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Development of inhibitors remains a major clinical complication in patients with hemophilia A receiving replacement therapy with factor VIII (FVIII). Understanding the immune mechanisms involved in the development of inhibitors can provide valuable information about pathways to human tolerance. Recent evidence indicates that B regulatory (Breg) cells play a pivotal role in controlling the production of antibodies (Abs) while promoting follicular T helper (Tfh) cells and monocytes, expressing the low-density lipoprotein receptor-related protein (LRP/CD91), which is involved in FVIII intake from the circulation. We studied circulating levels of Breg cells along with Tfh cells and the expression of LRP/CD91 on monocytes in patients with hemophilia A using 8-color flow cytometry and cell culture. Compared to healthy controls, patients with hemophilia A with inhibitors showed a severe reduction in levels of Breg cells and produced less interleukin-10 when activated via the CD40 signaling pathway. In addition, patients with hemophilia A with inhibitors exhibited an overexpression of LPR/CD91 on monocytes and normal levels of Tfh cells. Levels of Breg cells were not significantly related to LPR/CD91 although negative associations were evidenced. Collectively, these results provide new insights into the role of Breg cells and LPR/CD91 in the development of inhibitors in patients with hemophilia A.

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Recent observational cohort studies indicated that the incidence of connective tissue diseases such as systemic lupus erythematous (SLE), in adult patients with sickle cell disease (SCD), appears to be increasing. The exact causes underlying this increased risk are still unknown, but patients with SCD are at risk of infections due to immune dysfunction, and a link with regulatory B (Breg) cells is possible as these cells suppress inflammatory responses, maintain tolerance and prevent the development of SLE in animal models via the production of interleukin-10 (IL-10). Herein, we numerically and functionally evaluated Breg cells in a well-defined group of SCD patients. The classification for SCD was based on patients' history, clinical examination, hematological and radiological findings. The American College of Rheumatology (ACR) criteria were used to classify and diagnose SLE patients with or without SCD. Patients were stratified into three groups including SCD patients with SLE (n=21), patients with SCD only (n=24) and patients with SLE only (n=24). Normal healthy individuals (n=24) were used as controls. Circulating levels of Breg cells were prospectively assessed by immuno-phenotyping using specific surface markers, CD19, CD24 and CD38 by flow cytometry. The functional properties were evaluated by IL-10 production and STAT3 phosphorylation after stimulation and cell culture. Unstained cells and n-1 monoclonal antibodies along with live and dead stain were used as controls in all experiments. Comparisons among study groups were performed using ANOVA and unpaired t test, while the Spearman's correlation was used to assess associations. The demographic data were similar among the study groups. All participants were free of infections such as human immunodeficiency virus, hepatitis B and C virus and syphilis. SCD patients with SLE and patients with SLE only were positive for autoimmune markers and showed an average ACR score of five and six respectively. The frequency of Breg cells, as phenotypically defined as CD19+CD24hiCD38hi, ranged between 1.5-8% in healthy controls. The circulating levels of Breg cells were significantly reduced in SCD patients with or without SLE and patients with SLE only when compared to the healthy controls (p<0.0001). Similarly, compared to healthy controls, Breg cells from SCD patients with or without SLE and patients with SLE only produced significantly lower amount of IL-10 (p<0.0001). Likewise, STAT3 phosphorylation was also decreased in Breg cells from SCD patients with or without SLE and patients with SLE only compared to the healthy controls (p<0.0001). Demographic and hematological data along with the treatments such as hydroxyurea and hydroxychloroquine did not affect the levels and functions of Breg cells. Moreover, most of the associations among study variables did not reach a statistical significance, except a moderate negative correlation was evidenced between total white blood cells (x109/L) and Breg cells (ρ=-0.41, p=0.04) in SCD patient group. Collectively, these findings showed numerical and functional deficits of Breg cells in SCD patients with or without SLE and patients with SLE only. This may suggest that Breg cell capacity to maintain tolerance and control inflammation is imbalanced in SCD patients, thereby favoring the development of SLE. Disclosures No relevant conflicts of interest to declare.

Recent data suggests that invariant natural killer T (iNKT) cells, a unique subset of T lymphocytes that express markers characteristic of both T cells and natural killer cells, play a pivotal role in the pathogenesis of sickle cell disease (SCD). Indeed, these cells are being considered as a potential target to prevent or treat acute crises of SCD in adult patients. However, the phenotypic and functional characteristics of circulating iNKT cell subsets in children with SCD remain unknown. Herein, we functionally evaluated iNKT cell subsets in relation to myeloid dendritic (mDC) and plasmacytoid dendritic (pDC) cells and markers of SCD severity in well-defined groups of children with SCD. The classification criteria for SCD was based on the history of patients, clinical examination, hematological and radiological findings. Blood iNKT cell subsets were prospectively studied in 68 children with SCD and normal controls using peripheral blood mononuclear cells, 10-color flow cytometry and culture assays. The iNKT cell subsets were identified by the positive-staining of Vα24Jα18 T cell receptor alpha chain, along with CD3, CD4 and CD8 surface markers and the intra-cellular cytokine production of interferon-gamma (Th1-like), interleukin-4 (Th2-like) and interleukin-17 (Th17-like) cells. The mDC and pDC cells were phenotypically characterized by the expression of HLA-DR, CD123, CD11c, Lin and CD1d, a non-classical molecule that induces the activation of iNKT cells. SCD patients were stratified into three groups including surgically splenectomized (n=23), large spleen (n=21) and steady state (n=24). Comparisons among study groups were performed using ANOVA and unpaired t test, while the Spearman's correlation was used to assess associations. Compared to normal individuals, splenectomized and steady state subjects, large spleen patients exhibited significantly higher levels of CD3iNKT, CD4iNKT and CD8iNKT cells (P=0.04). There were no differences in the levels of iNKT cell subsets between splenectomized and steady state subjects (P=0.56). The levels of mDC and pDC cells were also similar among the study groups (P=0.70). Interestingly, the large spleen patients tend to have higher CD4, but not CD8, Th1-like, Th2-like and Th17-like iNKT cells compared to splenectomized and steady state subjects (p=0.08). The expression levels of CD1d on both mDC and pDC were equivalent among study groups. The levels of CD3iNKT cells were negatively associated with baseline haemoglobin F levels (r=0.45, P=0.04) but not with age, time since splenectomy, spleen size or total hemoglobin levels at phlebotomy. Collectively, these results further advance the functional characterization of circulating iNKT cell subsets in children with SCD and reveal that surgically splenectomized patients have preserved function of iNKT cell subsets that are to be considered for clinical purposes. Disclosures No relevant conflicts of interest to declare.