Alternative therapies for the management of inhibitors.

The development of inhibitors to factor VIII (FVIII) or factor IX (FIX) remains a major treatment complication encountered in the treatment of haemophilia. Not all patients with even the same severity and genotype develop inhibitors suggesting an underlying mechanism of tolerance against FVIII- or FIX-related immunity. One mechanism may be central tolerance observed in patients in whom the FVIII mutation enables some production of the protein. The other is a peripheral tolerance mechanism which may be evident in patients with null mutation. Recently, recombinant porcine FVIII (rpFVIII, Obixur, OBI-1, BAX801) has been developed for the haemostatic treatment of both congenital haemophilia with inhibitor (CHAWI) and acquired haemophilia A (AHA). In 28 subjects with AHA with life-/limb-threatening bleeding, rpFVIII reduced or stopped bleeding in all patients within 24 h. The cross-reactivity of anti-human FVIII antibodies to rpFVIII remains around 30-50%. Recently, new therapeutics based on the quite novel concepts have been developed and clinical studies are ongoing. These are humanized asymmetric antibody mimicking FVIIIa function by maintaining a suitable interaction between FIXa and FX (Emicizumab, ACE910), and small interfering RNAs (siRNA, ALN-AT3) suppress liver production of AT through post-transcriptional gene silencing and a humanized anti-TFPI monoclonal antibody (Concizumab). Their main advantages are longer half-life, subcutaneous applicability and efficacy irrespective of the presence of inhibitors which will make it easier to initiate more effective treatment especially early childhood.

Transcatheter infusion of epirubicin in water-in-oil-in-water emulsion via a cystic artery for the treatment of hepatocellular carcinoma.

PURPOSE: We have previously reported the clinical efficacy of water-in-oil-in-water (W/O/W) emulsion containing anticancer agent. The purpose of this study was to evaluate the safety and effectiveness of transcatheter arterial infusion (TAI) of W/O/W emulsion via a cystic artery for hepatocellular carcinoma (HCC). METHODS: TAI of a W/O/W emulsion was performed at our institute in five patients with Stage III or IV HCC with blood supply from the cystic artery. In all patients, 2-12 ml/O/W emulsion was infused via a cystic artery. Therapeutic effects and complications were evaluated in these patients. RESULTS: Of the five patients treated, one achieved a complete response and two achieved a partial response. After treatment, acute cholecystitis or gallbladder ischemia that required treatment was not encountered in any patient. CONCLUSIONS: W/O/W emulsion can be safely infused via a cystic artery without major complications; it is a good therapeutic option for the patients with advanced HCC fed by a cystic artery.

Analysis of localization of mutated tissue-nonspecific alkaline phosphatase proteins associated with neonatal hypophosphatasia using green fluorescent protein chimeras.

Hypophosphatasia is associated with a defect of the tissue-nonspecific alkaline phosphatase (TNSALP) gene. The onset and clinical severity are usually correlated in hypophosphatasia; patients with perinatal hypophosphatasia die approximately at the time of birth. In contrast, we describe a male neonatal patient with hypophosphatasia who had no respiratory problems and survived. He was compound heterozygous for the conversion of Phe to Leu at codon 310 (F310L) and the deletion of a nucleotide T at 1735 (delT1735), causing the frame shift with the result of the addition of 80 amino acids at the C-terminal of the protein. Because the C-terminal portion of TNSALP is known to be important for TNSALP to bind to the plasma membrane, the localization of wild-type and mutated TNSALP proteins was analyzed using green fluorescent protein chimeras. The expression vectors containing the complementary DNA of fusion proteins consisting of signal peptide, green fluorescent protein, and wild-type or mutated TNSALP, caused by delT1735 or F310L mutation, were introduced transiently or stably in Saos-2 cells. The delT1735 mutant failed to localize at the cell surface membrane, whereas the wild-type and the F310L mutants were located in the plasma membrane and cytoplasm. The assay for enzymatic activity of TNSALP revealed that the delT1735 mutant lost the activity and that the F310L mutant exhibited an enzymatic activity level that was 72% of the normal level. The F310L mutation was also detected in another neonatal patient with relatively mild (nonlethal) hypophosphatasia (reported in J Clin Endocrinol Metab, 81:4458-4461, 1996), suggesting that residual ALP activity of the F310L mutant contributes to the less severe phenotype. The patient is unique, with respect to a discrepancy between onset and clinical severity in hypophosphatasia.

Pancreatic tissue damage by transcatheter arterial embolization for hepatoma.

We analyzed the serial changes in serum pancreatic enzyme activities by transcatheter arterial embolization (TAE) in 20 hepatoma patients with liver cirrhosis in an attempt to evaluate the incidence of the pancreatic tissue damage by TAE. Serum amylase activities increased in two (10%) cases, elastase 1 levels in six (30%) cases, and trypsin and pancreatic secretory trypsin inhibitor (PSTI) levels in each of five (25%) cases. Consequently, TAE resulted in the elevation of at least more than one serum pancreatic enzyme in eight (40%) of 20 cases, although none had clinical symptoms related to pancreatitis. When the adverse effect on the pancreatic tissue was compared among 6 cases of the superselective TAE and 14 cases of the nonsuperselective TAE, which were performed from the segmental and the nonsegmental hepatic arteries, respectively, the elevation of serum pancreatic enzymes was caused only by nonsuperselective TAE, not by superselective TAE. The volumes of Spongel and Lipiodol used or the injected doses of the anticancer agent mitomycin C were not different between the two groups. These results indicate that TAE for the treatment of hepatoma frequently causes pancreatic tissue damage, and the position of the inserted catheter tip is very important to avoid the pancreatic tissue damage by TAE.

Clinical evaluation of recombinant human factor VIII (BAY w 6240) in the treatment of hemophilia A.

A pilot clinical trial was conducted in five patients with severe hemophilia A to evaluate the safety and efficacy of a recombinant human factor VIII preparation, BAY w 6240 (rFVIII). In a comparative pharmacokinetic study of rFVIII and a plasma-derived factor VIII preparation (pdFVIII), the mean t1/2 values for rFVIII at week 1 and week 13 were 16.8 and 14.4 h, while this value for pdFVIII at week -2 was 16.9 h. There were no statistical differences between these values. The mean in vivo recovery rates of rFVIII were comparable to those of pdFVIII. When rFVIII was administered prophylactically three times a week for 4 weeks, no bleeding episodes were observed. Seventy-four bleeding episodes were assessed during the 6-month treatment period. The efficacy rate of the hemostatic effect was confirmed to be 95.9%. No adverse reactions attributable to rFVIII were observed in a total of 178 infusions. Neither FVIII-inhibitors nor antibodies to foreign proteins were detected. Vital signs and laboratory findings showed no significant changes attributable to rFVIII. These results suggest that rFVIII is safe and efficacious as replacement therapy for hemophilia A.

23(S),25(R)-1,25-dihydroxyvitamin D3-26,23-lactone stimulates murine bone formation in vivo.

23(S),25(R)-1,25-Dihydroxyvitamin D3-26,23-lactone (1,25-lactone) has been shown to have unique actions different from those of 1,25-dihydroxyvitamin D3 [1,25-(OH)2D3]. In contrast to 1,25-(OH)2D3, 1,25-lactone causes a significant reduction in the serum Ca2+ level, stimulates collagen production in an osteoblastic cell line, and inhibits bone resorption induced by 1,25-(OH)2D3. A possible effect of 1,25-lactone on bone formation was examined in experiments on ectopic bone formation using a bone-inducing factor derived from Dunn osteosarcomas. 1,25-Lactone, a metabolite of 1,25-(OH)2D3, increased [3H]proline uptake at the stage of chondrogenesis and 85Sr uptake during bone formation. Significantly enlarged bone was also induced by this compound 3 weeks after implantation. These results suggest that the 1,25-lactone may be able to stimulate bone formation under in vivo conditions.

Effect of single oral phosphate loading on vitamin D metabolites in normal subjects and in X-linked hypophosphatemic rickets.

There have been several reports that document abnormal vitamin D metabolism in X-linked hypophosphatemic rickets (XLH). Those reports indicate a blunted renal 25-hydroxyvitamin D-1 alpha-hydroxylase response to a potent stimulator, phosphorus restriction. We examined here its response to phosphate supplementation. Seven normal volunteers and 12 patients with XLH were submitted to single oral phosphate loading. This treatment produced a marked elevation of the serum phosphorus level, with a mild reduction in the serum calcium level. In normal subjects, although the concentrations of intact parathyroid hormone and mid-region parathyroid hormone were increased, with two peaks at 2 and 8 h after treatment, there were no significant changes in vitamin D metabolites including 25-hydroxyvitamin D (25(OH)D), 24,25-dihydroxyvitamin D (24,25(OH)2D) and 1,25-dihydroxyvitamin D (1,25(OH)2D). On the other hand, in the patients with XLH, the serum 1,25(OH)2D level increased from 23.4 +/- 12.0 (mean +/- SD) pg/ml to 44.3 +/- 33.6 pg/ml 6 h after ingestion without any significant change in 25(OH)D or 24,25(OH)2D.

Effect of phosphorus supplementation on bone formation induced by osteosarcoma-derived bone-inducing substance in X-linked hypophosphatemic mice.

In our previous report, we demonstrated normal cartilage and bone matrix formation and a defect of bone mineralization in hypophosphatemic (Hyp) mice using an ectopic bone formation system. That system consisted of an osteogenic sarcoma-derived bone-inducing substance. In this report, we describe the effect of phosphorus supplementation on abnormal bone mineralization. The osteogenic sarcoma-derived bone-inducing substance was implanted in Hyp mice or control mice. The Hyp mice were divided into two groups after implantation. One group was fed a normal laboratory chow, while the other was fed a high-phosphorus diet for 4 weeks of the experimental period. Normal control mice were fed the normal laboratory chow. The mean serum phosphorus level in the high-phosphorus diet group was normal at 2, 3 and 4 weeks after implantation. Using the method of 85Sr incorporation, the high-phosphorus diet group showed marked improvement in bone mineralization at 2 and 4 weeks after implantation, but incomplete improvement at 3 weeks. On the other hand, histological study of the high-phosphorus diet group at 4 weeks after implantation still showed a meaningful amount of the osteoid matrix formation compared to the control. These findings suggest that the abnormal bone mineralization in Hyp mice was mainly due to their abnormally low serum phosphorus level. However, still other abnormalities might exist and these might be responsible for the incomplete improvement in bone mineralization.

Effect of intrahepatic arterial infusion of 131I-labelled lipiodol on hepatocellular carcinoma of rat.

Intrahepatic arterial infusion of 131I-labelled lipiodol was performed to study the intrahepatic distribution of lipiodol and to determine the radiation effect on 3'-Methyl-4-Dimethylaminobenzene (DAB) induced hepatocellular carcinoma (HCC) in rats. From the findings of the softex films and scintigrams of the liver, according to the time course, lipiodol was found to accumulate in the tumour tissues parallel with the degree of perfusion, and it remained in the tumour tissues for an extended period probably due to the delay of the degradation of lipiodol compared to that in non tumour tissues. It was noticed that the lipiodol, accumulated and deposited selectively in the tumour tissues, existed mostly in the extracellular space but not in the intracellular space. In histological studies of the resected specimens of the tumours, complete necrosis of hepatocellular carcinoma was recognized 2 to 8 weeks after the infusion of 131I-labelled lipiodol, while there was none in the control group where cold lipiodol was employed. These results suggest that the most effect on hepatocellular carcinoma in this study is caused by the radiation effect of 131I-labelled lipiodol.

Bone gamma-carboxyglutamic acid containing protein in the perinatal period.

We measured bone gamma-carboxyglutamic acid-containing protein (BGP), calcium (Ca), phosphorus (P), and alkaline phosphatase (Al-P) in paired maternal and cord sera, and urinary gamma-carboxyglutamic acid (gamma-Gla) in neonates. The circulating BGP was 41.21 +/- 2.47 ng/ml and 7.44 +/- 0.87 ng/ml in the cord (n = 15) and the maternal (n = 14) sera, respectively. The urinary gamma-Gla in the neonates was 147.68 +/- 10.75 mumol/g creatinine (n = 15). The cord serum BGP was significantly higher than the normal adult level. The maternal serum BGP was at the same level as in other adults. It is conceivable that the fetus may produce BGP during gestation, as the cord serum BGP level was significantly higher than the maternal level and there was no correlation between the cord and maternal serum BGP concentrations. The reason for the elevated circulating BGP level in the cord serum is not known, but increased bone turnover may be a factor. The cord serum BGP may include not only carboxylated but also non-gamma-carboxylated GP because of fetal vitamin K deficiency.