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Sinkovits G, Szilágyi Á, Farkas P, Inotai D, Szilvási A, Tordai A, Rázsó K, Réti M, Prohászka Z. Concentration and Subclass Distribution of Anti-ADAMTS13 IgG Autoantibodies in Different Stages of Acquired Idiopathic Thrombotic Thrombocytopenic Purpura. Front Immunol 2018; 9:1646. [PMID: 30061898 PMCID: PMC6054987 DOI: 10.3389/fimmu.2018.01646] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 07/04/2018] [Indexed: 12/14/2022] Open
Abstract
Background The acquired form of idiopathic thrombotic thrombocytopenic purpura (TTP) is an autoimmune disease, in which the underlying deficiency of the ADAMTS13 protease is caused by autoantibodies, predominantly of the IgG isotype. Certain HLA-DR-DQ haplotypes were associated with the risk of developing TTP. Objectives To investigate the development of the ADAMTS13-specific antibody response during the course of the disease, we analyzed the concentration, subclass distribution, and inhibitory potential of anti-ADAMTS13 IgG autoantibodies in samples of TTP patients drawn during the first acute phase, in remission, and during relapse. Additionally, we compared the anti-ADAMTS13 IgG levels between patients carrying and not carrying risk and protective HLA-DR-DQ haplotypes. Patients and Methods We determined the anti-ADAMTS13 IgG concentration and subclass distribution in 101 antibody-positive samples of 81 acquired TTP patients by ELISA methods. The presence and semi-quantitative amount of anti-ADAMTS13 inhibitors were determined in 97 of 100 deficient samples, and the specific inhibitory potential of anti-ADAMTS13 autoantibodies was determined in 49 selected samples, by mixing ADAMTS13-activity assays. HLA-DR-DQ typing and haplotype prediction were performed in 70 of the above patients. Results We found that IgG1 and IgG4 were the predominant subclasses, present in almost all samples. While IgG1 was the dominant subclass in almost half of the samples taken during the first acute episode, IgG4 was dominant in all samples taken during or following a relapse. The inhibitory potential of the samples correlated with levels of the IgG4 subclass. Anti-ADAMTS13 antibodies of IgG4-dominant samples had higher specific inhibitory potentials than IgG1-dominant samples, independently of disease stage. Interestingly, we found that patients carrying the protective DR7-DQ2 and DR13-DQ6 haplotypes had higher anti-ADAMTS13 IgG levels. Conclusion Our results indicate that IgG4 becomes the dominant subtype at some point of the disease course, apparently before the first relapse, parallel to the increase in inhibitory potential of the anti-ADAMTS13 autoantibodies. Furthermore, we found an association between the genetic background and the antibody response in TTP.
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Affiliation(s)
- György Sinkovits
- Research Laboratory, 3rd Department of Internal Medicine and MTA-SE Research Group of Immunology and Hematology, Hungarian Academy of Sciences and Semmelweis University, Budapest, Hungary
| | - Ágnes Szilágyi
- Research Laboratory, 3rd Department of Internal Medicine and MTA-SE Research Group of Immunology and Hematology, Hungarian Academy of Sciences and Semmelweis University, Budapest, Hungary
| | - Péter Farkas
- 3rd Department of Internal Medicine, Semmelweis University, Budapest, Hungary
| | - Dóra Inotai
- Laboratory of Transplantation Immunogenetics, Hungarian National Blood Transfusion Service, Budapest, Hungary
| | - Anikó Szilvási
- Laboratory of Transplantation Immunogenetics, Hungarian National Blood Transfusion Service, Budapest, Hungary
| | - Attila Tordai
- Department of Pathophysiology, Semmelweis University, Budapest, Hungary
| | - Katalin Rázsó
- Division of Haematology, Deptartment of Internal Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Marienn Réti
- Department of Haematology and Stem Cell Transplantation, Central Hospital of Southern Pest, National Institute of Haematology and Infectious Diseases, Budapest, Hungary
| | - Zoltán Prohászka
- Research Laboratory, 3rd Department of Internal Medicine and MTA-SE Research Group of Immunology and Hematology, Hungarian Academy of Sciences and Semmelweis University, Budapest, Hungary
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Vendramin C, Thomas M, Westwood JP, Scully M. Bethesda Assay for Detecting Inhibitory Anti-ADAMTS13 Antibodies in Immune-Mediated Thrombotic Thrombocytopenic Purpura. TH OPEN 2018; 2:e329-e333. [PMID: 31249957 PMCID: PMC6524890 DOI: 10.1055/s-0038-1672187] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Accepted: 08/09/2018] [Indexed: 11/16/2022] Open
Abstract
A diagnosis of thrombotic thrombocytopenic purpura (TTP) is confirmed by a severe deficiency (<10%) of a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13 (ADAMTS13) activity. Autoantibodies to ADAMTS13 can be detected with a simplified enzyme-linked immunosorbent assay (ELISA). An alternative methodology is a Bethesda assay, which has never been formally assessed in TTP. This study aimed to investigate the inhibitory anti-ADAMTS13 antibody assay and determine if the Bethesda assay is advantageous compared with the ELISA, measuring total immunoglobulin G (IgG) antibodies to ADAMTS 13. The Bethesda method determines the neutralizing activity of anti-ADAMTS13 antibodies in pooled normal plasma. We selected six immune-mediated TTP (iTTP) patients with ADAMTS13 activity levels <10% and strong ADAMTS13 inhibitors by 50:50 mixing studies and analyzed anti-ADAMTS13 antibodies using the Bethesda and ELISA assays. ADAMTS13 activity was stable at room temperature, while a time-dependent decrease in activity was detected in assay conditions of 37°C. Adding 5 mM Ca 2+ to citrated plasma prevented loss of ADAMTS13 activity with time. There was time dependence to the antibody-mediated inactivation, after 2-hour incubation. Two of the iTTP patients had no detectable ADAMTS13 antibodies by the Bethesda assay, but had high titer of anti-ADAMTS13 antibodies and low ADAMTS13 antigen levels. The Bethesda assay can only detect anti-ADAMTS13 antibodies that functionally inhibit ADAMTS13. The anti-ADAMTS13 IgG ELISA instead allows the rapid identification of total IgG autoantibodies, detecting both inhibitory and noninhibitory antibodies.
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Affiliation(s)
- Chiara Vendramin
- Department of Haematology, University College London Hospital, London, United Kingdom
| | - Mari Thomas
- Department of Haematology, University College London Hospital, Cardiometabolic Programme NIHR UCLH/UCL BRC, London, United Kingdom
| | - John-Paul Westwood
- Department of Haematology, University College London Hospital, London, United Kingdom
| | - Marie Scully
- Department of Haematology, University College London Hospital, Cardiometabolic Programme NIHR UCLH/UCL BRC, London, United Kingdom
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53
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Viner M, Murakhovskaya I. A rare combination of thrombotic thrombocytopenic purpura and antiphospholipid syndrome. Blood Coagul Fibrinolysis 2018; 28:411-415. [PMID: 27898514 DOI: 10.1097/mbc.0000000000000608] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
: Thrombocytopenia, in the setting of microangiopathic hemolytic anemia and thrombotic events, is characteristic of both thrombotic thrombocytopenic purpura and primary antiphospholipid syndrome. Clinically, it is difficult to distinguish between these two syndromes. We present a 41-year-old woman with chronic, relapsing thrombotic thrombocytopenic purpura in the presence of antiphospholipid antibodies. She had clinical manifestations of antiphospholipid syndrome without meeting laboratory criteria of the Sydney classification system. In the literature, there have only been nine cases of thrombotic thrombocytopenic purpura associated with primary antiphospholipid syndrome. Seven of the nine cases suffered from one or multiple strokes, a common feature in antiphospholipid syndrome, but an uncommon finding in thrombotic thrombocytopenic purpura. We introduce the possibility of an association between thrombotic thrombocytopenic purpura and the presence of antiphospholipid antibodies. Systematic testing of ADAMTS13 activity and anti-ADAMTS13 antibodies in patients who present with neurological symptoms and thrombocytopenia, in the presence of antiphospholipid antibodies, may help with the diagnosis of the rare thrombotic thrombocytopenic purpura-antiphospholipid syndrome combination.
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Affiliation(s)
- Maya Viner
- aUniversity of Illinois at Chicago, Chicago, Illinois bAlbert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York, USA
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54
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Hrdinová J, D'Angelo S, Graça NAG, Ercig B, Vanhoorelbeke K, Veyradier A, Voorberg J, Coppo P. Dissecting the pathophysiology of immune thrombotic thrombocytopenic purpura: interplay between genes and environmental triggers. Haematologica 2018; 103:1099-1109. [PMID: 29674502 PMCID: PMC6029525 DOI: 10.3324/haematol.2016.151407] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 04/13/2018] [Indexed: 01/04/2023] Open
Abstract
Although outstanding progress has been made in understanding the pathophysiology of thrombotic thrombocytopenic purpura (TTP), knowledge of the immunopathogenesis of the disease is only at an early stage. Anti-ADAMTS13 auto-antibodies were shown to block proteolysis of von Willebrand factor and/or induce ADAMTS13 clearance from the circulation. However, it still remains to identify which immune cells are involved in the production of anti-ADAMTS13 autoantibodies, and therefore account for the remarkable efficacy of the B-cell depleting agents in this disease. The mechanisms leading to the loss of tolerance of the immune system towards ADAMTS13 involve the predisposing genetic factors of the human leukocyte antigen class II locus DRB1*11 and DQB1*03 alleles as well as the protective allele DRB1*04, and modifying factors such as ethnicity, sex and obesity. Future studies have to identify why these identified genetic risk factors are also frequently to be found in the healthy population although the incidence of immune-mediated thrombotic thrombocytopenic purpura (iTTP) is extremely low. Moreover, the development of recombinant ADAMTS13 opens a new therapeutic era in the field. Interactions of recombinant ADAMTS13 with the immune system of iTTP patients will require intensive investigation, especially for its potential immunogenicity. Better understanding of iTTP immunopathogenesis should, therefore, provide a basis for the development of novel therapeutic approaches to restore immune tolerance towards ADAMTS13 and thereby better prevent refractoriness and relapses in patients with iTTP. In this review, we address these issues and the related challenges in this field.
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Affiliation(s)
- Johana Hrdinová
- Department of Plasma Proteins, Sanquin-Academic Medical Center Landsteiner Laboratory, Amsterdam, the Netherlands.,PharmaTarget B.V., Maastricht, the Netherlands.,Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, the Netherlands
| | - Silvia D'Angelo
- Laboratory for Thrombosis Research, IRF Life Sciences, KU Leuven Campus Kulak Kortrijk, Belgium.,Protobios LLC, Tallinn, Estonia
| | - Nuno A G Graça
- Department of Plasma Proteins, Sanquin-Academic Medical Center Landsteiner Laboratory, Amsterdam, the Netherlands.,Icosagen Cell Factory OÜ, Ülenurme Vald, Tartumaa, Estonia
| | - Bogac Ercig
- Department of Plasma Proteins, Sanquin-Academic Medical Center Landsteiner Laboratory, Amsterdam, the Netherlands.,PharmaTarget B.V., Maastricht, the Netherlands.,Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, the Netherlands
| | - Karen Vanhoorelbeke
- Laboratory for Thrombosis Research, IRF Life Sciences, KU Leuven Campus Kulak Kortrijk, Belgium
| | - Agnès Veyradier
- Service d'Hématologie Biologique and EA3518, Groupe Hospitalier Saint Louis-Lariboisière, Assistance Publique - Hôpitaux de Paris, Université Paris Diderot, France.,Centre de Référence des Microangiopathies Thrombotiques, Hôpital Saint-Antoine, AP-HP, Paris, France
| | - Jan Voorberg
- Department of Plasma Proteins, Sanquin-Academic Medical Center Landsteiner Laboratory, Amsterdam, the Netherlands
| | - Paul Coppo
- Centre de Référence des Microangiopathies Thrombotiques, Hôpital Saint-Antoine, AP-HP, Paris, France .,Service d'Hématologie, Assistance Publique - Hôpitaux de Paris, France.,Sorbonne Université, UPMC Univ Paris 06, France
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55
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Kremer Hovinga JA, Heeb SR, Skowronska M, Schaller M. Pathophysiology of thrombotic thrombocytopenic purpura and hemolytic uremic syndrome. J Thromb Haemost 2018; 16:618-629. [PMID: 29356300 DOI: 10.1111/jth.13956] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Thrombotic microangiopathies are rare disorders characterized by the concomitant occurrence of severe thrombocytopenia, microangiopathic hemolytic anemia, and a variable degree of ischemic end-organ damage. The latter particularly affects the brain, the heart, and the kidneys. The primary forms, thrombotic thrombocytopenic purpura (TTP) and hemolytic uremic syndrome (HUS), although their clinical presentations often overlap, have distinctive pathophysiologies. TTP is the consequence of a severe ADAMTS-13 deficiency, either immune-mediated as a result of circulating autoantibodies, or caused by mutations in ADAMTS-13. HUS develops following an infection with Shiga-toxin producing bacteria, or as the result of excessive activation of the alternative pathway of the complement system because of mutations in genes encoding complement system proteins.
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Affiliation(s)
- J A Kremer Hovinga
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, Bern, Switzerland
- Department for BioMedical Research, University of Bern, Bern, Switzerland
| | - S R Heeb
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, Bern, Switzerland
- Department for BioMedical Research, University of Bern, Bern, Switzerland
| | - M Skowronska
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, Bern, Switzerland
- Department for BioMedical Research, University of Bern, Bern, Switzerland
| | - M Schaller
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, Bern, Switzerland
- Department for BioMedical Research, University of Bern, Bern, Switzerland
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56
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Zickuhr L, Herlitz LC, Chatterjee S. A 22-Year-Old Woman With Systemic Lupus Erythematosus Presents With Two Damaged Kidneys, One Seizure, No Platelets, and Many Possible Diagnoses. Arthritis Care Res (Hoboken) 2018; 70:1686-1693. [PMID: 29579358 DOI: 10.1002/acr.23561] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Accepted: 03/20/2018] [Indexed: 11/09/2022]
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57
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Studt JD, Voorberg J, Hovinga JA, Schaller M. Acquired thrombotic thrombocytopenic purpura. Hamostaseologie 2018; 33:121-30. [DOI: 10.5482/hamo-12-12-0023] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2012] [Accepted: 01/17/2013] [Indexed: 01/16/2023] Open
Abstract
SummaryThe von Willebrand factor (VWF)-cleaving metalloprotease, ADAMTS13 (a disintegrin and metalloprotease with thrombospondin type 1 motifs-13) is the only known target of the dysregulated immune response in acquired TTP. Autoantibodies to ADAMTS13 either neutralize its activity or accelerate its clearance, thereby causing a severe deficiency of ADAMTS13 in plasma. As a consequence, size regulation of VWF is impaired and the persistence of ultra-large VWF (ULVWF) multimers facilitates micro vascular platelet aggregation causing microangiopathic haemolytic anaemia and ischaemic organ damage. Autoimmune TTP although a rare disease with an annual incidence of 1.72 cases has a mortality rate of 20% even with adequate therapy.We describe the mechanisms involved in ADAMTS13 autoimmunity with a focus on the role of B- and T-cells in the pathogenesis of this disorder. We discuss the potential translation of recent experimental findings into future therapeutic concepts for the treatment of acquired TTP.
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58
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Tan Y, Luan ZQ, Hao JB, Song D, Yu F, Zhao MH. Plasma ADAMTS-13 activity in proliferative lupus nephritis: a large cohort study from China. Lupus 2017; 27:389-398. [PMID: 28786769 DOI: 10.1177/0961203317723715] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives The aim of this study was to investigate plasma ADAMTS-13 activity in patients with proliferative lupus nephritis and to evaluate the role of clinical, laboratory and pathological features, especially the vascular lesions in lupus nephritis. Methods Plasma samples from 163 class III and IV lupus nephritis patients confirmed by biopsy examinations and 98 normal controls were collected. ADAMTS-13 activity was evaluated by a residual collagen binding assay. IgG autoantibodies against ADAMTS-13 were detected by ELISA using recombinant ADAMTS-13 as a solid-phase ligand. Levels of vWF were measured by ELISA. Their associations with clinical, laboratory and pathological features were further assessed. Results Plasma ADAMTS-13 activity in lupus nephritis patients was significantly lower than that in normal controls (84 ± 21% vs. 90 ± 13%, p = 0.005). IgG ADAMTS-13 autoantibodies were detected in only three patients. The plasma level of vWF was significantly higher in the lupus nephritis group than in normal controls (1.00 ± 0.79 vs. 0.70 ± 0.30, p = 0.025). Plasma ADAMTS-13 activity was negatively correlated with the level of serum creatinine and proteinuria ( r = –0.354, p < 0.001; r = –0.200, p = 0.011, respectively). Patients with a higher level of ADAMTS-13 activity had significantly higher levels of factor H (401.51 ± 183.01 µg/ml vs. 239.02 ± 155.45 µg/ml, p = 0.005). Plasma ADAMTS-13 activity was negatively associated with total pathological AI scores ( r = –0.326, p < 0.001), endocapillary hypercellularity ( r = –0.419, p < 0.001), cellular crescents ( r = –0.274, p < 0.001), subendothelial hyaline deposits ( r = –0.266, p = 0.001), interstitial inflammatory cell infiltration ( r = –0.304, P < 0.001), tubular atrophy ( r = –0.199, p = 0.011), acute glomerular vascular lesions ( r = –0.344, p < 0.001) and acute renal vascular lesions ( r = –0.338, p < 0.001). No association was found between level of vWF and plasma ADAMTS-13 activity ( r = 0.033, p = 0.671). Low level of ADAMTS-13 activity was a risk factor for renal outcomes ( p = 0.039, HR = 0.047, 95% CI: 0.120–1.005). Conclusions Decreased ADAMTS-13 activity was found in patients with proliferative lupus nephritis, and plasma ADAMTS-13 activity was closely associated with renal injury indices, especially pathological vascular scores. The role of ADAMTS-13 in the disease remains to be further investigated.
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Affiliation(s)
- Y Tan
- Renal Division, Department of Medicine, Peking University First Hospital; Peking University Institute of Nephrology; Key Laboratory of Renal Disease, Ministry of Health of China; Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Ministry of Education of China, Beijing, PR. China
| | - Z Q Luan
- Department of Nephrology, First Affiliated Hospital of Heilongjiang University of Chinese Medicine, Harbin, PR. China
| | - J B Hao
- Department of Nephrology, The First Clinical Medicine of Zhengzhou University, Zhengzhou, PR. China
| | - D Song
- Renal Division, Department of Medicine, Peking University First Hospital; Peking University Institute of Nephrology; Key Laboratory of Renal Disease, Ministry of Health of China; Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Ministry of Education of China, Beijing, PR. China
| | - F Yu
- Renal Division, Department of Medicine, Peking University First Hospital; Peking University Institute of Nephrology; Key Laboratory of Renal Disease, Ministry of Health of China; Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Ministry of Education of China, Beijing, PR. China
- Department of Nephrology, Peking University International Hospital, Beijing, PR. China
| | - M H Zhao
- Renal Division, Department of Medicine, Peking University First Hospital; Peking University Institute of Nephrology; Key Laboratory of Renal Disease, Ministry of Health of China; Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Ministry of Education of China, Beijing, PR. China
- Peking-Tsinghua Center for Life Sciences, Beijing, PR. China
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59
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Alwan F, Vendramin C, Vanhoorelbeke K, Langley K, McDonald V, Austin S, Clark A, Lester W, Gooding R, Biss T, Dutt T, Cooper N, Chapman O, Cranfield T, Douglas K, Watson HG, van Veen JJ, Sibson K, Thomas W, Manson L, Hill QA, Benjamin S, Ellis D, Westwood JP, Thomas M, Scully M. Presenting ADAMTS13 antibody and antigen levels predict prognosis in immune-mediated thrombotic thrombocytopenic purpura. Blood 2017; 130:466-471. [PMID: 28576877 DOI: 10.1182/blood-2016-12-758656] [Citation(s) in RCA: 82] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 05/02/2017] [Indexed: 02/04/2023] Open
Abstract
Immune-mediated thrombotic thrombocytopenic purpura (TTP) is a life-threatening disorder caused by antibodies against ADAMTS13. From the United Kingdom TTP registry, we undertook a prospective study investigating the impact of the presenting anti-ADAMTS13 IgG antibody and ADAMTS13 antigen on mortality. A total of 312 episodes involving 292 patients over 87 months were included; 68% were female, median age 46 (range, 11-88 years), and median presenting ADAMTS13 of <5% (range, <5%-18%). The mortality rate was 10.3% (n = 32); 68% of patients had a raised troponin at presentation conferring a sixfold increase in mortality compared with those with normal troponin levels (12.1% vs 2.0%, P = .04). Twenty-four percent had a reduced Glasgow Coma Score (GCS) at presentation with a ninefold increase in mortality (20% vs 2.2% for normal GCS at presentation, P < .0001). Mortality increased with higher anti-ADAMTS13 antibody levels and lower ADAMTS13 antigen levels. Those with antibody levels in the upper quartile (antibody >77%) had a mortality of 16.9% compared with 5.0% for the lowest quartile (antibody <20%) (P = .004). Those with an antigen level in the lowest quartile (antigen <1.5%) had a mortality of 18% compared with 3.8% for the highest quartile (antigen >11%) (P = .005). The synergistic effect of anti-ADAMTS13 IgG antibody in the upper quartile and ADAMTS13 antigen in the lowest quartile had the highest mortality of 27.3%. We conclude that both anti-ADAMTS13 IgG antibody and ADAMTS13 antigen levels correlate with outcome in TTP with increased cardiac and neurological involvement and increased mortality.
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Affiliation(s)
| | - Chiara Vendramin
- Haemostasis Research Unit, University College London, London, United Kingdom
| | - Karen Vanhoorelbeke
- Laboratory for Thrombosis Research, Katholieke Universiteit Leuven Campus Kulak Kortrijk, Kortrijk, Belgium
| | - Katy Langley
- Haemostasis Research Unit, University College London, London, United Kingdom
| | - Vickie McDonald
- Department of Haematology, Guys and St Thomas National Health Service (NHS) Trust, London, United Kingdom
| | - Steve Austin
- Department of Haematology, St George's NHS Trust, London, United Kingdom
| | - Amanda Clark
- Bristol Haemophilia Centre, University Hospitals Bristol Foundation Trust, Bristol, United Kingdom
| | - William Lester
- Department of Haematology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Richard Gooding
- Department of Haematology, University Hospitals of Leicester, Leicester, United Kingdom
| | - Tina Biss
- Department of Haematology, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, United Kingdom
| | - Tina Dutt
- Roald Dahl Haemostasis and Thrombosis Centre, Royal Liverpool University Hospital, Liverpool, United Kingdom
| | - Nichola Cooper
- Department of Haematology, Imperial College NHS Trust, London, United Kingdom
| | - Oliver Chapman
- Department of Haematology, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom
| | - Tanya Cranfield
- Department of Haematology, Queen Alexandra Hospital, Portsmouth, United Kingdom
| | - Kenny Douglas
- Scottish National Blood Transfusion Service (SNBTS) Clinical Apheresis Unit, Beatson West of Scotland Cancer Centre, Glasgow, United Kingdom
| | - H G Watson
- Department of Haematology, Aberdeen Royal Infirmary, Aberdeen, United Kingdom
| | - J J van Veen
- Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - Keith Sibson
- Department of Haematology, Great Ormond Street Hospital, London, United Kingdom
| | - William Thomas
- Department of Haematology, Addenbrookes Hospital, Cambridge, United Kingdom
| | - Lynn Manson
- SNBTS Department of Transfusion Medicine, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Quentin A Hill
- Department of Haematology, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Sylvia Benjamin
- Department of Clinical Haematology, Oxford University Hospitals, Oxford, United Kingdom; and
| | | | | | - Mari Thomas
- Department of Haematology and
- National Institute for Health Research Cardiometabolic Programme, University College London (UCL) Hospitals/UCL Biomedical Research Centre, London, United Kingdom
| | - Marie Scully
- Department of Haematology and
- National Institute for Health Research Cardiometabolic Programme, University College London (UCL) Hospitals/UCL Biomedical Research Centre, London, United Kingdom
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60
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Zanato V, Lombardi AM, Busetto L, Prà CD, Foletto M, Prevedello L, De Marinis GB, Fabris F, Vettor R, Fabris R. Weight loss reduces anti-ADAMTS13 autoantibodies and improves inflammatory and coagulative parameters in obese patients. Endocrine 2017; 56:521-527. [PMID: 27530508 DOI: 10.1007/s12020-016-1059-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Accepted: 07/12/2016] [Indexed: 01/03/2023]
Abstract
Obese patients have been described at increased risk of thrombotic thrombocytopenic purpura, a disease caused by anti-ADAMTS13 autoantibodies. ADAMTS13 has a structure homology with the adipokine thrombospondin-1. We previously demonstrated an increased presence of anti-ADAMTS13 antibodies in obese patients. We aimed to study the changes induced by weight loss after bariatric surgery on some inflammatory and coagulative parameters and their link with anti-ADAMTS13 autoantibodies. We studied 100 obese patients before and after weight loss induced by bariatric surgery and 79 lean volunteers as controls. We measured anthropometric, metabolic and inflammatory parameters, thrombospondin-1, ADAMTS13 activity, anti-ADAMTS13 autoantibodies, Von Willebrand factor. At baseline, 13 % of patients was positive for anti-ADAMTS13 autoantibodies, while all controls were negative. Thrombospondin-1 levels were higher in obese subjects with than without antibodies, with a positive correlation between the two parameters. In multiple logistic regression analysis only thrombospondin-1 levels predicted positivity for anti-ADAMTS13 antibodies. After weight loss both anti-ADAMTS13 antibodies and thrombospondin-1 reduced significantly. Weight loss in obesity improves the inflammatory and coagulative profile, and in particular anti-ADAMTS13 autoantibodies, ADAMTS13 activity and thrombospondin-1.
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Affiliation(s)
- Veronica Zanato
- Department of Medicine-DIMED, University of Padova, Internal Medicine 3, Padova, Italy.
| | - Anna Maria Lombardi
- Department of Medicine-DIMED, University of Padova, Internal Medicine 1, Padova, Italy
| | - Luca Busetto
- Department of Medicine-DIMED, University of Padova, Internal Medicine 3, Padova, Italy
| | - Chiara Dal Prà
- Department of Medicine-DIMED, University of Padova, Internal Medicine 3, Padova, Italy
| | - Mirto Foletto
- Week Surgery, Hospital Establishment of Padova, Padova, Italy
| | - Luca Prevedello
- Week Surgery, Hospital Establishment of Padova, Padova, Italy
| | | | - Fabrizio Fabris
- Department of Medicine-DIMED, University of Padova, Internal Medicine 1, Padova, Italy
| | - Roberto Vettor
- Department of Medicine-DIMED, University of Padova, Internal Medicine 3, Padova, Italy
| | - Roberto Fabris
- Department of Medicine-DIMED, University of Padova, Internal Medicine 3, Padova, Italy
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Dhanesha N, Doddapattar P, Chorawala MR, Nayak MK, Kokame K, Staber JM, Lentz SR, Chauhan AK. ADAMTS13 Retards Progression of Diabetic Nephropathy by Inhibiting Intrarenal Thrombosis in Mice. Arterioscler Thromb Vasc Biol 2017; 37:1332-1338. [PMID: 28495930 DOI: 10.1161/atvbaha.117.309539] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Accepted: 05/01/2017] [Indexed: 12/13/2022]
Abstract
OBJECTIVE ADAMTS13 (a disintegrin and metalloprotease with thrombospondin type I repeats-13) prevents microvascular thrombosis by cleaving prothrombogenic ultralarge von Willebrand factor (VWF) multimers. Clinical studies have found association between reduced ADAMTS13-specific activity, ultralarge VWF multimers, and thrombotic angiopathy in patients with diabetic nephropathy. It remains unknown, however, whether ADAMTS13 deficiency or ultralarge VWF multimers have a causative effect in diabetic nephropathy. APPROACH AND RESULTS The extent of renal injury was evaluated in wild-type (WT), Adamts13-/- and Adamts13-/-Vwf-/- mice after 26 weeks of streptozotocin-induced diabetic nephropathy. We found that WT diabetic mice exhibited low plasma ADAMTS13-specific activity and increased VWF levels (P<0.05 versus WT nondiabetic mice). Adamts13-/- diabetic mice exhibited deterioration of kidney function (increased albuminuria, plasma creatinine, and urea; P<0.05 versus WT diabetic mice), independent of hyperglycemia and hypertension. Deterioration of kidney function in Adamts13-/- diabetic mice was concomitant with aggravated intrarenal thrombosis (assessed by plasminogen activator inhibitor, VWF, fibrin(ogen), and CD41-positive microthrombi), increased mesangial cell expansion, and extracellular matrix deposition (P<0.05 versus WT diabetic mice). Genetic deletion of VWF in Adamts13-/- diabetic mice improved kidney function, inhibited intrarenal thrombosis, and alleviated histological changes in glomeruli, suggesting that exacerbation of diabetic nephropathy in the setting of ADAMTS13 deficiency is VWF dependent. CONCLUSIONS ADAMTS13 retards progression of diabetic nephropathy, most likely by inhibiting VWF-dependent intrarenal thrombosis. Alteration in ADAMTS13-VWF balance may be one of the key pathophysiological mechanisms of thrombotic angiopathy in diabetes mellitus.
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Affiliation(s)
- Nirav Dhanesha
- From the Department of Internal Medicine (N.D., P.D., M.R.C., M.K.N., S.R.L., A.K.C.) and Stead Family Department of Pediatrics (J.M.S.), University of Iowa; and Department of Molecular Pathogenesis, National Cardiovascular Centre Research Institute, Suita, Osaka, Japan (K.K.)
| | - Prakash Doddapattar
- From the Department of Internal Medicine (N.D., P.D., M.R.C., M.K.N., S.R.L., A.K.C.) and Stead Family Department of Pediatrics (J.M.S.), University of Iowa; and Department of Molecular Pathogenesis, National Cardiovascular Centre Research Institute, Suita, Osaka, Japan (K.K.)
| | - Mehul R Chorawala
- From the Department of Internal Medicine (N.D., P.D., M.R.C., M.K.N., S.R.L., A.K.C.) and Stead Family Department of Pediatrics (J.M.S.), University of Iowa; and Department of Molecular Pathogenesis, National Cardiovascular Centre Research Institute, Suita, Osaka, Japan (K.K.)
| | - Manasa K Nayak
- From the Department of Internal Medicine (N.D., P.D., M.R.C., M.K.N., S.R.L., A.K.C.) and Stead Family Department of Pediatrics (J.M.S.), University of Iowa; and Department of Molecular Pathogenesis, National Cardiovascular Centre Research Institute, Suita, Osaka, Japan (K.K.)
| | - Koichi Kokame
- From the Department of Internal Medicine (N.D., P.D., M.R.C., M.K.N., S.R.L., A.K.C.) and Stead Family Department of Pediatrics (J.M.S.), University of Iowa; and Department of Molecular Pathogenesis, National Cardiovascular Centre Research Institute, Suita, Osaka, Japan (K.K.)
| | - Janice M Staber
- From the Department of Internal Medicine (N.D., P.D., M.R.C., M.K.N., S.R.L., A.K.C.) and Stead Family Department of Pediatrics (J.M.S.), University of Iowa; and Department of Molecular Pathogenesis, National Cardiovascular Centre Research Institute, Suita, Osaka, Japan (K.K.)
| | - Steven R Lentz
- From the Department of Internal Medicine (N.D., P.D., M.R.C., M.K.N., S.R.L., A.K.C.) and Stead Family Department of Pediatrics (J.M.S.), University of Iowa; and Department of Molecular Pathogenesis, National Cardiovascular Centre Research Institute, Suita, Osaka, Japan (K.K.)
| | - Anil K Chauhan
- From the Department of Internal Medicine (N.D., P.D., M.R.C., M.K.N., S.R.L., A.K.C.) and Stead Family Department of Pediatrics (J.M.S.), University of Iowa; and Department of Molecular Pathogenesis, National Cardiovascular Centre Research Institute, Suita, Osaka, Japan (K.K.).
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Abstract
Thrombotic thrombocytopenic purpura (TTP; also known as Moschcowitz disease) is characterized by the concomitant occurrence of often severe thrombocytopenia, microangiopathic haemolytic anaemia and a variable degree of ischaemic organ damage, particularly affecting the brain, heart and kidneys. Acute TTP was almost universally fatal until the introduction of plasma therapy, which improved survival from <10% to 80-90%. However, patients who survive an acute episode are at high risk of relapse and of long-term morbidity. A timely diagnosis is vital but challenging, as TTP shares symptoms and clinical presentation with numerous conditions, including, for example, haemolytic uraemic syndrome and other thrombotic microangiopathies. The underlying pathophysiology is a severe deficiency of the activity of a disintegrin and metalloproteinase with thrombospondin motifs 13 (ADAMTS13), the protease that cleaves von Willebrand factor (vWF) multimeric strings. Ultra-large vWF strings remain uncleaved after endothelial cell secretion and anchorage, bind to platelets and form microthrombi, leading to the clinical manifestations of TTP. Congenital TTP (Upshaw-Schulman syndrome) is the result of homozygous or compound heterozygous mutations in ADAMTS13, whereas acquired TTP is an autoimmune disorder caused by circulating anti-ADAMTS13 autoantibodies, which inhibit the enzyme or increase its clearance. Consequently, immunosuppressive drugs, such as corticosteroids and often rituximab, supplement plasma exchange therapy in patients with acquired TTP.
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63
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Lee SJ, Kim JE, Han KS, Kim HK. Thrombotic risk of reduced ADAMTS13 activity in patients with antiphospholipid antibodies. Blood Coagul Fibrinolysis 2017; 27:907-912. [PMID: 26757014 DOI: 10.1097/mbc.0000000000000512] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Antiphospholipid syndrome (APS) is an autoimmune disease in which antiphospholipid antibodies (aPLs) are generated. Previous studies show concurrence of APS and thrombotic thrombocytopenic purpura; therefore it is plausible to assume that anti-ADAMTS13 autoantibody is also involved in the pathophysiology of APS. We investigated the clinical significance of ADAMTS13 activity and anti-ADAMTS13 antibody in patients with aPLs. Two hundred and sixteen patients with positive lupus anticoagulant and/or anticardiolipin antibody were included. ADAMTS13 activity and anti-ADAMTS13 antibody were measured using fluorescence resonance energy-transfer technology and ELISA, respectively. Reduced ADAMTS13 activity was observed in 40.3% (87/216) of patients with aPLs. Although 33.8% (73/216) of patients were positive for anti-ADAMTS13 antibody, 41 of these 73 patients had normal levels of ADAMTS13 activity. Reduced ADAMTS13 activity was a significant risk factor for thrombotic events. Thrombotic events and age contributed to the reduced level of ADAMTS13 activity. Presence of anti-ADAMTS13 antibody did not show any association with the level of ADAMTS13 activity. Patients with autoimmune diseases tended to show higher levels of anti-ADAMTS13 antibody. Our findings suggest that reduced ADAMTS13 activity is a significant thrombotic risk factor in patients with aPLs irrespective of the presence of anti-ADAMTS13 antibody. Presence of anti-ADAMTS13 antibody is not seen with reduced activity and it tends to be increased in patients with autoimmune diseases.
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Affiliation(s)
- Seung Jun Lee
- aDepartment of Laboratory Medicine bCancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
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64
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Todorović Ž, Jovanovic M, Todorovic D, Petrovic D, Djurdjevic P. Thrombotic Thrombocytopenic Purpura: Etiopathogenesis, Diagnostics and Basic Principles of Treatment. SERBIAN JOURNAL OF EXPERIMENTAL AND CLINICAL RESEARCH 2017. [DOI: 10.1515/sjecr-2016-0026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a clinical syndrome that manifests with thrombocytopenia, microangiopathic haemolytic anaemia and symptoms and signs of kidney and brain damage, but it rarely involves other organs. The main pathophysiological cause of TTP is diminished metalloproteinase ADAMTS13 activity; the main function of ADAMTS13 is to degrade large multimers of the von Willebrand factor. Diminished activity of ADAMTS13 is caused either by a genetic mutation in the gene that codes ADAMTS13 (congenital TTP) or by antibodies that block ADAMTS13 enzyme activity or accelerate the degradation of ADAMTS13 (acquired TTP). Clinically, TTP presents most frequently with signs and symptoms of brain and kidney damage with concomitant haemorrhagic syndrome. TTP is suspected when a patient presents with a low platelet count, microangiopathic haemolytic anaemia (negative Coombs tests, low haptoglobine concentration, increased serum concentration of indirect bilirubin and lactate dehydrogenase, increased number of schysocytes in peripheral blood) and the typical clinical presentation. A definitive diagnose can be made only by measuring the ADAMTS13 activity. The differential diagnosis in such cases includes both typical and atypical haemolytic uremic syndrome, disseminated intravascular coagulation, HELLP syndrome in pregnant women and other thrombotic microangiopathies. The first line therapy for TTP is plasma exchange. In patients with acquired TTP, in addition to plasma exchange, immunosuppressive medications are used (corticosteroids and rituximab). In patients with hereditary TTP, the administration of fresh frozen plasma is sometimes required.
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Affiliation(s)
- Željko Todorović
- Faculty of Medical Sciences, University of Kragujevac, Serbia
- Radnička 24/2, 34000 Kragujevac, Serbia
| | - Milena Jovanovic
- Center of Nephrology and Dialysis, Clinic for Urology and Nephrology, Clinical Center “Кragujevac”, Serbia
| | - Dusan Todorovic
- Faculty of Medical Sciences, University of Kragujevac, Serbia
| | - Dejan Petrovic
- Center of Nephrology and Dialysis, Clinic for Urology and Nephrology, Clinical Center “Кragujevac”, Serbia
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65
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Abstract
Rituximab, a monoclonal antibody targeting the B cell marker CD20, was initially approved in 1997 by the United States Food and Drug Administration (FDA) for the treatment of non-Hodgkin lymphoma. Since that time, rituximab has been FDA-approved for rheumatoid arthritis and vasculitides, such as granulomatosis with polyangiitis and microscopic polyangiitis. Additionally, rituximab has been used off-label in the treatment of numerous other autoimmune diseases, with notable success in pemphigus, an autoantibody-mediated skin blistering disease. The efficacy of rituximab therapy in pemphigus has spurred interest in its potential to treat other autoantibody-mediated diseases. This review summarizes the efficacy of rituximab in pemphigus and examines its off-label use in other select autoantibody-mediated diseases.
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Affiliation(s)
- Nina A Ran
- Department of Dermatology, University of Pennsylvania, 1009 Biomedical Research Building, 421 Curie Boulevard, PA, USA
| | - Aimee S Payne
- Department of Dermatology, University of Pennsylvania, 1009 Biomedical Research Building, 421 Curie Boulevard, PA, USA
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66
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The class I scavenger receptor CD163 promotes internalization of ADAMTS13 by macrophages. Blood Adv 2017; 1:293-305. [PMID: 29296945 DOI: 10.1182/bloodadvances.2016001321] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Accepted: 12/19/2016] [Indexed: 01/07/2023] Open
Abstract
Internalization of ADAMTS13 by macrophages may contribute to its clearance from the circulation. Here we investigated endocytic mechanisms that contribute to the uptake of ADAMTS13 by macrophages. Human monocyte-derived macrophages were used to monitor the uptake of fluorescently labeled recombinant ADAMTS13 by flow cytometry. Internalization of ADAMTS13 was blocked upon addition of the cell-permeable dynamin inhibitor dynasore. Partial blocking of ADAMTS13 uptake was observed by using mannan; however, uptake was not affected by an antibody that blocked binding to the macrophage mannose receptor CD206, which suggests that other endocytic receptors contribute to the internalization of ADAMTS13 by macrophages. A pull-down with ADAMTS13 and subsequent mass spectrometric analysis identified the class I scavenger receptor CD163 as a candidate receptor for ADAMTS13. Blocking experiments with monoclonal anti-CD163 antibody EDHu-1 resulted in decreased ADAMTS13 internalization by macrophages. Pronounced inhibition of ADAMTS13 uptake by EDHu-1 was observed in CD163 high-expressing macrophages. In agreement with these findings, CD163-expressing Chinese hamster ovary cells were capable of rapidly internalizing ADAMTS13. Surface plasmon resonance revealed binding of ADAMTS13 to scavenger receptor cysteine-rich domains 1-9 and 1-5 of CD163. Taken together, our data identify CD163 as a major endocytic receptor for ADAMTS13 on macrophages.
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67
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Abu-Hishmeh M, Sattar A, Zarlasht F, Ramadan M, Abdel-Rahman A, Hinson S, Hwang C. Systemic Lupus Erythematosus Presenting as Refractory Thrombotic Thrombocytopenic Purpura: A Diagnostic and Management Challenge. A Case Report and Concise Review of the Literature. AMERICAN JOURNAL OF CASE REPORTS 2016; 17:782-787. [PMID: 27777394 PMCID: PMC5083062 DOI: 10.12659/ajcr.898955] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Thrombotic thrombocytopenic purpura (TTP) is one of the thrombotic microangiopathic (TMA) syndromes, caused by severely reduced activity of the vWF-cleaving protease ADAMTS13. Systemic lupus erythematosus (SLE), on the other hand, is an autoimmune disease that affects various organs in the body, including the hematopoietic system. SLE can present with TMA, and differentiating between SLE and TTP in those cases can be very challenging, particularly in patients with no prior history of SLE. Furthermore, an association between these 2 diseases has been described in the literature, with most of the TTP cases occurring after the diagnosis of SLE. In rare cases, TTP may precede the diagnosis of SLE or occur concurrently. CASE REPORT We present a case of a previously healthy 34-year-old female who presented with dizziness and flu-like symptoms and was found to have thrombocytopenia, hemolytic anemia, and schistocytes in the peripheral smear. She was subsequently diagnosed with TTP and started on plasmapheresis and high-dose steroids, but without a sustained response. A diagnosis of refractory TTP was made, and she was transferred to our facility for further management. Initially, the patient was started on rituximab, but her condition continued to deteriorate, with worsening thrombocytopenia. Later, she also fulfilled the Systemic Lupus International Collaborating Clinics (SLICC) criteria for diagnosis of SLE. Treatment of TTP in SLE patients is generally similar to that in the general population, but in refractory cases there are few reports in the literature that show the efficacy of cyclophosphamide. We started our patient on cyclophosphamide and noticed a sustained improvement in the platelet count in the following weeks. CONCLUSIONS Thrombotic thrombocytopenic purpura is a life-threatening hematological emergency which must be diagnosed and treated in a timely manner. Refractory cases of TTP have been described in the literature, but without clear evidence-based guidelines for its management, and is solely based on expert opinion and previous case reports. Further studies are needed to establish guidelines for its management. We present this case to highlight the role that cyclophosphamide might carry in those cases and to be a foundation for these future studies.
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Affiliation(s)
- Mohammad Abu-Hishmeh
- Department of Internal Medicine, Lincoln Medical and Mental Health Center, Bronx, NY, USA
| | - Alamgir Sattar
- Department of Internal Medicine, Lincoln Medical and Mental Health Center, Bronx, NY, USA
| | - Fnu Zarlasht
- Department of Internal Medicine, Lincoln Medical and Mental Health Center, Bronx, NY, USA
| | - Mohamed Ramadan
- Department of Internal Medicine, Lincoln Medical and Mental Health Center, Bronx, NY, USA
| | - Aisha Abdel-Rahman
- Department of Internal Medicine, Lincoln Medical and Mental Health Center, Bronx, NY, USA
| | - Shante Hinson
- Internal Medicine, Lincoln Medical and Mental Health Center, Bronx, USA
| | - Caroline Hwang
- Department of Internal Medicine, Lincoln Medical and Mental Health Center, Bronx, NY, USA
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68
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Go RS, Winters JL, Leung N, Murray DL, Willrich MA, Abraham RS, Amer H, Hogan WJ, Marshall AL, Sethi S, Tran CL, Chen D, Pruthi RK, Ashrani AA, Fervenza FC, Cramer CH, Rodriguez V, Wolanskyj AP, Thomé SD, Hook CC. Thrombotic Microangiopathy Care Pathway: A Consensus Statement for the Mayo Clinic Complement Alternative Pathway-Thrombotic Microangiopathy (CAP-TMA) Disease-Oriented Group. Mayo Clin Proc 2016; 91:1189-211. [PMID: 27497856 DOI: 10.1016/j.mayocp.2016.05.015] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Revised: 04/12/2016] [Accepted: 05/27/2016] [Indexed: 12/15/2022]
Abstract
Thrombotic microangiopathies (TMAs) comprise a heterogeneous set of conditions linked by a common histopathologic finding of endothelial damage resulting in microvascular thromboses and potentially serious complications. The typical clinical presentation is microangiopathic hemolytic anemia accompanied by thrombocytopenia with varying degrees of organ ischemia. The differential diagnoses are generally broad, while the workup is frequently complex and can be confusing. This statement represents the joint recommendations from a multidisciplinary team of Mayo Clinic physicians specializing in the management of TMA. It comprises a series of evidence- and consensus-based clinical pathways developed to allow a uniform approach to the spectrum of care including when to suspect TMA, what differential diagnoses to consider, which diagnostic tests to order, and how to provide initial empiric therapy, as well as some guidance on subsequent management.
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Affiliation(s)
- Ronald S Go
- Division of Hematology, Mayo Clinic, Rochester, MN.
| | - Jeffrey L Winters
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Nelson Leung
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | - David L Murray
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Maria A Willrich
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Roshini S Abraham
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Hatem Amer
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | | | | | - Sanjeev Sethi
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Cheryl L Tran
- Division of Pediatric Nephrology, Mayo Clinic, Rochester, MN
| | - Dong Chen
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | | | | | | | - Carl H Cramer
- Division of Pediatric Nephrology, Mayo Clinic, Rochester, MN
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69
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Identification of glycans on plasma-derived ADAMTS13. Blood 2016; 128:e51-e58. [PMID: 27574189 DOI: 10.1182/blood-2016-06-720912] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Accepted: 08/11/2016] [Indexed: 12/16/2022] Open
Abstract
Patients suffering from acquired thrombotic thrombocytopenic purpura develop autoantibodies directed toward the plasma glycoprotein ADAMTS13. Here, we studied the glycan composition of plasma-derived ADAMTS13. Purified ADAMTS13 was reduced, alkylated, and processed into peptides with either trypsin or chymotrypsin. Glycopeptides were enriched using zwitterionic HILIC zip-tips and analyzed by tandem mass spectrometry employing higher-energy collision dissociation fragmentation. Upon detection of a diagnostic ion of a glycan fragment, electron transfer dissociation fragmentation was performed on the same precursor ion. The majority of N-linked glycans were of the complex type containing terminal sialic acids and fucose residues. A high mannose-containing glycan was attached to Asn614 in the spacer domain. Six O-linked glycans mostly terminating in sialic acid were found dispersed over ADAMTS13. Five O-linked glycans were attached to a Ser and one to Thr. All 6 O-linked glycans contained a terminal sialic acid. O-fucosylation is a common posttranslational modification of thrombospondin type 1 repeats. We identified 7 O-fucosylation sites in the thrombospondin (TSP) type 1 repeats. Unexpectedly, one additional O-fucosylation site was found in the disintegrin domain. This O-fucosylation site did not meet the proposed consensus sequence CSX(S/T)CG. C-mannosylation sites were identified in TSP1, linker TSP4-TSP5, and TSP8. Overall, our findings highlight the complexity of glycan modifications on ADAMTS13, which may have implications for its interaction with immune- or clearance receptors containing carbohydrate recognition domains.
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70
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Nakashima MO, Zhang X, Rogers HJ, Vengal L, Gibson B, Daly TM, Kottke-Marchant K. Validation of a panel of ADAMTS13 assays for diagnosis of thrombotic thrombocytopenic purpura: activity, functional inhibitor, and autoantibody test. Int J Lab Hematol 2016; 38:550-9. [DOI: 10.1111/ijlh.12542] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Accepted: 05/09/2016] [Indexed: 11/28/2022]
Affiliation(s)
- M. O. Nakashima
- Robert J. Tomsich Pathology and Laboratory Medicine Institute; Cleveland Clinic; Cleveland OH USA
| | - X. Zhang
- Robert J. Tomsich Pathology and Laboratory Medicine Institute; Cleveland Clinic; Cleveland OH USA
| | - H. J. Rogers
- Robert J. Tomsich Pathology and Laboratory Medicine Institute; Cleveland Clinic; Cleveland OH USA
| | - L. Vengal
- Robert J. Tomsich Pathology and Laboratory Medicine Institute; Cleveland Clinic; Cleveland OH USA
| | - B. Gibson
- Robert J. Tomsich Pathology and Laboratory Medicine Institute; Cleveland Clinic; Cleveland OH USA
| | - T. M. Daly
- Robert J. Tomsich Pathology and Laboratory Medicine Institute; Cleveland Clinic; Cleveland OH USA
| | - K. Kottke-Marchant
- Robert J. Tomsich Pathology and Laboratory Medicine Institute; Cleveland Clinic; Cleveland OH USA
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71
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Okubo M, Shoda H, Bannai E, Kubo K, Kanda H, Fujio K, Yamamoto K. Systemic lupus erythematosus with ADAMTS13 inhibitor-negative thrombotic microangiopathy treated with combination of mycophenolate mofetil, plasma exchange and steroid. Lupus 2016; 26:334-336. [PMID: 27416846 DOI: 10.1177/0961203316659547] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- M Okubo
- Department of Allergy and Rheumatology, Graduate School of Medicine, the University of Tokyo, Tokyo, Japan
| | - H Shoda
- Department of Allergy and Rheumatology, Graduate School of Medicine, the University of Tokyo, Tokyo, Japan
| | - E Bannai
- Department of Allergy and Rheumatology, Graduate School of Medicine, the University of Tokyo, Tokyo, Japan
| | - K Kubo
- Department of Allergy and Rheumatology, Graduate School of Medicine, the University of Tokyo, Tokyo, Japan
| | - H Kanda
- Department of Allergy and Rheumatology, Graduate School of Medicine, the University of Tokyo, Tokyo, Japan
| | - K Fujio
- Department of Allergy and Rheumatology, Graduate School of Medicine, the University of Tokyo, Tokyo, Japan
| | - K Yamamoto
- Department of Allergy and Rheumatology, Graduate School of Medicine, the University of Tokyo, Tokyo, Japan
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72
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Ostertag EM, Kacir S, Thiboutot M, Gulendran G, Zheng XL, Cines DB, Siegel DL. ADAMTS13 autoantibodies cloned from patients with acquired thrombotic thrombocytopenic purpura: 1. Structural and functional characterization in vitro. Transfusion 2016; 56:1763-74. [PMID: 27040144 PMCID: PMC4938786 DOI: 10.1111/trf.13584] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Revised: 01/25/2016] [Accepted: 02/06/2016] [Indexed: 12/15/2022]
Abstract
BACKGROUND Acquired thrombotic thrombocytopenia purpura (TTP) is a life-threatening illness caused by autoantibodies that decrease the activity of ADAMTS13, the von Willebrand factor-cleaving protease. Despite efficacy of plasma exchange, mortality remains high and relapse is common. Improved therapies may come from understanding the diversity of pathogenic autoantibodies on a molecular or genetic level. Cloning comprehensive repertoires of patient autoantibodies can provide the necessary tools for studying immunobiology of disease and developing animal models. STUDY DESIGN AND METHODS Anti-ADAMTS13 antibodies were cloned from four patients with acquired TTP using phage display and characterized with respect to genetic origin, inhibition of ADAMTS13 proteolytic activity, and epitope specificity. Anti-idiotypic antisera raised to a subset of autoantibodies enabled comparison of their relatedness to each other and to polyclonal immunoglobulin (Ig)G in patient plasma. RESULTS Fifty-one unique antibodies were isolated comprising epitope specificities resembling the diversity found in circulating patient IgG. Antibodies directed both to the amino terminal domains and to those requiring the ADAMTS13 cysteine-rich/spacer region for binding inhibited proteolytic activity, while those solely targeting carboxy-terminal domains were noninhibitory. Anti-idiotypic antisera raised to a subset of antibody clones crossreacted with and reduced the inhibitory activity of polyclonal IgG from a set of unrelated patients. CONCLUSIONS Anti-ADAMTS13 autoantibodies isolated by repertoire cloning display the diversity of epitope specificities found in patient plasma and provide tools for developing animal models of acquired TTP. Shared idiotypes of inhibitory clones with circulating IgG from multiple patients suggest common features of pathogenic autoantibodies that could be exploited for developing more targeted therapies.
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Affiliation(s)
- Eric M. Ostertag
- Departments of Pathology & Laboratory Medicine, Perelman School of Medicine at the University of Pennsylvania
| | - Stephen Kacir
- Departments of Pathology & Laboratory Medicine, Perelman School of Medicine at the University of Pennsylvania
| | - Michelle Thiboutot
- Departments of Pathology & Laboratory Medicine, Perelman School of Medicine at the University of Pennsylvania
| | - Gayathri Gulendran
- Departments of Pathology & Laboratory Medicine, Perelman School of Medicine at the University of Pennsylvania
| | - X. Long Zheng
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Douglas B. Cines
- Departments of Pathology & Laboratory Medicine, Perelman School of Medicine at the University of Pennsylvania
| | - Don L. Siegel
- Departments of Pathology & Laboratory Medicine, Perelman School of Medicine at the University of Pennsylvania
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Bardón Cancho E, Butragueño Laiseca L, Álvarez Blanco O, Alcaraz Romero A, Martínez López A. Typical haemolytic uraemic syndrome: Report of the first case due to Escherichia coli O26:H11 in Spain. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2016. [DOI: 10.1016/j.anpede.2015.09.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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74
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Bardón Cancho E, Butragueño Laiseca L, Álvarez Blanco O, Alcaraz Romero A, Martínez López A. Síndrome hemolítico urémico típico: comunicación del primer caso producido por Escherichia coli O26:H11 en España. An Pediatr (Barc) 2016; 84:171-2. [DOI: 10.1016/j.anpedi.2015.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Revised: 07/17/2015] [Accepted: 09/02/2015] [Indexed: 11/25/2022] Open
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Plaimauer B, Schiviz A, Kaufmann S, Höllriegl W, Rottensteiner H, Scheiflinger F. Neutralization of inhibitory antibodies and restoration of therapeutic ADAMTS-13 activity levels in inhibitor-treated rats by the use of defined doses of recombinant ADAMTS-13. J Thromb Haemost 2015; 13:2053-62. [PMID: 26340698 DOI: 10.1111/jth.13137] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Accepted: 08/27/2015] [Indexed: 11/27/2022]
Abstract
BACKGROUND Acquired thrombotic thrombocytopenic purpura (TTP) is caused by an autoantibody-mediated deficiency of the von Willebrand factor-cleaving protease ADAMTS-13. Acute episodes of the disease are treated with a combination of immunosuppression and repeated cycles of plasma exchange to remove anti-ADAMTS-13 autoantibodies and, at the same time, replenish functional ADAMTS-13. Although this is often effective, the mortality rate has remained between 10% and 20%, highlighting the need for safer treatment options. OBJECTIVES We previously showed that, in vitro, human recombinant ADAMTS-13 (rADAMTS-13) is able to override neutralizing antibodies and restore ADAMTS-13 activity in plasma from patients with acquired TTP. In the present study, we assessed the in vivo feasibility of this strategy by using a rat model. METHODS Wild-type rats were adjusted to an ADAMTS-13 inhibitor (inhibitor) titer of ~ 10 BU mL(-1) with goat anti-ADAMTS-13 IgG, and treated with increasing doses of rADAMTS-13. Blood samples were drawn and analyzed for ADAMTS-13-specific parameters, including FRETS-VWF73 activity, inhibitor, and ADAMTS-13-specific immune complexes (ICs). The pharmacokinetics of ADAMTS-13 activity and inhibitors were evaluated. RESULTS Administration of inhibitor titer-adjusted doses of rADAMTS-13 to inhibitor-treated rats predictably restored activity. Inhibitors were readily neutralized through formation of ADAMTS-13-specific ICs, which were cleared at a higher rate than the free inhibitor. Surplus protease was enzymatically active in plasma, and showed similar pharmacokinetics to ADAMTS-13 in not inhibitor-treated rats. CONCLUSIONS Defined doses of rADAMTS-13 neutralized circulating anti-ADAMTS-13 antibodies and enabled reconstitution of ADAMTS-13 activity in plasma in our model, indicating that the protease may be a promising candidate for further exploration in treating acute episodes of acquired TTP.
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Affiliation(s)
- B Plaimauer
- Baxalta Innovations GmbH, DC-Tower Vienna, Vienna, Austria
| | - A Schiviz
- Baxalta Innovations GmbH, DC-Tower Vienna, Vienna, Austria
| | - S Kaufmann
- Baxalta Innovations GmbH, DC-Tower Vienna, Vienna, Austria
| | - W Höllriegl
- Baxalta Innovations GmbH, DC-Tower Vienna, Vienna, Austria
| | | | - F Scheiflinger
- Baxalta Innovations GmbH, DC-Tower Vienna, Vienna, Austria
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77
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Froissart A, Veyradier A, Hié M, Benhamou Y, Coppo P. Rituximab in autoimmune thrombotic thrombocytopenic purpura: A success story. Eur J Intern Med 2015; 26:659-65. [PMID: 26293834 DOI: 10.1016/j.ejim.2015.07.021] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Revised: 07/30/2015] [Accepted: 07/31/2015] [Indexed: 11/20/2022]
Abstract
Despite a significant improvement of thrombotic thrombocytopenic purpura (TTP) prognosis since the use of plasma exchange, morbidity and mortality remained significant because of poor response to standard treatment or exacerbations and relapses. Rituximab, a chimeric monoclonal antibody directed against the B-lymphocyte CD20 antigen, has shown a particular interest in this indication. Recent studies also reported strong evidence for its efficiency in the prevention of relapses. This review addresses these recent progresses and still opened questions in this topic: should rituximab be proposed in all patients at the acute phase? Should all patients benefit from a preemptive treatment? Is the infectious risk acceptable in this context?
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Affiliation(s)
- Antoine Froissart
- Service de médecine interne, CHI, Créteil, France; Centre de Référence des Microangiopathies Thrombotiques, AP-HP, Paris, France
| | - Agnès Veyradier
- Centre de Référence des Microangiopathies Thrombotiques, AP-HP, Paris, France; Service d'hématologie biologique, Hôpital Lariboisière, Paris, France; Université Paris Diderot, Sorbonne Paris Cité, Paris, France
| | - Miguel Hié
- Service de Médecine Interne, Hôpital la Pitié-Salpétrière, Paris, France
| | - Ygal Benhamou
- Centre de Référence des Microangiopathies Thrombotiques, AP-HP, Paris, France; Service de médecine interne, CHU Charles Nicolle, Rouen, France
| | - Paul Coppo
- Centre de Référence des Microangiopathies Thrombotiques, AP-HP, Paris, France; Service d'hématologie, Hôpital Saint Antoine, Paris, France; Inserm U1009, Institut Gustave Roussy, Villejuif, France.
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78
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Mannucci P, Cugno M. The complex differential diagnosis between thrombotic thrombocytopenic purpura and the atypical hemolytic uremic syndrome: Laboratory weapons and their impact on treatment choice and monitoring. Thromb Res 2015; 136:851-4. [DOI: 10.1016/j.thromres.2015.09.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Revised: 09/02/2015] [Accepted: 09/06/2015] [Indexed: 10/23/2022]
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79
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Rodríguez-Pintó I, Espinosa G, Cervera R. Catastrophic APS in the context of other thrombotic microangiopathies. Curr Rheumatol Rep 2015; 17:482. [PMID: 25604575 DOI: 10.1007/s11926-014-0482-z] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The catastrophic antiphospholipid syndrome (CAPS) is a rare disease that affects 1 % of cases with antiphospholipid syndrome (APS). CAPS can mimic or overlap with different thrombotic diseases; many patients present with a microthrombotic storm or thrombotic microangiopathic hemolytic anemia (TMHA). Thus, the differential diagnosis of CAPS includes thrombotic thrombocytopenic purpura (TTP), typical and atypical hemolytic uremic syndrome (HUS), systemic infections, malignancies, pregnancy-related disorders, malignant hypertension, heparin-induced thrombocytopenia, and drug-induced thrombotic microangiopathies. Antiphospholipid antibody (aPL) positivity has been proposed as the clue in this differential diagnosis; however, aPL can also occur in healthy people and in those with infections or malignancies. Thus, the differential diagnosis of an aPL-positive patient presenting with a microthrombotic storm is broad; the workup should include a special attention to signs of infection and disseminated malignant disease, assessing the funduscopic signs of malignant hypertension, testing ADAMTS13 activity and anti-heparin-platelet factor 4 (HPF4) antibodies, and searching previous exposure to certain drugs. This article aims to review the main diseases included in the differential diagnosis of CAPS in the context of other thrombotic microangiopathies.
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Affiliation(s)
- Ignasi Rodríguez-Pintó
- Department of Autoimmune Diseases, Institut Clínic de Medicina i Dermatologia, Hospital Clínic, Barcelona, Catalonia, Spain
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80
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Erpenbeck L, Demers M, Zsengellér ZK, Gallant M, Cifuni SM, Stillman IE, Karumanchi SA, Wagner DD. ADAMTS13 Endopeptidase Protects against Vascular Endothelial Growth Factor Inhibitor-Induced Thrombotic Microangiopathy. J Am Soc Nephrol 2015; 27:120-31. [PMID: 26038528 DOI: 10.1681/asn.2014121165] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Accepted: 03/20/2015] [Indexed: 12/14/2022] Open
Abstract
Thrombotic microangiopathy (TMA) is a life-threatening condition that affects some, but not all, recipients of vascular endothelial growth factor (VEGF) inhibitors given as part of chemotherapy. TMA is also a complication of preeclampsia, a disease characterized by excess production of the VEGF-scavenging soluble VEGF receptor 1 (soluble fms-like tyrosine kinase 1; sFlt-1). Risk factors for VEGF inhibitor-related TMA remain unknown. We hypothesized that deficiency of the VWF-cleaving ADAMTS13 endopeptidase contributes to the development of VEGF inhibitor-related TMA. ADAMTS13(-/-) mice overexpressing sFlt-1 presented all hallmarks of TMA, including thrombocytopenia, schistocytosis, anemia, and VWF-positive microthrombi in multiple organs. Similar to VEGF inhibitor-related TMA in humans, these mice exhibited severely impaired kidney function and hypertension. In contrast, wild-type mice overexpressing sFlt-1 developed modest hypertension but no other features of TMA. Recombinant ADAMTS13 therapy ameliorated all symptoms of TMA in ADAMTS13(-/-) mice overexpressing sFlt-1 and normalized BP in wild-type mice. ADAMTS13 activity may thus be a critical determinant for the development of TMA secondary to VEGF inhibition. Administration of recombinant ADAMTS13 may serve as a therapeutic approach to treat or prevent thrombotic complications of VEGF inhibition.
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Affiliation(s)
- Luise Erpenbeck
- Program in Cellular and Molecular Medicine, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Melanie Demers
- Program in Cellular and Molecular Medicine, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Zsuzsanna K Zsengellér
- Departments of Medicine, Obstetrics and Gynecology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Maureen Gallant
- Program in Cellular and Molecular Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Stephen M Cifuni
- Program in Cellular and Molecular Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Isaac E Stillman
- Department of Pathology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts; and
| | - S Ananth Karumanchi
- Departments of Medicine, Obstetrics and Gynecology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Denisa D Wagner
- Program in Cellular and Molecular Medicine, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts; Division of Hematology/Oncology, Boston Children's Hospital, Boston, Massachusetts
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81
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Martin-Rodriguez S, Reverter JC, Tàssies D, Espinosa G, Heras M, Pino M, Escolar G, Diaz-Ricart M. Reduced ADAMTS13 activity is associated with thrombotic risk in systemic lupus erythematosus. Lupus 2015; 24:1143-9. [PMID: 25824235 DOI: 10.1177/0961203315579091] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2014] [Accepted: 03/03/2015] [Indexed: 11/17/2022]
Abstract
BACKGROUND Severe deficiency of ADAMTS13 activity leads to von Willebrand factor (VWF) ultralarge multimers with high affinity for platelets, causing thrombotic thrombocytopenic purpura. Other pathological conditions with moderate ADAMTS13 activity exhibit a thrombotic risk. We examined the ADAMTS13 activity in systemic lupus erythematosus (SLE) and its value as a thrombotic biomarker. METHODS ADAMTS13 activity, VWF antigen and multimeric structure, and vascular cell adhesion molecule 1 (VCAM-1) were measured in plasma samples from 50 SLE patients and 50 healthy donors. Disease activity (systemic lupus erythematosus disease activity index; SLEDAI) and organ damage (systemic lupus international collaborating clinics) scores, thrombotic events, antiphospholipid syndrome (APS) and antiphospholipid antibodies (aPLs) were registered. RESULTS SLE patients showed decreased ADAMTS13 activity and high VWF levels compared with controls (66 ± 27% vs. 101 ± 8%, P < 0.01, and 325 ± 151% vs. 81 ± 14%, P < 0.001). VCAM-1 levels were higher in SLE patients (P < 0.05). Considering three groups of SLE patients depending on ADAMTS13 activity (>60%, 60-40% and <40%), comparative analysis showed significant association between ADAMTS13 activity and SLEDAI (P < 0.05), presence of aPLs (P < 0.001), APS (P < 0.01) and thrombotic events (P < 0.01). Reduced ADAMTS13 activity together with increased VWF levels were especially notable in patients with active disease and with aPLs. CONCLUSION ADAMTS13 activity, in combination with other laboratory parameters, could constitute a potential prognostic biomarker of thrombotic risk in SLE.
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Affiliation(s)
| | | | | | | | - M Heras
- Cardiology Department. Institut Clinic del Torax. Institut d Investigacions Biomèdiques August Pi i Sunyer, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - M Pino
- Hemotherapy-Hemostasis Department
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82
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Mannucci PM. Understanding organ dysfunction in thrombotic thrombocytopenic purpura. Intensive Care Med 2015; 41:715-8. [PMID: 25600190 DOI: 10.1007/s00134-014-3630-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Accepted: 12/20/2014] [Indexed: 11/26/2022]
Affiliation(s)
- Pier Mannuccio Mannucci
- Scientific Direction, IRCCS Ca' Granda Maggiore Policlinico Hospital Foundation, Via Pace 9, 20122, Milan, Italy,
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83
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Sadler JE. What's new in the diagnosis and pathophysiology of thrombotic thrombocytopenic purpura. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2015; 2015:631-6. [PMID: 26637781 PMCID: PMC4777280 DOI: 10.1182/asheducation-2015.1.631] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
Severe ADAMTS13 (a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13) deficiency causes thrombotic thrombocytopenic purpura (TTP), which is characterized by microangiopathic hemolytic anemia, thrombocytopenia, and the absence of oliguric or anuric renal failure. However, some patients with this constellation of findings do not have ADAMTS13 deficiency, and some patients with ADAMTS13 deficiency have renal failure or relatively normal blood counts. Consequently, many investigators and clinicians have incorporated severe ADAMTS13 deficiency into the case definition of TTP. This change has facilitated the timely initiation of treatment for patients with atypical clinical features who otherwise would not be recognized as having TTP. Conversely, excluding severe ADAMTS13 deficiency focuses attention on the diagnosis and treatment of other causes of thrombotic microangiopathy that require different treatment. The rapid return of ADAMTS13 data is important to make the best use of this information.
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Affiliation(s)
- J. Evan Sadler
- Department of Medicine and Biochemistry, Washington University School of Medicine, St. Louis, MO
- Department of Molecular Biophysics, Washington University School of Medicine, St. Louis, MO
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84
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Pérez-Rodríguez A, Lourés E, Rodríguez-Trillo Á, Costa-Pinto J, García-Rivero A, Batlle-López A, Batlle J, López-Fernández MF. Inherited ADAMTS13 deficiency (Upshaw-Schulman syndrome): A short review. Thromb Res 2014; 134:1171-5. [DOI: 10.1016/j.thromres.2014.09.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Revised: 08/29/2014] [Accepted: 09/02/2014] [Indexed: 12/16/2022]
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85
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[Diagnostic and therapeutic guidelines of thrombotic microangiopathies of the Spanish Apheresis Group]. Med Clin (Barc) 2014; 144:331.e1-331.e13. [PMID: 25433791 DOI: 10.1016/j.medcli.2014.09.013] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2014] [Accepted: 09/18/2014] [Indexed: 12/18/2022]
Abstract
Thrombotic microangiopathies (TMA) are disorders defined by the presence of a microangiopathic hemolytic anemia (with the characteristic hallmark of schistocytes in the peripheral blood smear), thrombocytopenia and organ malfunction of variable intensity. Thrombotic thrombocytopenic purpura and hemolytic uremic syndrome are the most important forms of TMA and, without the adequate treatment, they are associated with high morbimortality. In recent years, significant advances in the knowledge of the pathophysiology of TMA have occurred. Those advances have allowed us to move from a syndromic diagnosis with a similar treatment to all entities to the search of etiologic diagnosis which would lead to a specific treatment, finally leading to a better outcome of the patient. This document pretends to summarize the current status of knowledge of the pathophysiology of TMA and the therapeutic options available, and to offer a diagnostic and therapeutic practical tool to the professionals caring for the patients.
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86
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Acquired TTP: ADAMTS13 meets the immune system. Blood Rev 2014; 28:227-34. [DOI: 10.1016/j.blre.2014.07.004] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Accepted: 07/14/2014] [Indexed: 02/06/2023]
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87
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Evaluation of a chromogenic commercial assay using VWF-73 peptide for ADAMTS13 activity measurement. Thromb Res 2014; 134:1074-80. [DOI: 10.1016/j.thromres.2014.09.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2014] [Revised: 08/14/2014] [Accepted: 09/04/2014] [Indexed: 11/23/2022]
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88
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Grillberger R, Gruber B, Skalicky S, Schrenk G, Knöbl P, Plaimauer B, Turecek PL, Scheiflinger F, Rottensteiner H. A novel flow-based assay reveals discrepancies in ADAMTS-13 inhibitor assessment as compared with a conventional clinical static assay. J Thromb Haemost 2014; 12:1523-32. [PMID: 25040659 DOI: 10.1111/jth.12653] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Accepted: 07/03/2014] [Indexed: 01/18/2023]
Abstract
BACKGROUND Several static Bethesda-type assays are routinely used to determine ADAMTS-13-neutralizing autoantibodies in acquired thrombotic thrombocytopenic purpura (TTP), but the inhibitory activity of these antibodies has not been thoroughly evaluated under the more physiologic condition of flow. OBJECTIVES We investigated whether ADAMTS-13 inhibitor assessment with the FRETS-VWF73 assay is predictive for evaluation under flow. METHODS Anti-ADAMTS-13 autoantibodies were purified from patients with acquired TTP by chromatography involving an ADAMTS-13 affinity matrix and/or protein G. ADAMTS-13 activity was measured with the FRETS-VWF73 assay and a novel flow assay determining the ADAMTS-13-mediated decrease in platelet aggregate surface coverage, caused by perfusion of a suspension containing platelets, erythrocytes and von Willebrand factor (VWF) over a surface coated with extracellular matrix components. The neutralizing activities of ADAMTS-13 inhibitors were compared under static conditions and under flow by use of the two assays. RESULTS The suitability of the flow-based ADAMTS-13 activity assay for quantification of ADAMTS-13 inhibitors could be demonstrated by reversibility of the ADAMTS-13-dependent decrease in surface coverage upon addition of goat ADAMTS-13 antiserum. Testing the neutralizing activity of purified autoantibodies from six patients in the flow assay according to their FRETS-VWF73-based inhibitor titers gave rise to vastly different inhibitory effects, indicating a discrepancy in inhibitor assessment between static and flow conditions. CONCLUSIONS Anti-ADAMTS-13 autoantibodies may show inhibitory properties in vivo that are not consistent with the ADAMTS-13 inhibitor levels determined in routine static assays, possibly because certain epitopes are selectively exposed under shear. Consequently, the course of disease and treatment efficacy may vary among TTP patients, despite common inhibitor titers.
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89
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Pandey S, Nakagawa M, Rosenbaum ER, Arnaoutakis K, Hutchins LF, Makhoul I, Milojkovic N, Cottler-Fox M. Rituximab and intermediate-purity plasma-derived factor VIII concentrate (Koate®) as adjuncts to therapeutic plasma exchange for thrombotic thrombocytopenic purpura in patients with an ADAMTS13 inhibitor. J Clin Apher 2014; 30:50-4. [DOI: 10.1002/jca.21348] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Revised: 06/29/2014] [Accepted: 07/01/2014] [Indexed: 11/06/2022]
Affiliation(s)
- Soumya Pandey
- Department of Pathology; University of Arkansas for Medical Sciences; Little Rock Arkansas
| | - Mayumi Nakagawa
- Department of Pathology; University of Arkansas for Medical Sciences; Little Rock Arkansas
| | - Eric R. Rosenbaum
- Department of Pathology; University of Arkansas for Medical Sciences; Little Rock Arkansas
| | - Konstantinos Arnaoutakis
- Department of Medicine (Division of Hematology/Oncology); University of Arkansas for Medical Sciences; Little Rock Arkansas
| | - Laura F. Hutchins
- Department of Medicine (Division of Hematology/Oncology); University of Arkansas for Medical Sciences; Little Rock Arkansas
| | - Issam Makhoul
- Department of Medicine (Division of Hematology/Oncology); University of Arkansas for Medical Sciences; Little Rock Arkansas
| | - Natasha Milojkovic
- Department of Medicine (Division of Hematology/Oncology); University of Arkansas for Medical Sciences; Little Rock Arkansas
| | - Michele Cottler-Fox
- Department of Pathology; University of Arkansas for Medical Sciences; Little Rock Arkansas
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Matsumoto M. [Recent progress of diagnosis and treatment for immune-mediated hematological diseases. Topics: III. Diagnosis and treatment; 4. Thrombotic thrombocytopenic purpura]. NIHON NAIKA GAKKAI ZASSHI. THE JOURNAL OF THE JAPANESE SOCIETY OF INTERNAL MEDICINE 2014; 103:1613-1621. [PMID: 25154256 DOI: 10.2169/naika.103.1613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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91
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Uğur Bilgin A, Karaselek MA, Çamlı K. Successful management of thrombotic thrombocytopenic purpura associated with pregnancy. Transfus Apher Sci 2014; 50:433-7. [DOI: 10.1016/j.transci.2014.02.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2013] [Revised: 02/20/2014] [Accepted: 02/24/2014] [Indexed: 11/27/2022]
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92
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Fatal refractory thrombotic thrombocytopenic purpura complicating systemic lupus erythematosus. J Clin Rheumatol 2014; 19:412-4. [PMID: 24048105 DOI: 10.1097/rhu.0b013e3182a703bf] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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93
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Refractory Thrombotic Thrombocytopenic Purpura Associated With Primary Sjogren Syndrome Treated With Rituximab. Am J Ther 2014; 21:e56-60. [DOI: 10.1097/mjt.0b013e3182459aa0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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94
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Lombardi AM, Fabris R, Berti de Marinis G, Marson P, Navaglia F, Plebani M, Vettor R, Fabris F. Defective ADAMTS13 synthesis as a possible consequence of NASH in an obese patient with recurrent thrombotic thrombocytopenic purpura. Eur J Haematol 2014; 92:497-501. [DOI: 10.1111/ejh.12273] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2014] [Indexed: 02/03/2023]
Affiliation(s)
- Anna Maria Lombardi
- Internal Medicine; Department of Medicine; University of Padova; Padova Italy
| | - Roberto Fabris
- Metabolic Diseases and Cardiovascular Risk - Bariatric Unit; Internal Medicine; Department of Medicine; University of Padova; Padova Italy
| | | | - Piero Marson
- Blood Transfusion Unit; Department of Medicine; University of Padova; Padova Italy
| | - Filippo Navaglia
- Laboratory Medicine; Department of Medicine; University of Padova; Padova Italy
| | - Mario Plebani
- Laboratory Medicine; Department of Medicine; University of Padova; Padova Italy
| | - Roberto Vettor
- Metabolic Diseases and Cardiovascular Risk - Bariatric Unit; Internal Medicine; Department of Medicine; University of Padova; Padova Italy
| | - Fabrizio Fabris
- Internal Medicine; Department of Medicine; University of Padova; Padova Italy
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Grillberger R, Casina VC, Turecek PL, Zheng XL, Rottensteiner H, Scheiflinger F. Anti-ADAMTS13 IgG autoantibodies present in healthy individuals share linear epitopes with those in patients with thrombotic thrombocytopenic purpura. Haematologica 2014; 99:e58-60. [PMID: 24532042 DOI: 10.3324/haematol.2013.100685] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
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96
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ABO blood group polymorphisms and risk for ischemic stroke and peripheral arterial disease. Mol Biol Rep 2014; 41:1771-7. [PMID: 24449362 DOI: 10.1007/s11033-014-3026-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2012] [Accepted: 01/03/2014] [Indexed: 10/25/2022]
Abstract
Recent studies have demonstrated association between ABO blood system and thrombosis, indicating that individuals belonging to non-O blood groups (A, B or AB) present an increased risk of venous thrombosis, heart disease, and ischemic stroke (IS) as compared to O blood group carriers. In this study, we investigated the frequency of ABO blood group polymorphisms and its association with IS and peripheral arterial disease. Significant differences were observed for O1 (OR 0.57, 95% CI 0.35-0.95, p < 0.05) and O2 (OR 3.47, 95% CI 1.15-10.28, p < 0.05) alleles among IS patients while significant differences were observed for B phenotype (26.3 vs 9.5%, OR 3.42, 95% CI 1.32-8.76, p = 0.01, patients vs controls, respectively) and alleles A1 (OR 0.31, 95% CI 0.11-0.84, p < 0.05), O2 (OR 4.61, 95% CI 1.59-13.23, p < 0.01) and B (OR 3.42, 95% CI 1.62-7.13, p < 0.001) alleles for PAD patients. O1 allele was an independent variable (OR 0.27, 95% CI 0.12-0.57, p < 0.001) for IS patients. These data suggest the relationship of non-O blood groups in pathogenesis of thrombosis events and a possible protective effect of O blood group.
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97
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Klonizakis P, Tselios K, Sarantopoulos A, Gougourellas I, Rouka E, Onufriadou Z, Kapali P, Kyriakou D, Boura P. ADAMTS-13 metalloprotease abnormalities in systemic lupus erythematosus: is there a correlation with disease status? Lupus 2014; 22:443-52. [PMID: 23554033 DOI: 10.1177/0961203313477898] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
To clarify the role of ADAMTS-13 in the pathogenesis of thrombotic microangiopathy in systemic lupus erythematosus (SLE) we evaluated ADAMTS-13 profile (metalloprotease antigen levels, anti-ADAMTS-13 autoantibody levels, activity) in distinct patient groups according to disease activity, extent of cumulative tissue damage and history of antiphospholipid syndrome or end-organ damage. Forty-one lupus patients were analysed. ADAMTS-13 metalloprotease antigen levels and anti-ADAMTS-13 autoantibodies were evaluated by ELISA. ADAMTS-13 activity was measured by Fluorescence resonance energy transfer (FRET) technique. ADAMTS-13 metalloprotease antigen levels were significantly decreased in patients with Systemic Lupus International Collaborative Clinics/American College of Rheumatology (SLICC/ACR) >1 (p<0.05). ADAMTS-13 metalloprotease antigen levels also exhibited a significant inverse correlation with anti-dsDNA levels (r= -0.60, p<0.05). Anti-ADAMTS-13 autoantibodies were marginally higher in patients with positive anti-dsDNA (p=0.08). Additionally, patients with positive anti-ADAMTS-13 autoantibodies exhibited the lowest activity levels (p<0.05). To our knowledge ADAMTS-13 profile in SLE has not been studied in regard to composite structured indices. The results of this study suggest that in patients with active SLE or considerable cumulative tissue damage, ADAMTS-13 levels may be decreased and anti-ADAMTS-13 autoantibodies may partially mediate this reduction. Further evaluation of ADAMTS-13 profile may explain its role in the pathogenesis of thrombotic microangiopathy in lupus patients and reveal a potential prognostic marker of microthrombotic manifestations in SLE.
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Affiliation(s)
- P Klonizakis
- Hematology Unit, Aristotle University of Thessaloniki, Greece.
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98
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El Sissy MH, El Hafez AA, El Sissy AH. Low incidence of ADAMTS13 missense mutation R1060W in adult Egyptian patients with thrombotic thrombocytopenic purpura. Acta Haematol 2014; 132:30-5. [PMID: 24401653 DOI: 10.1159/000355645] [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: 04/26/2013] [Accepted: 09/12/2013] [Indexed: 11/19/2022]
Abstract
Thrombotic thrombocytopenic purpura (TTP) is an acute life-threatening disorder, characterized by thrombocytopenia, microangiopathic hemolytic anemia, widespread microvascular thrombi and consequent clinical sequelae due to ischemic organ damage. TTP is most commonly associated with deficiency or inhibition of von Willebrand factor-cleaving protease (ADAMTS13) activity. ADAMTS13 mutations and polymorphisms have been reported in childhood congenital TTP, but their significance in adult-onset TTP is still under investigation. Two mutations stand out: the single base insertion 4143insA in exon 29 and the missense mutation R1060W in exon 24 have both been observed in several unrelated families, mainly in adult-onset TTP, and over a wide geographic area. Our objective in this study is to identify the prevalence of R1060W missense mutation in exon 24 ADAMTS13 in a sample of adult Egyptian TTP patients. Thirty-one adult-onset TTP patients were included in this study, with a male/female ratio of 1:4. Twenty-six cases (84%) presented with acute idiopathic TTP, 2 cases were drug abusers and 3 cases were pregnant. None of the study cases provided a history of suspicious TTP symptoms during childhood (2 cases gave a history of episodes of thrombocytopenia during childhood). All cases showed statistically significant decreased ADAMTS13 activity compared to normal controls (p < 0.001). The study revealed a high statistical difference regarding the ADAMTS13 inhibitor level in primary versus secondary cases (p = 0.003). None of our Egyptian cases or of the healthy normal controls are positive for exon 24 missense mutation. Larger studies and regional and national TTP registries are recommended.
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Affiliation(s)
- Maha H El Sissy
- Department of Clinical Pathology, University of Cairo, Cairo, Egypt
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Yamashita H, Takahashi Y, Kaneko H, Kano T, Mimori A. Thrombotic thrombocytopenic purpura with an autoantibody to ADAMTS13 complicating Sjögren’s syndrome: two cases and a literature review. Mod Rheumatol 2014. [DOI: 10.3109/s10165-012-0644-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Lotta LA, Valsecchi C, Pontiggia S, Mancini I, Cannavò A, Artoni A, Mikovic D, Meloni G, Peyvandi F. Measurement and prevalence of circulating ADAMTS13-specific immune complexes in autoimmune thrombotic thrombocytopenic purpura. J Thromb Haemost 2014; 12:329-36. [PMID: 24354764 DOI: 10.1111/jth.12494] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2013] [Indexed: 11/27/2022]
Abstract
BACKGROUND The formation of ADAMTS13-specific circulating immune complexes (CICs) may be a pathophysiologic mechanism in autoimmune thrombotic thrombocytopenic purpura (TTP), but has not been systematically investigated. OBJECTIVES (a) To develop an assay for ADAMTS13-specific CICs; (b) to evaluate their prevalence in autoimmune TTP; and (c) to assess their association with ADAMTS13-related measurements and clinical features in autoimmune TTP patients. PATIENTS/METHODS We developed and validated an ELISA method for ADAMTS13-specific CICs. ADAMTS13-specific CICs were searched for in 55 patients with autoimmune TTP from the Milan TTP Registry (URL:http://www.ttpdatabase.org/) and 28 controls. The associations between ADAMTS13-specific CIC levels and ADAMTS13 activity, antigen, anti-ADAMTS13 IgGs and acute TTP clinical features were assessed by multivariate linear regression. RESULTS Intra- and inter-assay coefficients of variation of the new test were 5.3 and 9.6%. In 36 patients with severe ADAMTS13 deficiency and anti-ADAMTS13 autoantibodies, the prevalence of ADAMTS13-specific CICs was 47% (n = 17; 95% confidence interval [CI], 32-63%). ADAMTS13-specific CICs were detected also in seven of 19 (37%; 95% CI, 19-59%) patients with reduced ADAMTS13 activity, but apparently negative anti-ADAMTS13 autoantibodies. ADAMTS13-specific CICs were not associated with ADAMTS13 activity, antigen or anti-ADAMTS13 IgGs. In patients with acute TTP, increasing levels of ADAMTS13-specific CICs were associated with a higher number of plasma-exchange procedures required to attain remission (per 0.1 increase in normalized OD values, beta, 2.9; 95% CI, -0.7 to 6.5). CONCLUSIONS Approximately one to two-thirds of patients with autoimmune TTP display ADAMTS13-specific CICs. A thorough investigation of the prognostic relevance of ADAMTS13-specific CIC levels in autoimmune TTP is warranted.
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Affiliation(s)
- L A Lotta
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Fondazione Luigi Villa and Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
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