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Barcellini W, Pane F, Patriarca A, Murakhovskaya I, Terriou L, DeSancho MT, Hanna WT, Leopold L, Rappold E, Szeto K, Wei S, Jäger U. Parsaclisib for the treatment of primary autoimmune hemolytic anemia: Results from a phase 2, open-label study. Am J Hematol 2024. [PMID: 39435908 DOI: 10.1002/ajh.27493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2024] [Revised: 09/13/2024] [Accepted: 09/19/2024] [Indexed: 10/23/2024]
Abstract
Autoimmune hemolytic anemia (AIHA) is a group of acquired autoimmune disorders characterized by red blood cell hemolysis. In a phase 2, open-label, multicenter study, adults with warm AIHA, cold agglutinin disease, or mixed-type AIHA were administered once-daily 1.0 or 2.5 mg parsaclisib (selective phosphoinositide 3-kinase δ inhibitor) orally for 12 weeks, followed by an extension period. Dose increases (for AIHA worsening) or decreases (for tolerability) were permitted. Primary efficacy endpoint was the proportion of patients with complete (≥12 g/dL hemoglobin [Hgb]) or partial (10-12 g/dL Hgb or ≥2 g/dL increase from baseline) response at any visit during weeks 6-12 not attributable to transfusion. Among 25 enrolled patients (median age, 63 y), 16 (64%) achieved a partial or complete Hgb response during weeks 6-12. Responses were observed by week 1 in 52.0% of patients with incremental improvements during weeks 6-12 and sustained responses during the extension period. Responses were higher among patients with warm AIHA versus other types (75.0% vs. 44.4%). Clinically meaningful improvements in Functional Assessment of Chronic Illness Therapy-Fatigue scores were observed at weeks 6 and 12. All patients had treatment-emergent adverse events (TEAEs), most commonly diarrhea (32.0%) and pyrexia (28.0%). Grade ≥3 TEAEs occurred in 13 patients (52.0%). TEAEs considered possibly related to treatment occurred in 11 patients (44.0%). No dose reductions were required; six patients (24%) discontinued for a TEAE. In summary, parsaclisib was well tolerated and resulted in substantial improvements in Hgb response at week 1, with durable responses through the extension period. CLINICAL TRIAL REGISTRATION: This trial was registered at ClinicalTrials.gov (NCT03538041).
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Affiliation(s)
- Wilma Barcellini
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Fabrizio Pane
- Department of Medicine and Surgery, University Federico II of Naples, Naples, Italy
| | - Andrea Patriarca
- University of Eastern Piedmont and AOU "Maggiore della Carità", Novara, Italy
| | - Irina Murakhovskaya
- Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA
| | - Louis Terriou
- Université de Lille, Inserm, CHU Lille, Centre de Référence des Maladies Autoimmunes Systémiques Rares du Nord et Nord-Ouest de France (CeRAINO), INFINITE-Institute for Translational Research in Inflammation, Lille, France
| | - Maria T DeSancho
- Weill Cornell Medicine, New York-Presbyterian Hospital, New York, New York, USA
| | - Wahid T Hanna
- University of Tennessee Graduate School of Medicine, Knoxville, Tennessee, USA
| | | | | | - Ke Szeto
- Incyte Corporation, Wilmington, Delaware, USA
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Barcellini W, Fattizzo B. Autoimmune Hemolytic Anemias: Challenges in Diagnosis and Therapy. Transfus Med Hemother 2024; 51:321-331. [PMID: 39371250 PMCID: PMC11452171 DOI: 10.1159/000540475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Accepted: 07/19/2024] [Indexed: 10/08/2024] Open
Abstract
Background Autoimmune hemolytic anemia (AIHA) is a rare disease due to increased destruction of erythrocytes by autoantibodies, with or without complement activation. Summary AIHA is usually classified in warm AIHA (wAIHA) and cold agglutinin disease (CAD), based on isotype and thermal amplitude of the autoantibody. The direct antiglobulin test (DAT) or Coombs test is the cornerstone of AIHA diagnosis, as it is positive with anti-IgG in wAIHA, and with anti-C3d/IgM antisera plus high titer cold agglutinins in CAD. Therapy is quite different, as steroids and rituximab are effective in the former, but have a lower response rate and duration in the latter. Splenectomy, which is still a good option for young/fit wAIHA, is contraindicated in CAD, and classic immunosuppressants are moving to further lines. Several new drugs are increasingly used or are in trials for relapsed/refractory AIHAs, including B-cell (parsaclisib, ibrutinib, rilzabrutinib), and plasma cell target therapies (bortezomib, daratumumab), bispecific agents (ianalumab, obexelimab, povetacicept), neonatal Fc receptor blockers (nipocalimab), and complement inhibitors (sutimlimab, riliprubart, pegcetacoplan, iptacopan). Clinically, AIHAs are highly heterogeneous, from mild/compensated to life-threatening/fulminant, and may be primary or associated with infections, neoplasms, autoimmune diseases, transplants, immunodeficiencies, and drugs. Along with all these variables, there are rare forms like mixed (wAIHA plus CAD), atypical (IgA or warm IgM driven), and DAT negative, where the diagnosis and clinical management are particularly challenging. Key Messages This article covers the classic clinical features, diagnosis, and therapy of wAIHA and CAD, and focuses, with the support of clinical vignettes, on difficult diagnosis and refractory/relapsing cases requiring novel therapies.
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Affiliation(s)
- Wilma Barcellini
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Bruno Fattizzo
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
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Binsfeld M, Devey A, Gothot A. Transfusion support and pre-transfusion testing in autoimmune haemolytic anaemia. Vox Sang 2024; 119:1029-1038. [PMID: 38922929 DOI: 10.1111/vox.13699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 03/29/2024] [Accepted: 04/19/2024] [Indexed: 06/28/2024]
Abstract
Autoimmune haemolytic anaemia (AIHA) is characterized by an increased destruction of red blood cells due to immune dysfunction and auto-antibody production. Clinical manifestations are mainly related to anaemia, which can become life-threatening in case of acute haemolysis. Aiming at counterbalancing severe anaemia, supportive treatments for these patients frequently include transfusions. Unfortunately, free serum auto-antibodies greatly interfere in pre-transfusion testing, and the identification of compatible red blood cell units for AIHA patients can be challenging or even impossible. Problems faced in pre-transfusion testing often lead to delay or abandonment of transfusions for AIHA patients. In this review, we discuss publications concerning global transfusion management in AIHA, with a focus on pre-transfusion testing, and practical clues to manage the selection of transfusion units for these patients. Depending on the degree of transfusion emergency, we propose an algorithm for the selection and laboratory testing of units to be transfused to AIHA patients.
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Affiliation(s)
- Marilène Binsfeld
- Immuno-Hematology Laboratory and Blood Blank, Department of Clinical Biology, University Hospital of Liège (B35), Liège, Belgium
| | - Anaïs Devey
- Immuno-Hematology Laboratory and Blood Blank, Department of Clinical Biology, University Hospital of Liège (B35), Liège, Belgium
| | - André Gothot
- Immuno-Hematology Laboratory and Blood Blank, Department of Clinical Biology, University Hospital of Liège (B35), Liège, Belgium
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Edwards BP, Senapati SG, Kasianchyk M, Shah J, Ayvali F, Maharaj S. Mixed autoimmune hemolytic anemia as the initial presentation of systemic lupus erythematosus: A case report and review. EJHAEM 2024; 5:1053-1056. [PMID: 39415922 PMCID: PMC11481010 DOI: 10.1002/jha2.1008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/19/2024] [Revised: 08/10/2024] [Accepted: 08/21/2024] [Indexed: 10/19/2024]
Abstract
Autoimmune hemolytic anemia (AIHA) is an acquired condition caused by autoantibody mediated destruction of erythrocytes. AIHA is classified as warm or cold depending on whether the autoantibodies involved react optimally at or below body temperature (37°C), respectively. Mixed AIHA, with features of both, is rare and clinically more severe. We report a case of mixed AIHA that was found to be the presentation of systemic lupus erythematosus (SLE). Treatment with rituximab and prednisone resulted in good response. Although more commonly associated with warm AIHA, SLE can present with mixed AIHA.
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Affiliation(s)
- Brian P. Edwards
- Department of Internal MedicineTexas Tech University Health Sciences CenterEl PasoTexasUSA
| | | | - Mariia Kasianchyk
- Department of Internal MedicineTexas Tech University Health Sciences CenterEl PasoTexasUSA
| | - Joel Shah
- Department of Internal MedicineTexas Tech University Health Sciences CenterEl PasoTexasUSA
| | - Fatih Ayvali
- Department of Internal MedicineTexas Tech University Health Sciences CenterEl PasoTexasUSA
| | - Satish Maharaj
- Department of Oncological SciencesMoffitt Cancer CenterUniversity of South FloridaTampaFloridaUSA
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Agarwala S, Kalra M, Sachdeva A, Anand K, Setia R. Paroxysmal Cold Hemoglobinuria: Mild to Catastrophic-Spectrum of a Rare Hemolytic Anemia of Childhood. J Pediatr Hematol Oncol 2024:00043426-990000000-00494. [PMID: 39324966 DOI: 10.1097/mph.0000000000002953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 08/20/2024] [Indexed: 09/27/2024]
Abstract
Paroxysmal cold hemoglobinuria (PCH) is among the rarest forms of autoimmune hemolytic anemia, most often seen in young children. PCH is caused by a biphasic immunoglobulin G antibody that binds to red cells at low temperatures and causes complement-mediated lysis as the temperature is raised. Diagnosis is based on high clinical suspicion followed by confirmation of the presence of Donath-Landsteiner antibodies. We have described 3 cases diagnosed with PCH over a span of 1 year, 2 cases presented with acute kidney injury with variable severity and needed hemodialysis. Another case showed prompt recovery with supportive treatment, suggesting variable severity of PCH. This report intends to generate awareness of this rare condition which is often misdiagnosed as nonspecific autoimmune hemolytic anemia and leads to unnecessary prolonged immunosuppressive therapy. It also emphasizes the rare possibility of the need for prompt renal replacement therapy in an otherwise benign self-limiting disorder.
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Affiliation(s)
- Sneha Agarwala
- Department of Pediatric Hematology Oncology and BMT, Sir Ganga Ram Hospital
| | - Manas Kalra
- Department of Pediatric Hematology Oncology and BMT, Sir Ganga Ram Hospital
| | - Anupam Sachdeva
- Department of Pediatric Hematology Oncology and BMT, Sir Ganga Ram Hospital
| | - Kanav Anand
- Department of Pediatric Nephrology, Sir Ganga Ram Hospital
| | - Rasika Setia
- Department of Transfusion Medicine, BLK-Max Super Specialty Hospital, New Delhi, India
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6
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Zhang C, Charland D, O'Hearn K, Steele M, Klaassen RJ, Speckert M. Childhood autoimmune hemolytic anemia: A scoping review. Eur J Haematol 2024; 113:273-282. [PMID: 38894537 DOI: 10.1111/ejh.14253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 05/24/2024] [Accepted: 06/04/2024] [Indexed: 06/21/2024]
Abstract
BACKGROUND AND OBJECTIVE Autoimmune hemolytic anemia (AIHA) is a rare but important cause of morbidity in pediatric hematology patients. Given its rarity, there is little high-quality evidence on which to base the investigation and management of pediatric AIHA. This scoping review aims to summarize the current evidence and highlight key gaps to inform future studies. METHODS This review searched MEDLINE and the Cochrane CENTRAL Trials Register from 2000 to November 03, 2023. Experimental and observational studies reporting AIHA diagnostic criteria, laboratory workup, or treatment/management in populations with at least 20% of patients ≤18 years were included. RESULTS Forty-three studies were included, with no randomized controlled trials identified. AIHA diagnostic criteria, diagnostic tests, and treatments were highly variable. First-line treatment approaches include corticosteroids, intravenous immunoglobulin, or both. Approaches to AIHA resistance to first-line therapy were widely variable between studies, but most commonly included rituximab and/or cyclosporine. CONCLUSIONS We identify a heterogenous group of observational studies into this complex, immune-mediated disorder. Standardized definitions and classifications are needed to guide collaborative efforts needed to study this rare disease. The work done by the CEREVANCE group provides an important paradigm for future studies.
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Affiliation(s)
- Caseng Zhang
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Danielle Charland
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Katie O'Hearn
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - MacGregor Steele
- Department of Pediatrics, Section of Pediatric Hematology, Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada
| | - Robert J Klaassen
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
- Division of Hematology Oncology, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Matthew Speckert
- Division of Hematology Oncology, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
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Nava Gutiérrez W, Villa Cortés P, Ramírez Morales R, Espinoza Garza JP, Espinosa Mora JE. The Vital Role of Immunohematology in Diagnosing Paroxysmal Cold Hemoglobinuria: A Clinical Case Report. Cureus 2024; 16:e69362. [PMID: 39398713 PMCID: PMC11471295 DOI: 10.7759/cureus.69362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/13/2024] [Indexed: 10/15/2024] Open
Abstract
Paroxysmal cold hemoglobinuria (PCH) is a rare autoimmune hemolytic anemia caused by the binding of IgG immunoglobulins to red blood cells at cold temperatures, leading to hemolysis upon rewarming. The Donath-Landsteiner test can show biphasic hemolysis, leading to diagnosis. There is no consensus, but chemoimmunotherapy with or without plasma exchange is commonly employed. We present the case of a 42-year-old male who experienced symptoms of hemolysis after cold exposure in a semi-arid, warm-climate city.
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Affiliation(s)
- Willy Nava Gutiérrez
- Hematology and Oncology, Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado de Nuevo León (ISSSTELEON), Monterrey, MEX
- Hematology, Universidad de Monterrey, Monterrey, MEX
| | - Paola Villa Cortés
- Critical Care Medicine, Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado de Nuevo León (ISSSTELEON), Monterrey, MEX
| | - Ricardo Ramírez Morales
- Rheumatology, Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado de Nuevo León (ISSSTELEON), Monterrey, MEX
| | - Juan P Espinoza Garza
- Pulmonology, Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado de Nuevo León (ISSSTELEON), Monterrey, MEX
| | - Jaime E Espinosa Mora
- Infectious Disease, Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado de Nuevo León (ISSSTELEON), Monterrey, MEX
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8
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Fujisawa Y, Horita S, Wakabayashi K. Efficacy of sutimlimab for cold agglutinin disease in a patient on chronic hemodialysis. CEN Case Rep 2024:10.1007/s13730-024-00917-8. [PMID: 39017802 DOI: 10.1007/s13730-024-00917-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Accepted: 07/12/2024] [Indexed: 07/18/2024] Open
Abstract
Reports of cold agglutinin disease (CAD), an autoimmune hemolytic anemia, in dialysis patients are limited. Recently, sutimlimab for CAD was covered by insurance. Herein, we report a case in which sutimlimab was effective in the treatment of CAD in a patient undergoing hemodialysis (HD). The patient was a 73 year-old Japanese man with an 11 year history of HD for diabetic nephropathy. He was admitted to our hospital for examination and treatment of erythropoiesis-stimulating agent (ESA)-induced hyporesponsive anemia and fatigue, which was present in the previous year October to March when temperatures were cooler. The patient was diagnosed with hemolytic anemia based on decreased hemoglobin levels, elevated reticulocyte count, elevated lactate dehydrogenase levels, and decreased haptoglobin levels. Furthermore, he was diagnosed with CAD based on a positive direct antiglobulin test for C3 and cold agglutinin tests. The patient did not respond well to an elevated dialysate temperature or rituximab therapy. After initiating sutimlimab treatment, an increase in the hemoglobin level was observed despite a decrease in temperature, and his fatigue disappeared. Anemia in hemodialysis patients is generally renal; however, some ESA resistance exists, which may be due to hemolytic anemia. In this case, the use of sutimlimab was effective in controlling hemolytic anemia due to CAD.
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Affiliation(s)
- Yuhei Fujisawa
- Department of Internal Medicine, Saiseikai Kanazawa Hospital, Akatsuchimachi, Kanazawa, Ishikawa, Ni13-6920-0353, Japan.
| | - Shigeto Horita
- Department of Internal Medicine, Saiseikai Kanazawa Hospital, Akatsuchimachi, Kanazawa, Ishikawa, Ni13-6920-0353, Japan
| | - Keiko Wakabayashi
- Department of Internal Medicine, Saiseikai Kanazawa Hospital, Akatsuchimachi, Kanazawa, Ishikawa, Ni13-6920-0353, Japan
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Rink DE, Riveros T, Fix C, Vande Vusse L. A Man with Neutropenic Fever, Perianal Pain, and Jaundice. Ann Am Thorac Soc 2024; 21:1094-1098. [PMID: 38949601 DOI: 10.1513/annalsats.202310-902cc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 02/16/2024] [Indexed: 07/02/2024] Open
Affiliation(s)
| | | | - Cora Fix
- Seattle Cancer Care Alliance, Seattle, Washington
| | - Lisa Vande Vusse
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington
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10
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Barcellini W, Fattizzo B. The evolving management algorithm for the patient with newly diagnosed cold agglutinin disease. Expert Rev Hematol 2024; 17:287-294. [PMID: 38872338 DOI: 10.1080/17474086.2024.2366540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Accepted: 06/06/2024] [Indexed: 06/15/2024]
Abstract
INTRODUCTION Cold agglutinin disease (CAD) is driven by IgM autoantibodies reactive at <37°C and able to fix complement. The activation of the classical complement pathway leads to C3-mediated extravascular hemolysis in the liver and to intravascular hemolytic crises in case of complement amplifying conditions. C3 positivity at direct Coombs test along with high titer agglutins are required for the diagnosis. Treatment is less standardized. AREAS COVERED This review recapitulates CAD diagnosis and then focus on the evolving management of the disease. Both current approach and novel targeted drugs are discussed. Literature search was conducted in PubMed and Scopus from 2000 to 2024 using 'CAD' and 'autoimmune hemolytic anemia' as keywords. EXPERT OPINION Rituximab represents the frontline approach in patients with symptomatic anemia or disabling cold-induced peripheral symptoms and is effective in 50-60% of cases. Refractory/relapsing patients are an unmet need and may now benefit from complement inhibitors, particularly the anti-C1s sutimlimab, effective in controlling hemolysis thus improving anemia in >80% of patients, but not active on cold-induced peripheral symptoms. Novel drugs include long-acting complement inhibitors, plasma cells, and B-cell targeting agents (proteasome inhibitors, anti-CD38, BTKi, PI3Ki, anti-BAFF). Combination therapy may be the future answer to CAD unmet needs.
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Affiliation(s)
- Wilma Barcellini
- SC Ematologia, SS Fisiopatologia delle Anemie, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Bruno Fattizzo
- SC Ematologia, SS Fisiopatologia delle Anemie, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
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11
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Tyzack-Clark H, Jackson B. A woman with dry cough and breathlessness. BMJ 2024; 385:e078329. [PMID: 38843893 DOI: 10.1136/bmj-2023-078329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/10/2024]
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Das SS, Das S, Agrawal S, Shastry S, Shenoy V, Datta SS. A national survey of current immunohematologic testing practices for the diagnosis of autoimmune hemolytic anemia in India. Immunohematology 2024; 40:65-72. [PMID: 38910441 DOI: 10.2478/immunohematology-2024-010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/25/2024]
Abstract
Autoimmune hemolytic anemia (AIHA) is a common term for several disorders that differ from one another in terms of etiology, pathogenesis, clinical features, and treatment. Management of patients with AIHA has become increasingly evidence-based in recent years. While this development has resulted in therapeutic improvements, it also carries increased requirements for optimal diagnosis using more advanced laboratory tests. Unfortunately, limited data are available from developing countries regarding the testing and transfusion management of patients with AIHA. The main objective of this survey was to explore the current immunohematologic testing practices for the diagnosis of AIHA in India. This online survey consisted of 30 questions, covering the place of work, the number of AIHA cases encountered in the 3 preceding years, testing method(s), transfusion management, and so forth. Individuals representing 89 laboratories completed the survey; only 78 of which responded that AIHA testing was performed in their facility's laboratory. The majority of respondents agreed that the most commonly affected age-group comprised individuals of older than 20 years, with a female preponderance. Regarding transfusion management, respondents indicated that transfusion with "best-match" red blood cell units remains the most common practice. Column-agglutination technology is used by 92 percent of respondents as the primary testing method. Although a monospecific direct antiglobulin test is available at 73 percent of the sites, most of them have limited access to other resources that could diagnose cold or mixed AIHA. Merely 49 percent of responding laboratories have the resources to perform adsorption studies for the detection of alloantibodies. Furthermore, three-cell antibody screening reagents are unavailable at 32 percent of laboratories. In 72 percent of centers, clinical hematologists would prefer to consult a transfusion medicine specialist before administering treatment to AIHA patients. There is unanimous agreement regarding the need for a national registry. The survey data indicate wide variability in testing practices for patients with AIHA in India. Future studies are needed to focus on the feasibility and cost-effectiveness of different testing strategies for developing countries.
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Affiliation(s)
- Sudipta S Das
- 1Department of Transfusion Medicine, Apollo Multi-speciality Hospitals, Kolkata, India
| | - Soumya Das
- 2Department of Transfusion Medicine, All India Institute of Medical Sciences, Nagpur, India
| | - Soma Agrawal
- 3Department of Transfusion Medicine, Indraprastha Apollo Hospitals, New Delhi, India
| | - Shamee Shastry
- 4Department of Immunohematology and Blood Transfusion, Kasturba Medical College Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Veena Shenoy
- 5Department of Transfusion Medicine, Amrita Institute of Medical Sciences, Kochi, India
| | - Suvro S Datta
- 6Department of Transfusion Medicine, Tata Medical Center, Rajarhat, New Town, Kolkata India
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Namineni N, Waldron C, Tormey C, Goshua G. Severe, Refractory Primary Warm Autoimmune Hemolytic Anemia Requiring 90 Erythrocyte Transfusions. ANNALS OF INTERNAL MEDICINE. CLINICAL CASES 2024; 3:e231141. [PMID: 38725710 PMCID: PMC11081177 DOI: 10.7326/aimcc.2023.1141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/12/2024]
Abstract
A previously healthy 60-year-old man presented to the hospital with a hemoglobin of 3.5 g/dL. He was diagnosed with severe warm autoimmune hemolytic anemia (wAIHA) with reticulocytopenia on hospital day 1 that was not responsive to steroids, immune globulin, and rituximab. Over a 42-day hospital stay, the patient remained continuously transfusion-dependent with a ninety red cell unit requirement for his refractory disease. He was trialed on therapeutic plasma exchange before ultimately undergoing inpatient splenectomy that led to a response within hours. He remains in complete remission at six months of follow-up.
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Affiliation(s)
| | | | - Christopher Tormey
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, CT
| | - George Goshua
- Section of Hematology, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
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Liu H, Ding K, Zhang W, Xing L, Wang Y, Wang H, Song J, Li L, Fu R. A pilot study of orelabrutinib treatment in three cases of refractory/relapsed autoimmune haemolytic anaemia/Evans syndrome. Br J Haematol 2024; 204:1082-1085. [PMID: 37932927 DOI: 10.1111/bjh.19146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Revised: 09/24/2023] [Accepted: 09/27/2023] [Indexed: 11/08/2023]
Abstract
Currently, there is no effective treatment for refractory/relapsed (R/R) autoimmune haemolytic anaemia (AIHA), associated with poor quality of life. Bruton tyrosine kinase inhibitors have begun to be used in some autoimmune diseases. We initiated the clinical trial of orelabrutinib treatment on R/R AIHA/Evans Syndrome, which is in progress. The preliminary results showed that nine of the 12 enrolled patients responded to orelabrutinib treatment. Here, we reported three cases who have completed the treatment and were followed up for 6 months, achieving complete or partial remission. Orelabrutinib is expected to become a new second-line treatment for R/R AIHA/Evans syndrome.
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Affiliation(s)
- Hui Liu
- Tianjin Medical University General Hospital, Tianjin, P.R. China
| | - Kai Ding
- Tianjin Medical University General Hospital, Tianjin, P.R. China
| | - Wei Zhang
- Tianjin Medical University General Hospital, Tianjin, P.R. China
| | - Limin Xing
- Tianjin Medical University General Hospital, Tianjin, P.R. China
| | - Yihao Wang
- Tianjin Medical University General Hospital, Tianjin, P.R. China
| | - Huaquan Wang
- Tianjin Medical University General Hospital, Tianjin, P.R. China
| | - Jia Song
- Tianjin Medical University General Hospital, Tianjin, P.R. China
| | - Lijuan Li
- Tianjin Medical University General Hospital, Tianjin, P.R. China
| | - Rong Fu
- Tianjin Medical University General Hospital, Tianjin, P.R. China
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D’Sa S, Vos JMI, Barcellini W, Wardęcki M, Perrin L, Barker G, Zilberstein M, Storek M, Chow T, Röth A. Safety, tolerability, and activity of the active C1s antibody riliprubart in cold agglutinin disease: a phase 1b study. Blood 2024; 143:713-720. [PMID: 38085846 PMCID: PMC10900135 DOI: 10.1182/blood.2023022153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 11/28/2023] [Indexed: 02/23/2024] Open
Abstract
ABSTRACT Cold agglutinin disease is a rare autoimmune hemolytic anemia characterized by complement pathway-mediated hemolysis. Riliprubart (SAR445088, BIVV020), a second-generation classical complement inhibitor, is a humanized monoclonal antibody that selectively inhibits only the activated form of C1s. This Phase 1b study evaluated the safety, tolerability, and effect on hemolysis of riliprubart in adult patients with cold agglutinin disease. On day 1, 12 patients received a single IV dose of either 30 mg/kg (n = 6) or 15 mg/kg (n = 6) of riliprubart and were subsequently followed for 15 weeks. Riliprubart was generally well tolerated; there were no treatment-emergent serious adverse events, or treatment-emergent adverse events leading to death or permanent study discontinuation. There were no reports of serious infections, encapsulated bacterial infections including meningococcal infections, hypersensitivity, or thromboembolic events. Rapid improvements in hemoglobin (day 5) and bilirubin (day 1) were observed in both treatment cohorts. Mean hemoglobin levels were maintained at >11.0 g/dL from day 29 and mean levels of bilirubin were normalized by day 29; both responses were maintained throughout the study. Improvements in clinical markers closely correlated with a sustained reduction in the 50% hemolytic complement (CH50) throughout the study. Mean C4 levels, an in vivo marker of treatment activity, increased 1 week after treatment with either dose of riliprubart and were sustained throughout the study. In conclusion, a single IV dose of riliprubart was well tolerated, and led to rapid classical complement inhibition, control of hemolysis, and improvement in anemia, all of which were sustained over 15 weeks. This trial was registered at www.ClinicalTrials.gov as #NCT04269551.
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Affiliation(s)
- Shirley D’Sa
- UCLH Centre for Waldenström’s Macroglobulinaemia and Related Conditions, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Josephine M. I. Vos
- Amsterdam University Medical Center, University of Amsterdam, and Sanquin, Amsterdam, The Netherlands
| | - Wilma Barcellini
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | | | | | | | | | | | | | - Alexander Röth
- Department of Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
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16
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Ogbue OD, Bahaj W, Kewan T, Ahmed R, Dima D, Willimas N, Durmaz A, Visconte V, Maskal SM, Gurnari C, Steven R, Maciejewski JP. Splenectomy outcomes in immune cytopenias: Treatment outcomes and determinants of response. J Intern Med 2024; 295:229-241. [PMID: 37953670 DOI: 10.1111/joim.13742] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2023]
Abstract
BACKGROUND Splenectomy is commonly used to treat refractory immune-mediated cytopenia, but there are no established factors that are associated with response to the procedure. OBJECTIVES A cohort study was conducted to evaluate the hematologic and surgical outcomes of splenectomy in adult patients with immune cytopenias and identify preoperative factors associated with response. METHODS Data from the Cleveland Clinic Foundation for 1824 patients aged over 18 who underwent splenectomy from 2002 to 2020 were analyzed. RESULTS The study found that the most common indications for splenectomy were immune thrombocytopenic purpura (ITP) and autoimmune hemolytic anemia, with a median age of 55 years and median time from diagnosis to splenectomy of 11 months. Hematologic response rates were 74% overall, with relapse in 12% of cases. Postsplenectomy discordant diagnoses were present in 13% of patients, associated with higher relapse rates. Surgery-related complications occurred in 12% of cases, whereas only 3% of patients died from disease complications. On univariate analysis, preoperative factors associated with splenectomy treatment failure were ≥3 lines of pharmacologic treatment, whereas isolated thrombocytopenia, primary ITP, and age ≤40 years had a strong association with response. The multivariable regression confirmed that treatment failure with multiple lines of medical therapy was associated with the failure to respond to splenectomy. CONCLUSION Overall, the study demonstrates that splenectomy is an effective treatment option for immune-mediated cytopenias with a low complication rate.
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Affiliation(s)
- Olisaemeka D Ogbue
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Waled Bahaj
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Tariq Kewan
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Department of Hematology and Oncology, Yale University, New Haven, Connecticut, USA
| | - Ramsha Ahmed
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Danai Dima
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Nakisha Willimas
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Arda Durmaz
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Valeria Visconte
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Sara M Maskal
- Department of General Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Carmelo Gurnari
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Rosenblatt Steven
- Department of Hematology and Oncology, Yale University, New Haven, Connecticut, USA
| | - Jaroslaw P Maciejewski
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
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17
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Jain R, Bansal D. Autoimmune Hemolytic Anemia, Inborn Errors of Immunity and Genetics: An Evolving Arena. Indian J Pediatr 2024; 91:115-116. [PMID: 38157115 DOI: 10.1007/s12098-023-05011-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 12/22/2023] [Indexed: 01/03/2024]
Affiliation(s)
- Richa Jain
- Pediatric Hematology-Oncology Unit, Department of Pediatrics, Advanced Pediatrics Center, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Deepak Bansal
- Pediatric Hematology-Oncology Unit, Department of Pediatrics, Advanced Pediatrics Center, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
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18
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Ribeiro L, Nwanwene K, Anwar K, Abdallah M, Shenouda M. Autoimmune Hemolytic Anemia Associated With Myelodysplastic Syndrome: A Case Report. J Investig Med High Impact Case Rep 2024; 12:23247096241273215. [PMID: 39171743 PMCID: PMC11342316 DOI: 10.1177/23247096241273215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2024] [Revised: 07/03/2024] [Accepted: 07/08/2024] [Indexed: 08/23/2024] Open
Abstract
Myelodysplastic syndrome (MDS) represents a spectrum of myeloid disorders occasionally linked to autoimmune diseases. Here, we present a case of a 60-year-old man demonstrating an unusual coexistence of MDS with warm-autoantibody autoimmune hemolytic anemia (wAIHA). Diagnostic evaluation, including positive direct antiglobulin testing, confirmed the autoimmune etiology of his anemia despite his low-risk MDS classification. Prompt initiation of prednisone therapy resulted in significant hematological and clinical improvement, allowing for a conservative management approach without transfusion requirements. This case underscores the importance of identifying the relationship between wAIHA and MDS, particularly in low-risk scenarios. Moreover, these findings suggest the efficacy of corticosteroids in managing autoimmune anemia in the context of concomitant wAIHA and MDS.
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19
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Zhao M, Wang Y, Yang J, Wang Y, Feng Y, Chen L, Shao Z, Wang H, Xing L. Iron metabolism abnormalities in autoimmune hemolytic anemia and Jianpishengxue keli can ameliorate hemolysis and improve iron metabolism in AIHA mouse models. Ann Med 2023; 55:231-240. [PMID: 36576329 PMCID: PMC9809345 DOI: 10.1080/07853890.2022.2157475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE Autoimmune hemolytic anemia (AIHA) is rare heterogeneous disorder characterized by red blood cell (RBC) destruction via auto-antibodies, and after RBC is destroyed, proinflammatory danger-associated molecular patterns including extracellular hemoglobin, heme, and iron which causing cell injury. And oxidative stress represents one of the most significant effects of chronic hemolysis. Jianpishengxue keli can improve the symptoms of anemia patients with kidney disease and tumors and are beneficial in promoting recovery from chronic inflammation. Therefore, it is presumed that Jianpishengxue keli can improve the symptoms of AIHA. We aimed to investigate iron metabolism in AIHA and effects of Jianpishengxue keli on AIHA murine model. METHODS Nineteen hemolytic episode AIHA patients, 10 remission patients and 10 healthy controls (HCs) were enrolled in this study. Serum hepcidin, ferritin and other related indicators of iron metabolism were measured. Mouse models of AIHA were established and received high, medium, or low doses of Jianpishengxue keli by gavage daily for 14 and 28 days respectively. The level of RBCs, Hb, bilirubin, LDH, hepcidin, and the expression level of hepcidin mRNA, and hepatic ferroportin 1(FPN1) protein were evaluated. RESULTS Serum hepcidin in hemolytic episode AIHA patients and remission patients were significantly higher than that in HCs (p = 0.0083 and p = 0.0473, respectively). Serum ferritin in hemolytic AIHA patients was significantly higher than that in HCs (p = 0.008). Serum transferrin saturation levels are increased in patients with AIHA[ (57.21 ± 8.96) %]. EPO in hemolytic group was higher than that in healthy control (p<0.05). In AIHA mouse models, IBIL decreased after 14 days of high dose drug intervention. After 28 days, TBIL and IBIL both significantly decreased in all dose groups and LDH significantly decreased in the medium-and high-dose groups. Body weight improved, and the level of RBCs, Hb and hepcidin in the high-dose group returned to normal. After 14 and 28 days of intervention, hepatic hepcidin mRNA in all dose group significantly decreased. Hepatic FPN1 protein which were significantly lower in the AIHA mouse models, increased in all dose groups after drug intervention for 28 days. CONCLUSION Iron metabolism abnormalities exists in AIHA patients and Jianpishengxue keli can ameliorate hemolysis and improve iron metabolism in AIHA mouse models.KEY MESSAGESIron metabolism abnormalities exists in hemolytic episode AIHA patients. Hepcidin and ferritin levels significantly elevated and also correlated with the severity of AIHA patients. Jianpishengxue keli can ameliorate hemolysis and prompt the recovery of AIHA.
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Affiliation(s)
- Manjun Zhao
- Department of Hematology, General Hospital of Tianjin Medical University, Tianjin, China
| | - Yan Wang
- Department of Hematology, General Hospital of Tianjin Medical University, Tianjin, China
| | - Jin Yang
- Department of Hematology, General Hospital of Tianjin Medical University, Tianjin, China
| | - Yi Wang
- Third Medical Center of Chinese People's Liberation Army General Hospital, Beijing, China
| | - Yingying Feng
- Department of Hematology, General Hospital of Tianjin Medical University, Tianjin, China
| | - Lei Chen
- Department of Hematology, General Hospital of Tianjin Medical University, Tianjin, China
| | - Zonghong Shao
- Department of Hematology, General Hospital of Tianjin Medical University, Tianjin, China
| | - Huaquan Wang
- Department of Hematology, General Hospital of Tianjin Medical University, Tianjin, China
| | - Limin Xing
- Department of Hematology, General Hospital of Tianjin Medical University, Tianjin, China
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20
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Schlatterer K, Marschner M, Hausdorf C. [In macrohematuria, medication history also needs to be considered : Penicillin-induced immune hemolysis: a case report and review of literature]. INNERE MEDIZIN (HEIDELBERG, GERMANY) 2023; 64:1218-1223. [PMID: 37493757 DOI: 10.1007/s00108-023-01555-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/16/2023] [Indexed: 07/27/2023]
Abstract
BACKGROUND Drug-mediated immune hemolysis is a rare but potentially life-threatening condition. Based on a case of penicillin-induced immune hemolysis, a structured literature review of case reports and studies on penicillin-mediated Drug-Induced Immune Hemolytic Anemia (DIIHA) was carried out. CASE REPORT A 28-year-old male patient presented to the emergency department with gross hematuria and non-specific abdominal complaints. The patient had a 10-day history of respiratory infection with bacterial tonsillitis, treated orally with penicillin V on an outpatient basis. Laboratory diagnostics detected pathologically altered direct and indirect hemolysis parameters. After stopping the medication, the patient's condition could be stabilized. CONCLUSION Diagnosis of penicillin-mediated immune hemolysis requires structured cooperation between clinic and laboratory, as clinical and serological findings may be highly variable with the risk of misdiagnosis. Due to the rarity of the disease, this case report is intended to raise awareness with respect to the triad of abrupt drop in hemoglobin levels in connection with drug therapy and in combination with a strongly positive direct Coombs test.
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Affiliation(s)
- K Schlatterer
- Medizinische Hochschule Brandenburg Theodor Fontane, Neuruppin, Deutschland.
- Institut für Laboratoriumsmedizin, Sankt Gertrauden-Krankenhaus, Paretzer Str. 12, 10713, Berlin, Deutschland.
| | - M Marschner
- Abteilung für Innere Medizin/Kardiologie, Sankt Gertrauden-Krankenhaus, Berlin, Deutschland
| | - C Hausdorf
- Abteilung für Innere Medizin/Kardiologie, Sankt Gertrauden-Krankenhaus, Berlin, Deutschland
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21
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Zhang Z, Hu Q, Yang C, Chen M, Han B. Sirolimus is effective for primary refractory/relapsed warm autoimmune haemolytic anaemia/Evans syndrome: a retrospective single-center study. Ann Med 2023; 55:2282180. [PMID: 37967535 PMCID: PMC10653746 DOI: 10.1080/07853890.2023.2282180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 10/31/2023] [Indexed: 11/17/2023] Open
Abstract
BACKGROUND Some patients with warm autoimmune haemolytic anaemia (wAIHA) or Evans syndrome (ES) have no response to glucocorticoid or relapse. Recent studies found that sirolimus was effective in autoimmune cytopenia with a low relapse rate. METHODS Data from patients with refractory/relapsed wAIHA and ES in Peking Union Medical College Hospital from July 2016 to May 2022 who had been treated with sirolimus for at least 6 months and followed up for at least 12 months were collected retrospectively. Baseline and follow-up clinical data were recorded and the rate of complete response (CR), partial response (PR) at different time points, adverse events, relapse, outcomes, and factors that may affect the efficacy and relapse were analyzed. RESULTS There were 44 patients enrolled, with 9 (20.5%) males and a median age of 44 (range: 18-86) years. 37 (84.1%) patients were diagnosed as wAIHA, and 7 (15.9%) as ES. Patients were treated with sirolimus for a median of 23 (range: 6-80) months and followed up for a median of 25 (range: 12-80) months. 35 (79.5%) patients responded to sirolimus, and 25 (56.8%) patients achieved an optimal response of CR. Mucositis (11.4%), infection (9.1%), and alanine aminotransferase elevation (9.1%) were the most common adverse events. 5/35 patients (14.3%) relapsed at a median of 19 (range: 15-50) months. Patients with a higher sirolimus plasma trough concentration had a higher overall response (OR) and CR rate (p = 0.009, 0.011, respectively). At the time of enrolment, patients were divided into two subgroups that relapsed or refractory to glucocorticoid, and the former had poorer relapse-free survival (p = 0.032) than the other group. CONCLUSION Sirolimus is effective for patients with primary refractory/relapsed wAIHA and ES, with a low relapse rate and mild side effects. Patients with a higher sirolimus plasma trough concentration had a higher OR and CR rate, and patients who relapsed to glucocorticoid treatment had poorer relapse-free survival than those who were refractory.
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Affiliation(s)
- Zhuxin Zhang
- Department of Hematology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Science, Beijing, China
| | - Qinglin Hu
- Department of Hematology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Science, Beijing, China
| | - Chen Yang
- Department of Hematology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Science, Beijing, China
| | - Miao Chen
- Department of Hematology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Science, Beijing, China
| | - Bing Han
- Department of Hematology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Science, Beijing, China
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22
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Mitsuishi A, Miura Y, Saeki K, Nomura Y, Yoshifumi K, Yoshida K. Total arch replacement for an aortic arch aneurysm with cold agglutinin disease after rituximab and plasmapheresis. J Cardiothorac Surg 2023; 18:281. [PMID: 37817219 PMCID: PMC10566192 DOI: 10.1186/s13019-023-02388-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 09/30/2023] [Indexed: 10/12/2023] Open
Abstract
BACKGROUND Cold agglutinin disease can lead to significant complications, especially for patients undergoing arch repair requiring hypothermic circulatory arrest. Rituximab and plasmapheresis are treatments for cold agglutinin disease. However, its use in patients with Stanford type A dissection has not been reported. Therefore, after consultation with hematologists, we used rituximab and plasmapheresis before mild hypothermic aortic arch surgery to maintain the body temperature above the thermal altitude. CASE PRESENTATION This report describes an 86-year-old male patient with acute type A aortic dissection who received outpatient treatment for rheumatoid arthritis and a 55-mm thoracic aortic aneurysm. The patient was scheduled to undergo urgent surgery for a type A intramural hematoma and progressive aortic aneurysm; however, laboratory test results indicated blood clotting and cold agglutinin. Consequently, urgent surgery was rescheduled. After consulting with hematologists, rituximab was initiated 3 months before surgery, and plasmapheresis was performed 2 days before surgery for cold agglutinin disease. Under mild hypothermia conditions, total arch replacement using the frozen elephant trunk technique was performed while maintaining cerebral and lower body perfusion. The postoperative course was uneventful. On postoperative day 42, the patient was discharged without any neurological deficits. CONCLUSIONS This case involving total arch replacement with mild hypothermia for an aortic arch aneurysm with cold agglutinin disease after rituximab treatment and plasmapheresis resulted in a successful outcome.
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Affiliation(s)
- Atsuyuki Mitsuishi
- Department of Cardiovascular Surgery Kochi Medical School, 185-1, Kohasu, Nankoku-shi, Okohcho, Kochi Prefecture, 783-8505, Japan.
| | - Yujiro Miura
- Department of Cardiovascular Surgery Kochi Medical School, 185-1, Kohasu, Nankoku-shi, Okohcho, Kochi Prefecture, 783-8505, Japan
| | - Kyosuke Saeki
- Department of Hematology Ehime Prefectural Central Hospital, Matsuyama-shi, Ehime Prefecture, Kasugamachi, 790-0024, 83, Japan
| | - Yoshinori Nomura
- Department of Clinical Engineering Kochi Medical School, 185-1, Kohasu, Nankoku-shi, Okohcho, Kochi Prefecture, 783-8505, Japan
| | - Katsumata Yoshifumi
- Department of Anesthesiology and intensive Care Medicine Kochi Medical School, 185-1, Kohasu, Nankoku-shi, Okohcho, Kochi Prefecture, 783-8505, Japan
| | - Keisuke Yoshida
- Department of Cardiovascular Surgery Kochi Medical School, 185-1, Kohasu, Nankoku-shi, Okohcho, Kochi Prefecture, 783-8505, Japan
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23
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Durigon G, Sekine L, Franz JPM, Fogliatto LM, da Rocha Silla LM. Aspects of laboratory characteristics, analysis of alloimmunization, and searching for predictors related to survival in patients with Autoimmune Hemolytic Anemia. Transfus Apher Sci 2023; 62:103741. [PMID: 37271665 DOI: 10.1016/j.transci.2023.103741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 05/17/2023] [Accepted: 05/25/2023] [Indexed: 06/06/2023]
Abstract
Autoimmune hemolytic anemia (AIHA) is characterized by hemolysis caused by autoantibodies. However, many patients do not respond to therapies and may have an unfavorable outcome. It has been hypothesized that patients with AIHA and alloantibodies have a lower survival compared to patients with this disease and without alloimmunization. To this end, the clinical and laboratory profile was described and sought to identify features associated with survival in patients with AIHA. This is a single-site retrospective observational study that included patients (children, adolescents, adults and elderly) diagnosed with AIHA from January 2000 to June 2019. Epidemiological data, laboratory tests, treatment response, alloantibody and autoantibody profile, red cell transfusion and clinical course were analyzed. Survival analysis was performed using Kaplan-Meier curves and Cox proportional hazards regression. The study included 138 patients, mostly caucasians and female. The median age at diagnosis was 48.5 years (0.16-88) and 82 (59.4 %) patients had secondary AIHA. In addition, 33 % (25/75) of subjects had alloantibodies at the time of AIHA diagnosis and 40 % (16/40) detected alloantibody emergence later. The overall 10-year survival rate was 51 % (median follow-up was 39 months). Monocytosis, IgM class autoantibody and Direct Antiglobulin Test (DAT) intensity had a significant impact on predicting mortality in this population. On the other hand, alloimmunization at diagnosis and after did not affect survival in this population.
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Affiliation(s)
- Giane Durigon
- Laboratory Diagnostic Service, Porto Alegre Clinical Hospital, Porto Alegre, RS, Brazil; Laboratório Clínico, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | - Leo Sekine
- Hemotherapy Service, Porto Alegre Clinical Hospital, Porto Alegre, RS, Brazil
| | | | | | - Lucia Mariano da Rocha Silla
- Hematology Service, Porto Alegre Hospital de Clínicas, Porto Alegre, RS, Brazil; Hematology Service, Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil
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24
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Suzuki E, Kanno T, Saito Y, Shimbo T. Systemic Lupus Erythematosus and Antiphospholipid Syndrome Accompanied by Mixed-Type Autoimmune Hemolytic Anemia. Case Rep Rheumatol 2023; 2023:4963196. [PMID: 37766758 PMCID: PMC10522428 DOI: 10.1155/2023/4963196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 08/27/2023] [Accepted: 08/30/2023] [Indexed: 09/29/2023] Open
Abstract
Systemic lupus erythematosus (SLE) is an autoimmune disease that leads to a wide spectrum of clinical and immunological abnormalities. Hematologic abnormalities are an important manifestation of SLE. The incidence of autoimmune hemolytic anemia (AIHA) has been reported in approximately 10% of patients with SLE. Among them, mixed-type AIHA, which is caused by warm autoantibodies and cold hemagglutinin, is relatively rarely reported. We report the case of a 72-year-old woman, who was admitted to our hospital due to shortness of breath, jaundice, and severe anemia, with SLE and antiphospholipid syndrome (APS) complicated by mixed-type AIHA. Laboratory data revealed severe hemolytic anemia (low hemoglobin, high indirect bilirubin, and high lactate dehydrogenase levels), low complement levels, and the presence of antinuclear antibodies and lupus anticoagulant. Imaging results revealed pleural effusion and pulmonary embolisms, and echocardiogram revealed high estimated right ventricular pressure. She was diagnosed with SLE and APS complicated by mixed-type AIHA based on positive direct antiglobulin and cold agglutinin tests (thermal amplitude ≥30°C). As mixed-type AIHA is a severe and chronic condition, she was administered potent treatments with immunosuppressants. However, because she was a carrier of human T-cell leukemia virus type-1, only a moderate amount of prednisolone was administered. She refused to take warfarin. Fortunately, her symptoms and laboratory abnormalities improved after prednisolone administration, and no relapse occurred after tapering the prednisolone dose. Although mixed-type AIHA is characterized by fewer clinical symptoms than cold agglutinin disease, hemolytic anemia is more severe and chronic. Therefore, it is important to confirm the presence of cold agglutinins, which are active at ≥30°C in patients with SLE and warm AIHA. In addition, it is important to consider that AIHA is associated with thromboembolism, and patients with lupus anticoagulant or anticardiolipin antibodies having a history of AIHA are at a high risk of developing thrombosis.
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Affiliation(s)
- Eiji Suzuki
- Department of Rheumatology, Ohta-Nishinouchi Hospital, 2-5-20, Nishinouchi, Koriyama, Fukushima 963-8558, Japan
| | - Takashi Kanno
- Department of Rheumatology, Ohta-Nishinouchi Hospital, 2-5-20, Nishinouchi, Koriyama, Fukushima 963-8558, Japan
| | - Yurie Saito
- Department of Hematology, Ohta-Nishinouchi Hospital, 2-5-20, Nishinouchi, Koriyama, Fukushima 963-8558, Japan
| | - Takuro Shimbo
- Department of Internal Medicine, Ohta-Nishinouchi Hospital, 2-5-20, Nishinouchi, Koriyama, Fukushima 963-8558, Japan
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25
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Mulder FVM, Evers D, de Haas M, Cruijsen MJ, Bernelot Moens SJ, Barcellini W, Fattizzo B, Vos JMI. Severe autoimmune hemolytic anemia; epidemiology, clinical management, outcomes and knowledge gaps. Front Immunol 2023; 14:1228142. [PMID: 37795092 PMCID: PMC10545865 DOI: 10.3389/fimmu.2023.1228142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 08/28/2023] [Indexed: 10/06/2023] Open
Abstract
Autoimmune hemolytic anemia (AIHA) is an acquired hemolytic disorder, mediated by auto-antibodies, and has a variable clinical course ranging from fully compensated low grade hemolysis to severe life-threatening cases. The rarity, heterogeneity and incomplete understanding of severe AIHA complicate the recognition and management of severe cases. In this review, we describe how severe AIHA can be defined and what is currently known of the severity and outcome of AIHA. There are no validated predictors for severe clinical course, but certain risk factors for poor outcomes (hospitalisation, transfusion need and mortality) can aid in recognizing severe cases. Some serological subtypes of AIHA (warm AIHA with complement positive DAT, mixed, atypical) are associated with lower hemoglobin levels, higher transfusion need and mortality. Currently, there is no evidence-based therapeutic approach for severe AIHA. We provide a general approach for the management of severe AIHA patients, incorporating monitoring, supportive measures and therapeutic options based on expert opinion. In cases where steroids fail, there is a lack of rapidly effective therapeutic options. In this era, numerous novel therapies are emerging for AIHA, including novel complement inhibitors, such as sutimlimab. Their potential in severe AIHA is discussed. Future research efforts are needed to gain a clearer picture of severe AIHA and develop prediction models for severe disease course. It is crucial to incorporate not only clinical characteristics but also biomarkers that are associated with pathophysiological differences and severity, to enhance the accuracy of prediction models and facilitate the selection of the optimal therapeutic approach. Future clinical trials should prioritize the inclusion of severe AIHA patients, particularly in the quest for rapidly acting novel agents.
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Affiliation(s)
- Femke V. M. Mulder
- Sanquin Research and Landsteiner Laboratory, Translational Immunohematology, Amsterdam UMC, Amsterdam, Netherlands
- Department of Hematology, Leiden University Medical Center, Leiden, Netherlands
| | - Dorothea Evers
- Department of Hematology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Masja de Haas
- Sanquin Research and Landsteiner Laboratory, Translational Immunohematology, Amsterdam UMC, Amsterdam, Netherlands
- Department of Hematology, Leiden University Medical Center, Leiden, Netherlands
- Department of Immunohematology Diagnostics, Sanquin Diagnostic Services, Amsterdam, Netherlands
| | | | - Sophie J. Bernelot Moens
- Department of Hematology and Amsterdam Institute for Infection and Immunity, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Wilma Barcellini
- Department of Hematology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Bruno Fattizzo
- Department of Hematology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Josephine M. I. Vos
- Department of Immunohematology Diagnostics, Sanquin Diagnostic Services, Amsterdam, Netherlands
- Department of Hematology and Amsterdam Institute for Infection and Immunity, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
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Cvetković Z, Pantić N, Cvetković M, Virijević M, Sabljić N, Marinković G, Milosavljević V, Pravdić Z, Suvajdžić-Vuković N, Mitrović M. The Role of the Spleen and the Place of Splenectomy in Autoimmune Hemolytic Anemia-A Review of Current Knowledge. Diagnostics (Basel) 2023; 13:2891. [PMID: 37761258 PMCID: PMC10527817 DOI: 10.3390/diagnostics13182891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 09/04/2023] [Accepted: 09/06/2023] [Indexed: 09/29/2023] Open
Abstract
Autoimmune hemolytic anemia (AIHA) is a rare, very heterogeneous, and sometimes life-threatening acquired hematologic disease characterized by increased red blood cell (RBC) destruction by autoantibodies (autoAbs), either with or without complement involvement. Recent studies have shown that the involvement of T- and B-cell dysregulation and an imbalance of T-helper 2 (Th2) and Th17 phenotypes play major roles in the pathogenesis of AIHA. AIHA can be primary (idiopathic) but is more often secondary, triggered by infections or drug use or as a part of other diseases. As the location of origin of autoAbs and the location of autoAb-mediated RBC clearance, as well as the location of extramedullary hematopoiesis, the spleen is crucially involved in all the steps of AIHA pathobiology. Splenectomy, which was the established second-line therapeutic option in corticosteroid-resistant AIHA patients for decades, has become less common due to increasing knowledge of immunopathogenesis and the introduction of targeted therapy. This article provides a comprehensive overview of current knowledge regarding the place of the spleen in the immunological background of AIHA and the rapidly growing spectrum of novel therapeutic approaches. Furthermore, this review emphasizes the still-existing expediency of laparoscopic splenectomy with appropriate perioperative thromboprophylaxis and the prevention of infection as a safe and reliable therapeutic option in the context of the limited availability of rituximab and other novel therapies.
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Affiliation(s)
- Zorica Cvetković
- Department of Hematology, University Hospital Medical Center Zemun, 11080 Belgrade, Serbia
- Medical Faculty, University of Belgrade, 11000 Belgrade, Serbia
| | - Nikola Pantić
- Clinic for Hematology, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Mirjana Cvetković
- Clinic for Hematology, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Marijana Virijević
- Medical Faculty, University of Belgrade, 11000 Belgrade, Serbia
- Clinic for Hematology, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Nikica Sabljić
- Clinic for Hematology, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Gligorije Marinković
- Department of Hematology, University Hospital Medical Center Zemun, 11080 Belgrade, Serbia
| | - Vladimir Milosavljević
- Department for HPB Surgery, University Hospital Medical Center Bežanijska Kosa, 11070 Belgrade, Serbia
| | - Zlatko Pravdić
- Clinic for Hematology, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Nada Suvajdžić-Vuković
- Medical Faculty, University of Belgrade, 11000 Belgrade, Serbia
- Clinic for Hematology, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Mirjana Mitrović
- Medical Faculty, University of Belgrade, 11000 Belgrade, Serbia
- Clinic for Hematology, University Clinical Center of Serbia, 11000 Belgrade, Serbia
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Rodríguez-Rodríguez S, Álvarez-Blanco JM, Sánchez-Díaz S, Rangel-Patiño J, Sierra-Salazar A, Apodaca-Chávez E, Demichelis-Gómez R. Are accessory spleen screening and resection in refractory immune cytopenia an effective strategy or a waste of resources? Ann Hematol 2023; 102:2309-2315. [PMID: 37439893 DOI: 10.1007/s00277-023-05360-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 07/04/2023] [Indexed: 07/14/2023]
Abstract
Splenectomy remains an effective treatment for refractory immune cytopenia (RIC), which encompasses immune thrombocytopenia (ITP) and autoimmune hemolytic anemia (AIHA). Accessory spleens (AS) have been described without identifying specific risk factors. We retrospectively analyzed patients with RIC after splenectomy who underwent splenic scintigraphy (SS) at our institution. Seventy-one patients were included. Sixty-two patients had ITP, five had AIHA, and four had Evans syndrome. Seventy-five percent (n = 53) were women. Eleven patients (15.5%) had an AS detected by SS. A complete response (CR) to first-line steroids (odds ratio (OR) 5.75, 95% confidence interval (CI) 1.37-24.14, p = 0.017) and the absence of Howell-Jolly bodies (HJB) in peripheral blood smear (PBS) (OR 11.37, 95% CI 2.70-47.85, p = 0.001) were found to be risk factors. Patients with both elements had a higher rate of AS (83.3%) when compared to those with one or no factors (p < 0.001). Eight patients (73%) underwent an accessory splenectomy: seven (87.5%) achieved a CR, and none had perioperative complications. The presence of HJB in PBS changed from 25 to 87.5% after accessory splenectomy. We recommend the search for an AS via SS in patients with RIC due to ITP, who had a CR to corticosteroids and the absence of HJB in PBS. Accessory splenectomy is a safe and effective procedure.
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Affiliation(s)
- Sergio Rodríguez-Rodríguez
- Hematology and Oncology Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Belisario Domínguez, Tlalpan, 14080, Mexico City, ZC, Mexico
| | - José Miguel Álvarez-Blanco
- Hematology and Oncology Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Belisario Domínguez, Tlalpan, 14080, Mexico City, ZC, Mexico
| | - Susana Sánchez-Díaz
- Hematology and Oncology Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Belisario Domínguez, Tlalpan, 14080, Mexico City, ZC, Mexico
| | - Juan Rangel-Patiño
- Hematology and Oncology Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Belisario Domínguez, Tlalpan, 14080, Mexico City, ZC, Mexico
| | - Ana Sierra-Salazar
- Hematology and Oncology Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Belisario Domínguez, Tlalpan, 14080, Mexico City, ZC, Mexico
| | - Elia Apodaca-Chávez
- Hematology and Oncology Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Belisario Domínguez, Tlalpan, 14080, Mexico City, ZC, Mexico
| | - Roberta Demichelis-Gómez
- Hematology and Oncology Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Belisario Domínguez, Tlalpan, 14080, Mexico City, ZC, Mexico.
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Cennamo M, Sirocchi D, Giudici C, Giagnacovo M, Petracco G, Ferrario D, Garganigo S, Papa A, Veniani E, Squizzato A, Del Vecchio L, Patriarca C, Partenope M, Modena P. A Peculiar CLL Case with Complex Chromosome 6 Rearrangements and Refinement of All Breakpoints at the Gene Level by Genomic Array: A Case Report. J Clin Med 2023; 12:4110. [PMID: 37373803 DOI: 10.3390/jcm12124110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 06/13/2023] [Accepted: 06/14/2023] [Indexed: 06/29/2023] Open
Abstract
INTRODUCTION Chronic lymphocytic leukemia (CLL), the most common leukemia in Western countries, is a mature B-cell chronic lymphoproliferative disorder characterized by the accumulation of neoplastic CD5+ B lymphocytes, functionally incompetent and usually monoclonal in origin, in bone marrow, lymph nodes and blood. Diagnosis occurs predominantly in elderly patients, with a median age reported between 67 and 72 years. CLL has a heterogeneous clinical course, which can vary from indolent to, less frequently, aggressive forms. Early-stage asymptomatic CLL patients do not require immediate therapeutic intervention, but only observation; treatment is necessary for patients with advanced disease or when "active disease" is observed. The most frequent autoimmune cytopenia (AIC) is autoimmune haemolytic anaemia (AHIA). The main mechanisms underlying the appearance of AIC in CLL are not fully elucidated, the predisposition of patients with CLL to suffering autoimmune complications is variable and autoimmune cytopenia can precede, be concurrent, or follow the diagnosis of CLL. CASE PRESENTATION A 74-year-old man was admitted to the emergency room following the finding of severe macrocytic anaemia during blood tests performed that same day, in particular the patient showed a profound asthenia dating back several months. The anamnesis was silent and the patient was not taking any medications. The blood examination showed an extremely high White Blood Cell count and findings of AIHA in CLL-type mature B-cell lymphoproliferative neoplasia. Genetic investigations: Conventional karyotyping was performed and it obtained a trisomy 8 and an unbalanced translocation between the short arm of chromosome 6 and the long arm of chromosome 11, concurrent with interstitial deletions in chromosomes 6q and 11q that could not be defined in detail. Molecular cytogenetics (FISH) analyses revealed Ataxia Telangiectasia Mutated (ATM) monoallelic deletion (with loss of ATM on derivative chromosome 11) and retained signals for TP53, 13q14 and centromere 12 FISH probes. TP53 and IGHV were not mutated. Array-CGH confirmed trisomy of the entire chromosome 8 and allowed us to resolve in detail the nature of the unbalanced translocation, revealing multiple regions of genomic losses on chromosomes 6 and 11. DISCUSSION The present case report is an unusual CLL case with complex karyotype and refinement of all breakpoints at the gene level by the genomic array. From a genetic point of view, the case under study presented several peculiarities. CONCLUSIONS We report the genetic findings of a CLL patient with abrupt disease onset, so far responding properly to treatments despite the presence of distinct genetic adverse traits including ATM deletion, complex karyotype and chromosome 6q chromoanagenesis event. Our report confirms that interphase FISH alone is not able to provide an overview of the whole genomic landscape in selected CLL cases and that additional techniques are required to reach an appropriate cytogenetic stratification of patients.
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Affiliation(s)
- Michele Cennamo
- Department of Translational Medical Sciences, University of Naples "Federico II", 80131 Naples, Italy
- Clinical Pathology and Microbiology Unit, Laboratory Analysis, ASST Lariana, Hospital Sant'Anna, 22100 Como, Italy
| | - Davide Sirocchi
- General Medicine Unit, ASST Lariana, Hospital Sant'Anna, 22100 Como, Italy
| | - Carolina Giudici
- Genetics Unit, ASST Lariana, Hospital Sant'Anna, 22100 Como, Italy
| | | | - Guido Petracco
- Pathological Unit, ASST Lariana, Hospital Sant'Anna, 22100 Como, Italy
| | - Daniela Ferrario
- Pathological Unit, ASST Lariana, Hospital Sant'Anna, 22100 Como, Italy
| | - Simona Garganigo
- Clinical Pathology and Microbiology Unit, Laboratory Analysis, ASST Lariana, Hospital Sant'Anna, 22100 Como, Italy
| | - Angela Papa
- Clinical Pathology and Microbiology Unit, Laboratory Analysis, ASST Lariana, Hospital Sant'Anna, 22100 Como, Italy
| | - Emanuela Veniani
- Clinical Pathology and Microbiology Unit, Laboratory Analysis, ASST Lariana, Hospital Sant'Anna, 22100 Como, Italy
| | - Alessandro Squizzato
- General Medicine Unit, ASST Lariana, Hospital Sant'Anna, 22100 Como, Italy
- Department of Medicine and Surgery, Research Centre on Thromboembolic Disorders and Antithrombotic Therapies, University of Insubria, 21110 Varese, Italy
| | - Lucia Del Vecchio
- Department of Nephrology and Dialysis, ASST Lariana, Hospital Sant'Anna, 22100 Como, Italy
| | - Carlo Patriarca
- Pathological Unit, ASST Lariana, Hospital Sant'Anna, 22100 Como, Italy
| | - Michelarcangelo Partenope
- Clinical Pathology and Microbiology Unit, Laboratory Analysis, ASST Lariana, Hospital Sant'Anna, 22100 Como, Italy
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Papadakis E, Brenner B. Thrombosis in Pregnant Women with Hemolytic Anemia. Semin Thromb Hemost 2023; 49:364-370. [PMID: 36410400 DOI: 10.1055/s-0042-1758819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Hemolytic anemias are a group of uncommon disorders affecting both genders, frequently occurring at the reproductive age. While a link between hemolysis and hypercoagulability has been suggested based on the elucidation of certain involved pathophysiological mechanisms, the extent of thrombotic risk in pregnant women with hemolytic anemia remains debatable. Due to the paucity of pregnancy-related data, risk assessment of gestations in women with hemolytic anemia is complicated. This review will highlight the latest advances in the diagnosis and management of these challenging disorders in pregnancy.
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Affiliation(s)
| | - Benjamin Brenner
- Department of Hematology, Rambam Health Care Campus, Haifa, Israel
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
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Berentsen S, Fattizzo B, Barcellini W. The choice of new treatments in autoimmune hemolytic anemia: how to pick from the basket? Front Immunol 2023; 14:1180509. [PMID: 37168855 PMCID: PMC10165002 DOI: 10.3389/fimmu.2023.1180509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 04/13/2023] [Indexed: 05/13/2023] Open
Abstract
Autoimmune hemolytic anemia (AIHA) is defined by increased erythrocyte turnover mediated by autoimmune mechanisms. While corticosteroids remain first-line therapy in most cases of warm-antibody AIHA, cold agglutinin disease is treated by targeting the underlying clonal B-cell proliferation or the classical complement activation pathway. Several new established or investigational drugs and treatment regimens have appeared during the last 1-2 decades, resulting in an improvement of therapy options but also raising challenges on how to select the best treatment in individual patients. In severe warm-antibody AIHA, there is evidence for the upfront addition of rituximab to prednisolone in the first line. Novel agents targeting B-cells, extravascular hemolysis, or removing IgG will offer further options in the acute and relapsed/refractory settings. In cold agglutinin disease, the development of complement inhibitors and B-cell targeting agents makes it possible to individualize therapy, based on the disease profile and patient characteristics. For most AIHAs, the optimal treatment remains to be found, and there is still a need for more evidence-based therapies. Therefore, prospective clinical trials should be encouraged.
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Affiliation(s)
- Sigbjørn Berentsen
- Department of Research and Innovation, Haugesund Hospital, Helse Fonna Hospital Trust, Haugesund, Norway
| | - Bruno Fattizzo
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, and Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Wilma Barcellini
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
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31
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Abdel-Salam A, Bassiouni ST, Goher AM, Shafie ES. Autoimmune Hemolytic Anemia in the Pediatric Age Group: The Egyptian Experience. Ann Hematol 2023:10.1007/s00277-023-05230-5. [PMID: 37093240 DOI: 10.1007/s00277-023-05230-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 04/11/2023] [Indexed: 04/25/2023]
Abstract
Autoimmune hemolytic anemia (AIHA) is a common disease entity among adults; however, it is rare among the pediatric age group. Evidence is scarce regarding pediatric AIHA in the literature. The objective of this study is to assess the frequency of AIHA and describe the clinical and laboratory characteristics and treatment outcomes of a cohort of children with AIHA in Egypt. A retrospective study was conducted on 50 children with AIHA who were registered and followed up at the New Children's Hospital in Cairo, Egypt, between January 2010 and January 2021. The study group comprised 60% females and 40% males. Their median age was 8.25 years. All patients showed low hemoglobin levels with a mean of 5.40 ± 1.34 g/dl and a median reticulocyte count of 10 (IQR: 8-15). Twelve (24%) patients were diagnosed with Evans syndrome, and a positive Coombs test was detected in 46 patients (92%). The frequency of primary AIHA was 40%, whereas it was 60% for secondary AIHA. The first line of therapy for acute attacks was high-dose IV steroids which responded well in 38 (76%) patients. Secondary AIHA was more common among our children (60%). AIHA is more prevalent in females (60%). The clinical and laboratory characteristics matched previous reports.
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Affiliation(s)
- Amina Abdel-Salam
- Deparment of Pediatrics, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Sherifa Tarek Bassiouni
- Department of Clinical and Chemical Pathology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Alaa Magdi Goher
- Deparment of Pediatrics, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Eman Shafik Shafie
- Deparment of Pediatrics, Faculty of Medicine, Cairo University, Cairo, Egypt.
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32
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Khot RS, Patil A, Rathod BD, Patidar M, Joshi PP. Uncovering the Unusual: A Case of Mixed Connective Tissue Disease With Rare Presentation, Atypical Complications, and Therapeutic Dilemmas. Cureus 2023; 15:e36298. [PMID: 37073214 PMCID: PMC10106112 DOI: 10.7759/cureus.36298] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2023] [Indexed: 03/19/2023] Open
Abstract
Mixed connective tissue disease (MCTD) is an overlap syndrome characterized by features of systemic lupus erythematosus, scleroderma, and polymyositis, along with the presence of the U1RNP antibody. A 46-year-old female patient presented with severe anemia, cough, and breathlessness, and was diagnosed with cold agglutinin disease, a type of autoimmune hemolytic anemia (AIHA). Autoimmune workup revealed MCTD by positive antinuclear and U1RNP antibodies. She had bilateral miliary mottling on X-ray and a tree-in-bud appearance on high-resolution computed tomography of the thorax, which were suggestive of pulmonary tuberculosis. Standard therapy with steroids was not advisable. She was subsequently started on anti-tuberculosis treatment (anti-Koch's therapy), followed by steroid therapy and immunosuppressive therapy after three weeks. The patient responded well to treatment, but after two months, she developed cytomegalovirus (CMV) retinitis. Adult-onset CMV disease may occur as a result of primary infection, reinfection, or activation of a latent infection. Although not directly related, it can occur as an atypical association in the setting of immunosuppressive therapy. Morbidity and mortality are significantly increased in this population secondary to infectious potentiation: immunosuppression causes infections, and infections cause AIHA. The management of MCTD and secondary AIHA and immunosuppression poses a therapeutic challenge.
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Das SS, Das S, Shastry S, Shenoy V, Mandal S, Datta SS. Real-world data from India on clinical practices in the management of autoimmune haemolytic anaemia: A survey-based cross-sectional assessment. Transfus Clin Biol 2023; 30:137-142. [PMID: 36202315 DOI: 10.1016/j.tracli.2022.09.069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Revised: 09/27/2022] [Accepted: 09/28/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Autoimmune haemolytic anaemia (AIHA) is a decompensated acquired haemolysis caused by the host's immune system acting against its own red cell antigens. The aim of this national survey is to capture real-world data of clinical practices in AIHA by collecting responses from clinical haematologists across India. METHODOLOGY In this cross-sectional study, a structured, 26-question online survey was conducted in India by few members of the special interest group in immunohaematology between January and March, 2022. The final survey consisted of questions covering place of work, amount of AIHA cases being evaluated by the haematologist over preceding years, basic demographic, clinical and laboratory features of the patients being treated under them etc. Descriptive statistical analysis was performed during the assessment. RESULTS The survey response rate was 48.2% (53/110), 69.8% (37/53) have diagnosed and managed more than 10 AIHA cases in the last 3 years with a female preponderance. There was considerable variability in response. While 56.6% (30/53) of respondents do have the access to the facilities to subtype AIHA cases; 32.1% (17/53) of clinicians would prefer administering high dose steroids for 6 weeks or more in non-responding patients, and only 45.3% (24/53) would assess the risks of thrombosis in AIHA. There is unanimous agreement among the participants that health-related quality of life should be taken into consideration in patients and the need for a national registry of patients with AIHA in India. CONCLUSION The current national survey showed that some aspects of AIHA management were consistent; others were less so, but also significant variations were observed in certain clinical practices, where the evidence base is limited. A joint effort is needed to establish a national patient registry by including both clinical haematologists and transfusion medicine specialists which could potentially standardise AIHA management and future research in India.
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Affiliation(s)
- Sudipta Sekhar Das
- Department of Transfusion Medicine, Apollo Multispeciality Hospitals, Kolkata, India
| | - Soumya Das
- Department of Transfusion Medicine, All India Institute of Medical Sciences, Nagpur, Maharashtra, India
| | - Shamee Shastry
- Department of Immunohematology and Blood Transfusion, Kasturba Medical College, Manipal, Karnataka, India
| | - Veena Shenoy
- Department of Transfusion Medicine, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - Saikat Mandal
- Department of Transfusion Medicine & Blood Centre, Jaypee Hospital, Noida, Delhi NCR, India
| | - Suvro Sankha Datta
- Department of Transfusion Medicine, Tata Medical Center, Newtown, Rajarhat, Kolkata 700160, India.
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Alebbi SM, Kambal A, Abo Samra H, Sharaf Eldean MZ, Mohamed SF, Al-Shokri SD. Case Report: Tuberculosis-Induced Autoimmune Hemolytic Anemia. Am J Trop Med Hyg 2023; 108:313-316. [PMID: 36535253 PMCID: PMC9896313 DOI: 10.4269/ajtmh.22-0217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 09/01/2022] [Indexed: 12/23/2022] Open
Abstract
Tuberculosis (TB) is an infectious disease that affects different organs, causing multiple complications, including hematological sequelae. One of the most common TB-hematological complications is anemia of chronic disease. Very rarely autoimmune hemolytic anemia (AIHA) has been reported as an uncommon manifestation of TB. In this case, we present a female who presented with refractory AIHA, which was attributed to disseminated TB. The patient responded well to steroids, anti-TB medications, and rituximab.
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Affiliation(s)
- Seham M. Alebbi
- Department of Medical Education, Hamad Medical Corporation, Doha, Qatar
| | - Aalaa Kambal
- Clinical Imaging Department, Hamad Medical Corporation, Doha, Qatar
| | - Hayan Abo Samra
- Department of Laboratory Medicine and Pathology, Hamad Medical Corporation, Doha, Qatar
- Histopathology Department, Hamad Medical Corporation, Doha, Qatar
| | - Mouhammad Z. Sharaf Eldean
- Department of Laboratory Medicine and Pathology, Hamad Medical Corporation, Doha, Qatar
- Histopathology Department, Hamad Medical Corporation, Doha, Qatar
| | - Shehab Fareed Mohamed
- Department of Hematology and Medical Oncology, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar
| | - Shaikha D. Al-Shokri
- Department of Medical Education, Hamad Medical Corporation, Doha, Qatar
- Department of Internal Medicine, Case Western Reserve University–MetroHealth Medical Center, Cleveland, Ohio
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35
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Argüello Marina M, López Rubio M, Castilla García L. [Autoimmune haemolytic anaemia]. Med Clin (Barc) 2023; 160:30-38. [PMID: 36334945 DOI: 10.1016/j.medcli.2022.07.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 07/28/2022] [Accepted: 07/29/2022] [Indexed: 12/29/2022]
Abstract
Autoimmune haemolytic anaemias (AIHA) are acquired haematological disorders caused by increased peripheral erythrocyte destruction mediated by autoantibodies against erythrocyte antigens. They classified according to aetiology into primary and secondary, and according to the type of antibody and reaction temperature into AIHA due to warm antibodies (w-AIHA) and AIHA due to cold antibodies (c-AIHA). The mainstay of management in w-AIHA remains glucocorticoid therapy, and the early addition of rituximab has shown good results in recent studies. Primary c-AIHA is mainly treated with rituximab, alone or in combination with chemotherapy. New drugs such as Syk inhibitors, anti-FcRn Ig and complement inhibitors are in advanced development and will expand the therapeutic arsenal, especially in refractory or relapsed cases.
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Affiliation(s)
- María Argüello Marina
- Servicio de Hematología y Hemoterapia, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, España.
| | - Montserrat López Rubio
- Servicio de Hematología y Hemoterapia, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, España
| | - Lucía Castilla García
- Servicio de Hematología y Hemoterapia, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, España
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36
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Hematologic and Oncologic Emergencies. Crit Care Nurs Q 2023; 46:100-113. [DOI: 10.1097/cnq.0000000000000440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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37
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Johnson ST, Puca KE. Evaluating patients with autoimmune hemolytic anemia in the transfusion service and immunohematology reference laboratory: pretransfusion testing challenges and best transfusion-management strategies. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2022; 2022:96-104. [PMID: 36485094 PMCID: PMC9820620 DOI: 10.1182/hematology.2022000406] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
The serologic evaluation of autoimmune hemolytic anemia (AIHA) confirms the clinical diagnosis, helps distinguish the type of AIHA, and identifies whether any underlying alloantibodies are present that might complicate the selection of the safest blood for any needed transfusion. The spectrum of testing is generally dependent on the amount and class (immunoglobulin G or M) of autoantibody as well as the resources and methodologies where testing is performed. The approach may range from routine pretransfusion testing, including the direct antiglobulin test, to advanced techniques such as adsorptions, elution, and red cell genotyping. When transfusion is needed, the selection of the optimal unit of red blood cells is based on urgency and whether time allows for the completion of sophisticated serologic and molecular testing methods. From the start of when AIHA is suspected until the completion of testing, communication among the clinical team and medical laboratory scientists in the transfusion service and immunohematology reference laboratory is critical as testing can take several hours and the need for transfusion may be urgent. The frequent exchange of information including the patient's transfusion history and clinical status, the progress of testing, and any available results is invaluable for timely diagnosis, ongoing management of the patient, and the safety of transfusion if required before testing is complete.
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Affiliation(s)
- Susan T Johnson
- Clinical Education and Diagnostic Laboratories Immunohematology Reference Laboratory, Versiti Blood Center of Wisconsin, Milwaukee, WI
| | - Kathleen E Puca
- Clinical Education and Diagnostic Laboratories Immunohematology Reference Laboratory, Versiti Blood Center of Wisconsin, Milwaukee, WI
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38
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Pattanakitsakul P, Sirachainan N, Tassaneetrithep B, Priengprom T, Kijporka P, Apiwattanakul N. Enterovirus 71-Induced Autoimmune Hemolytic Anemia in a Boy. CLINICAL MEDICINE INSIGHTS-CASE REPORTS 2022; 15:11795476221132283. [PMID: 36277905 PMCID: PMC9580087 DOI: 10.1177/11795476221132283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 09/23/2022] [Indexed: 11/07/2022]
Abstract
Autoimmune hemolytic anemia (AIHA) can be induced by recent or concomitant infections. Many infectious agents are postulated to be associated with this condition. Treatment of infection induced AIHA still varies. This report describes a previously healthy Thai boy who developed AIHA associated with enterovirus-71 infection. He was successfully treated with oral prednisone.
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Affiliation(s)
- Ploy Pattanakitsakul
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Nongnuch Sirachainan
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Boonrat Tassaneetrithep
- Center of Research Excellence in Immunoregulation, Research Department, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Thongkoon Priengprom
- Center of Research Excellence in Immunoregulation, Research Department, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Pimpun Kijporka
- Department of Pathology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Nopporn Apiwattanakul
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand,Nopporn Apiwattanakul, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, 270 Rama VI Road, Ratchathewi District, Bangkok 10400, Thailand.
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39
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Higuchi T, Hoshi T, Toriyama M, Nakajima A, Haruki K. Infrequent Thrombotic Complications in Japanese Patients with Warm Autoimmune Hemolytic Anemia. Intern Med 2022; 62:1441-1447. [PMID: 36171129 DOI: 10.2169/internalmedicine.0541-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Objective Patients with autoimmune hemolytic anemia (AIHA) are considered to be at an increased risk of thrombosis, and prophylaxis for venous thromboembolism (VTE) is often recommended. However, the occurrence of thrombosis in Asian patients has not been specifically studied. Thrombotic complications and features of Japanese warm AIHA (WAIHA) patients were studied to see if Japanese patients were at an increased risk of thrombosis and should receive prophylaxis for VTE. Patients and Methods Forty-seven consecutive patients with warm WAIHA were retrospectively studied. Twenty-nine patients were diagnosed as primary cases and 18 as secondary cases, and 10 patients were diagnosed with Evans syndrome. Results No patient presented with thrombosis, and over a median observation period of 15 months, 3 patients had ischemic cerebral vascular accidents. However, all three of those patients had other known risks for thrombosis, with only one taking thrombotic prophylaxis. No venous thrombosis occurred in any patients during the follow-up period. There was no mortality associated with thrombosis. D-dimer levels were often elevated in patients with WAIHA, indicating that the coagulation was activated in a considerable number of patients, but not to such a level as to be associated with clinically overt thrombosis. Conclusion Thrombotic complications occur infrequently in Japanese WAIHA patients, and these individuals do not appear to be at a particularly increased risk of thrombosis because of WAIHA. The indication of VTE prophylaxis should be determined individually, considering other risks.
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Affiliation(s)
- Takakazu Higuchi
- Blood Transfusion Department, Dokkyo Medical University Saitama Medical Center, Japan
| | - Takao Hoshi
- Clinical Laboratory, Dokkyo Medical University Saitama Medical Center, Japan
| | - Mitsuru Toriyama
- Blood Transfusion Department, Dokkyo Medical University Saitama Medical Center, Japan
| | - Atsuko Nakajima
- Clinical Laboratory, Dokkyo Medical University Saitama Medical Center, Japan
| | - Kosuke Haruki
- Clinical Laboratory, Dokkyo Medical University Saitama Medical Center, Japan
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40
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Behzadifard M, Arianezhad A, Bandehzadeh A, Gholampour M. Severe hemolysis with negative direct antiglobulin test: A case report. Ann Med Surg (Lond) 2022; 81:104444. [PMID: 36147176 PMCID: PMC9486623 DOI: 10.1016/j.amsu.2022.104444] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Revised: 08/06/2022] [Accepted: 08/12/2022] [Indexed: 11/21/2022] Open
Abstract
A 49-year-old woman with type 2 diabetes mellitus (T2DM) presented to the emergency department. Her examination showed marked pallor, exhaustion, lethargy, yellowish eyes, anorexia, nausea and vomiting. Hematuria; negative standard direct antiglobulin test (DAT); normal glucose 6 phosphate dehydrogenase (G6PD); hemoglobin (Hb), 4.8 g/dl; Mean cell volume (MCV), 91fl; platelet count, 233 × 106/L; Total bilirubin, 7.0 mg/dl; Glucose, 316 mg/dl; lactate dehydrogenase (LDH), 1750U/L. Undoubtedly, therapeutic panel should have been used for hemolytic anemia. Intravenous (IV) fluids and 2 units of packed cell were transfused. Methylprednisolone with rituximab were started for the patient. After 3 weeks of the patient admission, she was discharged home with stable vital signs and Hb, 10 g/dl. We concluded in the cases that presented along with a severe drop in Hb and evidence of hemolysis which non immune hemolytic anemia is excluded in spite of negative standard DAT limited transfusion besides corticosteroids combined with rituximab, could be helpful in saving the patient. Autoimmune hemolytic anemia (AIHA) is caused by increased erythrocyte destruction with autoantibodies directed against the person's own red blood cells and susceptible them to lyse and consequent insufficient number of red blood cells in the circulation. A diagnosis of DAT-negative AIHA can be made following careful exclusion of alternative causes of hemolysis, and confirmation by a sensitive technique and by a response to steroid therapy.
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Affiliation(s)
- Mahin Behzadifard
- Dezful University of Medical Sciences, Dezful, Iran
- Corresponding author. Dezful University of Medical Sciences, Dezful, Iran. Tel.: +98 6142429531.
| | | | | | - Mohammadali Gholampour
- Department of Medicine, Lung Biology Center, Cardiovascular Research Institute, University of California, San Francisco, CA, USA
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41
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Röth A, Berentsen S, Barcellini W, D'Sa S, Jilma B, Michel M, Weitz IC, Yamaguchi M, Nishimura JI, Vos JMI, Storek M, Wong N, Patel P, Jiang X, Vagge DS, Wardęcki M, Shafer F, Lee M, Broome CM. Sutimlimab in patients with cold agglutinin disease: results of the randomized placebo-controlled phase 3 CADENZA trial. Blood 2022; 140:980-991. [PMID: 35687757 PMCID: PMC9437710 DOI: 10.1182/blood.2021014955] [Citation(s) in RCA: 42] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 05/30/2022] [Indexed: 11/20/2022] Open
Abstract
Sutimlimab, a first-in-class humanized immunoglobulin G4 (IgG4) monoclonal antibody that selectively inhibits the classical complement pathway at C1s, rapidly halted hemolysis in the single-arm CARDINAL study in recently transfused patients with cold agglutinin disease (CAD). CADENZA was a 26-week randomized, placebo-controlled phase 3 study to assess safety and efficacy of sutimlimab in patients with CAD without recent (within 6 months prior to enrollment) transfusion history. Forty-two patients with screening hemoglobin ≤10 g/dL, elevated bilirubin, and ≥1 CAD symptom received sutimlimab (n = 22) or placebo (n = 20) on days 0 and 7 and then biweekly. Composite primary endpoint criteria (hemoglobin increase ≥1.5 g/dL at treatment assessment timepoint [mean of weeks 23, 25, 26], avoidance of transfusion, and study-prohibited CAD therapy [weeks 5-26]) were met by 16 patients (73%) on sutimlimab, and 3 patients (15%) on placebo (odds ratio, 15.9 [95% confidence interval, 2.9, 88.0; P < .001]). Sutimlimab, but not placebo, significantly increased mean hemoglobin and FACIT-Fatigue scores at treatment assessment timepoint. Sutimlimab normalized mean bilirubin by week 1. Improvements correlated with near-complete inhibition of the classical complement pathway (2.3% mean activity at week 1) and C4 normalization. Twenty-one (96%) sutimlimab patients and 20 (100%) placebo patients experienced ≥1 treatment-emergent adverse event. Headache, hypertension, rhinitis, Raynaud phenomenon, and acrocyanosis were more frequent with sutimlimab vs placebo, with a difference of ≥3 patients between groups. Three sutimlimab patients discontinued owing to adverse events; no placebo patients discontinued. These data demonstrate that sutimlimab has potential to be an important advancement in the treatment of CAD. This trial was registered at www.clinicaltrials.gov as #NCT03347422.
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Affiliation(s)
- Alexander Röth
- Department of Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Sigbjørn Berentsen
- Department of Research and Innovation, Haugesund Hospital, Haugesund, Norway
| | - Wilma Barcellini
- Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Shirley D'Sa
- UCLH Centre for Waldenström's Macroglobulinemia and Related Conditions, University College London Hospitals National Health Service (NHS) Foundation Trust, London, United Kingdom
| | - Bernd Jilma
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Marc Michel
- Henri-Mondor University Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris Est Créteil (UPEC), Créteil, France
| | - Ilene C Weitz
- Jane Anne Nohl Division of Hematology Keck-University of Southern California (USC) School of Medicine, Los Angeles, CA
| | - Masaki Yamaguchi
- Department of Hematology, Ishikawa Prefectural Central Hospital, Kanazawa, Japan
| | - Jun-Ichi Nishimura
- Department of Hematology and Oncology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Josephine M I Vos
- Department of Hematology, Amsterdam University Medical Centers (UMC) & Sanquin, Amsterdam, The Netherlands
| | | | | | | | | | | | | | | | | | - Catherine M Broome
- Division of Hematology, MedStar Georgetown University Hospital, Washington, DC
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42
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Ehrlich S, Wichmann C, Spiekermann K. [Autoimmune haemolytic anemias]. Dtsch Med Wochenschr 2022; 147:1243-1250. [PMID: 36126922 DOI: 10.1055/a-1767-8281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Autoimmune haemolytic anemia (AIHA) is defined as the immune-mediated destruction of red blood cells. In most cases, antibodies that target surface antigens on erythrocytes lead to their premature degradation in the spleen or, less commonly, in the liver. The term includes a heterogenous group of diseases, which differ largely in pathophysiology and treatment. The two most common entities are warm AIHA and cold AIHA. Diagnostic testing involves the analysis of haemolytic markers like lactate dehydrogenase, haptoglobin and unconjugated bilirubin as well as a hemoglobin and reticulocytes. In case of a haemolytic anemia, further testing like a blood smear and a direct antiglobulin test should follow. As diagnostic testing and treatment of AIHA are complex, affected patients should always be referred to a hematologist.In warm AIHA, mainly IgG autoantibodies bind to their antigen on the erythrocyte surface at body temperature, leading to their premature destruction in the spleen. First line treatment options include the administration of steroids which mitigate the destruction of red blood cells by macrophages in the spleen. In contrast, IgM autoantibodies in cold AIHA lead to intravasal agglutination of erythrocytes and complement activation. The IgM antibodies have their highest affinity below body temperature which is why patients experience symptoms mainly in cold-exposed body areas. Although the IgM antibodies dissolve at body temperature, the complement-loaded erythrocytes are destroyed in the liver. Therapeutic options include protection from cold and immunosuppressive agents or complement inhibition.
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43
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Fatone MC, Cirasino L. Practical therapy for primary autoimmune hemolytic anemia in adults. Clin Exp Med 2022:10.1007/s10238-022-00869-2. [PMID: 35980482 DOI: 10.1007/s10238-022-00869-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Accepted: 07/25/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND AIM Autoimmune hemolytic anemias (AIHA) constitute a rare and heterogeneous group of diseases whose therapy differs according to the type of antibody involved in the genesis of the disease and the existence or not of an identified cause. With the aim of providing a practical guide for the therapy of AIHA, we summarize the emergency therapy and general measures habitually used in all forms of AIHA, as well as the specific treatment of the most frequent primary forms of AIHA: primary warm AIHA and AIHA from cold agglutinin disease (AIHA from CAD). We discuss the dependence of the treatment of the secondary forms on their underlying causes and the changes in the treatment of the primary forms in recent years. METHODS We examined the options available for the treatment of primary warm AIHA and AIHA from CAD. RESULTS We found many differences and only one similarity in their treatment. DISCUSSION The differences, particularly due to the non-responsiveness of AIHA from CAD to many treatments useful for primary warm AIHA, such as steroids, splenectomy and immunosuppressive agents, must be considered in the face of each, single case of AIHA. Preliminary identification of the type of antibody involved in the genesis of the disease and careful exclusion of a secondary form are particularly important. Rituximab plays a central role in the treatment of primary warm AIHA and AIHA from CAD.
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Affiliation(s)
| | - Lorenzo Cirasino
- UO di Medicina, Ospedale di Ostuni, via Villafranca SN, Ostuni, BR, Italy.
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44
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Abstract
The World Health Organization estimates that approximately a quarter of the world's population suffers from anemia, including almost half of preschool-age children. Globally, iron deficiency anemia is the most common cause of anemia. Other important causes of anemia in children are hemoglobinopathies, infection, and other chronic diseases. Anemia is associated with increased morbidity, including neurologic complications, increased risk of low birth weight, infection, and heart failure, as well as increased mortality. When approaching a child with anemia, detailed historical information, particularly diet, environmental exposures, and family history, often yield important clues to the diagnosis. Dysmorphic features on physical examination may indicate syndromic causes of anemia. Diagnostic testing involves a stepwise approach utilizing various laboratory techniques. The increasing availability of genetic testing is providing new mechanistic insights into inherited anemias and allowing diagnosis in many previously undiagnosed cases. Population-based approaches are being taken to address nutritional anemias. Novel pharmacologic agents and advances in gene therapy-based therapeutics have the potential to ameliorate anemia-associated disease and provide treatment strategies even in the most difficult and complex cases.
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Affiliation(s)
- Patrick G Gallagher
- Departments of Pediatrics, Pathology, and Genetics, Yale University School of Medicine, New Haven, CT
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45
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Berentsen S, Barcellini W, D'Sa S, Jilma B. Sutimlimab for treatment of cold agglutinin disease: why, how and for whom? Immunotherapy 2022; 14:1191-1204. [PMID: 35946351 DOI: 10.2217/imt-2022-0085] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Therapies for cold agglutinin disease have been directed at the pathogenic B-cell clone. Sutimlimab, a monoclonal antibody that targets C1s, is the first complement inhibitor to be extensively studied in cold agglutinin disease. Sutimlimab selectively blocks the classical activation pathway and leaves the alternative and lectin pathways intact. Trials have documented high response rates with rapid improvement in hemolysis, hemoglobin levels and fatigue scores and low toxicity. Sutimlimab was recently approved in the USA. This drug appears to be particularly useful in severely anemic patients who require a rapid response, in acute exacerbations that do not resolve spontaneously and in patients in whom chemoimmunotherapy is contraindicated or has failed. The choice of therapy in cold agglutinin disease should be individualized.
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Affiliation(s)
- Sigbjørn Berentsen
- Department of Research and Innovation, Haugesund Hospital, Helse Fonna Hospital Trust, Haugesund, Norway
| | - Wilma Barcellini
- Hematology Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Shirley D'Sa
- University College London Hospitals Centre for Waldenström and Associated Conditions, University College London Hospitals National Health Service Foundation Trust, London, UK
| | - Bernd Jilma
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
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46
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Jackson EM, Harper S, Webb GJ, Thomas W. Severe refractory warm autoimmune haemolytic anaemia after the SARS-CoV-2 Pfizer-BioNTech vaccine (BNT162b2 mRNA) managed with emergency splenectomy and complement inhibition with eculizumab. BMJ Case Rep 2022; 15:15/8/e250774. [PMID: 36107725 PMCID: PMC9438040 DOI: 10.1136/bcr-2022-250774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
A male in his teens with a history of liver transplant for biliary atresia (aged 2 years) and autoimmune haemolytic anaemia (AIHA, aged 6 years) presented with jaundice, dark urine, fatigue and chest discomfort that began 48 hours after the first dose of SARS-CoV-2 Pfizer-BioNTech vaccine (BNT162b2 mRNA). Investigations revealed a warm AIHA picture. Over 4 weeks the patient developed life-threatening anaemia culminating in haemoglobin of 35 g/L (after transfusion), lactate dehydrogenase of 1293 units/L and bilirubin of 228 µmol/L, refractory to standard treatment with corticosteroids and rituximab. An emergency splenectomy was performed that slowed haemolysis but did not completely ameliorate it. Eculizumab, a terminal complement pathway inhibitor, was initiated to arrest intravascular haemolysis and showed a favourable response. AIHA is rare but described after the SARS-CoV-2 Pfizer-BioNTech vaccine. This case highlights the rare complication of AIHA, the use of emergency splenectomy for disease control, and the use of eculizumab.
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Affiliation(s)
| | - Simon Harper
- Hepatopancreaticobiliary Surgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Gwilym J Webb
- Department of hepatology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Will Thomas
- Department of haematology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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47
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Lu Y, Huang XM. Autoimmune hemolytic anemia as an initial presentation in children with systemic lupus erythematosus: two case reports. J Int Med Res 2022; 50:3000605221115390. [PMID: 35971316 PMCID: PMC9386865 DOI: 10.1177/03000605221115390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
We report the cases of two children who presented with autoimmune hemolytic anemia (AIHA) as an initial presentation of systemic lupus erythematosus (SLE). Both patients had a positive Coombs test, anemia, and an increased number of spherocytes in their blood smear. The patient in Case 1 presented with fever, urticarial erythema, facial paresis, AIHA, and leucopenia. Immunological screening revealed low complement protein levels and positive anti-nuclear antibody, anti-double-stranded DNA, and antiphospholipid antibody results. A further laboratory workup revealed a positive lupus anticoagulant (LA) result and low factor II levels. She was diagnosed with lupus anticoagulant hypoprothrombinemia syndrome (LAHPS) in addition to SLE. The patient in Case 2 presented with fever, butterfly rash, thyroid enlargement, leucopenia, and AIHA. She was diagnosed with SLE with thyroiditis. Both patients were started on combined immunosuppressive therapy, and both patients’ clinical symptoms finally resolved. A literature review on childhood SLE showed that AIHA is common in patients with SLE. LAHPS is an uncommonly identified cause of bleeding in patients with SLE, and it must be considered when evaluating children with a positive LA result.
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Affiliation(s)
- Yan Lu
- Department of Pediatrics, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, No. 261, Huansha Road, Hangzhou, Zhejiang Province People's Republic of China
| | - Xian-Mei Huang
- Department of Pediatrics, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, No. 261, Huansha Road, Hangzhou, Zhejiang Province People's Republic of China
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48
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Liu JQ, Zhang FK. [Recent progress in the diagnosis and treatment of cold agglutinin disease]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2022; 43:524-528. [PMID: 35968599 PMCID: PMC9800217 DOI: 10.3760/cma.j.issn.0253-2727.2022.06.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Indexed: 12/24/2022]
Affiliation(s)
- J Q Liu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, CAMS & PUMC, Tianjin 300020, China
| | - F K Zhang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, CAMS & PUMC, Tianjin 300020, China
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49
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Gelbenegger G, Jaeger U, Fillitz M, D'Sa S, Cartwright R, Shafer F, Wardecki M, Wang J, Schoergenhofer C, Jilma B. Sustained sutimlimab response for 3 years in patients with cold agglutinin disease: A phase I, open‐label, extension trial. Br J Haematol 2022; 198:e59-e62. [DOI: 10.1111/bjh.18289] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 05/03/2022] [Accepted: 05/18/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Georg Gelbenegger
- Department of Clinical Pharmacology Medical University of Vienna Vienna Austria
| | - Ulrich Jaeger
- Division of Haematology and Haemostasis, Department of Medicine I Medical University of Vienna Vienna Austria
| | | | - Shirley D'Sa
- University College London Hospitals (UCLH) Centre for Waldenströms Macroglobulinaemia and Related Conditions, UCLH National Health Service (NHS) Foundation Trust London UK
| | - Ronwyn Cartwright
- Worthing Hospital Western Sussex Hospitals, NHS Foundation Trust Worthing UK
| | | | | | | | | | - Bernd Jilma
- Department of Clinical Pharmacology Medical University of Vienna Vienna Austria
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50
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Williams JD, Jayaprakash RK, Kithany H, Tighe MP. How to use Donath-Landsteiner test to diagnose paroxysmal cold haemoglobinuria (PCH). Arch Dis Child Educ Pract Ed 2022; 107:199-206. [PMID: 34433582 PMCID: PMC9125376 DOI: 10.1136/archdischild-2020-319568] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/16/2021] [Indexed: 11/22/2022]
Abstract
Paroxysmal cold haemoglobinuria (PCH) accounts for around a third of cases of autoimmune haemolytic anaemia in children. PCH is caused by an autoantibody that fixes complement to red cells at low temperatures and dissociates at warmer temperatures (a biphasic haemolysin), triggering complement-mediated intravascular haemolysis. Named the Donath-Landsteiner (D-L) antibody after its discoverers, it is usually formed in response to infection and demonstrates specificity for the ubiquitous red cell P-antigen. A D-L test can be used to detect the presence of the D-L autoantibody in the patients' serum. Here we discuss the use of the D-L test in identifying PCH in a 2-year-old boy who presented with haemolytic anaemia. A summary of the key information can be found in the infographic.
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Affiliation(s)
| | - Ram K Jayaprakash
- Haematology, University Hospitals Dorset NHS Foundation Trust, Poole, Dorset, UK
| | - Heena Kithany
- Paediatrics, University Hospitals Dorset NHS Foundation Trust, Poole, Dorset, UK
| | - Mark Peter Tighe
- Paediatrics, University Hospitals Dorset NHS Foundation Trust, Poole, Dorset, UK
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