The most serious complication in hemophilia A (HA) treatment is the development of factor (F)VIII inhibitors or anti-drug antibodies (ADA) occurring in 25-35% of patients with severe HA. The immunological mechanisms underlying the development of ADA against FVIII products have not been completely understood yet. Immunological danger signals associated with events such as infection or surgery have been suggested to play a critical role. In previous studies, we have demonstrated that plasma-derived (pd)FVIII but not recombinant (r)FVIII can activate human monocyte-derived dendritic cells (DC) in a danger signaldependent manner, which subsequently mediate the proliferation of autologous CD4+ T cells. In this study, we have investigated the ability of plasma components, naturally present in pdFVIII products, to mediate T cell responses. In fact, we show that addition of plasma to rFVIII plus lipopolysaccharide (LPS)-stimulated DC induces proliferation of autologous CD4+ T cells. Interestingly, although DC pulsed with LPS plus plasma induce T cell proliferation upon co-culture, the addition of FVIII significantly increased the number of proliferating as well as FVIII-specific CD4+ T cells. Total proliferating CD4+ T cells and FVIII-specific subsets were identified mainly as central memory T cells. Experiments using blocking antibodies and receptor antagonists revealed that the complement proteins C3a and, to a lesser extent, C5a are critically involved in these LPS-mediated T cell responses. Collectively, our results indicate that complement proteins are potent drivers of T cell responses towards FVIII. Data presented provide a model how event-related substitution of FVIII in HA patients might contribute to inhibitor development.
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