The girl, the father and the uncle presented macrothrombocytopenia (40-100 X 10(9)/l, size 4-8 mum) with prolonged bleeding time (which precluded renal biopsy) and cytoplasmic inclusions in neutrophils (Döhle bodies). These hematologic abnormalities characterize the May-Hegglin anomaly. This kind of association has not been reported so far.

The role of HIV infectivity and composition of factor VIII concentrates on the immunity of haemophiliacs positive for HIV antibodies.

Forty-six subjects (44 HIV antibody-positive) with some degree of immune deficiency (at least TH/TS ratio below 1) were randomly distributed into 4 treatment groups. Each group was assigned to 1 of 4 products to be used exclusively for a 1-year period: 1 concentrate was of intermediate purity and not heat-treated, and 3 were heat-treated in order to inactivate HIV, 2 of them being of higher purity. At 4-6-month intervals, check-ups, including as markers clinical examination, platelet, lymphocyte and T cell subset counts, IgG levels and delayed hypersensitivity test, were carried out. At entry as well as at the end of the study, groups were not statistically distinguishable. No intra- nor inter-group differences were demonstrable for any of the markers. In contrast, using a scoring system for each marker and the results of check-up at entry as reference, significant differences between groups appeared on subsequent check-ups. Patients receiving intermediate-purity factor VIII, whether heat-treated or not, were mostly steady, while groups receiving heat-treated concentrates of a higher purity significantly worsened. This surprising outcome was no related to differences in anti-HIV titers or specificities. From this study, the potential long-term predictive value of this scoring system could not be established.

Genetic counselling, carrier detection, and prenatal diagnosis in hemophilia. A service experience.

Our experience over three years (1984-1986) is described in carrier detection and prenatal testing for hemophilia. We have analysed 50 families: 37 hemophilia A and 13 hemophilia B, 22 isolated cases and 28 familial. Eighty-three women belonging to this panel asked for a genetic risk. Pedigree and coagulation studies were performed to estimate genetic risks according to the Bayesian method. At this point, 40% of the females at risk were recognized carriers before the DNA analysis. Molecular biology allowed the detection of only 7% more carriers and the exclusion of 34%. In 19% of the cases, it was impossible to estimate the genetic risk because the families were uninformative for the DNA polymorphisms used. Twenty-two prenatal diagnoses were performed; 3 affected male fetuses were recognized by DNA analysis and pregnancies were terminated. Eleven healthy boys were born.

[Disorders of haemostasis in patients undergoing maintenance haemodialysis, with special reference to recurrent arteriovenous fistula thrombosis. Effects of dipyridamole (author's transl)]. / Les anomalies de l'hémostase chez les sujets en hémodialyse chronique, notamment compliquée de thromboses itératives des fistules artérioveineuses. Effets du dipyridamole

Platelet functions and blood coagulation have been regularly investigated in 31 patients undergoing maintenance haemodialysis for 5 months to 6 years. Fifteen of them suffered from at least two arteriovenous fistula thrombosis during the year prior the first examination. Eleven patients, including eight with recurrent thrombosis, received 300-400 mg per day dipyridamole during 1 month to 2 years. Some abnormalities are commonly observed in the whole studied population: lowering of platelet adhesiveness, defective aggregation in the presence of both collagen and ADP 5. 10-5 M; increased level of factor V and mainly factor VIII. Mean platelet factor 3 activity was in the normal range with variations from one case to another. The only unusual feature observed in patients with recurrent thrombosis was an increase of platelet aggregation induced by ADP 0.5. 10-6 M. Neither spontaneous aggregation nor significant abnormality of plasminogen level and plasma antithrombin activity were observed. Under dipyridamole therapy, correction of platelet hyperaggregability was observed in all patients and improvement of platelet adhesiveness in half the studied cases (despite the unchanged anaemia). The treatment significantly decreased the frequency of arteriovnous fistule thrombosis in the six patients observed during two consecutive years, the first one without and the second under treatment: the total number of thrombosis was 18 during the first and 3 in the second period.

[A case of AIDS in a hemophilia B patient in France]. / Un cas de SIDA chez un hémophile B en France.

AIDS is reported in a 14 year old hemophiliac B. This patient was treated on demand and used 800 F IX IU per kg B.W. and per year. He presented with severe opportunistic infection (Toxoplasmosis) and profound impairment of cellular immunity. He suffered of chronic active hepatitis and he was chronic HBs Ag carrier. A retrovirus (LAV) was isolated from his cultured T lymphocytes. He had no other identified risk factor than severe hemophilia B. The occurrence of AIDS in hemophiliacs suggests a relationship between the transfusion of blood products and the disease. The cause of AIDS is unknown. A possible relationship between LAV and AIDS is discussed.

Non-A, non-B hepatitis in hemophilic patients with inhibitor treated with activated prothrombin complex concentrates: lack of correlation with an antigen possibly related to non-A, non-B hepatitis.

A population of 30 severe hemophilia-A patients with antibodies to factor VIII, treated with Autoplex since 1980, experienced a 30% incidence of non-A, non-B (NANB) hepatitis. 8 of the 9 patients affected had clinical signs of hepatitis and 7 had ALT levels in excess of 200 IU/l; the mean incubation time was 13 days. Only 5 of the 26 lots of Autoplex used were possibly transmitting the infective agent. An ELISA test to detect an antigen (DS-Ag) possibly related to NANB hepatitis was used to screen hemophilia-A and B patients. Its incidence was lower in patients treated less than 5 times a year (7.9%) than in patients treated over 15 times a year (25-27%) with locally prepared blood derivatives. Following treatment with Autoplex, the incidence of DS-Ag in inhibitor patients increased significantly (50%). In this last population, DS-Ag was shown to be unrelated to the NANB hepatitis observed. Although no direct evidence could be given, Autoplex was likely to transmit both the agent responsible for short incubation NANB hepatitis and DS-Ag.

HEMOCO: a French prospective study of hemophiliacs infected by human immunodeficiency virus type 1 (HIV-1).

HEMOCO is a multicenter prospective cohort set up in 1989 to monitor 407 French hemophiliacs infected by HIV-1 and recruited in 4 hemophilia treatment centers in the Paris region. As of 15 July 1995, 42% of the patients in the cohort had developed stage B HIV disease and 29% stage C disease (AIDS); 23.1% of the patients had died. The cumulative proportion of patients with AIDS was 4.5% at 5 years and 27.4% at 10 years, while the respective mortality rates were 3.8% and 19.5%. In our study, only age was predictive of AIDS, with an estimated relative risk of 1.2 per 10-year age increment; this factor was also predictive of death. After 10 years of follow-up, 6.1% of the study population had no clinical or laboratory signs of immunodepression. The follow-up protocol in the HEMOCO protocol is the same as that in the French SEROCO study, which includes men infected by HIV-1 through sexual contact. This will allow us to compare the progression of HIV infection between these two exposure groups.

Hepatitis C virus genotypes in French haemophiliacs: kinetics and reappraisal of mixed infections.

The distribution and kinetics of hepatitis C virus (HCV) genotypes and the prevalence of mixed infections were studied in a group of 45 French patients with haemophilia A or B or von Willebrand's disease, 21 of them being anti-human immunodeficiency virus (HIV) positive; genotyping was carried out by three methods based on the core, 5' untranslated region (5'UTR), and the detection of type-specific NS4 antibodies. Genotyping of the 5'UTR revealed genotypes 1a (n = 10), 1b (n = 13), 2a (n = 3), 2b (n = 4), 2NC (n = 3), 3a (n = 10), and two mixed infections (1a + 1b and 3a + 2). Five of 33 patients showed a change from one HCV genotype to another. The core genotyping assay showed 8 of 45 mixed infections: 6/8 1a + 1b and 2/8 3a + 2. Sequencing of core polymerase chain reaction (PCR) products showed that mixed infection 1a + 1b could be explained by nonspecific annealing of the 1b primer to type 1a sequence. By designing new primers whose sequence was more specific to HCV types 1a and 1b, we could confirm 1a + 1b mixed infection in only one of six cases. Serotyping assay showed for 17 of 21 anti-HIV negative patients a concordance with the 5'UTR genotype; however, only 6 of 19 anti-HIV positive patients showed detectable serological reactivity. In summary, we have observed a similar HCV genotype distribution between our haemophilic group and the French anti-HCV positive patients. The study demonstrates the difficulties of assessing with the presently available genotyping and serotyping assays the real prevalence of mixed infections in multiply transfused patients.