Coversin Blocked in Vitro Hemolysis in an Eculizumab-Resistant PNH Patient with the C5 Polymorphism (c.2654G>A)
Authors: Ueda Yasutaka , Osato Makiko , Weston-Davies Wynne , Nunn Miles A , Hayashi Satoru , Nishimura Jun-Ichi , Kanakura Yuzuru 
Published: October 2019

Abstract
Background:
Paroxysmal Nocturnal Hemoglobinurea (PNH) is a rare stem cell disease caused by the expansion of PIGA mutated clone(s). PNH-type cells are deficient in the expression of GPI-anchored proteins including DAF and CD59, which protect red blood cells (RBC) from complement-mediated intravascular hemolysis. Eculizumab (Soliris®,　Alexion Pharmaceuticals) is a humanized monoclonal antibody against C5 which efficiently inhibits hemolysis by blocking the terminal complement cascade. Eculizumab dramatically ameliorates several clinical symptoms, and improves the prognosis in PNH patients. However, among 345 Japanese PNH patients who were treated with eculizumab, 11 patients showed poor response. All the poor responders had a single missense C5 heterozygous mutation, c.2654G>A, which predicts the polymorphism p.Arg885His (Nishimura et al, NEJM. 2014 13;370(7):632-9). Two of those patients have already passed away due to severe complications related to PNH, and the rest of them are still suffered from various clinical symptoms including hemolytic episodes and RBC transfusion. In these circumstances, multiple new anti-complement drugs are under development in Japan. Coversin (Volution Immuno Pharmaceuticals) is a recombinant protein (16,740 Da) derived from a secreted protein in the saliva of the Ornithodoros moubata tick, and it blocks complement-mediated hemolysis at C5 level. In this study, we examined this new anti-complement agent to a PNH patient with C5 polymorphism c.2654G>A, as well as those without the polymorphism.
Materials:
Peripheral blood samples were collected from a poor responder to eculizumab and hemolytic PNH patients with written informed consent as approved by the Institutional Review Board of Osaka University Hospital.
In vitro hemolytic assay:
RBC from ABO-matched PNH patients off eculizumab treatment were washed 3 times in saline, and subsequently incubated with Mg2+ supplemented serum of the poor responder in the presence or absence of an anti-complement agent. Alternative pathway was activated by adding HCl (22:1 of 0.4M HCl) to the serum. Heat-inactivated (56°C for 30min) serum was used as a negative control. After a 24-hour incubation at 37°C, hemolysis was quantified by measuring the optical density at 405nm (OD405). The hemolytic activity was normalized against maximum hemolysis as induced by HCl (100%) and minimum hemolysis with inactivated acidified serum (0%).
Results:
A 41-year-old male with fatigue was diagnosed as aplastic anemia with PNH in 2008, and cyclosporine (CyA) was initiated at the dose of 150mg/day. The PNH clone expanded from 30.6% to 70.2% in granulocytes from 2008 to 2011 with elevated LDH (700 U/L) and the patient was referred to our hospital to undergo eculizumab treatment. CyA was reduced to 100mg/day and eculizumab was initiated in May 2012. Eculizumab treatment did not change the serum LDH level without any improvement of the symptoms: fatigue, abdominal pain, and periodical hemoglobinurea. A heterozygous mutation c.2654G>A was identified as the cause of the failure to eculizumab treatment, and he is still suffered from continuous intravascular hemolysis (LDH > 1400 U/L) with periodical acute hemolytic episodes, requiring frequent RBC transfusion.
In the hemolytic assay, Coversin completely blocked hemolysis at the concentration of 10ug/ml, similar to the effective inhibition with hemolytic PNH patients without the polymorphism.
Discussion:
Eculizumab has dramatically improved the quality-of-life in the majority of the PNH patients by blocking intravascular hemolysis, but there are still some concerns; poor response due to C5 polymorphism, C3b deposition on the RBC, high cost and burden for scheduled infusion. Blocking the complement cascade at C5 level has shown to be relatively safe if meningococcal vaccination is properly performed, but still an extravascular hemolysis remains problematic at least in some cases. Inhibiting C3 amplification would resolve both intra and extravascular hemolysis, but susceptibility to infections remains a major concern.
Our study showed that Coversin efficiently blocked in vitro hemolysis in the eculizumab resistant patient with C5 heterozygous mutation, c.2654G>A. Coversin might be a therapeutic option for the population of C5 polymorphism c.2654G>A in PNH patients. Our results warrant further investigation to explore new anti-complement agents for hemolytic PNH patients.

Disclosures
Ueda: Alexion Pharma: Research Funding. Osato:Alexion Pharma: Research Funding. Weston-Davies:Volution Immuno Pharmaceuticals (UK) Ltd: Employment, Equity Ownership. Nunn:Volution Immuno Pharmaceuticals: Employment, Equity Ownership. Hayashi:Alexion Pharma: Research Funding. Nishimura:Alexion Pharma: Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau. Kanakura:Alexion Pharma: Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau.