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Yamazaki O, Hirohama D, Ishizawa K, Shibata S. Role of the Ubiquitin Proteasome System in the Regulation of Blood Pressure: A Review. Int J Mol Sci 2020; 21:E5358. [PMID: 32731518 PMCID: PMC7432568 DOI: 10.3390/ijms21155358] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 07/24/2020] [Accepted: 07/24/2020] [Indexed: 12/18/2022] Open
Abstract
The kidney and the vasculature play crucial roles in regulating blood pressure. The ubiquitin proteasome system (UPS), a multienzyme process mediating covalent conjugation of the 76-amino acid polypeptide ubiquitin to a substrate protein followed by proteasomal degradation, is involved in multiple cellular processes by regulating protein turnover in various tissues. Increasing evidence demonstrates the roles of UPS in blood pressure regulation. In the kidney, filtered sodium is reabsorbed through diverse sodium transporters and channels along renal tubules, and studies conducted till date have provided insights into the complex molecular network through which ubiquitin ligases modulate sodium transport in different segments. Components of these pathways include ubiquitin ligase neuronal precursor cell-expressed developmentally downregulated 4-2, Cullin-3, and Kelch-like 3. Moreover, accumulating data indicate the roles of UPS in blood vessels, where it modulates nitric oxide bioavailability and vasoconstriction. Cullin-3 not only regulates renal salt reabsorption but also controls vascular tone using different adaptor proteins that target distinct substrates in vascular smooth muscle cells. In endothelial cells, UPS can also contribute to blood pressure regulation by modulating endothelial nitric oxide synthase. In this review, we summarize current knowledge regarding the role of UPS in blood pressure regulation, focusing on renal sodium reabsorption and vascular function.
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Affiliation(s)
| | | | | | - Shigeru Shibata
- Division of Nephrology, Department of Internal Medicine, Teikyo University School of Medicine, Tokyo 173-8605, Japan; (O.Y.); (D.H.); (K.I.)
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Rassner M, Jung J, Schneider J, Wäsch R, Engelhardt M. Dapsone-Induced Hemolytic Anemia in Multiple Myeloma: Case Report of Various Differential Diagnoses. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2020; 20:e821-e825. [PMID: 32753123 DOI: 10.1016/j.clml.2020.06.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 06/22/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Michael Rassner
- Department of Medicine I (Hematology, Oncology, and Stem Cell Transplantation), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Johannes Jung
- Department of Medicine I (Hematology, Oncology, and Stem Cell Transplantation), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Johanna Schneider
- Department of Medicine IV, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ralph Wäsch
- Department of Medicine I (Hematology, Oncology, and Stem Cell Transplantation), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Monika Engelhardt
- Department of Medicine I (Hematology, Oncology, and Stem Cell Transplantation), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
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Casiez C, Pica GM, Bally S. Syndrome hémolytique et urémique lié au carfilzomib: évolution favorable sous éculizumab. Nephrol Ther 2020; 16:221-224. [DOI: 10.1016/j.nephro.2020.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 02/09/2020] [Accepted: 03/10/2020] [Indexed: 10/24/2022]
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Bridoux F, Arnulf B, Karlin L, Blin N, Rabot N, Macro M, Audard V, Belhadj K, Pegourie B, Gobert P, Cornec Le Gall E, Joly B, Karras A, Jaccard A, Augeul-Meunier K, Manier S, Royer B, Caillot D, Tiab M, Delbes S, Suarez F, Vigneau C, Caillard S, Arakelyan-Laboure N, Roos-Weil D, Chevret S, Fermand JP. Randomized Trial Comparing Double Versus Triple Bortezomib-Based Regimen in Patients With Multiple Myeloma and Acute Kidney Injury Due to Cast Nephropathy. J Clin Oncol 2020; 38:2647-2657. [PMID: 32574117 DOI: 10.1200/jco.20.00298] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
PURPOSE We report a multicenter controlled trial comparing renal recovery and tolerance profile of doublet versus triplet bortezomib-based regimens in patients with initial myeloma cast nephropathy (CN) and acute kidney injury (AKI) without need for dialysis. METHODS After symptomatic measures and high-dose dexamethasone, patients were randomly assigned to receive bortezomib plus dexamethasone (BD), or BD plus cyclophosphamide (C-BD). In patients with < 50% reduction of serum free light chains (sFLCs) after 3 cycles, chemotherapy was reinforced with either cyclophosphamide (BD group) or thalidomide (C-BD group). RESULTS Ninety-two patients were enrolled in each group. At random assignment, characteristics of the 2 groups were similar, including median age (68 years) and serum creatinine level (305.5 and 273.5 µmol/L in BD and C-BD group, respectively). At 3 months, renal response rate (primary end point) was not different (41 v 47 responders in the BD and C-BD groups, respectively; relative risk [RR], 0.87; P = .46). Very good partial response (free light chain reduction ≥ 90%) or more was achieved in 36 and 47 patients, respectively (RR, 0.76; P = .10). After 1 cycle of chemotherapy, 69 in the BD group and 67 patients in the C-BD group had achieved sFLC level ≤ 500 mg/L. Serious adverse events were recorded in 30 and 40 patients, respectively. At 12 months, 19 patients had died (9 in the BD group v 10 in the C-BD group), including 10 (6 in the BD group and 4 in the C-BD group) from myeloma progression and 3 (0 in the BD group and 3 in the C-BD group) from infection. Within median follow-up of 27 months, 43 and 42 patients switched to new therapy, respectively. Overall, 50 patients (24 in the BD group and 26 in the C-BD group) had died. CONCLUSION This randomized study did not show any benefit of C-BD compared with BD on renal recovery of patients with initial CN not requiring dialysis. Adding cyclophosphamide did not sufficiently improve the efficacy-toxicity balance. Patients with myeloma with AKI are fragile, and indication for doublet or triplet regimen should be adapted to frailty.
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Affiliation(s)
- Frank Bridoux
- Department of Nephrology, Centre Hospitalier Universitaire de Poitiers, INSERM CIC 1402, Poitiers University, France.,Centre de référence maladies rares "amylose AL et autres maladies par dépôt d'immunoglobulines monoclonales," Centre Hospitalier Universitaire de Poitiers, Poitiers, France.,CNRS UMR 7276, Université de Limoges, Limoges, France
| | - Bertrand Arnulf
- Department of Hematology and Immunology, Hôpital Saint Louis, Assistance Publique-Hôpitaux de Paris, INSERM UMR 1126, Paris, France
| | - Lionel Karlin
- Department of Clinical Hematology, Centre Hospitalier Universitaire Lyon Sud, Hospices Civils de Lyon, Pierre-Benite, France
| | - Nicolas Blin
- Department of Hematology, Centre Hospitalier Universitaire de Nantes, Nantes, France
| | - Nolwenn Rabot
- Department of Nephrology and Clinical Immunology, Hôpital Bretonneau, Centre Hospitalier Universitaire de Tours, Tours, France
| | - Margaret Macro
- Department of Hematology, Centre Hospitalier Universitaire de Caen, Caen, France
| | - Vincent Audard
- Department of Nephrology and Renal Transplantation, Hôpital Henri Mondor, Créteil, Assistance Publique-Hôpitaux de Paris, INSERM U955, Université Paris Est Créteil, Créteil, France
| | - Karim Belhadj
- Department of Hematology, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Université Paris Est Créteil, Créteil, France
| | - Brigitte Pegourie
- Department of Hematology, Centre Hospitalier Universitaire de Grenoble, Grenoble, France
| | - Pierre Gobert
- Department of Nephrology, Centre Hospitalier Avignon, and Clinique Rhône Durance, Avignon, France
| | - Emilie Cornec Le Gall
- Department of Nephrology, Centre Hospitalier Universitaire de Brest, INSERM U1078, Université de Brest, Brest, France
| | - Bertrand Joly
- Department of Hematology, Centre Hospitalier Sud Francilien, Corbeil-Essonnes, France
| | - Alexandre Karras
- Department of Nephrology, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Université Paris Descartes Sorbonne Paris Cité, Paris, France
| | - Arnaud Jaccard
- Centre de référence maladies rares "amylose AL et autres maladies par dépôt d'immunoglobulines monoclonales," Centre Hospitalier Universitaire de Poitiers, Poitiers, France.,CNRS UMR 7276, Université de Limoges, Limoges, France.,Department of Hematology, Hôpital Dupuytren, Centre Hospitalier Universitaire de Limoges, Université de Limoges, Limoges, France
| | - Karine Augeul-Meunier
- Department of Hematology, Institut de Cancérologie Lucien Neuwirth, Saint-Priest-en-Jarez, France
| | - Salomon Manier
- Department of Hematology, Centre Hospitalier Universitaire de Lille, INSERM UMR-S1172, University of Lille, Lille, France
| | - Bruno Royer
- Department of Hematology, Centre Hospitalier Universitaire d'Amiens, Amiens, France
| | - Denis Caillot
- Department of Clinical Hematology, Centre Hospitalier Universitaire de Dijon, Dijon, France
| | - Mourad Tiab
- Department of Clinical Hematology, Centre Hospitalier de Vendée, La Roche sur Yon, France
| | - Sébastien Delbes
- Department of Nephrology, Centre Hospitalier La Rochelle, La Rochelle, France
| | - Felipe Suarez
- Department of Hematology, Hôpital Necker, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Cécile Vigneau
- Department of Nephrology, Centre Hospitalier Universitaire Pontchaillou, Rennes, France
| | - Sophie Caillard
- Department of Nephrology and Transplantation, Centre Hospitalier Universitaire de Strasbourg, Strasbourg, France
| | - Nina Arakelyan-Laboure
- Department of Clinical Hematology and Cellular Therapy, Centre Hospitalier Régional d'Orléans, Orléans, France
| | - Damien Roos-Weil
- Department of Clinical Hematology, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Sylvie Chevret
- Department of Biostatistics and Medical Information, UMR 1153, ECSTRRA Team, Inserm, Paris Diderot University, Hôpital Saint Louis, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Jean Paul Fermand
- Department of Hematology and Immunology, Hôpital Saint Louis, Assistance Publique-Hôpitaux de Paris, INSERM UMR 1126, Paris, France
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Wu P, Oren O, Gertz MA, Yang EH. Proteasome Inhibitor-Related Cardiotoxicity: Mechanisms, Diagnosis, and Management. Curr Oncol Rep 2020; 22:66. [DOI: 10.1007/s11912-020-00931-w] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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56
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Blasco M, Martínez-Roca A, Rodríguez-Lobato LG, Garcia-Herrera A, Rosiñol L, Castro P, Fernández S, Quintana LF, Cibeira MT, Bladé J, Fernández de Larrea C, Tovar N, Jimenez R, Poch E, Guillen E, Campistol JM, Carreras E, Diaz-Ricart M, Palomo M. Complement as the enabler of carfilzomib-induced thrombotic microangiopathy. Br J Haematol 2020; 193:181-187. [PMID: 32469083 DOI: 10.1111/bjh.16796] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 05/05/2020] [Indexed: 01/07/2023]
Abstract
Carfilzomib has been associated with the development of thrombotic microangiopathy (TMA) in relapsed/refractory multiple myeloma patients, a severe disease with no currently available aetiological treatment. We evaluated the potential role of terminal complement pathway in four patients with carfilzomib-induced TMA. Membrane attack complex (C5b-9) deposition on endothelial cells in culture exposed to plasma from patients during the acute phase of the disease suggests complement overactivation as a mechanism of potential endothelial damage in three out of four patients. If confirmed in larger cohorts, C5b-9 evaluation will allow early identification of patients who could benefit from complement blockade and treatment monitoring.
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Affiliation(s)
- Miquel Blasco
- Nephrology and Kidney Transplantation Department, Centro de Referencia en Enfermedad Glomerular Compleja del Sistema Nacional de Salud (CSUR), Hospital Clínic, University of Barcelona, Barcelona, Spain.,Institute of Biomedical Research August Pi i Sunyer (IDIPABS), Malalties nefro-urològiques i Trasplantament Renal, Barcelona, Spain
| | - Alexandra Martínez-Roca
- Amyloidosis and Myeloma Unit, Department of Hematology, Hospital Clínic of Barcelona, Institute of Biomedical Research August Pi i Sunyer (IDIPABS), University of Barcelona, Barcelona, Spain
| | - Luis G Rodríguez-Lobato
- Amyloidosis and Myeloma Unit, Department of Hematology, Hospital Clínic of Barcelona, Institute of Biomedical Research August Pi i Sunyer (IDIPABS), University of Barcelona, Barcelona, Spain
| | | | - Laura Rosiñol
- Amyloidosis and Myeloma Unit, Department of Hematology, Hospital Clínic of Barcelona, Institute of Biomedical Research August Pi i Sunyer (IDIPABS), University of Barcelona, Barcelona, Spain
| | - Pedro Castro
- Medical Intensive Care Unit, Hospital Clínic, Institute of Biomedical Research August Pi i Sunyer (IDIPABS), University of Barcelona, Barcelona, Spain
| | - Sara Fernández
- Medical Intensive Care Unit, Hospital Clínic, Institute of Biomedical Research August Pi i Sunyer (IDIPABS), University of Barcelona, Barcelona, Spain
| | - Luis F Quintana
- Nephrology and Kidney Transplantation Department, Centro de Referencia en Enfermedad Glomerular Compleja del Sistema Nacional de Salud (CSUR), Hospital Clínic, University of Barcelona, Barcelona, Spain.,Institute of Biomedical Research August Pi i Sunyer (IDIPABS), Malalties nefro-urològiques i Trasplantament Renal, Barcelona, Spain
| | - María T Cibeira
- Amyloidosis and Myeloma Unit, Department of Hematology, Hospital Clínic of Barcelona, Institute of Biomedical Research August Pi i Sunyer (IDIPABS), University of Barcelona, Barcelona, Spain
| | - Joan Bladé
- Amyloidosis and Myeloma Unit, Department of Hematology, Hospital Clínic of Barcelona, Institute of Biomedical Research August Pi i Sunyer (IDIPABS), University of Barcelona, Barcelona, Spain
| | - Carlos Fernández de Larrea
- Amyloidosis and Myeloma Unit, Department of Hematology, Hospital Clínic of Barcelona, Institute of Biomedical Research August Pi i Sunyer (IDIPABS), University of Barcelona, Barcelona, Spain
| | - Natalia Tovar
- Amyloidosis and Myeloma Unit, Department of Hematology, Hospital Clínic of Barcelona, Institute of Biomedical Research August Pi i Sunyer (IDIPABS), University of Barcelona, Barcelona, Spain
| | - Raquel Jimenez
- Amyloidosis and Myeloma Unit, Department of Hematology, Hospital Clínic of Barcelona, Institute of Biomedical Research August Pi i Sunyer (IDIPABS), University of Barcelona, Barcelona, Spain
| | - Esteban Poch
- Nephrology and Kidney Transplantation Department, Centro de Referencia en Enfermedad Glomerular Compleja del Sistema Nacional de Salud (CSUR), Hospital Clínic, University of Barcelona, Barcelona, Spain.,Institute of Biomedical Research August Pi i Sunyer (IDIPABS), Malalties nefro-urològiques i Trasplantament Renal, Barcelona, Spain
| | - Elena Guillen
- Nephrology and Kidney Transplantation Department, Centro de Referencia en Enfermedad Glomerular Compleja del Sistema Nacional de Salud (CSUR), Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Josep M Campistol
- Nephrology and Kidney Transplantation Department, Centro de Referencia en Enfermedad Glomerular Compleja del Sistema Nacional de Salud (CSUR), Hospital Clínic, University of Barcelona, Barcelona, Spain.,Institute of Biomedical Research August Pi i Sunyer (IDIPABS), Malalties nefro-urològiques i Trasplantament Renal, Barcelona, Spain
| | - Enric Carreras
- Josep Carreras Leukaemia Research Institute, Hospital Clinic/University of Barcelona Campus, Barcelona, Spain.,Barcelona Endothelium Team, Barcelona, Spain
| | - Maribel Diaz-Ricart
- Barcelona Endothelium Team, Barcelona, Spain.,Department of Hematopathology, Biomedical Diagnosis Center (CDB), Institute of Biomedical Research August Pi i Sunyer (IDIBAPS), Hospital Clínic of Barcelona, University of Barcelona, Barcelona, Spain
| | - Marta Palomo
- Josep Carreras Leukaemia Research Institute, Hospital Clinic/University of Barcelona Campus, Barcelona, Spain.,Barcelona Endothelium Team, Barcelona, Spain.,Department of Hematopathology, Biomedical Diagnosis Center (CDB), Institute of Biomedical Research August Pi i Sunyer (IDIBAPS), Hospital Clínic of Barcelona, University of Barcelona, Barcelona, Spain
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Ball S, Behera TR, Anwer F, Chakraborty R. Risk of kidney toxicity with carfilzomib in multiple myeloma: a meta-analysis of randomized controlled trials. Ann Hematol 2020; 99:1265-1271. [DOI: 10.1007/s00277-020-04062-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 04/27/2020] [Indexed: 01/12/2023]
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Kozlowski P, Kameran Behnam K, Uggla B, Åström M. Carfilzomib-induced hemolysis is noticeably common but rarely shows features of thrombotic microangiopathy: A retrospective study. Eur J Haematol 2020; 104:588-593. [PMID: 32115785 PMCID: PMC7318150 DOI: 10.1111/ejh.13401] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 02/25/2020] [Accepted: 02/26/2020] [Indexed: 11/29/2022]
Abstract
Objective Hemolysis is a sporadically reported but potentially serious side effect of the proteasome inhibitor carfilzomib. We aimed to investigate the frequency of hemolysis in an unselected cohort. Methods We performed a retrospective, single‐center study of the incidence of hemolysis in patients treated with carfilzomib, based mainly on consecutive haptoglobin levels. The patients were diagnosed with myeloma (n = 20), AL amyloidosis (n = 3), and light‐chain deposition disease (n = 1). Carfilzomib treatment was applied after a median of 3 (range: 1‐7) therapy lines. Results Haptoglobin levels were normal/increased before, generally suppressed during, and normalized after treatment with carfilzomib. Very low haptoglobin (<0.1 g/L) implying the presence of hemolysis was observed in 16 of 24 (67%) patients during carfilzomib therapy. Hemolysis was mild in 11 of 16 (69%) affected patients, whereas 5 of 16 (31%) required transfusion. Severe hemolysis was explained by thrombotic microangiopathy (TMA) in one patient who died of the complication. Mechanisms were unclear in the remaining 15 patients. Conclusions Hemolysis was surprisingly common but mostly mild during carfilzomib treatment. However, the possibility of TMA should be kept in mind in this setting. Hypothetically, non‐TMA hemolysis could be attributed to the accumulation of globin chains due to the suppression of eukaryotic translation initiation inhibition by carfilzomib.
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Affiliation(s)
- Piotr Kozlowski
- Division of Hematology, Department of Medicine, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Klodia Kameran Behnam
- School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Bertil Uggla
- Division of Hematology, Department of Medicine, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Maria Åström
- Division of Hematology, Department of Medicine, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
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59
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Sapet M, Fouillet L, Daguenet E, Laurent B, Guyotat D, Le Jeune C. [Proteinuria in multiple myeloma: Be careful to iatrogeny]. Bull Cancer 2020; 107:519-520. [PMID: 32178835 DOI: 10.1016/j.bulcan.2020.01.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 01/30/2020] [Accepted: 01/30/2020] [Indexed: 11/25/2022]
Affiliation(s)
- Manon Sapet
- Institut de cancérologie Lucien-Neuwirth, département d'hématologie clinique, 42270 Saint-Priest-en-Jarez, France
| | - Ludovic Fouillet
- Institut de cancérologie Lucien-Neuwirth, département d'hématologie clinique, 42270 Saint-Priest-en-Jarez, France
| | - Elisabeth Daguenet
- Institut de cancérologie Lucien-Neuwirth, département d'hématologie clinique, 42270 Saint-Priest-en-Jarez, France
| | - Blandine Laurent
- Laboratoire d'histologie rénale, CHU de St.-Etienne, 42055 St.-Etienne cedex 02, France
| | - Denis Guyotat
- Institut de cancérologie Lucien-Neuwirth, département d'hématologie clinique, 42270 Saint-Priest-en-Jarez, France
| | - Caroline Le Jeune
- Institut de cancérologie Lucien-Neuwirth, département d'hématologie clinique, 42270 Saint-Priest-en-Jarez, France.
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60
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What the Intensivists Need to Know About Critically Ill Myeloma Patients. ONCOLOGIC CRITICAL CARE 2020. [PMCID: PMC7121630 DOI: 10.1007/978-3-319-74588-6_98] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Multiple myeloma (MM) is a hematological malignancy characterized by an increase in aberrant plasma cells in the bone marrow leading to rising monoclonal protein in serum and urine. With the introduction of novel therapies with manageable side effects, this incurable disease has evolved into a chronic disease with an acceptable quality of life for the majority of patients. Accordingly, management of acute complications is fundamental in reducing the morbidity and mortality in MM. MM emergencies include symptoms and signs related directly to the disease and/or to the treatment; many organs may be involved including, but not limited to, renal, cardiovascular, neurologic, hematologic, and infectious complications. This review will focus on the numerous approaches that are aimed at managing these complications.
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61
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Nicolaysen A. Nephrotoxic Chemotherapy Agents: Old and New. Adv Chronic Kidney Dis 2020; 27:38-49. [PMID: 32147000 DOI: 10.1053/j.ackd.2019.08.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 08/01/2019] [Indexed: 02/08/2023]
Abstract
In the last several decades, advancements in chemotherapy have improved the overall survival of cancer patients. These agents, however, are associated with adverse effects, including various kidney lesions. This review summarizes the nephrotoxic potential of chemotherapy agents, old and new, as well as the different factors that contribute to kidney injury. Provided for each class of chemotherapy agent is the associated kidney lesion and a brief discussion of clinical manifestation, mechanism of action, and possible treatment when available. Understanding the nephrotoxic potential of these agents have on the kidneys is imperative for both the oncologist and the nephrologist to properly care for cancer patients and ensure their best outcomes.
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Moreira Fonseca N, Cardoso F, Monteiro M, Góis M, Sousa H, Fidalgo T, Calado J, Nolasco F. A case of bortezomib-associated thrombotic microangiopathy in a multiple myeloma patient. ACTA ACUST UNITED AC 2019. [DOI: 10.1177/2399369319894343] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Bortezomib is a first-generation proteasome inhibitor used in the treatment of multiple myeloma. We present a case of a 70-year-old woman with multiple myeloma, who presented thrombotic microangiopathy with multi-organ involvement thrombotic microangiopathy (ocular, cardiac, and renal) after bortezomib initiation. A kidney biopsy confirmed the diagnosis of thrombotic microangiopathy. A temporal relation between bortezomib exposure and thrombotic microangiopathy onset was seen in the absence of other concurrent medication or disease known to cause thrombotic microangiopathy, and thrombotic microangiopathy was only resolved after drug discontinuation. The exact pathophysiological mechanism remains unknown. To our knowledge, this is the second biopsy-proven published case of bortezomib-associated thrombotic microangiopathy. Since bortezomib is extensively used for treating patients with multiple myeloma, prescribing clinicians should maintain a high index of suspicion of this potentially fatal complication.
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Affiliation(s)
- Nuno Moreira Fonseca
- Nephrology Department, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
| | - Filipa Cardoso
- Nephrology Department, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
| | - Manuel Monteiro
- Internal Medicine Department, Centro Hospitalar e Universitário de Lisboa Central, Lisbon, Portugal
| | - Mário Góis
- Nephrology Department, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
- Laboratory of Renal Morphology, Centro Hospitalar e Universitário de Lisboa Central, Lisbon, Portugal
| | - Helena Sousa
- Nephrology Department, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
- Laboratory of Renal Morphology, Centro Hospitalar e Universitário de Lisboa Central, Lisbon, Portugal
| | - Teresa Fidalgo
- Clinical Hematology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Joaquim Calado
- Nephrology Department, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
- ToxOmics, Centre for Toxicogenomics and Human Health, Nova Medical School, Lisbon, Portugal
| | - Fernando Nolasco
- Nephrology Department, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
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Thrombotic microangiopathy after carfilzomib in a very young myeloma patient. Blood Cells Mol Dis 2019; 81:102400. [PMID: 31887694 DOI: 10.1016/j.bcmd.2019.102400] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 12/20/2019] [Indexed: 11/23/2022]
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64
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Cohen JB, Geara AS, Hogan JJ, Townsend RR. Hypertension in Cancer Patients and Survivors: Epidemiology, Diagnosis, and Management. JACC CardioOncol 2019; 1:238-251. [PMID: 32206762 PMCID: PMC7089580 DOI: 10.1016/j.jaccao.2019.11.009] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 11/01/2019] [Accepted: 11/04/2019] [Indexed: 12/28/2022] Open
Abstract
Cancer patients and survivors of cancer have a greater burden of cardiovascular disease compared to the general population. Much of the elevated cardiovascular risk in these individuals is likely attributable to hypertension, as individuals with cancer have a particularly high incidence of hypertension following cancer diagnosis. Treatment with chemotherapy is an independent risk factor for hypertension due to direct effects of many agents on endothelial function, sympathetic activity, and renin-angiotensin system activity as well as nephrotoxicity. Diagnosis and management of hypertension in cancer patients requires accurate blood pressure measurement and consideration of potential confounding factors, such as adjuvant treatments and acute pain, that can temporarily elevate blood pressure readings. Home blood pressure monitoring can be a useful tool to facilitate longitudinal blood pressure monitoring for titration of antihypertensive medications. Selection of antihypertensive agents in cancer patients should account for treatment-specific morbidities and target organ injury.
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Affiliation(s)
- Jordana B. Cohen
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Abdallah S. Geara
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jonathan J. Hogan
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Raymond R. Townsend
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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65
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A review of thrombotic microangiopathies in multiple myeloma. Leuk Res 2019; 85:106195. [DOI: 10.1016/j.leukres.2019.106195] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 07/24/2019] [Accepted: 07/25/2019] [Indexed: 12/11/2022]
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Carfilzomib-induced aHUS responds to early eculizumab and may be associated with heterozygous CFHR3-CFHR1 deletion. Blood Adv 2019; 2:3443-3446. [PMID: 30518536 DOI: 10.1182/bloodadvances.2018027532] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Accepted: 11/16/2018] [Indexed: 12/14/2022] Open
Abstract
Key Points
Rapid initiation of eculizumab mitigates progression of carfilzomib-induced aHUS. Development of carfilzomib-induced aHUS may be associated with heterozygous CFHR3-CFHR1 deletion.
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67
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Cassol CA, Williams MP, Caza TN, Rodriguez S. Renal and pulmonary thrombotic microangiopathy triggered by proteasome-inhibitor therapy in patient with smoldering myeloma: A renal biopsy and autopsy case report. Medicine (Baltimore) 2019; 98:e17148. [PMID: 31574818 PMCID: PMC6775360 DOI: 10.1097/md.0000000000017148] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
RATIONALE Thrombotic microangiopathy (TMA) is a group of clinical syndromes characterized by excessive platelet activation and endothelial injury that leads to acute or chronic microvascular obliteration by intimal mucoid and fibrous thickening, with or without associated thrombi. It frequently involves the kidney but may involve any organ or system at variable frequencies depending on the underlying etiology. Among its numerous causes, drug toxicities and complement regulation abnormalities stand out as some of the most common. A more recently described association is with monoclonal gammopathy. Lung involvement by TMA is infrequent, but has been described in Cobalamin C deficiency and post stem-cell transplantation TMA. PATIENT CONCERNS This is the case of a patient with smoldering myeloma who received proteasome-inhibitor therapy due to retinopathy and developed acute renal failure within one week of therapy initiation. DIAGNOSES A renal biopsy showed thrombotic microangiopathy. At the time, mild pulmonary hypertension was also noted and presumed to be idiopathic. INTERVENTIONS Given the known association of proteasome-inhibitor therapy with thrombotic microangiopathy, Bortezomib was discontinued and dialysis was initiated. OUTCOMES Drug withdrawal failed to prevent disease progression and development of end-stage renal disease, as well as severe pulmonary hypertension that eventually lead to the patient's death. LESSONS To our knowledge, this is the first reported case of pulmonary involvement by TMA associated with monoclonal gammopathy which appears to have been triggered by proteasome-inhibitor therapy. Clinicians should be aware of this possibility to allow for more prompt recognition of pulmonary hypertension as a potential manifestation of monoclonal gammopathy-associated TMA, especially in patients also receiving proteasome-inhibitors, so that treatment aiming to slow disease progression can be instituted.
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Affiliation(s)
| | | | | | - Sophia Rodriguez
- Queens Office of the Chief Medical Examiner of the City of New York, New York
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Cornell RF, Ky B, Weiss BM, Dahm CN, Gupta DK, Du L, Carver JR, Cohen AD, Engelhardt BG, Garfall AL, Goodman SA, Harrell SL, Kassim AA, Jadhav T, Jagasia M, Moslehi J, O’Quinn R, Savona MR, Slosky D, Smith A, Stadtmauer EA, Vogl DT, Waxman A, Lenihan D. Prospective Study of Cardiac Events During Proteasome Inhibitor Therapy for Relapsed Multiple Myeloma. J Clin Oncol 2019; 37:1946-1955. [PMID: 31188726 PMCID: PMC9798911 DOI: 10.1200/jco.19.00231] [Citation(s) in RCA: 118] [Impact Index Per Article: 23.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
PURPOSE Cardiovascular adverse events (CVAEs) can occur during proteasome inhibitor (PI) therapy. We conducted a prospective, observational, multi-institutional study to define risk factors and outcomes in patients with multiple myeloma (MM) receiving PIs. PATIENTS AND METHODS Patients with relapsed MM initiating carfilzomib- or bortezomib-based therapy underwent baseline assessments and repeated assessments at regular intervals over 6 months, including cardiac biomarkers (troponin I or T, brain natriuretic peptide [BNP], and N-terminal proBNP), ECG, and echocardiography. Monitoring occurred over 18 months for development of CVAEs. RESULTS Of 95 patients enrolled, 65 received carfilzomib and 30 received bortezomib, with median 25 months of follow-up. Sixty-four CVAEs occurred, with 55% grade 3 or greater in severity. CVAEs occurred in 51% of patients treated with carfilzomib and 17% of those treated with bortezomib (P = .002). Median time to first CVAE from treatment start was 31 days, and 86% occurred within the first 3 months. Patients receiving carfilzomib-based therapy with a baseline elevated BNP level higher than 100 pg/mL or N-terminal proBNP level higher than 125 pg/mL had increased risk for CVAE (odds ratio, 10.8; P < .001). Elevated natriuretic peptides occurring mid-first cycle of treatment with carfilzomib were associated with a substantially higher risk of CVAEs (odds ratio, 36.0; P < .001). Patients who experienced a CVAE had inferior progression-free survival (log-rank P = .01) and overall survival (log-rank P < .001). PI therapy was safely resumed in 89% of patients, although 41% required chemotherapy modifications. CONCLUSION CVAEs are common during PI therapy for relapsed MM, especially with carfilzomib, particularly within the first 3 months of therapy. CVAEs were associated with worse overall outcomes, but usually, discontinuation of therapy was not required. Natriuretic peptides were highly predictive of CVAEs; however, validation of this finding is necessary before uniform incorporation into the routine management of patients receiving carfilzomib.
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Affiliation(s)
- Robert F. Cornell
- Vanderbilt University Medical Center, Nashville, TN,Robert F. Cornell, MS, MD, Division of Hematology and Oncology, Vanderbilt University Medical Center, 777 Preston Research Building, Nashville, TN 37232; Twitter: @myeloma_doc_com; e-mail:
| | - Bonnie Ky
- University of Pennsylvania, Philadelphia, PA
| | | | | | | | - Liping Du
- Vanderbilt University Medical Center, Nashville, TN
| | - Joseph R. Carver
- University of Pennsylvania, Philadelphia, PA,Abramson Cancer Center, Penn Medicine, Philadelphia, PA
| | - Adam D. Cohen
- Abramson Cancer Center, Penn Medicine, Philadelphia, PA
| | | | | | | | | | | | | | | | | | | | | | - David Slosky
- Vanderbilt University Medical Center, Nashville, TN
| | | | | | - Dan T. Vogl
- Abramson Cancer Center, Penn Medicine, Philadelphia, PA
| | - Adam Waxman
- Abramson Cancer Center, Penn Medicine, Philadelphia, PA
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Higuero Saavedra V, González-Calle V, Sobejano E, Sebastiá J, Cabrero M, Bastida JM, Puig N, Ocio EM, Mateos MV. Drug-induced Thrombotic Microangiopathy During Maintenance Treatment in a Patient With Multiple Myeloma. Hemasphere 2019; 3:e192. [PMID: 31723829 PMCID: PMC6746023 DOI: 10.1097/hs9.0000000000000192] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 02/18/2019] [Accepted: 02/20/2019] [Indexed: 01/14/2023] Open
Affiliation(s)
- Víctor Higuero Saavedra
- Hematology Department, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
- Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain
| | - Verónica González-Calle
- Hematology Department, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
- Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain
| | - Eduardo Sobejano
- Hematology Department, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
- Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain
| | - Josefa Sebastiá
- Nephrology Department, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | - Mónica Cabrero
- Hematology Department, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
- Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain
| | - Jose María Bastida
- Hematology Department, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | - Noemi Puig
- Hematology Department, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
- Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain
| | - Enrique M. Ocio
- Hematology Department, Hospital Universitario Marqués de Valdecilla
| | - María-Victoria Mateos
- Hematology Department, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
- Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain
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70
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Schroeder MA, Fiala MA, Huselton E, Cardone MH, Jaeger S, Jean SR, Shea K, Ghobadi A, Wildes T, Stockerl-Goldstein KE, Vij R. A Phase I/II Trial of Carfilzomib, Pegylated Liposomal Doxorubicin, and Dexamethasone for the Treatment of Relapsed/Refractory Multiple Myeloma. Clin Cancer Res 2019; 25:3776-3783. [PMID: 30952640 DOI: 10.1158/1078-0432.ccr-18-1909] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 11/08/2018] [Accepted: 03/27/2019] [Indexed: 11/16/2022]
Abstract
PURPOSE Pegylated liposomal doxorubicin (PLD) combined with bortezomib is an effective salvage regimen for relapsed refractory multiple myeloma (RRMM). Carfilzomib, a second-generation proteasome inhibitor, has clinical efficacy even among bortezomib-refractory patients. PATIENTS AND METHODS We performed a phase I/II trial of carfilzomib, PLD, and dexamethasone (KDD) with the primary endpoints being safety and efficacy (NCT01246063). Twenty-three patients were enrolled in the phase I portion and the MTD of carfilzomib was determined to be 56 mg/m2 (days 1, 2, 8, 9, 15, and 16) when combined with PLD (30 mg/m2 on day 8) and dexamethasone (20 mg on days 1, 2, 8, 9, 15, and 16). Seventeen additional patients were enrolled in the phase II portion. RESULTS KDD was determined to be well tolerated with the only common grade 3/4 nonhematologic adverse events of infection. Grade 3/4 hematologic toxicity included lymphopenia (63%), thrombocytopenia (40%), anemia (40%), and neutropenia (28%). In the cohort of patients treated at the MTD, where median prior therapies were 2% and 42% were refractory to bortezomib, the overall response rate was 83% (20/24) with 54% (13/24) having a very good partial response or better. The median progression-free survival was 13.7 months (95% CI, 5.0-21.7). CONCLUSIONS This trial is the first to report outcomes using a triplet regimen of high-dose carfilzomib. KDD was well tolerated and appears efficacious in RRMM. Additional study is needed to more precisely determine patient outcomes with this regimen and its utility compared with other carfilzomib containing salvage regimens.
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Affiliation(s)
- Mark A Schroeder
- BMT and Leukemia Program, Washington University School of Medicine, St Louis, Missouri.
| | - Mark A Fiala
- BMT and Leukemia Program, Washington University School of Medicine, St Louis, Missouri
| | - Eric Huselton
- Hematology/Oncology Division, University of Rochester Medical Center, Rochester, New York
| | | | | | - Sae Rin Jean
- Eutropics Pharmaceuticals, Cambridge, Massachusetts
| | - Kathryn Shea
- Eutropics Pharmaceuticals, Cambridge, Massachusetts
| | - Armin Ghobadi
- BMT and Leukemia Program, Washington University School of Medicine, St Louis, Missouri
| | - Tanya Wildes
- BMT and Leukemia Program, Washington University School of Medicine, St Louis, Missouri
| | | | - Ravi Vij
- BMT and Leukemia Program, Washington University School of Medicine, St Louis, Missouri
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71
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Late Presentation of Carfilzomib Associated Thrombotic Microangiopathy. AMERICAN JOURNAL OF MEDICAL CASE REPORTS 2019; 7:240-243. [PMID: 31457071 PMCID: PMC6711615 DOI: 10.12691/ajmcr-7-10-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Multiple Myeloma (MM) is a plasma cell disorder characterized by abnormal proliferation of plasma cells resulting in overproduction of paraprotein. Proteasome inhibitors (PI) have been a corner stone for the treatment of MM. Thrombotic Microangiopathy (TMA) is a recent hematological adverse event that has newly been recognized in multiple PI. TMA leads to end-organ damage and infarction by microthromobi. TMA pathophysiology is not well understood and has multiple etiologies. We present a case of PI-induced TMA, along with literature review of cases diagnosed from 2008-2018. Unique to our case is the onset of presentation, more than 24 months after initiating carfilzomib. Our case highlights the need for vigilant monitoring and the importance of clinical suspicion in patients at risk for TMA.
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72
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Abstract
Thrombotic microangiopathy (TMA) is a syndrome involving fragmentation haemolysis, thrombocytopenia, and thrombosis. A range of disorders including cancer may have TMA as a clinical manifestation. TMA in cancer may be caused by several mechanisms, including systemic microvascular metastases, but may also be due to extensive bone marrow involvement with cancer or secondary necrosis. Chemotherapeutic agents may also cause associated TMA through a range of different mechanisms. Gemcitabine, platinum-based drugs, mitomycin C, and proteasome inhibitors are known to cause TMA in cancer patients. Transplant-associated TMA (TA-TMA) may affect either solid organ or HSCT patients. TA-TMA remains a difficult complication to address due to its high mortality rate, lack of standard diagnostic criteria, and limited therapeutic options. The challenge of cancer-associated TMA is furthered by the fact that plasma exchange is ineffective in its management.
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73
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Moliz C, Gutiérrez E, Cavero T, Redondo B, Praga M. Síndrome hemolítico urémico atípico secundario al uso de carfilzomib tratado con eculizumab. Nefrologia 2019; 39:86-88. [DOI: 10.1016/j.nefro.2018.02.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 02/06/2018] [Accepted: 02/12/2018] [Indexed: 11/15/2022] Open
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Drug-Induced Thrombotic Microangiopathy due to Cumulative Toxicity of Ixazomib. Case Rep Hematol 2018; 2018:7063145. [PMID: 30057831 PMCID: PMC6051099 DOI: 10.1155/2018/7063145] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Accepted: 06/05/2018] [Indexed: 01/09/2023] Open
Abstract
Drug-induced thrombotic microangiopathies (DTMAs) are increasingly being recognized as an important category of thrombotic microangiopathies (TMAs). Cancer therapeutic agents including proteasome inhibitors (PIs) are among the most common medications reported to cause DTMA. PIs could cause DTMA either by an immune mechanism or dose-dependent/cumulative toxicity. Eleven cases of DTMA have been reported with bortezomib and carfilzomib. To the best of our knowledge, only one case of DTMA has been reported with ixazomib due to an immune-mediated mechanism. Here, we report the first case of ixazomib-induced DTMA due to cumulative toxicity rather than immune-mediated mechanism. In this article, we discuss the precipitating factors for cumulative toxicity of ixazomib, resulting in DTMA, diagnostic workup, and management of DTMA. We also discuss clinical reasoning based analysis of DTMA versus cancer-associated TMA as well as DTMA versus cyclic thrombocytopenia seen in PI use.
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75
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Waxman AJ, Clasen S, Hwang WT, Garfall A, Vogl DT, Carver J, O'Quinn R, Cohen AD, Stadtmauer EA, Ky B, Weiss BM. Carfilzomib-Associated Cardiovascular Adverse Events: A Systematic Review and Meta-analysis. JAMA Oncol 2018; 4:e174519. [PMID: 29285538 DOI: 10.1001/jamaoncol.2017.4519] [Citation(s) in RCA: 175] [Impact Index Per Article: 29.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Importance Cardiovascular adverse events (CVAE) with carfilzomib in patients with multiple myeloma can be potentially life-threatening and remain incompletely characterized. We performed the first systematic review and meta-analysis of carfilzomib-associated CVAE. Objective To determine the incidence of carfilzomib-associated CVAE and to compare the rates of carfilzomib CVAE among different doses and companion therapies. Data Sources PubMed, EMBASE, Web of Science, and clinicaltrials.gov were queried for the keywords "carfilzomib," "Kyprolis," and "PX-171" through January 1, 2017. Study Selection Phase 1 to 3 prospective clinical trials of carfilzomib in patients with multiple myeloma with evaluable toxic effects data were eligible for meta-analysis. Data Extraction and Synthesis Data were independently extracted by 2 reviewers following Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Pooled incidence rates and relative risks (for randomized trials) and 95% confidence intervals were calculated using a random effects model. Subgroup analyses were performed to assess study-level characteristics associated with CVAE. Main Outcomes and Measures Cardiovascular adverse events were defined as heart failure, hypertension, ischemia, and arrhythmia. All-grade and grades 3 or higher AEs and study characteristics were recorded. Results A total of 514 studies were assessed for eligibility. Of those, 24 studies were eligible, including a total of 2594 patients with multiple myeloma. All-grade and grades 3 and higher CVAE were seen in 617 (18.1%) and 274 (8.2%), respectively. Phase 2 or 3 studies and carfilzomib doses of 45 mg/m2 or higher were associated with high-grade CVAE. Median age older than 65 years, prior myeloma therapies, and concurrent myeloma therapies were not associated with CVAE. For the 3 randomized clinical trials, the summary relative risk of all-grade and grade 3 or higher CVAE for patients receiving carfilzomib compared with noncarfilzomib-receiving control patients were 1.8 and 2.2, respectively. Conclusions and Relevance Carfilzomib was associated with a significant incidence of CVAE, with higher rates seen with higher doses of carfilzomib. Phase 1 studies may be underdetecting CVAE. Future studies are needed to identify patients at high risk for CVAE, develop optimal monitoring strategies, and explore strategies to mitigate these risks.
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Affiliation(s)
- Adam J Waxman
- Division of Hematology and Oncology, Abramson Cancer Center, University of Pennsylvania, Philadelphia
| | - Suparna Clasen
- Cardio-Oncology Program, Division of Cardiovascular Medicine, Abramson Cancer Center, University of Pennsylvania, Philadelphia
| | - Wei-Ting Hwang
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia
| | - Alfred Garfall
- Division of Hematology and Oncology, Abramson Cancer Center, University of Pennsylvania, Philadelphia
| | - Dan T Vogl
- Division of Hematology and Oncology, Abramson Cancer Center, University of Pennsylvania, Philadelphia
| | - Joseph Carver
- Cardio-Oncology Program, Division of Cardiovascular Medicine, Abramson Cancer Center, University of Pennsylvania, Philadelphia
| | - Rupal O'Quinn
- Cardio-Oncology Program, Division of Cardiovascular Medicine, Abramson Cancer Center, University of Pennsylvania, Philadelphia
| | - Adam D Cohen
- Division of Hematology and Oncology, Abramson Cancer Center, University of Pennsylvania, Philadelphia
| | - Edward A Stadtmauer
- Division of Hematology and Oncology, Abramson Cancer Center, University of Pennsylvania, Philadelphia
| | - Bonnie Ky
- Cardio-Oncology Program, Division of Cardiovascular Medicine, Abramson Cancer Center, University of Pennsylvania, Philadelphia
| | - Brendan M Weiss
- Division of Hematology and Oncology, Abramson Cancer Center, University of Pennsylvania, Philadelphia
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Brocklebank V, Kavanagh D. Complement C5-inhibiting therapy for the thrombotic microangiopathies: accumulating evidence, but not a panacea. Clin Kidney J 2017; 10:600-624. [PMID: 28980670 PMCID: PMC5622895 DOI: 10.1093/ckj/sfx081] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Accepted: 06/21/2017] [Indexed: 02/07/2023] Open
Abstract
Thrombotic microangiopathy (TMA), characterized by organ injury occurring consequent to severe endothelial damage, can manifest in a diverse range of diseases. In complement-mediated atypical haemolytic uraemic syndrome (aHUS) a primary defect in complement, such as a mutation or autoantibody leading to over activation of the alternative pathway, predisposes to the development of disease, usually following exposure to an environmental trigger. The elucidation of the pathogenesis of aHUS resulted in the successful introduction of the complement inhibitor eculizumab into clinical practice. In other TMAs, although complement activation may be seen, its role in the pathogenesis remains to be confirmed by an interventional trial. Although many case reports in TMAs other than complement-mediated aHUS hint at efficacy, publication bias, concurrent therapies and in some cases the self-limiting nature of disease make broader interpretation difficult. In this article, we will review the evidence for the role of complement inhibition in complement-mediated aHUS and other TMAs.
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Affiliation(s)
- Vicky Brocklebank
- The National Renal Complement Therapeutics Centre (NRCTC), Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - David Kavanagh
- The National Renal Complement Therapeutics Centre (NRCTC), Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
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Abstract
Targeted therapies that act via unique molecular pathways and interfere with cancer cell growth and tumor progression have dramatically changed the cancer treatment paradigm. However, although, ideally, these therapies intend to target only cancer cells, they do often affect nonmalignant tissue. Numerous renal side effects have been reported to date. This article will review clinical presentation, presumed pathophysiology, and treatment of kidney side effects of targeted therapies. Feasibility of the continuation of cancer therapy despite renal toxicity will also be addressed.
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78
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None of the above: thrombotic microangiopathy beyond TTP and HUS. Blood 2017; 129:2857-2863. [PMID: 28416509 DOI: 10.1182/blood-2016-11-743104] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Accepted: 02/21/2017] [Indexed: 12/13/2022] Open
Abstract
Acquired thrombotic thrombocytopenic purpura (TTP) and hemolytic uremic syndrome (HUS) are appropriately at the top of a clinician's differential when a patient presents with a clinical picture consistent with an acute thrombotic microangiopathy (TMA). However, there are several additional diagnoses that should be considered in patients presenting with an acute TMA, especially in patients with nondeficient ADAMTS13 (a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13) activity (>10%). An increased awareness of drug-induced TMA is also essential because the key to their diagnosis more often is an appropriately detailed medical history to inquire about potential exposures. Widespread inflammation and endothelial damage are central in the pathogenesis of the TMA, with the treatment directed at the underlying disease if possible. TMA presentations in the critically ill, drug-induced TMA, cancer-associated TMA, and hematopoietic transplant-associated TMA (TA-TMA) and their specific treatment, where applicable, will be discussed in this manuscript. A complete assessment of all the potential etiologies for the TMA findings including acquired TTP will allow for a more accurate diagnosis and prevent prolonged or inappropriate treatment with plasma exchange therapy when it is less likely to be successful.
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79
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Grangé S, Coppo P. Thrombotic microangiopathies and antineoplastic agents. Nephrol Ther 2017; 13 Suppl 1:S109-S113. [DOI: 10.1016/j.nephro.2017.01.016] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Revised: 01/20/2017] [Accepted: 01/30/2017] [Indexed: 11/16/2022]
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80
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Dingli D, Ailawadhi S, Bergsagel PL, Buadi FK, Dispenzieri A, Fonseca R, Gertz MA, Gonsalves WI, Hayman SR, Kapoor P, Kourelis T, Kumar SK, Kyle RA, Lacy MQ, Leung N, Lin Y, Lust JA, Mikhael JR, Reeder CB, Roy V, Russell SJ, Sher T, Stewart AK, Warsame R, Zeldenrust SR, Rajkumar SV, Chanan Khan AA. Therapy for Relapsed Multiple Myeloma: Guidelines From the Mayo Stratification for Myeloma and Risk-Adapted Therapy. Mayo Clin Proc 2017; 92:578-598. [PMID: 28291589 PMCID: PMC5554888 DOI: 10.1016/j.mayocp.2017.01.003] [Citation(s) in RCA: 106] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Revised: 12/12/2016] [Accepted: 01/04/2017] [Indexed: 12/13/2022]
Abstract
Life expectancy in patients with multiple myeloma is increasing because of the availability of an increasing number of novel agents with various mechanisms of action against the disease. However, the disease remains incurable in most patients because of the emergence of resistant clones, leading to repeated relapses of the disease. In 2015, 5 novel agents were approved for therapy for relapsed multiple myeloma. This surfeit of novel agents renders management of relapsed multiple myeloma more complex because of the occurrence of multiple relapses, the risk of cumulative and emergent toxicity from previous therapies, as well as evolution of the disease during therapy. A group of physicians at Mayo Clinic with expertise in the care of patients with multiple myeloma regularly evaluates the evolving literature on the biology and therapy for multiple myeloma and issues guidelines on the optimal care of patients with this disease. In this article, the latest recommendations on the diagnostic evaluation of relapsed multiple myeloma and decision trees on how to treat patients at various stages of their relapse (off study) are provided together with the evidence to support them.
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Affiliation(s)
- David Dingli
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN.
| | | | - P Leif Bergsagel
- Division of Hematology and Oncology, Mayo Clinic, Scottsdale, AZ
| | - Francis K Buadi
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Angela Dispenzieri
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Rafael Fonseca
- Division of Hematology and Oncology, Mayo Clinic, Scottsdale, AZ
| | - Morie A Gertz
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Wilson I Gonsalves
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Susan R Hayman
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Prashant Kapoor
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Taxiarchis Kourelis
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Shaji K Kumar
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Robert A Kyle
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Martha Q Lacy
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Nelson Leung
- Division of Nephrology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Yi Lin
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - John A Lust
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Joseph R Mikhael
- Division of Hematology and Oncology, Mayo Clinic, Scottsdale, AZ
| | - Craig B Reeder
- Division of Hematology and Oncology, Mayo Clinic, Scottsdale, AZ
| | - Vivek Roy
- Division of Hematology and Oncology, Mayo Clinic, Jacksonville, FL
| | - Stephen J Russell
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Taimur Sher
- Division of Hematology and Oncology, Mayo Clinic, Jacksonville, FL
| | - A Keith Stewart
- Division of Hematology and Oncology, Mayo Clinic, Scottsdale, AZ
| | - Rahma Warsame
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Stephen R Zeldenrust
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - S Vincent Rajkumar
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
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81
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Yui JC, Dispenzieri A, Leung N. Ixazomib-induced thrombotic microangiopathy. Am J Hematol 2017; 92:E53-E55. [PMID: 28133842 DOI: 10.1002/ajh.24662] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Revised: 01/18/2017] [Accepted: 01/23/2017] [Indexed: 12/26/2022]
Affiliation(s)
- Jennifer C. Yui
- Department of Medicine; Mayo Clinic; Rochester Minnesota USA
| | | | - Nelson Leung
- Division of Hematology; Mayo Clinic; Rochester Minnesota USA
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82
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Wanchoo R, Abudayyeh A, Doshi M, Edeani A, Glezerman IG, Monga D, Rosner M, Jhaveri KD. Renal Toxicities of Novel Agents Used for Treatment of Multiple Myeloma. Clin J Am Soc Nephrol 2017; 12:176-189. [PMID: 27654928 PMCID: PMC5220662 DOI: 10.2215/cjn.06100616] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Survival for patients with multiple myeloma has significantly improved in the last decade in large part due to the development of proteasome inhibitors and immunomodulatory drugs. These next generation agents with novel mechanisms of action as well as targeted therapies are being used both in the preclinical and clinical settings for patients with myeloma. These agents include monoclonal antibodies, deacetylase inhibitors, kinase inhibitors, agents affecting various signaling pathways, immune check point inhibitors, and other targeted therapies. In some cases, off target effects of these therapies can lead to unanticipated effects on the kidney that can range from electrolyte disorders to AKI. In this review, we discuss the nephrotoxicities of novel agents currently in practice as well as in development for the treatment of myeloma.
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Affiliation(s)
- Rimda Wanchoo
- Division of Nephrology, Hofstra Northwell School of Medicine, Great Neck, New York
| | - Ala Abudayyeh
- Division of Internal Medicine, Section of Nephrology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Mona Doshi
- Division of Nephrology, Wayne State University School of Medicine, Detroit, Michigan
| | - Amaka Edeani
- Kidney Diseases Branch, National Institute of Diabetes, Digestive and Kidney Disease, National Institutes of Health, Bethesda, Maryland
| | - Ilya G. Glezerman
- Department of Medicine, Renal Service, Memorial Sloan Kettering Cancer Center and Department of Medicine, Weill Cornell Medical Center, New York, New York
| | - Divya Monga
- Nephrology Division, University of Mississippi Medical Center, Jackson, Mississippi; and
| | - Mitchell Rosner
- Division of Nephrology, Department of Medicine, University of Virginia Health System, Charlottesville, Virginia
| | - Kenar D. Jhaveri
- Division of Nephrology, Hofstra Northwell School of Medicine, Great Neck, New York
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83
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Ziogas DC, Kastritis E, Terpos E, Roussou M, Migkou M, Gavriatopoulou M, Spanomichou D, Eleutherakis-Papaiakovou E, Fotiou D, Panagiotidis I, Kafantari E, Psimenou E, Boletis I, Vlahakos DV, Gakiopoulou H, Matsouka C, Dimopoulos MA. Hematologic and renal improvement of monoclonal immunoglobulin deposition disease after treatment with bortezomib-based regimens. Leuk Lymphoma 2016; 58:1832-1839. [PMID: 27967286 DOI: 10.1080/10428194.2016.1267349] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Monoclonal immunoglobulin deposition disease (MIDD) is characterized by non-organized immunoglobulin-fragments along renal basement membranes with subsequent organ deterioration. Treatment is directed against the immunoglobulin-producing clone. We treated 18 MIDD patients with bortezomib-based regimens (12 received bortezomib-dexamethasone, 6 bortezomib-dexamethasone with cyclophosphamide). Eleven (61%) patients achieved a hematologic response, but only 6 (33.3%) reached to a complete (CR) or very good partial response (VGPR). Regarding renal outcomes 77.8 and 55.6% had ≥30 and ≥50% reduction of proteinuria, respectively, but 33.3% ended up in end-stage renal disease (ESRD). Among patients with CR or VGPR, median eGFR improvement was 7.7 ml/min/1.73 m2 and none progressed to ESRD, but no significant renal recovery was observed in patients achieving a partial response or less, with 50% progressing to dialysis. Pretreatment eGFR seems to influence renal prognosis. Bortezomib-based treatment is considered an effective approach in MIDD and reaching to a deep hematologic response (≥VGPR) conditionally controls further renal declining.
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Affiliation(s)
- Dimitrios C Ziogas
- a Department of Clinical Therapeutics , Alexandra General Hospital, National and Kapodistrian University of Athens, School of Medicine , Athens , Greece
| | - Efstathios Kastritis
- a Department of Clinical Therapeutics , Alexandra General Hospital, National and Kapodistrian University of Athens, School of Medicine , Athens , Greece
| | - Evangelos Terpos
- a Department of Clinical Therapeutics , Alexandra General Hospital, National and Kapodistrian University of Athens, School of Medicine , Athens , Greece
| | - Maria Roussou
- a Department of Clinical Therapeutics , Alexandra General Hospital, National and Kapodistrian University of Athens, School of Medicine , Athens , Greece
| | - Magdalini Migkou
- a Department of Clinical Therapeutics , Alexandra General Hospital, National and Kapodistrian University of Athens, School of Medicine , Athens , Greece
| | - Maria Gavriatopoulou
- a Department of Clinical Therapeutics , Alexandra General Hospital, National and Kapodistrian University of Athens, School of Medicine , Athens , Greece
| | - Despoina Spanomichou
- a Department of Clinical Therapeutics , Alexandra General Hospital, National and Kapodistrian University of Athens, School of Medicine , Athens , Greece
| | - Evangelos Eleutherakis-Papaiakovou
- a Department of Clinical Therapeutics , Alexandra General Hospital, National and Kapodistrian University of Athens, School of Medicine , Athens , Greece
| | - Despoina Fotiou
- a Department of Clinical Therapeutics , Alexandra General Hospital, National and Kapodistrian University of Athens, School of Medicine , Athens , Greece
| | - Ioannis Panagiotidis
- a Department of Clinical Therapeutics , Alexandra General Hospital, National and Kapodistrian University of Athens, School of Medicine , Athens , Greece
| | - Eftychia Kafantari
- a Department of Clinical Therapeutics , Alexandra General Hospital, National and Kapodistrian University of Athens, School of Medicine , Athens , Greece
| | - Erasmia Psimenou
- a Department of Clinical Therapeutics , Alexandra General Hospital, National and Kapodistrian University of Athens, School of Medicine , Athens , Greece
| | - Ioannis Boletis
- b Department of Nephrology and Renal Transplantation Unit , Laiko General Hospital , Athens , Greece
| | - Demetrios V Vlahakos
- c Renal Unit, Attikon General Hospital , National and Kapodistrian University of Athens, School of Medicine , Athens , Greece
| | - Hariklia Gakiopoulou
- d Department of Histopathology , National and Kapodistrian University of Athens, School of Medicine , Athens , Greece
| | - Charis Matsouka
- a Department of Clinical Therapeutics , Alexandra General Hospital, National and Kapodistrian University of Athens, School of Medicine , Athens , Greece
| | - Meletios A Dimopoulos
- a Department of Clinical Therapeutics , Alexandra General Hospital, National and Kapodistrian University of Athens, School of Medicine , Athens , Greece
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84
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Bortezomib therapy in patients with relapsed/refractory acquired thrombotic thrombocytopenic purpura. Ann Hematol 2016; 95:1751-6. [DOI: 10.1007/s00277-016-2804-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Accepted: 08/28/2016] [Indexed: 10/21/2022]
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