title: Innovating immune tolerance induction for haemophilia.
abstract: BACKGROUND
  Haemophilia A is an X-linked bleeding disorder characterized by a deficiency of coagulation protein factor VIII (FVIII). A challenging complication of therapeutic FVIII infusions is the formation of neutralizing alloantibodies against the FVIII protein defined as inhibitors. The development of FVIII inhibitors drastically alters the quality of life of the patients and is associated with tremendous increases in morbidity as well as treatment costs.
  
  
  OBJECTIVE
  Current clinical immune tolerance induction protocols to reverse inhibitors are lengthy, costly and not effective in all patients. Prophylactic protocols to prevent inhibitor formation have not yet been developed in the clinical setting. However, there has been ample progress towards this goal in recent years in preclinical studies using animal models of haemophilia.
  
  
  METHODS
  Here, we review the mechanisms that lead to inhibitor formation against FVIII and two promising new strategies for antigen-specific tolerance induction.
  
  
  RESULTS
  CD4+ T cells play an important role in the FVIII-specific B cell response. Immune tolerance can be induced based on transplacental delivery of FVIII domains fused to Fc or on oral delivery of leaf cells from chloroplast transgenic crop plants.
  
  
  CONCLUSIONS
  Recent literature suggests that prophylactic tolerance induction protocols for FVIII may be feasible in haemophilia A patients.
authors.affiliation: Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta/Emory University, Atlanta, GA, USA.
authors.forename: G
authors.initials: G
authors.lastname: Batsuli
authors.affiliation: Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta/Emory University, Atlanta, GA, USA.
authors.forename: S L
authors.initials: SL
authors.lastname: Meeks
authors.affiliation: Department of Pediatrics, University of Florida, Gainesville, FL, USA.
authors.forename: R W
authors.initials: RW
authors.lastname: Herzog
authors.affiliation: Sorbonne Universités, UPMC Univ Paris 06, INSERM, Université Paris Descartes, Sorbonne Paris Cité, UMR_S 1138, Centre de Recherche des Cordeliers, Paris, France.
authors.forename: S
authors.initials: S
authors.lastname: Lacroix-Desmazes
mesh_terms: D000818:Animals; D057134:Antibodies, Neutralizing / Q000097:blood; D001402:B-Lymphocytes / Q000276:immunology / Q000378:metabolism; D015496:CD4-Positive T-Lymphocytes / Q000276:immunology / Q000378:metabolism; D004195:Disease Models, Animal; D005169:Factor VIII / Q000276:immunology / Q000627:therapeutic use; D005260:Female; D006467:Hemophilia A / Q000188:drug therapy / Q000276:immunology*; D006801:Humans; D007108:Immune Tolerance; D007141:Immunoglobulin Fc Fragments / Q000235:genetics / Q000378:metabolism; D008431:Maternal-Fetal Exchange; D030821:Plants, Genetically Modified / Q000276:immunology; D011247:Pregnancy
chemical_list: D057134:Antibodies, Neutralizing; D007141:Immunoglobulin Fc Fragments; D005169:Factor VIII
keywords: factor VIII; inhibitor; tolerance