Original Paper Haemostasis 1992;22:25-31
Factor VIII Concentrates in HIV-1-Positive Hemophiliacs Is Pure Better?
S. Eichingera I. Pabingera P.A. Kyriea U. Kollerb P. Kier 'ä B. Schneiderc K Lechnera First Department of Internal Medicine, Division of Hematology and Blood Coagulation; Institute of Immunology; Institute of Medical Statistics and Documentation, Vienna, Austria
Key Words
Abstract
Hemophilia HIV-1 infection FVIII concentrates Decline of CD4 cells
39 human immunodeficiency-virus-1 (HlV-l)-positive hemo philiacs who had been regularly treated with non-virus-inactivated intermediate-purity factor VIII concentrates were di vided into two groups. Group A consisted of 21 patients with a CD4/CD8 cell ratio of less than 1.0 and group B of 18 patients with a CD4/CD8 cell ratio of greater than 1.0. All patients of group A were switched to a high-purity virus-inactivated fac tor VIII concentrate, whereas patients of group B continued to receive the intermediate-purity concentrate. There was no sig nificant difference in the average decline of CD4 cells between the two groups during the observation period. 9 patients of group A and 4 patients of group B developed AIDS. 5 patients of group A but 11 patients of group B remained clinically asymptomatic. We conclude that the 15-fold increase in purity of the factor VIII concentrate had no apparent beneficial effect on the CD4 cell counts in this patient group.
Between 1978 and 1983 a large proportion of hemophiliacs who were regularly treated with non-virus-inactivated factor VIII con-
Received: June 28, 1991 Received in revised form: October 15, 1991 Accepted: October 28, 1991
centrâtes became infected with HIV-1. Al though infected patients may remain clini cally asymptomatic over many years, eventu ally most patients progress to AIDS [1,2] and require specific treatment [3].
Dr. Sabine Eichinger Department of Internal Medicine Division of Hematology and Blood Coagulation Wàhringer Giirtel 18-20 A - 1090 Vienna (Austria)
© 1992 S. Karger AG, Basel 0301 -0147/92/ 0221—0025$2.75/0
Downloaded by: Nagoya University 133.6.82.173 - 1/14/2019 5:55:10 PM
Introduction
26
Patients and Methods Patients In 1983 patients who were regularly treated with intermediate-purity factor VIII concentrates were studied systematically with regard to immunological abnormalities including CD4 and CD8 cell counts, assay of immunoglobulins and clinical examination. HIV-1 antibody testing was not available at that time but HIV-1 antibodies were determined later on. Of 51 (male) patients with severe hemophilia A, 23 had a CD4/CD8 cell ratio of less than 1.0. Since May 1983, all patients with a CD4/CD8 cell ratio of less than 1.0 were switched to the highly purified factor VIII con centrate with the aim to reduce the degree of immuno suppression possibly due to high protein load. The remaining patients continued to receive the same in termediate-purity factor VIII concentrate. In 1985, when HIV-1 testing became available, HIV-1 antibody was determined in stored frozen se rum samples obtained in 1983. It turned out that 21 out of 23 patients with a ratio below 1.0 were HIV-1 positive whereas only 18 out of 28 patients with a ratio of greater than 1.0 were HIV-1 positive. Thus, the two cohorts described in this paper con sisted of 21 HIV-1-antibody-positive patients treated with a highly purified factor VIII concentrate (group A, table 1) and 18 HIV-1-positive patients treated with an intermediate-purity factor VIII con centrate (group B, table 1). Methods Calculation o f the CD4 Cell Count Decline during Follow-Up. For each individual patient a regression line was calculated using all CD4 cell counts available during the observation period. From this regression line, the decline of CD4 cells per year was estimated. For comparison of the average decline of CD4 cells between the two groups a nonparametric test (Wilcoxon 2-sample test) was used [12], In addition, a matched-pair analysis comparing patients with the same initial CD4 cell count was performed by the Wilcoxon 2-sample test. Laboratory and Statistical Methods. T lymphocyte phenotyping was done by a FACS Analyzer (Becton and Dickinson) with flow cytometry and monoclonal antibodies (leu 3a and 2a). The absolute number of cells was calculated from the differential blood count. Antibodies to HIV-1 were assessed by the ELISA technique (Abbott) and in case of a positive result con firmed by the ‘Confirmatory’ test (Abbott) and West ern blot analysis. For quantification of (F-microglobu-
Eichinger/Pabinger/Kyrle/Koller/Kier/ Schneider/Lechner
Factor VIII Concentrates in HIV-1-Positive Hemophiliacs
Downloaded by: Nagoya University 133.6.82.173 - 1/14/2019 5:55:10 PM
In almost all patients, the infection with HIV-1 leads to a continuous decline of CD4 cells. The risk of opportunistic infections or other consequences of CD4 cell depletion in creases steeply with a CD4 cell count below 500/jil. Currently, no drug is available which may prevent the decline of CD4 cell count. However, it may be important and clinically beneficial to avoid additional factors which could increase the risk of immunosuppres sion. From in vitro and in vivo data [4, 5] there is evidence of an immunosuppressive activity of factor VIII concentrates. This has been ascribed to other proteins in the concen trates such as immunoglobulins, immune complexes and fibrinogen [6, 7], With the availability of highly purified factor VIII con centrates, the question whether the decline of CD4 cells may be less pronounced in patients treated with these concentrates has attracted new interest. Recently, Brettler et al. [8] re ported on preliminary promising results in patients treated with a highly purified prepa ration (Monoclate®, Armour Pharmaceuti cals, Blue Bell, Pa., USA). In 1983, when the first cases of AIDS were reported in hemophiliacs, we decided to treat patients who appeared to be at a higher risk for AIDS with a high-purity concentrate [9]. This concentrate (FVIII ‘HS’®, Behringwerke) was also heat-inactivated and it was later demonstrated that it did not transmit HIV-1 [10]. The remaining patients continued to receive the same intermediate-purity concen trate (Kryobulin S-TIM 3®; Immuno) which was heat-inactivated since 1984. We followed up these two cohorts of patients for 7 years and report on the laboratory changes, in par ticular CD4 cell counts, and the clinical out come.
Table 1. Patient characteristics at study entry (1983)
Group
Group A
Group B
Number
21
18
25 11-61
21 8-59
HIV-1 antibody
+
+
F VIII consumption median IU/year1 range
71,000 55-229,000
74,000 25-142,000
n.s.
CD4/gl
median range
539 264-1,464
679 330-1,120
n.s.
CD8/pl
median range
980 371-3,403
449
Factor VIII Concentrates in HIV-1-Positive Hemophiliacs Is Pure Better?
S. Eichingera I. Pabingera P.A. Kyriea U. Kollerb P. Kier 'ä B. Schneiderc K Lechnera First Department of Internal Medicine, Division of Hematology and Blood Coagulation; Institute of Immunology; Institute of Medical Statistics and Documentation, Vienna, Austria
Key Words
Abstract
Hemophilia HIV-1 infection FVIII concentrates Decline of CD4 cells
39 human immunodeficiency-virus-1 (HlV-l)-positive hemo philiacs who had been regularly treated with non-virus-inactivated intermediate-purity factor VIII concentrates were di vided into two groups. Group A consisted of 21 patients with a CD4/CD8 cell ratio of less than 1.0 and group B of 18 patients with a CD4/CD8 cell ratio of greater than 1.0. All patients of group A were switched to a high-purity virus-inactivated fac tor VIII concentrate, whereas patients of group B continued to receive the intermediate-purity concentrate. There was no sig nificant difference in the average decline of CD4 cells between the two groups during the observation period. 9 patients of group A and 4 patients of group B developed AIDS. 5 patients of group A but 11 patients of group B remained clinically asymptomatic. We conclude that the 15-fold increase in purity of the factor VIII concentrate had no apparent beneficial effect on the CD4 cell counts in this patient group.
Between 1978 and 1983 a large proportion of hemophiliacs who were regularly treated with non-virus-inactivated factor VIII con-
Received: June 28, 1991 Received in revised form: October 15, 1991 Accepted: October 28, 1991
centrâtes became infected with HIV-1. Al though infected patients may remain clini cally asymptomatic over many years, eventu ally most patients progress to AIDS [1,2] and require specific treatment [3].
Dr. Sabine Eichinger Department of Internal Medicine Division of Hematology and Blood Coagulation Wàhringer Giirtel 18-20 A - 1090 Vienna (Austria)
© 1992 S. Karger AG, Basel 0301 -0147/92/ 0221—0025$2.75/0
Downloaded by: Nagoya University 133.6.82.173 - 1/14/2019 5:55:10 PM
Introduction
26
Patients and Methods Patients In 1983 patients who were regularly treated with intermediate-purity factor VIII concentrates were studied systematically with regard to immunological abnormalities including CD4 and CD8 cell counts, assay of immunoglobulins and clinical examination. HIV-1 antibody testing was not available at that time but HIV-1 antibodies were determined later on. Of 51 (male) patients with severe hemophilia A, 23 had a CD4/CD8 cell ratio of less than 1.0. Since May 1983, all patients with a CD4/CD8 cell ratio of less than 1.0 were switched to the highly purified factor VIII con centrate with the aim to reduce the degree of immuno suppression possibly due to high protein load. The remaining patients continued to receive the same in termediate-purity factor VIII concentrate. In 1985, when HIV-1 testing became available, HIV-1 antibody was determined in stored frozen se rum samples obtained in 1983. It turned out that 21 out of 23 patients with a ratio below 1.0 were HIV-1 positive whereas only 18 out of 28 patients with a ratio of greater than 1.0 were HIV-1 positive. Thus, the two cohorts described in this paper con sisted of 21 HIV-1-antibody-positive patients treated with a highly purified factor VIII concentrate (group A, table 1) and 18 HIV-1-positive patients treated with an intermediate-purity factor VIII con centrate (group B, table 1). Methods Calculation o f the CD4 Cell Count Decline during Follow-Up. For each individual patient a regression line was calculated using all CD4 cell counts available during the observation period. From this regression line, the decline of CD4 cells per year was estimated. For comparison of the average decline of CD4 cells between the two groups a nonparametric test (Wilcoxon 2-sample test) was used [12], In addition, a matched-pair analysis comparing patients with the same initial CD4 cell count was performed by the Wilcoxon 2-sample test. Laboratory and Statistical Methods. T lymphocyte phenotyping was done by a FACS Analyzer (Becton and Dickinson) with flow cytometry and monoclonal antibodies (leu 3a and 2a). The absolute number of cells was calculated from the differential blood count. Antibodies to HIV-1 were assessed by the ELISA technique (Abbott) and in case of a positive result con firmed by the ‘Confirmatory’ test (Abbott) and West ern blot analysis. For quantification of (F-microglobu-
Eichinger/Pabinger/Kyrle/Koller/Kier/ Schneider/Lechner
Factor VIII Concentrates in HIV-1-Positive Hemophiliacs
Downloaded by: Nagoya University 133.6.82.173 - 1/14/2019 5:55:10 PM
In almost all patients, the infection with HIV-1 leads to a continuous decline of CD4 cells. The risk of opportunistic infections or other consequences of CD4 cell depletion in creases steeply with a CD4 cell count below 500/jil. Currently, no drug is available which may prevent the decline of CD4 cell count. However, it may be important and clinically beneficial to avoid additional factors which could increase the risk of immunosuppres sion. From in vitro and in vivo data [4, 5] there is evidence of an immunosuppressive activity of factor VIII concentrates. This has been ascribed to other proteins in the concen trates such as immunoglobulins, immune complexes and fibrinogen [6, 7], With the availability of highly purified factor VIII con centrates, the question whether the decline of CD4 cells may be less pronounced in patients treated with these concentrates has attracted new interest. Recently, Brettler et al. [8] re ported on preliminary promising results in patients treated with a highly purified prepa ration (Monoclate®, Armour Pharmaceuti cals, Blue Bell, Pa., USA). In 1983, when the first cases of AIDS were reported in hemophiliacs, we decided to treat patients who appeared to be at a higher risk for AIDS with a high-purity concentrate [9]. This concentrate (FVIII ‘HS’®, Behringwerke) was also heat-inactivated and it was later demonstrated that it did not transmit HIV-1 [10]. The remaining patients continued to receive the same intermediate-purity concen trate (Kryobulin S-TIM 3®; Immuno) which was heat-inactivated since 1984. We followed up these two cohorts of patients for 7 years and report on the laboratory changes, in par ticular CD4 cell counts, and the clinical out come.
Table 1. Patient characteristics at study entry (1983)
Group
Group A
Group B
Number
21
18
25 11-61
21 8-59
HIV-1 antibody
+
+
F VIII consumption median IU/year1 range
71,000 55-229,000
74,000 25-142,000
n.s.
CD4/gl
median range
539 264-1,464
679 330-1,120
n.s.
CD8/pl
median range
980 371-3,403
449
