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Yang LP, Liu X, Zhang XH. [Advances in the diagnosis and management of transplant-associated thrombotic microangiopathy]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2021; 42:693-699. [PMID: 34547882 PMCID: PMC8501284 DOI: 10.3760/cma.j.issn.0253-2727.2021.08.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Indexed: 12/02/2022]
Affiliation(s)
- L P Yang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing 100044, China
| | - X Liu
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing 100044, China
| | - X H Zhang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing 100044, China
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52
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Saha BK. A Deadly Thrombotic Microangiopathy Syndrome without Schistocytosis. South Med J 2021; 114:416-418. [PMID: 34215894 DOI: 10.14423/smj.0000000000001265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Biplab K Saha
- From the Division of Pulmonary and Critical Care Medicine, Ozarks Medical Center, West Plains, Missouri
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Li A, Gupta R, Amos CI, Davis C, Pao E, Lee SJ, Hingorani SR. Thrombotic microangiopathy increases the risk of chronic kidney disease but not overall mortality in long-term transplant survivors. Transplant Cell Ther 2021; 27:864.e1-864.e5. [PMID: 34217847 DOI: 10.1016/j.jtct.2021.06.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 06/14/2021] [Accepted: 06/23/2021] [Indexed: 11/26/2022]
Abstract
Thrombotic microangiopathy (TMA) after allogeneic hematopoietic cell transplant (HCT) is associated with acute kidney injury (AKI) and increased mortality. The impact of TMA on chronic kidney disease (CKD) and long-term mortality among HCT survivors has not been fully examined. To assess the risk of CKD and mortality in HCT survivors with and without history of TMA, we conducted a retrospective cohort study among adult allogeneic HCT recipients who survived to at least 1 year post-transplantation. We examined the association between the history of TMA within 1 year and the onset of CKD longitudinally for 5 years with generalized estimating equation (GEE) while adjusting for other key confounders. CKD was defined as an estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2 using the CKD-EPI formula with outpatient creatinine values collected during the annual long-term follow-up unit follow-up visits. Kaplan Meier curves landmarked at 1 year were used for survival analyses. Among 2091 adult patients who underwent allogeneic HCT, we identified 1151 patients who survived at least 1 year and had available long-term follow-up data. Among them, 57 patients developed TMA within 1 year and 1094 did not have TMA. There was no pretransplantation baseline difference in eGFR between groups. After adjusting for confounders, history of TMA was associated with an odds ratio of 2.83 (95% confidence interval 1.33-6.03) for CKD development over 5 years after transplantation. The conditional 5-year survival was 78% in the TMA survivors and 80% in the non-TMA survivors (log rank P = .122). HCT survivors with a history of TMA had increased risk of CKD development. Although TMA was associated with high risk of mortality within 1 year after transplantation, long-term survival was comparable with non-TMA survivors. Future therapeutic interventions should focus on not only short-term mortality outcomes, but also short- and long-term kidney outcomes for HCT patients with TMA.
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Affiliation(s)
- Ang Li
- Section of Hematology-Oncology, Department of Medicine, Baylor College of Medicine, Houston, Texas; Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington.
| | - Rohit Gupta
- School of Medicine, Baylor College of Medicine, Houston, Texas
| | - Christopher I Amos
- Division of Epidemiology and Population Science, Baylor College of Medicine, Houston, Texas; Institute of Clinical and Translational Medicine, Baylor College of Medicine, Houston, Texas
| | - Chris Davis
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Emily Pao
- Division of Nephrology, Seattle Children's Hospital, Seattle, Washington
| | - Stephanie J Lee
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Division of Medical Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Sangeeta R Hingorani
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Division of Nephrology, Seattle Children's Hospital, Seattle, Washington; Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
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Zhang R, Qi J, Zhou M, Pan T, Zhang Z, Yao Y, Han H, Han Y. Upregulation of Nrf2 Attenuates Oxidative Stress-Induced, Complement Activation-Associated Endothelial Injury and Apoptosis in Transplant-Associated Thrombotic Microangiopathy. Transplant Cell Ther 2021; 27:758.e1-758.e8. [PMID: 34174470 DOI: 10.1016/j.jtct.2021.06.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 06/07/2021] [Accepted: 06/16/2021] [Indexed: 11/27/2022]
Abstract
Transplant-associated thrombotic microangiopathy (TA-TMA) is a serious and life-threatening complication after hematopoietic stem cell transplantation. Studies have reported that the main pathological manifestation of the disease is an endothelial injury associated with complement activation, but its molecular biological mechanisms remain unclear. Our previous studies have shown that oxidative stress may induce complement activation in TA-TMA. Nuclear factor erythroid 2-related factor 2 (Nrf2), a molecule that regulates oxidative stress, can inhibit endothelial stimulation by reactive oxygen species (ROS). We assessed Nrf2 expression in peripheral blood mononuclear cells (PBMCs) from patients with TA-TMA compared with healthy donors. Nrf2 expression, ROS accumulation, complement activation, and apoptosis were then assessed in human umbilical vein endothelial cells (HUVECs) incubated with TA-TMA plasma to identify whether complement-associated endothelial damage induced by oxidative stress occurs in TA-TMA. The protective effect of Nrf2 pathway activation on TA-TMA-induced endothelial injury was also investigated to explore a new avenue for TA-TMA prevention and treatment. In this study, peripheral blood was collected from six patients with TA-TMA, and healthy donors served as negative controls. We determined the expression of Nrf2 through in vitro and in vivo experiments and measured the level of apoptosis. We found increased expression of Nrf2 in PBMCs from patients with TA-TMA. HUVECs were then incubated with plasma from patients with TA-TMA or with plasma from healthy donors, and we found that complement 3 (C3) levels were increased in HUVECs treated with TA-TMA plasma. In contrast, total Nrf2 levels were decreased, and ROS production and apoptosis levels were increased. To determine whether complement activation and apoptosis were caused by oxidative stress, we added N-acetyl-L-cysteine to HUVECs incubated with TA-TMA plasma. As a result, ROS production, complement activation, and apoptosis levels were reduced. Finally, we upregulated Nrf2 in HUVECs by rescue experiments, and we found that activation of Nrf2 attenuated endothelial cell apoptosis and ROS production and reduced C3 and C5b-9 levels. These results suggest that oxidative stress-induced, complement activation-associated endothelial injury occurs in TA-TMA and that upregulation of Nrf2 protects endothelial cells from damage. Activation of the Nrf2 pathway may be a potential target for the treatment of complement activation-associated endothelial injury in TA-TMA.
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Affiliation(s)
- Rui Zhang
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China; Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China; Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Institute of Blood and Marrow Transplantation, Suzhou, China
| | - Jiaqian Qi
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China; Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China; Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Institute of Blood and Marrow Transplantation, Suzhou, China
| | - Meng Zhou
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China; Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China; Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Institute of Blood and Marrow Transplantation, Suzhou, China
| | - Tingting Pan
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China; Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China; Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Institute of Blood and Marrow Transplantation, Suzhou, China
| | - Ziyan Zhang
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China; Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China; Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Institute of Blood and Marrow Transplantation, Suzhou, China
| | - Yifang Yao
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China; Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China; Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Institute of Blood and Marrow Transplantation, Suzhou, China
| | - Haohao Han
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China; Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China; Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Institute of Blood and Marrow Transplantation, Suzhou, China
| | - Yue Han
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China; Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China; Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Institute of Blood and Marrow Transplantation, Suzhou, China; State Key Laboratory of Radiation Medicine and Protection, Soochow University, Suzhou, China.
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55
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Transplant-associated thrombotic microangiopathy in pediatric patients: pre-HSCT risk stratification and prophylaxis. Blood Adv 2021; 5:2106-2114. [PMID: 33877298 DOI: 10.1182/bloodadvances.2020003988] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 03/08/2021] [Indexed: 12/19/2022] Open
Abstract
Transplant-associated thrombotic microangiopathy (TA-TMA) is an endothelial injury syndrome that complicates hematopoietic stem cell transplant (HSCT). Morbidity and mortality from TA-TMA remain high, making prevention critical. We describe our retrospective single-center experience of TA-TMA after pediatric allogeneic HSCT and present a novel pre-HSCT risk-stratification system and prophylaxis regimen. From January 2012 through October 2019, 257 patients underwent 292 allogeneic HSCTs. Prospective risk stratification was introduced in December 2016. High-risk (HR) patients were treated with combination prophylaxis with eicosapentaenoic acid and N-acetylcysteine. The 1-year cumulative incidence of TA-TMA was 6.3% (95% confidence interval [CI], 3.2-9.4). Age ≥10 years, myeloablative conditioning with total body irradiation, HLA mismatch, diagnosis of severe aplastic anemia or malignancy, prior calcineurin inhibitor exposure, and recipient cytomegalovirus seropositivity were found to be pre-HSCT risk factors for development of TA-TMA. Before routine prophylaxis, TA-TMA rates were significantly different between the HR and standard-risk groups, at 28.2% (95% CI, 0-12.7) vs 3.2% (0.1-6.3), respectively (P < .001). After introduction of prophylaxis, the 1-year cumulative incidence of TA-TMA in the HR group decreased to 4.5% (95% CI, 0-13.1; P = .062, compared with the incidence before prophylaxis). Multicenter pediatric studies are needed to validate these risk criteria and to confirm the efficacy of the prophylactic regimen.
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56
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Risk factors and appropriate therapeutic strategies for thrombotic microangiopathy after allogeneic HSCT. Blood Adv 2021; 4:3169-3179. [PMID: 32658984 DOI: 10.1182/bloodadvances.2020002007] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 06/04/2020] [Indexed: 12/14/2022] Open
Abstract
Transplant-associated thrombotic microangiopathy (TA-TMA) is a fatal complication of allogeneic hematopoietic stem cell transplantation (allo-HSCT). However, so far, no large cohort study determined the risk factors and the most effective therapeutic strategies for TA-TMA. Thus, the present study aimed to clarify these clinical aspects based on a large multicenter cohort. This retrospective cohort study was performed by the Kyoto Stem Cell Transplantation Group (KSCTG). A total of 2425 patients were enrolled from 14 institutions. All patients were aged ≥16 years, presented with hematological diseases, and received allo-HSCT after the year 2000. TA-TMA was observed in 121 patients (5.0%) on day 35 (median) and was clearly correlated with inferior overall survival (OS) (hazard ratio [HR], 4.93). Pre- and post-HSCT statistically significant risk factors identified by multivariate analyses included poorer performance status (HR, 1.69), HLA mismatch (HR, 2.17), acute graft-versus-host disease (aGVHD; grades 3-4) (HR, 4.02), Aspergillus infection (HR, 2.29), and veno-occlusive disease/sinusoidal obstruction syndrome (VOD/SOS; HR, 4.47). The response rate and OS significantly better with the continuation or careful reduction of calcineurin inhibitors (CNI) than the conventional treatment strategy of switching from CNI to corticosteroids (response rate, 64.7% vs 20.0%). In summary, we identified the risk factors and the most appropriate therapeutic strategies for TA-TMA. The described treatment strategy could improve the outcomes of patients with TA-TMA in the future.
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57
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A pragmatic multi-institutional approach to understanding transplant-associated thrombotic microangiopathy after stem cell transplant. Blood Adv 2021; 5:1-11. [PMID: 33570619 DOI: 10.1182/bloodadvances.2020003455] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 11/22/2020] [Indexed: 12/26/2022] Open
Abstract
Transplant-associated thrombotic microangiopathy (TA-TMA) is a severe complication of hematopoietic stem cell transplantation (HSCT). A single-center prospective screening study has shown that the incidence of TA-TMA is much higher than prior retrospective studies that did not systematically screen. These data have not been replicated in a multicenter study. Our objective was to determine the incidence and risk factors for TA-TMA and compare outcomes of pediatric HSCT patients with and without TA-TMA. Patients were prospectively screened for TA-TMA at participating centers using a simple to implement and inexpensive strategy from the start of the preparative regimen through day +100. TA-TMA was diagnosed if ≥4 of 7 laboratory/clinical markers diagnostic for TA-TMA were present concurrently or if tissue histology showed TA-TMA. A total of 614 patients (359 males; 58%) received prospective TA-TMA screening at 13 pediatric centers. TA-TMA was diagnosed in 98 patients (16%) at a median of 22 days (interquartile range, 14-44) posttransplant. Patients with TA-TMA had significantly increased bloodstream infections (38% [37/98] vs 21% [107/51], P ≤ .001), mean total hospitalization days (68; 95% confidence interval [CI], 63-74 vs 43; 95% CI, 41-45; P ≤ .001), and number of days spent in the intensive care unit (10.1; 95% CI, 6.4-14; vs 1.6; 95% CI, 1.1-2.2; P ≤ .001) in the first 100 days after HSCT compared with patients without TA-TMA. Overall survival was significantly higher in patients without TA-TMA (93%; 490/516) compared with patients with TA-TMA (78%; 76/98) (P ≤ .001). These data support the need for systematic screening for TA-TMA and demonstrate the feasibility and efficacy of an easy to implement strategy to do so.
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58
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Complement inhibition does not impair the clinical antiviral capabilities of virus-specific T-cell therapy. Blood Adv 2021; 4:3252-3257. [PMID: 32697816 DOI: 10.1182/bloodadvances.2020002252] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 06/19/2020] [Indexed: 02/07/2023] Open
Abstract
Key Points
The use of terminal complement blockade is compatible with virus-specific T-cell (VST) expansion and clinical effectiveness. VST and complement-blocking agent concurrent therapy may be safely used in patients with thrombotic microangiopathy and viral infections.
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Satoh K, Okuyama M, Irie Y, Kameyama K, Kitamura T, Nakae H. Continuous plasma exchange with dialysis for thrombotic microangiopathy in intensive care unit: Retrospective observational study. Ther Apher Dial 2021; 25:377-383. [PMID: 33885227 DOI: 10.1111/1744-9987.13654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 11/24/2020] [Indexed: 11/26/2022]
Abstract
Continuous plasma exchange with dialysis is a novel method of blood purification and is a modification of the plasma exchange. Technically, this process suggests a reduction in adverse events, cost-effectiveness, and compatibility with hemodynamic instability. The therapeutic effect of plasma exchange on thrombotic microangiopathies has been established. We present three clinical cases in the intensive care unit that illustrate continuous plasma exchange with dialysis as a flexible blood purification therapy for critically ill patients; a radical treatment, thrombotic microangiopathies; supportive therapy, multiple organ failure; and fluid balance regulator. The retrospective analysis of 13 continuous plasma exchange with dialysis sessions showed that the platelet count increased significantly (p = 0.0096) after its administration. The total protein, albumin, fibrinogen, or calcium did not decrease significantly after continuous plasma exchange with dialysis, suggesting therapeutic efficacy and fewer adverse events. A prospective study on thrombotic microangiopathies for continuous plasma exchange with dialysis is currently underway.
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Affiliation(s)
- Kasumi Satoh
- Department of Emergency and Critical Care Medicine, Akita University Graduate School of Medicine, Akita, Japan
| | - Manabu Okuyama
- Department of Emergency and Critical Care Medicine, Akita University Graduate School of Medicine, Akita, Japan
| | - Yasuhito Irie
- Department of Emergency and Critical Care Medicine, Akita University Graduate School of Medicine, Akita, Japan
| | - Koumei Kameyama
- Department of Emergency and Critical Care Medicine, Akita University Graduate School of Medicine, Akita, Japan
| | - Toshiharu Kitamura
- Department of Emergency and Critical Care Medicine, Akita University Graduate School of Medicine, Akita, Japan
| | - Hajime Nakae
- Department of Emergency and Critical Care Medicine, Akita University Graduate School of Medicine, Akita, Japan
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Transplant-associated thrombotic microangiopathy: theoretical considerations and a practical approach to an unrefined diagnosis. Bone Marrow Transplant 2021; 56:1805-1817. [PMID: 33875812 PMCID: PMC8338557 DOI: 10.1038/s41409-021-01283-0] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 03/08/2021] [Accepted: 03/24/2021] [Indexed: 02/07/2023]
Abstract
Transplant-associated thrombotic microangiopathy (TA-TMA) is an increasingly recognized complication of hematopoietic stem cell transplant (HSCT) with high morbidity and mortality. The triad of endothelial cell activation, complement dysregulation, and microvascular hemolytic anemia has the potential to cause end organ dysfunction, multiple organ dysfunction syndrome and death, but clinical features mimic other disorders following HSCT, delaying diagnosis. Recent advances have implicated complement as a major contributor and the therapeutic potential of complement inhibition has been explored. Eculizumab has emerged as an effective therapy and narsoplimab (OMS721) has been granted priority review by the FDA. Large studies performed mostly in pediatric patients suggest that earlier recognition and treatment may lead to improved outcomes. Here we present a clinically focused summary of recently published literature and propose a diagnostic and treatment algorithm.
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Valério P, Barreto JP, Ferreira H, Chuva T, Paiva A, Costa JM. Thrombotic microangiopathy in oncology - a review. Transl Oncol 2021; 14:101081. [PMID: 33862523 PMCID: PMC8065296 DOI: 10.1016/j.tranon.2021.101081] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 03/18/2021] [Indexed: 12/31/2022] Open
Abstract
Thrombotic microangiopathy is a syndrome triggered by a wide spectrum of situations, some of which are specific to the Oncology setting. It is characterized by a Coombs-negative microangiopathic haemolytic anemia, thrombocytopenia and organ injury, with characteristic pathological features, resulting from platelet microvascular occlusion. TMA is rare and its cancer-related subset even more so. TMA triggered by drugs is the most common within this group, including classic chemotherapy and the latest targeted therapies. The neoplastic disease itself and hematopoietic stem-cell transplantation could also be potential triggers. Evidence-based medical guidance in the management of cancer-related TMA is scarce and the previous knowledge about primary TMA is valuable to understand the disease mechanisms and the potential treatments. Given the wide spectrum of potential causes for TMA in cancer patients, the aim of this review is to gather the vast information available. For each entity, pathophysiology, clinical features, therapeutic approaches and prognosis will be covered.
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Affiliation(s)
- Patrícia Valério
- Nephrology Department, Setúbal Hospital Center, Portugal Rua Camilo Castelo Branco 175, 2910-549 Setúbal, Portugal.
| | - João Pedro Barreto
- Laboratory Diagnosis Department, Portuguese Oncology Institute of Porto, Portugal Rua Dr. António Bernardino de Almeida, 4200-072 Porto, Portugal
| | - Hugo Ferreira
- Nephrology Department, Portuguese Oncology Institute of Porto, Portugal Rua Dr. António Bernardino de Almeida, 4200-072 Porto, Portugal
| | - Teresa Chuva
- Nephrology Department, Portuguese Oncology Institute of Porto, Portugal Rua Dr. António Bernardino de Almeida, 4200-072 Porto, Portugal
| | - Ana Paiva
- Nephrology Department, Portuguese Oncology Institute of Porto, Portugal Rua Dr. António Bernardino de Almeida, 4200-072 Porto, Portugal
| | - José Maximino Costa
- Nephrology Department, Portuguese Oncology Institute of Porto, Portugal Rua Dr. António Bernardino de Almeida, 4200-072 Porto, Portugal
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Bridoux F, Cockwell P, Glezerman I, Gutgarts V, Hogan JJ, Jhaveri KD, Joly F, Nasr SH, Sawinski D, Leung N. Kidney injury and disease in patients with haematological malignancies. Nat Rev Nephrol 2021; 17:386-401. [PMID: 33785910 DOI: 10.1038/s41581-021-00405-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/29/2021] [Indexed: 02/07/2023]
Abstract
Acute kidney injury (AKI) is common in patients with cancer, especially in those with haematological malignancies. Kidney injury might be a direct consequence of the underlying haematological condition. For example, in the case of lymphoma infiltration or extramedullary haematopoiesis, it might be caused by a tumour product; in the case of cast nephropathy it might be due to the presence of monoclonal immunoglobulin; or it might result from tumour complications, such as hypercalcaemia. Kidney injury might also be caused by cancer treatment, as many chemotherapeutic agents are nephrotoxic. High-intensity treatments, such as high-dose chemotherapy followed by haematopoietic stem cell transplantation, not only increase the risk of infection but can also cause AKI through various mechanisms, including viral nephropathies, engraftment syndrome and sinusoidal obstruction syndrome. Some conditions, such as thrombotic microangiopathy, might also result directly from the haematological condition or the treatment. Novel immunotherapies, such as immune checkpoint inhibitors and chimeric antigen receptor T cell therapy, can also be nephrotoxic. As new therapies for haematological malignancies with increased anti-tumour efficacy and reduced toxicity are developed, the number of patients receiving these treatments will increase. Clinicians must gain a good understanding of the different mechanisms of kidney injury associated with cancer to better care for these patients.
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Affiliation(s)
- Frank Bridoux
- Department of Nephrology, and Centre d'Investigation Clinique (CIC INSERM 1402), Centre Hospitalier Universitaire et Université de Poitiers, Poitiers, France.,CNRS, UMR7276, Limoges, France.,Centre de référence Amylose AL et autres maladies par dépôt d'immunoglobulines monoclonales, Poitiers, France
| | - Paul Cockwell
- Department of Nephrology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Ilya Glezerman
- Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Weill Cornell Medical College, New York, NY, USA
| | - Victoria Gutgarts
- Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Weill Cornell Medical College, New York, NY, USA
| | - Jonathan J Hogan
- Renal, Electrolyte and Hypertension Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Kenar D Jhaveri
- Division of Kidney Diseases and Hypertension, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Great Neck, NY, USA
| | - Florent Joly
- Department of Nephrology, and Centre d'Investigation Clinique (CIC INSERM 1402), Centre Hospitalier Universitaire et Université de Poitiers, Poitiers, France
| | - Samih H Nasr
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Deirdre Sawinski
- Renal, Electrolyte and Hypertension Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Nelson Leung
- Division of Nephrology and Hypertension, Division of Hematology, Mayo Clinic, Rochester, MN, USA.
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63
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[Chinese consensus on the diagnosis and management of transplant-associated thrombotic microangiopathy (2021)]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2021; 42:177-184. [PMID: 33910301 PMCID: PMC8081937 DOI: 10.3760/cma.j.issn.0253-2727.2021.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Indexed: 01/04/2023]
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Yang W, Zhu G, Qin M, Li Z, Wang B, Yang J, Wang T. The Effectiveness of Ruxolitinib for Acute/Chronic Graft-versus-Host Disease in Children: A Retrospective Study. DRUG DESIGN DEVELOPMENT AND THERAPY 2021; 15:743-752. [PMID: 33654380 PMCID: PMC7910527 DOI: 10.2147/dddt.s287218] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 12/22/2020] [Indexed: 01/23/2023]
Abstract
Objective This study aimed to evaluate the effectiveness of Ruxolitinib for acute/chronic graft-versus-host disease in children. Methods This study was a retrospective trial. We analyzed the clinical characteristics of children who responded poorly to previous treatment for graft-versus-host disease (GVHD) and received ruxolitinib treatment after allogeneic hematopoietic stem cell transplantation (allo-HSCT) as an additional or replacement therapy. Results A total of 53 patients were analyzed: aGVHD and cGVHD. The overall response rate (ORR) to ruxolitinib was 75.5%. The ORR was 64.7% (11/17) in the aGVHD group including 6, 5, and 6 patients with partial responses (PRs), complete responses (CRs), and treatment failure, respectively. The ORR was 80.6% (29/36) in the cGVHD group including 10 with CRs and 19 with PRs. Five and 2 patients showed no response and treatment failure, respectively. Four and 14 patients were GVHD recurrence in aGVHD and cGVHD respectively. A total of 14 patients (39%) discontinued steroids and 8 patients (22.2%) reduced steroids. The incidence of obvious adverse events was 94.1% (16/17) in the aGVHD group, which was higher than that in the cGVHD group. Meanwhile, the prognosis of children with cGVHD was superior to that of children with aGVHD after treatment with ruxolitinib. During the ruxolitinib treatment, only 1 patient suffered a relapse of the primary tumor. Eleven patients also suffered transplantation-associated thrombotic microangiopathy (TA-TMA) after allo-HSCT. Conclusion Pediatric patients with GVHD (especially cGVHD) responded well to ruxolitinib treatment. Ruxolitinib can also be used as an alternative treatment for patients with TMA.
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Affiliation(s)
- Wenli Yang
- Department of Clinical Nutrition, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, People's Republic of China
| | - Guanghua Zhu
- Department of Hematology and Oncology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing Key Laboratory of Pediatric Hematology Oncology, Key Laboratory of Major Diseases in Children, Ministry of Education, National Key Discipline of Pediatrics, Beijing, People's Republic of China
| | - Maoquan Qin
- Department of Hematology and Oncology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing Key Laboratory of Pediatric Hematology Oncology, Key Laboratory of Major Diseases in Children, Ministry of Education, National Key Discipline of Pediatrics, Beijing, People's Republic of China
| | - Zhigang Li
- Hematology and Oncology Laboratory, Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing Key Laboratory of Pediatric Hematology Oncology, Key Laboratory of Major Diseases in Children, Ministry of Education, National Key Discipline of Pediatrics, Beijing, People's Republic of China
| | - Bin Wang
- Department of Hematology and Oncology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing Key Laboratory of Pediatric Hematology Oncology, Key Laboratory of Major Diseases in Children, Ministry of Education, National Key Discipline of Pediatrics, Beijing, People's Republic of China
| | - Jun Yang
- Department of Hematology and Oncology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing Key Laboratory of Pediatric Hematology Oncology, Key Laboratory of Major Diseases in Children, Ministry of Education, National Key Discipline of Pediatrics, Beijing, People's Republic of China
| | - Tianyou Wang
- Department of Hematology and Oncology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing Key Laboratory of Pediatric Hematology Oncology, Key Laboratory of Major Diseases in Children, Ministry of Education, National Key Discipline of Pediatrics, Beijing, People's Republic of China
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Therapeutic plasma exchange: single-center experience in children with kidney disorders. Pediatr Nephrol 2021; 36:621-629. [PMID: 32949283 DOI: 10.1007/s00467-020-04744-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 07/31/2020] [Accepted: 08/25/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Therapeutic plasma exchange (TPE) is used in kidney diseases as an adjunct treatment. Little has been described as to its effectiveness in kidney disorders in children. This study aimed to assess the safety, efficacy, and outcomes of patients who underwent TPE for kidney indications. METHODS Retrospective chart review of patients receiving TPE from 2010 to 2018 for kidney indications, such as antibody-mediated rejection, bone marrow transplant-associated thrombotic microangiopathy (TA-TMA), atypical hemolytic uremic syndrome, transplant recurrence of focal segmental glomerulosclerosis, and glomerulonephritis. Outcomes assessed were trends in kidney function, mortality, and progression to stage 5 chronic kidney disease (CKD 5). Significant hypocalcemia was defined as ionized calcium < 1 mmol/L. RESULTS A total of 641 TPE procedures were performed on 47 patients (25 male). Average age was 12.8 ± 5.9 years. Median glomerular filtration rate (GFR) improved from baseline to end of TPE treatments (pre 44.9 (19.8, 79), end 56.1 (23, 98) [p = 0.02]). Ten out of 47 children developed CKD 5. Seven out of 47 patients died; 5 had TA-TMA. Initial 7 consecutive sessions were reviewed for complications. Among 335 procedures, 41 episodes of significant hypocalcemia were noted (12.2%); only 1 was symptomatic. Of the 26 episodes (7.7%) of allergic reactions, all were associated with the use of FFP; 5 were anaphylactic. No TPE-associated mortality was noted. CONCLUSIONS TPE is a relatively well-tolerated useful adjunct therapy in children with kidney indications. The benefit of TPE has to be balanced with risks such as hypocalcemia and allergic reactions which can occur more frequently with FFP. Graphical abstract.
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Punatar S, Kalantri SA, Chichra A, Agrawal AK, Nayak L, Bonda A, Gokarn A, Bagal B, Mathew L, Kannan S, Khattry N. Pre-transplant use of tyrosine kinase inhibitors and transplant associated thrombotic microangiopathy - a single centre analysis of incidence, risk factors and outcomes. Bone Marrow Transplant 2021; 56:1558-1562. [PMID: 33514924 DOI: 10.1038/s41409-021-01213-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 12/18/2020] [Accepted: 01/07/2021] [Indexed: 11/10/2022]
Abstract
Transplant associated thrombotic microangiopathy (TA-TMA) is life-threatening complication post allogeneic stem cell transplant (ASCT). Risk factors and prognosis of TA-TMA are not well defined. We retrospectively studied consecutive ASCT patients with AML, ALL, and CML from January 2008 to March 2019 to study the incidence, risk factors, and outcomes of TMA. Definitive and probable TA-TMA was defined using Blood and Marrow Transplant Clinical Trials Network (BMT-CTN) and Cho criteria, respectively. Risk factors explored were age, gender, diagnosis, type of transplant, use of tyrosine kinase inhibitors (TKI) pre transplant, conditioning regimen, and acute GVHD. Standard statistical methods were used. Total 241 patients, 179 (74.2 %) males, median age of 29 years were studied. Diagnoses were AML in 104, ALL in 85 (Ph+ve 23) and CML 52. Total 26 (10.7%) patients (22 males) developed TA-TMA at median of day+102. On multivariate analysis, pre-HSCT TKI (OR 2.7, p = 0.028), haplo-HSCT (OR 3.16, p = 0.018) and presence of acute GVHD (OR 4.17, p = 0.003) were significant risk factors. With a median follow up of 60 months, median OS with and without TA-TMA was 18 and 97 months respectively (p = 0.021). The association of pre-HSCT with TKI with TA-TMA merits further exploration in prospective studies.
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Affiliation(s)
- Sachin Punatar
- HSCT unit, Department of Medical Oncology Tata Memorial Centre, HSCT unit, ACTREC, Kharghar, Navi Mumbai, 410210, India.,Homi Bhabha National Institute (HBNI), Anushakti Nagar, Mumbai, India
| | - Siddhesh A Kalantri
- HSCT unit, Department of Medical Oncology Tata Memorial Centre, HSCT unit, ACTREC, Kharghar, Navi Mumbai, 410210, India.,Homi Bhabha National Institute (HBNI), Anushakti Nagar, Mumbai, India
| | - Akanksha Chichra
- HSCT unit, Department of Medical Oncology Tata Memorial Centre, HSCT unit, ACTREC, Kharghar, Navi Mumbai, 410210, India.,Homi Bhabha National Institute (HBNI), Anushakti Nagar, Mumbai, India
| | - Amit Kumar Agrawal
- HSCT unit, Department of Medical Oncology Tata Memorial Centre, HSCT unit, ACTREC, Kharghar, Navi Mumbai, 410210, India
| | - Lingaraj Nayak
- HSCT unit, Department of Medical Oncology Tata Memorial Centre, HSCT unit, ACTREC, Kharghar, Navi Mumbai, 410210, India.,Homi Bhabha National Institute (HBNI), Anushakti Nagar, Mumbai, India
| | - Avinash Bonda
- HSCT unit, Department of Medical Oncology Tata Memorial Centre, HSCT unit, ACTREC, Kharghar, Navi Mumbai, 410210, India.,Homi Bhabha National Institute (HBNI), Anushakti Nagar, Mumbai, India
| | - Anant Gokarn
- HSCT unit, Department of Medical Oncology Tata Memorial Centre, HSCT unit, ACTREC, Kharghar, Navi Mumbai, 410210, India.,Homi Bhabha National Institute (HBNI), Anushakti Nagar, Mumbai, India
| | - Bhausaheb Bagal
- HSCT unit, Department of Medical Oncology Tata Memorial Centre, HSCT unit, ACTREC, Kharghar, Navi Mumbai, 410210, India.,Homi Bhabha National Institute (HBNI), Anushakti Nagar, Mumbai, India
| | - Libin Mathew
- HSCT unit, Department of Medical Oncology Tata Memorial Centre, HSCT unit, ACTREC, Kharghar, Navi Mumbai, 410210, India
| | - Sadhana Kannan
- Department of Biostatistics, Tata Memorial Centre, Paymaster Shodhika, ACTREC, Kharghar, Navi Mumbai, 410210, India
| | - Navin Khattry
- HSCT unit, Department of Medical Oncology Tata Memorial Centre, HSCT unit, ACTREC, Kharghar, Navi Mumbai, 410210, India. .,Homi Bhabha National Institute (HBNI), Anushakti Nagar, Mumbai, India.
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Risk Factor and Long-Term Outcome Analyses for Acute Limbic Encephalitis and Calcineurin Inhibitor-Induced Encephalopathy in Adults following Allogeneic Hematopoietic Cell Transplantation. Transplant Cell Ther 2021; 27:437.e1-437.e9. [PMID: 33965190 DOI: 10.1016/j.jtct.2021.01.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 01/22/2021] [Indexed: 12/11/2022]
Abstract
Post-transplantation acute limbic encephalitis (PALE) is a rare, severe inflammatory disorder in the bilateral limbic system, including the hippocampus. To date, only a few studies have reported details, including risk factors for PALE; however, further clinical evidence of PALE, especially in cerebrospinal fluid human herpesvirus 6-negative cases, is warranted. In addition, data are sparse regarding the risk factors for calcineurin inhibitor (CNI)-induced encephalopathy (CNIE) following allogeneic hematopoietic cell transplantation (allo-HCT) in adults. Therefore, we examined the risk factors for and clinical details of PALE and CNIE. We retrospectively analyzed consecutive patients who underwent allo-HCT between January 2005 and November 2017. A total of 485 patients age 46 years (median) were eligible. In total, 14 PALE cases and 11 CNIE cases were identified. Multivariable analyses identified older age, use of an HLA-mismatched unrelated donor (URD), graft-versus-host disease (GVHD) prophylaxis with CNI and mycophenolate mofetil, and grade II-IV acute GVHD as significantly associated with an increased risk of PALE. In 13 patients who received high-dose methylprednisolone (mPSL) therapy, 6 (46%) responded to mPSL therapy, and 3 (23%) achieved complete remission at day 90 after mPSL administration. Furthermore, myelodysplastic syndrome (MDS), HLA-mismatched URD, and grade II-IV acute GVHD were significantly associated with an increased risk of CNIE. The 5-year nonrelapse mortality rate was 50% in PALE and 63% in CNIE, suggesting a very poor prognosis. In conclusion, this study provides evidence that HLA-mismatched URD and acute GVHD may independently contribute to the development of PALE, possibly in part through HLA-mismatch-derived alloimmune responses. Other than acute GVHD, we have identified MDS and HLA-mismatched URD as novel predictors of CNIE after allo-HCT.
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68
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Zhang R, Zhou M, Qi J, Miao W, Zhang Z, Wu D, Han Y. Efficacy and Safety of Eculizumab in the Treatment of Transplant-Associated Thrombotic Microangiopathy: A Systematic Review and Meta-Analysis. Front Immunol 2021; 11:564647. [PMID: 33552043 PMCID: PMC7856300 DOI: 10.3389/fimmu.2020.564647] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 11/30/2020] [Indexed: 12/18/2022] Open
Abstract
Background Transplant-associated thrombotic microangiopathy (TA-TMA) is a dangerous and life-threatening complication in patients undergoing hematopoietic stem cell transplantation (HSCT). Eculizumab has been used in the treatment of TA-TMA, and several studies have confirmed the benefit of Eculizumab in patients with TA-TMA. However, the results remain controversial. We conducted a systematic review and meta-analysis to evaluate the efficacy and safety of Eculizumab for TA-TMA. Materials and Methods We searched PubMed and Embase for studies on the efficacy and safety of Eculizumab in TA-TMA patients. Efficacy outcomes consisted of overall response rate (ORR), complete response rate (CRR), and survival rate at the last follow-up (SR). Safety outcomes were adverse events (AEs), including infection, sepsis, impaired liver function, infusion reactions, and death. Results A total of 116 patients from six studies were subjected to meta-analysis. The pooled estimates of ORR, CRR, and SR for TA-TMA patients were 71% (95% CI: 58-82%), 32% (95% CI: 11-56%), and 52% (95% CI: 40-65%), respectively. Only one patient presented with a severe rash, and infection was the most common AEs. The main causes of death were infection and GvHD. Conclusion Current evidence suggests that Eculizumab improves SR and ORR in patients with TA-TMA and that Eculizumab is well tolerated. However, the number of studies is limited, and the findings are based mainly on data from observational studies. Higher quality randomized controlled trials and more extensive prospective cohort studies are needed.
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Affiliation(s)
- Rui Zhang
- Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China.,Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China.,Institute of Blood and Marrow Transplantation, Suzhou, China.,Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, China
| | - Meng Zhou
- Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China.,Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China.,Institute of Blood and Marrow Transplantation, Suzhou, China.,Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, China.,National Clinical Research Center for Hematologic Diseases, Suzhou, China
| | - Jiaqian Qi
- Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China.,Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China.,Institute of Blood and Marrow Transplantation, Suzhou, China.,Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, China.,National Clinical Research Center for Hematologic Diseases, Suzhou, China
| | - Wenjing Miao
- Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China.,Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China.,Institute of Blood and Marrow Transplantation, Suzhou, China.,Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, China
| | - Ziyan Zhang
- Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China.,Institute of Blood and Marrow Transplantation, Suzhou, China.,National Clinical Research Center for Hematologic Diseases, Suzhou, China
| | - Depei Wu
- Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China.,Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China.,Institute of Blood and Marrow Transplantation, Suzhou, China.,Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, China.,National Clinical Research Center for Hematologic Diseases, Suzhou, China.,State Key Laboratory of Radiation Medicine and Protection, Soochow University, Suzhou, China
| | - Yue Han
- Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China.,Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China.,Institute of Blood and Marrow Transplantation, Suzhou, China.,Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, China.,National Clinical Research Center for Hematologic Diseases, Suzhou, China.,State Key Laboratory of Radiation Medicine and Protection, Soochow University, Suzhou, China
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Li A, Bhatraju PK, Chen J, Chung DW, Hilton T, Houck K, Pao E, Weiss NS, Lee SJ, Davis C, Schmidt MJ, Lopez JA, Liles WC, Dong JF, Hingorani SR. Prognostic Biomarkers for Thrombotic Microangiopathy after Acute Graft-versus-Host Disease: A Nested Case-Control Study. Transplant Cell Ther 2020; 27:308.e1-308.e8. [PMID: 33836868 PMCID: PMC10122917 DOI: 10.1016/j.jtct.2020.12.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 12/07/2020] [Accepted: 12/10/2020] [Indexed: 12/27/2022]
Abstract
Transplantation-associated thrombotic microangiopathy (TA-TMA) is a complication of allogeneic hematopoietic cell transplantation (HCT) that often occurs following the development of acute graft-versus-host disease (aGVHD). In this study, we aimed to identify early TMA biomarkers among patients with aGVHD. We performed a nested-case-control study from a prospective cohort of allogeneic HCT recipients, matching on the timing and severity of antecedent aGVHD. We identified 13 TMA cases and 25 non-TMA controls from 208 patients in the cohort. Using multivariable conditional logistic regression, the odds ratio for TMA compared with non-TMA was 2.65 (95% confidence interval [CI], 1.00 to 7.04) for every 100 ng/mL increase in terminal complement complex sC5b9 and 2.62 (95% CI, 1.56 to 4.38) for every 1000 pg/mL increase in angiopoietin-2 (ANG2) at the onset of aGVHD. ADAMTS13 and von Willebrand factor (VWF) antigens were not appreciably associated with TMA. Using a Cox regression model incorporating sC5b9 >300 ng/mL and ANG2 >3000 pg/mL at the onset of aGVHD, the adjusted hazard ratio for mortality was 5.33 (95% CI, 1.57 to 18.03) for the high-risk group (both elevated) and 4.40 (95% CI, 1.60 to 12.07) for the intermediate-risk group (one elevated) compared with the low-risk group (neither elevated). In conclusion, we found that elevated sC5b9 and ANG2 levels at the onset of aGVHD were associated with the development of TMA and possibly mortality after accounting for the timing and severity of aGVHD. The results suggest important roles of complement activation and endothelial dysfunction in the pathogenesis of TMA. Measurement of these biomarkers at the onset of aGVHD may inform prognostic enrichment for preventive trials and improve clinical care.
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Affiliation(s)
- Ang Li
- Section of Hematology-Oncology, Department of Medicine, Baylor College of Medicine, Houston, Texas; Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington.
| | - Pavan K Bhatraju
- Division of Pulmonary Critical Care and Sleep Medicine, Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Junmei Chen
- Bloodworks NW Research Institute, Seattle, Washington
| | | | | | - Katie Houck
- Bloodworks NW Research Institute, Seattle, Washington
| | - Emily Pao
- Division of Nephrology, Seattle Children's Hospital, Seattle, Washington
| | - Noel S Weiss
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, Washington
| | - Stephanie J Lee
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Division of Medical Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Chris Davis
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | | | - Jose A Lopez
- Bloodworks NW Research Institute, Seattle, Washington; Divsion of Allergy and Infectious Diseases, Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - W Conrad Liles
- Divsion of Allergy and Infectious Diseases, Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Jing-Fei Dong
- Bloodworks NW Research Institute, Seattle, Washington; Division of Hematology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Sangeeta R Hingorani
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Division of Nephrology, Seattle Children's Hospital, Seattle, Washington; Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
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70
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Zhou L, Wang Y, Zhou F, Ma X, He X. Elevated troponin in hematopoietic stem cell transplantation-associated thrombotic microangiopathy: A case report. THROMBOSIS UPDATE 2020. [DOI: 10.1016/j.tru.2020.100005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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71
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Onodera R, Nihei S, Kimura T, Tomita T, Kudo K. Severe proteinuria during the administration of bevacizumab plus mFOLFOX6 in a colorectal cancer patient after kidney transplantation: a case report. J Pharm Health Care Sci 2020. [DOI: 10.1186/s40780-020-00175-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Bevacizumab (BEV) leads to proteinuria and renal damage. It is not clear whether the administration of immunosuppressive drugs after renal transplantation affects the safety of BEV administration. We report a case of severe proteinuria caused by BEV plus 5-fluorouracil, levofolinate, and oxaliplatin (mFOLFOX6) in a patient who had previously undergone kidney transplantation and the administration of tacrolimus.
Case presentation
The patient was a 67-year-old man with a history of diabetes and hypertension. He developed chronic renal failure 14 years earlier and underwent right kidney transplantation from a living donor followed by the administration of tacrolimus and mycophenolate mofetil for immunosuppression. After kidney transplantation, the patient was diagnosed with colorectal cancer with multiple lung and liver metastases and received BEV plus mFOLFOX6. After 5 cycles, proteinuria was observed, with a urinary protein concentration of > 300 mg/dL (urine protein creatinine ratio: 3.5), and after 16 cycles, the urinary protein concentration was > 1000 mg/dL (urine protein creatinine ratio: 7.1). Subsequently, BEV was discontinued, and only mFOLFOX6 administration was continued. Tacrolimus continued to be administered during chemotherapy. There was no association between serum tacrolimus concentration and proteinuria.
Conclusions
In this case, BEV administration caused severe proteinuria without affecting blood levels of tacrolimus. Patients with risk factors for renal impairment should be carefully evaluated for the risks and benefits of BEV administration.
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72
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Han Y. [How I treat transplant-associated thrombotic microangiopathy]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2020; 41:272-275. [PMID: 32447928 PMCID: PMC7364922 DOI: 10.3760/cma.j.issn.0253-2727.2020.04.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Y Han
- Department of Hematology, the First Affiliated Hospital of Soochow University, Jiangsu Institute of Hematology, Suzhou 215006, China
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73
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Sagou K, Fukushima N, Ukai S, Goto M, Ozeki K, Kohno A. Clinical usefulness of diagnostic criteria for transplant-associated thrombotic microangiopathy. Int J Hematol 2020; 112:697-706. [DOI: 10.1007/s12185-020-02963-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 07/21/2020] [Accepted: 07/28/2020] [Indexed: 12/19/2022]
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Allogeneic reactivity-mediated endothelial cell complications after HSCT: a plea for consensual definitions. Blood Adv 2020; 3:2424-2435. [PMID: 31409584 DOI: 10.1182/bloodadvances.2019000143] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 07/02/2019] [Indexed: 12/21/2022] Open
Abstract
Endothelial cell (EC) activation has been suspected of triggering a group of rare and dismal complications that can occur after allogeneic hematopoietic stem cell transplantation (HSCT). Capillary leak syndrome, engraftment syndrome, transplant-associated microangiopathy, diffuse alveolar hemorrhage, and idiopathic pneumonia syndrome are the main nosological entities. Post-HSCT endotheliitis can be triggered by chemotherapy, infections, and calcineurin inhibitors, but allogeneic reactivity is claimed to be the common denominator. Endothelial damages are thought to activate several deleterious pathways (proapoptotic, procoagulant, proinflammatory) and can lead to multiorgan failure; however, clinical manifestations of each syndrome overlap, and their relationship with graft-versus-host disease could be minimal. The lack of well-defined diagnostic criteria does not allow for a clear-cut comparison in the current literature. Therapeutic efforts have been made to intercept the pathogenic mechanisms leading to EC dysfunction, but remission rates and survival remain mostly unsatisfactory. In this article, we have reviewed the incidence, clinical features, and treatment approaches of EC activation syndromes, and we plead for the development of internationally accepted standard definitions.
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A critical role of the Gas6-Mer axis in endothelial dysfunction contributing to TA-TMA associated with GVHD. Blood Adv 2020; 3:2128-2143. [PMID: 31300420 DOI: 10.1182/bloodadvances.2019000222] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 05/31/2019] [Indexed: 12/11/2022] Open
Abstract
Endothelial dysfunction in the early phases of hematopoietic stem cell transplantation (HSCT) contributes to a common pathology between transplant-associated thrombotic microangiopathy (TA-TMA) and graft-versus-host disease (GVHD), which are serious complications of HSCT. Growth arrest-specific (Gas) 6 structurally belongs to the family of plasma vitamin K-dependent proteins working as a cofactor for activated protein C, and has growth factor-like properties through its interaction with receptor tyrosine kinases of the TAM family: Tyro3, Axl, and Mer. Serum Gas6 levels were significantly increased in HSCT patients with grade II to IV acute GVHD (aGVHD), and Gas6 and Mer expression levels were upregulated in aGVHD lesions of the large intestine and skin. The increased serum Gas6 levels were also correlated with elevated lactate dehydrogenase, d-dimer, and plasmin inhibitor complex values in HSCT patients with aGVHD. In human umbilical vein endothelial cells (ECs), exogenous Gas6 or the exposure of sera isolated from patients with grade III aGVHD to ECs induced the downregulation of thrombomodulin and the upregulation of PAI-1, as well as the upregulation of intercellular adhesion molecule-1 and vascular cell adhesion molecule-1, which were inhibited by UNC2250, a selective Mer tyrosine kinase inhibitor. In mouse HSCT models, we observed hepatic GVHD with hepatocellular apoptosis, necrosis, and fibrosis, as well as TA-TMA, which is characterized pathologically by thrombosis formation in the microvasculature of the liver and kidney. Of note, intravenous administration of UNC2250 markedly suppressed GVHD and TA-TMA in these mouse HSCT models. Our findings suggest that the Gas6-Mer axis is a promising target for TA-TMA after GVHD.
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New insights into risk factors for transplant-associated thrombotic microangiopathy in pediatric HSCT. Blood Adv 2020; 4:2418-2429. [PMID: 32492158 PMCID: PMC7284098 DOI: 10.1182/bloodadvances.2019001315] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 04/16/2020] [Indexed: 12/27/2022] Open
Abstract
This study aimed to identify a risk profile for development of transplant-associated thrombotic microangiopathy (TA-TMA) in children undergoing hematopoietic stem cell transplantation (HSCT). Between 2013 and 2016, 439 children underwent 474 HSCTs at 2 supraregional United Kingdom centers. At a median of 153 days post-HSCT, TA-TMA occurred among 25 of 441 evaluable cases (5.6%) with no evidence of center variation. Sex, underlying disease, intensity of the conditioning, total body irradiation-based conditioning, the use of calcineurin inhibitors, venoocclusive disease, and viral reactivation did not influence the development of TA-TMA. Donor type: matched sibling donor/matched family donor vs matched unrelated donor vs mismatched unrelated donor/haplo-HSCT, showed a trend toward the development of TA-TMA in 1.8% vs 6.1% vs 8.3%, respectively. Presence of active comorbidity was associated with an increased risk for TA-TMA; 13% vs 3.7% in the absence of comorbidity. The risk of TA-TMA was threefold higher among patients who received >1 transplant. TA-TMA rates were significantly higher among patients with acute graft-versus-host disease (aGVHD) grades III to IV vs aGVHD grade 0 to II. On multivariate analysis, the presence of active comorbidity, >1 transplant, aGVHD grade III to IV were risk factors for TA-TMA (odds ratio [OR]: 5.1, 5.2, and 26.9; respectively), whereas the use of cyclosporine A/tacrolimus-based GVHD prophylaxis was not a risk factor for TA-TMA (OR: 0.3). Active comorbidity, subsequent transplant, and aGVHD grades III to IV were significant risk factors for TA-TMA. TA-TMA might represent a form of a vascular GVHD, and therefore, continuing control of aGVHD is important to prevent worsening of TA-TMA associated with GVHD.
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Saha BK, Saha A, Chong W, Beegle S. A Fatal Case of Thrombotic Microangiopathy Without Schistocytosis and Absent Biochemical Markers of Hemolysis. Am J Med Sci 2020; 359:296-302. [PMID: 32265009 DOI: 10.1016/j.amjms.2020.01.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 12/19/2019] [Accepted: 01/24/2020] [Indexed: 02/02/2023]
Abstract
Thrombotic microangiopathy (TMA) is characterized by microangiopathic hemolytic anemia with thrombocytopenia. In addition to the primary TMA syndromes, microangiopathic hemolytic anemia with thrombocytopenia can be seen in many systemic diseases. Transplant associated TMA (TA-TMA) affects patients following stem cell or solid organ transplant. A 48-year-old male who underwent autologous stem cell transplant for nonsecretory multiple myeloma was admitted to our hospital with worsening anemia, thrombocytopenia, renal dysfunction and hepatosplenomegaly. Initial blood work revealed rare schistocytes and normal lactate dehydrogenase and haptoglobin levels. He underwent an extensive workup looking for an infectious, inflammatory or malignant etiology but a definitive diagnosis could not be reached. Over his prolonged stay at the hospital, he suffered from multiorgan failure and eventually passed away. An autopsy revealed TMA involving all clinically affected organ systems and was deemed to be the cause of his demise. The absence of typical blood work suggestive of hemolysis does not rule out a diagnosis of TA-TMA. Knowledge of this rare disease entity will help physicians identify and treat this life-threatening condition early and effectively.
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Affiliation(s)
- Biplab K Saha
- Division of Pulmonary and Critical Care Medicine, Albany Medical College, Albany, New York.
| | - Aditi Saha
- Division of Internal Medicine, Saint Barnabas Medical Center, Livingston, New Jersey
| | - Woon Chong
- Division of Pulmonary and Critical Care Medicine, Albany Medical College, Albany, New York
| | - Scott Beegle
- Division of Pulmonary and Critical Care Medicine, Albany Medical College, Albany, New York
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78
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Impact of blood pressure early after allogeneic hematopoietic cell transplantation on clinical outcomes. Ann Hematol 2020; 99:1369-1376. [PMID: 32173768 DOI: 10.1007/s00277-020-03990-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 03/08/2020] [Indexed: 01/20/2023]
Abstract
Allogeneic hematopoietic transplantation (allo-HCT) is still associated with significant morbidity and mortality, and risk stratification is critical. In this study, we analyzed the relationship between blood pressure control early after allo-HCT and survival outcomes. All patients who survived longer than 28 days after allo-HCT at our center between June 2007 and June 2018 (n = 353) were included, and the average systolic blood pressure (asBP) from 1 to 28 days after allo-HCT was calculated. According to the results of a ROC curve analysis, an asBP of 131 mmHg was defined as a cut-off value between high and low asBP groups. Non-relapse mortality (NRM) and OS were significantly inferior in the high asBP group (2-year-NRM 28.0% vs 11.1%, P < 0.001; 2-year-OS 46.7% vs 65.7%, P = 0.001). In addition, baseline asBP before commencement of the conditioning regimen and elevation of asBP (asBP - baseline asBP) were both associated with inferior NRM. While these results were also observed in the younger patients (≤ 50 years), no relationship was observed in the older patients (> 50 years). High blood pressure within 28 days after allo-HCT was associated with inferior survival outcomes, especially in patients younger than 50 years.
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79
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Epperla N, Li A, Logan B, Fretham C, Chhabra S, Aljurf M, Chee L, Copelan E, Freytes CO, Hematti P, Lazarus HM, Litzow M, Nishihori T, Olsson RF, Prestidge T, Saber W, Wirk B, Yared JA, Loren A, Pasquini M. Incidence, Risk Factors for and Outcomes of Transplant-Associated Thrombotic Microangiopathy. Br J Haematol 2020; 189:1171-1181. [PMID: 32124435 DOI: 10.1111/bjh.16457] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 12/01/2019] [Accepted: 12/04/2019] [Indexed: 12/14/2022]
Abstract
Transplant-associated thrombotic microangiopathy (TA-TMA) is a complication of allogeneic transplantation (allo-HCT). The incidence and risk factors associated with TA-TMA are not well known. A retrospective analysis from the Center for International Blood and Marrow Transplant Research (CIBMTR) was conducted including patients receiving allo-HCT between 2008 and 2016, with the primary objective of evaluating the incidence of TA-TMA. Secondary objectives included identification of risk factors associated with TA-TMA, and the impact of TA-TMA on overall survival and the need for renal replacement therapy (RRT). Among 23,665 allo-HCT recipients, the 3-year cumulative incidence of TA-TMA was 3%. Variables independently-associated with increased incidence of TA-TMA included female sex, prior autologous transplant, primary disease (acute lymphoblastic leukaemia and severe aplastic anaemia), donor type (mismatched or unrelated donor), conditioning intensity (myeloablative), GVHD prophylaxis (sirolimus + calcineurin inhibitor), pre-transplant kidney dysfunction and acute GVHD (time-varying effect). TA-TMA was associated with higher mortality (HR = 3·1, 95% Confidence Interval [CI] = 2·8-16·3) and RRT requirement (HR = 7·1, 95% CI = 5·7-311·6). This study provides epidemiologic data on TA-TMA and its impact on transplant outcomes. Increased awareness of the risk factors will enable providers to be vigilant of this uncommon but serious transplant complication. The results will also provide benchmarking for future study designs and comparisons.
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Affiliation(s)
- Narendranath Epperla
- Division of Hematology, Department of Medicine, The James Cancer Hospital and Solove Research Institute, The Ohio State University, Columbus, OH
| | - Ang Li
- University of Washington, Seattle, WA
| | - Brent Logan
- CIBMTR (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI.,Division of Biostatistics, Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, WI
| | - Caitrin Fretham
- CIBMTR (Center for International Blood and Marrow Transplant Research), National Marrow Donor Program/Be The Match, Minneapolis, MN
| | - Saurabh Chhabra
- CIBMTR (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Mahmoud Aljurf
- Department of Oncology, King Faisal Specialist Hospital Center & Research, Riyadh, Saudi Arabia
| | - Lynette Chee
- Royal Melbourne Hospital City Campus, Victoria, Australia
| | - Edward Copelan
- Levine Cancer Institute, Atrium Health, Carolinas HealthCare System, Charlotte, NC
| | | | - Peiman Hematti
- Division of Hematology/Oncology/Bone Marrow Transplantation, Department of Medicine, University of Wisconsin, Madison, WI
| | | | - Mark Litzow
- Division of Hematology and Transplant Center, Mayo Clinic Rochester, Rochester, MN
| | - Taiga Nishihori
- Department of Blood & Marrow Transplant and Cellular Immunotherapy (BMT CI), Moffitt Cancer Center, Tampa, FL
| | - Richard F Olsson
- Department of Laboratory Medicine, Karolinska Institutet, Stockholm.,Centre for Clinical Research Sormland, Uppsala University, Uppsala, Sweden
| | - Tim Prestidge
- Blood and Cancer Centre, Starship Children's Hospital, Auckland, New Zealand
| | - Wael Saber
- CIBMTR (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Baldeep Wirk
- Division of Bone Marrow Transplant, Seattle Cancer Care Alliance, Seattle, WA
| | - Jean A Yared
- Blood & Marrow Transplantation Program, Division of Hematology/Oncology, Department of Medicine, Greenebaum Comprehensive Cancer Center, University of Maryland, Baltimore, MD
| | - Alison Loren
- Division of Hematology/Oncology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Marcelo Pasquini
- CIBMTR (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
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80
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Guo QX, Zhang MY, Wang JG, Zhou F, Liu YQ, Liu JH. [Pulmonary arterial hypertension caused by graft-related thrombotic microangiopathy after ETP-ALL haplotype hematopoietic stem cell transplantation: a case report and literatures review]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2020; 41:164-166. [PMID: 32135636 PMCID: PMC7357948 DOI: 10.3760/cma.j.issn.0253-2727.2020.02.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Indexed: 01/23/2023]
Affiliation(s)
- Q X Guo
- Department of Hematology, The General Hospital of Northern Theater Command, Shenyang 110016, China
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81
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Scordo M, Giralt SA. A key step towards setting a benchmark for tackling transplant‐associated thrombotic microangiopathy. Br J Haematol 2020; 189:1006-1009. [DOI: 10.1111/bjh.16507] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 12/31/2019] [Indexed: 12/12/2022]
Affiliation(s)
- Michael Scordo
- Adult Bone Marrow Transplant Service Department of Medicine Memorial Sloan Kettering Cancer Center New York NY USA
- Department of Medicine Weill Cornell Medical College New York NY USA
| | - Sergio A. Giralt
- Adult Bone Marrow Transplant Service Department of Medicine Memorial Sloan Kettering Cancer Center New York NY USA
- Department of Medicine Weill Cornell Medical College New York NY USA
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82
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Dandoy CE, Kim S, Chen M, Ahn KW, Ardura MI, Brown V, Chhabra S, Diaz MA, Dvorak C, Farhadfar N, Flagg A, Ganguly S, Hale GA, Hashmi SK, Hematti P, Martino R, Nishihori T, Nusrat R, Olsson RF, Rotz SJ, Sung AD, Perales MA, Lindemans CA, Komanduri KV, Riches ML. Incidence, Risk Factors, and Outcomes of Patients Who Develop Mucosal Barrier Injury-Laboratory Confirmed Bloodstream Infections in the First 100 Days After Allogeneic Hematopoietic Stem Cell Transplant. JAMA Netw Open 2020; 3:e1918668. [PMID: 31913492 PMCID: PMC6991246 DOI: 10.1001/jamanetworkopen.2019.18668] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
IMPORTANCE Patients undergoing hematopoietic stem cell transplant (HSCT) are at risk for bloodstream infection (BSI) secondary to translocation of bacteria through the injured mucosa, termed mucosal barrier injury-laboratory confirmed bloodstream infection (MBI-LCBI), in addition to BSI secondary to indwelling catheters and infection at other sites (BSI-other). OBJECTIVE To determine the incidence, timing, risk factors, and outcomes of patients who develop MBI-LCBI in the first 100 days after HSCT. DESIGN, SETTING, AND PARTICIPANTS A case-cohort retrospective analysis was performed using data from the Center for International Blood and Marrow Transplant Research database on 16 875 consecutive pediatric and adult patients receiving a first allogeneic HSCT from January 1, 2009, to December 31, 2016. Patients were classified into 4 categories: MBI-LCBI (1481 [8.8%]), MBI-LCBI and BSI-other (698 [4.1%]), BSI-other only (2928 [17.4%]), and controls with no BSI (11 768 [69.7%]). Statistical analysis was performed from April 5 to July 17, 2018. MAIN OUTCOMES AND MEASURES Demographic characteristics and outcomes, including overall survival, chronic graft-vs-host disease, and transplant-related mortality (only for patients with malignant disease), were compared among groups. RESULTS Of the 16 875 patients in the study (9737 [57.7%] male; median [range] age, 47 [0.04-82] years) 13 686 (81.1%) underwent HSCT for a malignant neoplasm, and 3189 (18.9%) underwent HSCT for a nonmalignant condition. The cumulative incidence of MBI-LCBI was 13% (99% CI, 12%-13%) by day 100, and the cumulative incidence of BSI-other was 21% (99% CI, 21%-22%) by day 100. Median (range) time from transplant to first MBI-LCBI was 8 (<1 to 98) days vs 29 (<1 to 100) days for BSI-other. Multivariable analysis revealed an increased risk of MBI-LCBI with poor Karnofsky/Lansky performance status (hazard ratio [HR], 1.21 [99% CI, 1.04-1.41]), cord blood grafts (HR, 2.89 [99% CI, 1.97-4.24]), myeloablative conditioning (HR, 1.46 [99% CI, 1.19-1.78]), and posttransplant cyclophosphamide graft-vs-host disease prophylaxis (HR, 1.85 [99% CI, 1.38-2.48]). One-year mortality was significantly higher for patients with MBI-LCBI (HR, 1.81 [99% CI, 1.56-2.12]), BSI-other (HR, 1.81 [99% CI, 1.60-2.06]), and MBI-LCBI plus BSI-other (HR, 2.65 [99% CI, 2.17-3.24]) compared with controls. Infection was more commonly reported as a cause of death for patients with MBI-LCBI (139 of 740 [18.8%]), BSI (251 of 1537 [16.3%]), and MBI-LCBI plus BSI (94 of 435 [21.6%]) than for controls (566 of 4740 [11.9%]). CONCLUSIONS AND RELEVANCE In this cohort study, MBI-LCBI, in addition to any BSIs, were associated with significant morbidity and mortality after HSCT. Further investigation into risk reduction should be a clinical and scientific priority in this patient population.
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Affiliation(s)
- Christopher E. Dandoy
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Soyoung Kim
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee
- Division of Biostatistics, Institute for Health and Equity, Medical College of Wisconsin, Milwaukee
| | - Min Chen
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee
| | - Kwang Woo Ahn
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee
- Division of Biostatistics, Institute for Health and Equity, Medical College of Wisconsin, Milwaukee
| | - Monica I. Ardura
- Division of Infectious Disease, Department of Pediatrics, Nationwide Children’s Hospital, Columbus, Ohio
| | - Valerie Brown
- Division of Pediatric Oncology/Hematology, Department of Pediatrics, Penn State Hershey Children’s Hospital and College of Medicine, Hershey, Pennsylvania
| | - Saurabh Chhabra
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee
- Divsion of Hematology/Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee
| | - Miguel Angel Diaz
- Department of Hematology/Oncology, Hospital Infantil Universitario Nino Jesus, Madrid, Spain
| | - Christopher Dvorak
- Divsion of Pediatric Allergy, Immunology & Bone Marrow Transplantation, Benioff Children’s Hospital, University of California, San Francisco
| | - Nosha Farhadfar
- Division of Hematology/Oncology, University of Florida College of Medicine, Gainesville
| | - Aron Flagg
- Division of Pediatric Hematology-Oncology, Department of Pediatrics, Yale New Haven Hospital, New Haven, Connecticut
| | - Siddartha Ganguly
- Division of Hematological Malignancy and Cellular Therapeutics, University of Kansas Health System, Kansas City
| | - Gregory A. Hale
- Department of Hematology/Oncology, Johns Hopkins All Children’s Hospital, St Petersburg, Florida
| | - Shahrukh K. Hashmi
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
- Oncology Center, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Peiman Hematti
- Division of Hematology/Oncology/Bone Marrow Transplantation, Department of Medicine, University of Wisconsin, Madison
| | - Rodrigo Martino
- Division of Clinical Hematology, Hospital de la Santa Creu I Sant Pau, Barcelona, Spain
| | - Taiga Nishihori
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Roomi Nusrat
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Richard F. Olsson
- Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
- Centre for Clinical Research Sormland, Uppsala University, Uppsala, Sweden
| | - Seth J. Rotz
- Department of Pediatric Hematology, Oncology and Blood and Marrow Transplantation, Cleveland Clinic Children’s Hospital, Cleveland, Ohio
| | - Anthony D. Sung
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Miguel-Angel Perales
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Caroline A. Lindemans
- Pediatric Blood and Marrow Transplantation Program, University Medical Center Utrecht, Utrecht University, Netherlands
- Division of Pediatric Stem Cell Transplantation, Department of Pediatrics, Princess Maxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | | | - Marcie L. Riches
- Division of Hematology/Oncology, The University of North Carolina at Chapel Hill
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83
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Xu Z, Luo C, Lai P, Ling W, Wu S, Huang X, Huang L, Zhang G, Du X, Weng J. von Willebrand Factor as a Predictor for Transplant-Associated Thrombotic Microangiopathy. Clin Appl Thromb Hemost 2020; 26:1076029619892684. [PMID: 32088973 PMCID: PMC7256332 DOI: 10.1177/1076029619892684] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 11/04/2019] [Accepted: 11/13/2019] [Indexed: 12/29/2022] Open
Abstract
CONCLUSION von Willebrand factor is a useful predictor and prognostic measure for TA-TMA, which may help clinicians identify and manage this life-threatening disease earlier.
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Affiliation(s)
- Zhenzhen Xu
- Department of Hematology, Guangdong Provincial People’s Hospital, Guangdong
Academy of Medical Sciences, Guangzhou, Guangdong, People’s Republic of China
| | - Chengwei Luo
- Department of Hematology, Guangdong Provincial People’s Hospital, Guangdong
Academy of Medical Sciences, Guangzhou, Guangdong, People’s Republic of China
| | - Peilong Lai
- Department of Hematology, Guangdong Provincial People’s Hospital, Guangdong
Academy of Medical Sciences, Guangzhou, Guangdong, People’s Republic of China
| | - Wei Ling
- Department of Hematology, Guangdong Provincial People’s Hospital, Guangdong
Academy of Medical Sciences, Guangzhou, Guangdong, People’s Republic of China
| | - Suijing Wu
- Department of Hematology, Guangdong Provincial People’s Hospital, Guangdong
Academy of Medical Sciences, Guangzhou, Guangdong, People’s Republic of China
| | - Xin Huang
- Department of Hematology, Guangdong Provincial People’s Hospital, Guangdong
Academy of Medical Sciences, Guangzhou, Guangdong, People’s Republic of China
| | - Lisi Huang
- Department of Hematology, Guangdong Provincial People’s Hospital, Guangdong
Academy of Medical Sciences, Guangzhou, Guangdong, People’s Republic of China
| | - Guanrong Zhang
- Information and Statistics Center, Guangdong Provincial People’s Hospital,
Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, People’s Republic of
China
| | - Xin Du
- Department of Hematology, Guangdong Provincial People’s Hospital, Guangdong
Academy of Medical Sciences, Guangzhou, Guangdong, People’s Republic of China
| | - Jianyu Weng
- Department of Hematology, Guangdong Provincial People’s Hospital, Guangdong
Academy of Medical Sciences, Guangzhou, Guangdong, People’s Republic of China
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84
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Zini G, De Cristofaro R. Diagnostic Testing for Differential Diagnosis in Thrombotic Microangiopathies. Turk J Haematol 2019; 36:222-229. [PMID: 31337190 PMCID: PMC6863018 DOI: 10.4274/tjh.galenos.2019.2019.0165] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 07/22/2019] [Indexed: 12/16/2022] Open
Abstract
Thrombotic microangiopathies (TMAs) are multiple disease entities with different etiopathogeneses, characterized by thrombocytopenia, microangiopathic hemolytic anemia (MAHA) with schistocytosis, variable symptoms including fever, and multi-organ failure such as mild renal impairment and neurological deficits. The two paradigms of TMAs are represented on one hand by acquired thrombotic thrombocytopenic purpura (TTP) and on the other by hemolytic uremic syndrome (HUS). The differential diagnosis between these two paradigmatic forms of TMA is based on the presence of either frank renal failure in HUS or a severe deficiency (<10%) of the zinc-protease ADAMTS13 (a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13) in TTP. ADAMTS13 is an enzyme involved in the proteolytic processing of von Willebrand factor (vWF), and its deficiency results in formation of high-molecular-weight vWF-rich microthrombi in the environment of the microvasculature. The presence of these ultra-large vWF multimers in the microcirculation can recruit platelets, promoting multi-organ ischemic lesions. The presence of ADAMTS13 activity at >10% could rule out the presence of a TTP form. However, it is often difficult to differentiate either a TTP or HUS clinical scenario presenting with typical symptoms of TMA. There are in fact several additional diagnoses that should be considered in patients with ADAMTS13 activity of >10%. Widespread inflammation with endothelial damage and adverse reactions to drugs play a central role in the pathogenesis of several forms of TMA, and in these cases, the differential diagnosis should be directed at the underlying disease. Hence, a correct etiologic diagnosis of TMA should involve a critical illness, cancer-associated TMA, drug-induced TMA, and hematopoietic transplant-associated TMA. A complete assessment of all the possible etiologies for TMA symptoms, including acquired or congenital TTP, will allow for a more accurate diagnosis and application of a more appropriate treatment.
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Affiliation(s)
- Gina Zini
- Fondazione Policlinico Universitario A. Gemelli IRCCS - Rome, Italy
- Institute of Hematology, Università Cattolica del S. Cuore, Rome, Italy
| | - Raimondo De Cristofaro
- Fondazione Policlinico Universitario A. Gemelli IRCCS - Rome, Italy
- Institute of Internal Medicine and Geriatrics, Università Cattolica del S. Cuore, Rome, Italy
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85
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Padmanabhan A, Connelly-Smith L, Aqui N, Balogun RA, Klingel R, Meyer E, Pham HP, Schneiderman J, Witt V, Wu Y, Zantek ND, Dunbar NM, Schwartz GEJ. Guidelines on the Use of Therapeutic Apheresis in Clinical Practice - Evidence-Based Approach from the Writing Committee of the American Society for Apheresis: The Eighth Special Issue. J Clin Apher 2019; 34:171-354. [PMID: 31180581 DOI: 10.1002/jca.21705] [Citation(s) in RCA: 766] [Impact Index Per Article: 153.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The American Society for Apheresis (ASFA) Journal of Clinical Apheresis (JCA) Special Issue Writing Committee is charged with reviewing, updating and categorizing indications for the evidence-based use of therapeutic apheresis (TA) in human disease. Since the 2007 JCA Special Issue (Fourth Edition), the committee has incorporated systematic review and evidence-based approaches in the grading and categorization of apheresis indications. This Eighth Edition of the JCA Special Issue continues to maintain this methodology and rigor in order to make recommendations on the use of apheresis in a wide variety of diseases/conditions. The JCA Eighth Edition, like its predecessor, continues to apply the category and grading system definitions in fact sheets. The general layout and concept of a fact sheet that was introduced in the Fourth Edition, has largely been maintained in this edition. Each fact sheet succinctly summarizes the evidence for the use of TA in a specific disease entity or medical condition. The Eighth Edition comprises 84 fact sheets for relevant diseases and medical conditions, with 157 graded and categorized indications and/or TA modalities. The Eighth Edition of the JCA Special Issue seeks to continue to serve as a key resource that guides the utilization of TA in the treatment of human disease.
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Affiliation(s)
- Anand Padmanabhan
- Medical Sciences Institute & Blood Research Institute, Versiti & Department of Pathology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Laura Connelly-Smith
- Department of Medicine, Seattle Cancer Care Alliance & University of Washington, Seattle, Washington
| | - Nicole Aqui
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rasheed A Balogun
- Department of Medicine, University of Virginia, Charlottesville, Virginia
| | - Reinhard Klingel
- Apheresis Research Institute, Cologne, Germany & First Department of Internal Medicine, University of Mainz, Mainz, Germany
| | - Erin Meyer
- Department of Hematology/Oncology/BMT/Pathology, Nationwide Children's Hospital, Columbus, Ohio
| | - Huy P Pham
- Department of Pathology, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Jennifer Schneiderman
- Department of Pediatric Hematology/Oncology/Neuro-oncology/Stem Cell Transplant, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University, Chicago, Illinois
| | - Volker Witt
- Department for Pediatrics, St. Anna Kinderspital, Medical University of Vienna, Vienna, Austria
| | - Yanyun Wu
- Bloodworks NW & Department of Laboratory Medicine, University of Washington, Seattle, Washington, Yale University School of Medicine, New Haven, Connecticut
| | - Nicole D Zantek
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota
| | - Nancy M Dunbar
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
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86
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Risk Factors for Transplant-Associated Thrombotic Microangiopathy after Autologous Hematopoietic Cell Transplant in High-Risk Neuroblastoma. Biol Blood Marrow Transplant 2019; 25:2031-2039. [DOI: 10.1016/j.bbmt.2019.06.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 05/21/2019] [Accepted: 06/05/2019] [Indexed: 12/12/2022]
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87
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Rosner MH, Perazella MA. Acute kidney injury in the patient with cancer. Kidney Res Clin Pract 2019; 38:295-308. [PMID: 31284363 PMCID: PMC6727896 DOI: 10.23876/j.krcp.19.042] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 05/05/2019] [Accepted: 05/13/2019] [Indexed: 02/06/2023] Open
Abstract
Dramatic advances in the care of patients with cancer have led to significant improvement in outcomes and survival. However, renal manifestations of the underlying cancer as well as the effects of anti-neoplastic therapies leave patients with significant morbidity and chronic kidney disease risks. The most common renal manifestations associated with cancer include acute kidney injury (AKI) in the setting of multiple myeloma, tumor lysis syndrome, post-hematopoietic stem cell therapy, and AKI associated with chemotherapy. Knowledge of specific risk factors, modification of risk and careful attention to rapid AKI diagnosis are critical for improving outcomes.
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Affiliation(s)
- Mitchell H Rosner
- Division of Nephrology, University of Virginia Health System, Charlottesville, VA, USA
| | - Mark A Perazella
- Department of Internal Medicine, Section of Nephrology, Yale University School of Medicine, New Haven, CT, USA
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88
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Yamada R, Nemoto T, Ohashi K, Tonooka A, Horiguchi SI, Motoi T, Hishima T. Distribution of Transplantation-Associated Thrombotic Microangiopathy (TA-TMA) and Comparison between Renal TA-TMA and Intestinal TA-TMA: Autopsy Study. Biol Blood Marrow Transplant 2019; 26:178-188. [PMID: 31491486 DOI: 10.1016/j.bbmt.2019.08.025] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 08/19/2019] [Accepted: 08/21/2019] [Indexed: 01/08/2023]
Abstract
Transplantation-associated thrombotic microangiopathy (TA-TMA) is an important complication of hematopoietic stem cell transplantation. To date, information regarding the organs that are affected by TA-TMA as confirmed histologically remains limited; the clinicopathologic differences between renal TA-TMA and intestinal TA-TMA have not been examined despite being the well-known and commonly affected sites of TA-TMA. We therefore examined 165 autopsied patients after hematopoietic stem cell transplantation and compared the clinicopathologic factors of renal and intestinal TA-TMA. It was clear that 38 (23%) of our patients had TA-TMA. In the TA-TMA cases, the kidney (61%) and intestine (53%) were commonly affected, and the ileum and right colon were vulnerable. Other organs that we found to be affected by TA-TMA included the stomach (8%), gallbladder (5%), and oral cavity, pharynx, esophagus, liver, heart, urinary bladder, and ureter (all at 3%), and symptoms thought to be caused by TA-TMA of these organs were not observed in any patient. Histologically, TA-TMA only affected the arteriole, or small arteries, regardless of the organ, and the veins or larger arteries were not affected at all. In the kidney, the glomerular capillary was also affected, and mesangiolysis and double contours of the basement membranes were often in evidence. The histologic overlap of renal and intestinal TA-TMA was rare (13%), and the patients in the intestinal TA-TMA group exhibited more frequency of a history of intestinal acute graft-versus-host disease (GVHD) during the clinical course compared with that of the renal TA-TMA group (80% versus 22%, P = .0016). Although TA-TMA can affect many other organs, the frequency of these ancillary events was low, and the clinical effect may have been small. Our results suggest that in comparison to renal TA-TMA, intestinal GVHD could be more closely associated with intestinal TA-TMA as a risk factor.
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Affiliation(s)
- Rin Yamada
- Department of Pathology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | - Tetsuo Nemoto
- Department of Pathology, Showa University Northern Yokohama Hospital, Kanagawa, Japan
| | - Kazuteru Ohashi
- Department of Hematology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | - Akiko Tonooka
- Department of Pathology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | - Shin-Ichiro Horiguchi
- Department of Pathology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | - Toru Motoi
- Department of Pathology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | - Tsunekazu Hishima
- Department of Pathology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan.
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89
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Fahmawi Y, Campos Y, Khushman M, Alkharabsheh O, Manne A, Zubair H, Haleema S, Polski J, Bessette S. Vitamin B12 deficiency presenting as pseudo-thrombotic microangiopathy: a case report and literature review. Clin Pharmacol 2019; 11:127-131. [PMID: 31695518 PMCID: PMC6717731 DOI: 10.2147/cpaa.s207258] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 08/20/2019] [Indexed: 01/17/2023] Open
Abstract
Pseudo-thrombotic microangiopathy (pseudo-TMA) is a recognized, yet uncommon, clinical presentation of vitamin B12 deficiency. Patients with pseudo-TMA present with microangiopathic hemolytic anemia (MAHA), thrombocytopenia and schistocytes. They are often misdiagnosed as thrombotic thrombocytopenia purpura (TTP) and receive unnecessary therapy. Here, we report a case of a 60-year-old male who presented with thrombocytopenia and normocytic normochromic anemia. Anemia work-up was remarkable for severe B12 deficiency (<60 pg/mL) and a positive non-immune hemolysis panel. Peripheral smear was reviewed and showed anisocytes, poikilocytes, schistocytes and hypersegmented neutrophils. Vitamin B12 replacement (1000 mcg IM daily) was started, ADAMTS13 activity was sent and daily plasmapheresis was initiated. Over the next 3 days, the patient’s hemoglobin and platelets were stable and the hemolysis panel showed gradual improvement. On day 4, ADAMTS13 activity results came back normal at 61%. Accordingly, plasmapheresis was discontinued, parenteral B12 replacement was continued and that resulted in gradual improvement and eventually cessation of hemolysis and normalization of hemoglobin and platelets. In this patient, parietal cell autoantibodies were positive and so the diagnosis of pernicious anemia was made. Patients with severe vitamin B12 deficiency may present with features mimicking TTP such as MAHA, thrombocytopenia and schistocytosis. An early and accurate diagnosis of pseudo-TMA has a critical clinical impact with respect to administering the correct treatment with vitamin B12 replacement and avoiding, or shortening the duration of, unnecessary therapy with plasmapheresis.
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Affiliation(s)
- Yazan Fahmawi
- Department of Internal Medicine, University of South Alabama, Mobile, AL, USA
| | - Yesica Campos
- Department of Internal Medicine, University of South Alabama, Mobile, AL, USA
| | - Moh'd Khushman
- Department of Hematology-Oncology, Mitchell Cancer Institute, University of South Alabama, Mobile, AL, USA
| | - Omar Alkharabsheh
- Department of Hematology-Oncology, Mitchell Cancer Institute, University of South Alabama, Mobile, AL, USA
| | - Ashish Manne
- Department of Hematology-Oncology, Mitchell Cancer Institute, University of South Alabama, Mobile, AL, USA
| | - Haseeb Zubair
- Department of Hematology-Oncology, Mitchell Cancer Institute, University of South Alabama, Mobile, AL, USA
| | - Saadia Haleema
- Department of Pathology, University of South Alabama, Mobile, AL, USA
| | - Jacek Polski
- Department of Pathology, University of South Alabama, Mobile, AL, USA
| | - Sabrina Bessette
- Department of Internal Medicine, University of South Alabama, Mobile, AL, USA
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90
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Circulating Heme Oxygenase-1 and Complement Activation in Transplant-Associated Thrombotic Microangiopathy. Biol Blood Marrow Transplant 2019; 25:1486-1491. [DOI: 10.1016/j.bbmt.2019.03.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Accepted: 03/01/2019] [Indexed: 01/08/2023]
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91
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Joo SJ, Yildirim I, Stenger EO, Anderson EJ. Sirolimus-associated pericardial effusion with cardiac tamponade and interstitial pneumonitis in a hematopoietic stem cell transplant recipient. Pediatr Transplant 2019; 23:e13425. [PMID: 31012209 DOI: 10.1111/petr.13425] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2018] [Revised: 02/10/2019] [Accepted: 03/11/2019] [Indexed: 12/24/2022]
Abstract
Sirolimus, a mammalian target of rapamycin (mTOR) inhibitor, is a potent immunosuppressant that is increasingly used in prevention and treatment of graft-vs-host disease (GVHD) in allogeneic hematopoietic stem cell transplant (HSCT) patients. However, data regarding its adverse effects in HSCT patients remain limited. We describe an 18-year-old HSCT patient with a history of invasive fungal infection, who developed pericardial effusion with cardiac tamponade and interstitial pneumonitis while receiving sirolimus for GVHD prophylaxis. Our case illustrates potentially life-threatening complications of sirolimus use in allogeneic HSCT patients.
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Affiliation(s)
- Su Jin Joo
- Division of Pediatric Infectious Diseases, Nationwide Children's Hospital, Columbus, Ohio.,Division of Pediatric Infectious Diseases, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Inci Yildirim
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia.,Rollins School of Public Health, Department of Epidemiology, Emory University, Atlanta, Georgia
| | - Elizabeth O Stenger
- Division of Pediatric Hematology and Oncology, Emory University, Atlanta, Georgia
| | - Evan J Anderson
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia.,Division of Infectious Diseases, Department of Internal Medicine, Emory University School of Medicine, Atlanta, Georgia
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92
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Schuh MP, Bennett MR, Lane A, Jodele S, Laskin BL, Devarajan P. Haptoglobin degradation product as a novel serum biomarker for hematopoietic stem cell transplant-associated thrombotic microangiopathy. Pediatr Nephrol 2019; 34:865-871. [PMID: 30569313 PMCID: PMC6728916 DOI: 10.1007/s00467-018-4178-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Revised: 12/10/2018] [Accepted: 12/12/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND Hematopoietic stem cell transplant (HSCT)-associated thrombotic microangiopathy (TA-TMA) is a well-known complication of HSCT and carries high risk of morbidity and mortality. A lack of consistent non-invasive diagnostic criteria can delay diagnosis and lead to irreversible organ damage. METHODS Serum samples of 100 patients that underwent HSCT at Cincinnati Children's Hospital were serially collected. Unbiased proteomic profiling by SELDI-TOF-MS was performed on serum from TA-TMA patients at baseline (pre-HSCT), 2 weeks before TMA diagnosis (pre-TMA), and at clinical TMA diagnosis. Two proteins with mass to charge ratios of 12-13 kDa were consistently elevated at the 2 week pre-TMA time point by SELDI-TOF, compared to control samples. Potential peptides were isolated and analyzed by liquid chromatography-tandem mass spectrometry (LC-MS/MS) on the Linear Trap Quadropole (LTQ). A MASCOT search identified haptoglobin fragments in the 12-17-kDa range. Western blot was performed to validate haptoglobin fragments as a potential biomarker. RESULTS Western blot of TA-TMA patients showed haptoglobin fragments at 12, 14, and 17 kDa that varied between baseline, pre-TMA, and TMA time points for each patient. By densitometric analysis, the 17-kDa fragment in the pre-TMA samples differed significantly from TMA diagnosis (p < 0.0001). There was no significant difference in the concentrations of the 12-kDa and 14-kDa fragments. CONCLUSION The 17-kDa haptoglobin degradation product may represent a novel early serum biomarker for TA-TMA that could potentially allow for earlier diagnosis and intervention.
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Affiliation(s)
- Meredith P Schuh
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, USA.
| | - Michael R Bennett
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, USA
| | - Adam Lane
- Division of Bone Marrow Transplantation, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, USA
| | - Sonata Jodele
- Division of Bone Marrow Transplantation, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, USA
| | - Benjamin L Laskin
- Division of Nephrology, The Children's Hospital of Philadelphia and the Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Prasad Devarajan
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, USA
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93
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Hypertension in hematologic malignancies and hematopoietic cell transplantation: An emerging issue with the introduction of novel treatments. Blood Rev 2019; 35:51-58. [DOI: 10.1016/j.blre.2019.03.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2018] [Revised: 12/29/2018] [Accepted: 03/12/2019] [Indexed: 12/12/2022]
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94
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Palomo M, Diaz-Ricart M, Carreras E. Endothelial Dysfunction in Hematopoietic Cell Transplantation. Clin Hematol Int 2019; 1:45-51. [PMID: 34595410 PMCID: PMC8432381 DOI: 10.2991/chi.d.190317.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 03/14/2019] [Indexed: 12/24/2022] Open
Abstract
The goal of this review is to look at the role of endothelial damage and dysfunction in the initiation and development of early complications that appear after hematopoietic cell transplantation (HCT). These early complications share overlapping clinical manifestations and the suspicion of underlying endothelial damage. Several studies using different approaches, such as animal and in vitro models, the analysis of soluble biomarkers and clinical findings have provided evidence of this endothelial dysfunction. Historically, the first complication in which the role of endothelial damage was elucidated was the veno-oclusive disease/sinusoidal obstructive syndrome. In the last two decades, increasing evidence of the implication of the endothelium in the pathophysiology of other syndromes such as capillary leak syndrome, transplant-associated microangiopathy, or even graft versus host disease has accumulated. This knowledge opens up potential pharmacologic interventions to prevent/and/or treat endothelial damage and, therefore, to improve the outcome of patients receiving HCT.
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Affiliation(s)
- Marta Palomo
- Josep Carreras Leukaemia Research Institute, Hospital Clinic/University of Barcelona Campus, Barcelona, Spain.,Hematopathology, Department of Pathology, Hospital Clinic of Barcelona, Biomedical Diagnosis Center (CDB), Institute of Biomedical Research August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain.,Barcelona Endothelium Team
| | - Maribel Diaz-Ricart
- Hematopathology, Department of Pathology, Hospital Clinic of Barcelona, Biomedical Diagnosis Center (CDB), Institute of Biomedical Research August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain.,Barcelona Endothelium Team
| | - Enric Carreras
- Josep Carreras Leukaemia Research Institute, Hospital Clinic/University of Barcelona Campus, Barcelona, Spain.,Barcelona Endothelium Team
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95
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Gavriilaki E, Anagnostopoulos A, Mastellos DC. Complement in Thrombotic Microangiopathies: Unraveling Ariadne's Thread Into the Labyrinth of Complement Therapeutics. Front Immunol 2019; 10:337. [PMID: 30891033 PMCID: PMC6413705 DOI: 10.3389/fimmu.2019.00337] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Accepted: 02/08/2019] [Indexed: 12/20/2022] Open
Abstract
Thrombotic microangiopathies (TMAs) are a heterogeneous group of syndromes presenting with a distinct clinical triad: microangiopathic hemolytic anemia, thrombocytopenia, and organ damage. We currently recognize two major entities with distinct pathophysiology: thrombotic thrombocytopenic purpura (TTP) and hemolytic uremic syndrome (HUS). Beyond them, differential diagnosis also includes TMAs associated with underlying conditions, such as drugs, malignancy, infections, scleroderma-associated renal crisis, systemic lupus erythematosus (SLE), malignant hypertension, transplantation, HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets), and disseminated intravascular coagulation (DIC). Since clinical presentation alone is not sufficient to differentiate between these entities, robust pathophysiological features need to be used for early diagnosis and appropriate treatment. Over the last decades, our understanding of the complement system has evolved rapidly leading to the characterization of diseases which are fueled by complement dysregulation. Among TMAs, complement-mediated HUS (CM-HUS) has long served as a disease model, in which mutations of complement-related genes represent the first hit of the disease and complement inhibition is an effective and safe strategy. Based on this knowledge, clinical conditions resembling CM-HUS in terms of phenotype and genotype have been recognized. As a result, the role of complement in TMAs is rapidly expanding in recent years based on genetic and functional studies. Herein we provide an updated overview of key pathophysiological processes underpinning complement activation and dysregulation in TMAs. We also discuss emerging clinical challenges in streamlining diagnostic algorithms and stratifying TMA patients that could benefit more from complement modulation. With the advent of next-generation complement therapeutics and suitable disease models, these translational perspectives could guide a more comprehensive, disease- and target-tailored complement intervention in these disorders.
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Affiliation(s)
- Eleni Gavriilaki
- BMT Unit, Hematology Department, G. Papanicolaou Hospital, Thessaloniki, Greece
| | | | - Dimitrios C Mastellos
- Division of Biodiagnostic Sciences and Technologies, INRASTES, National Center for Scientific Research Demokritos, Athens, Greece
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96
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Elfeky R, Shah RM, Unni MNM, Ottaviano G, Rao K, Chiesa R, Amrolia P, Worth A, Flood T, Abinun M, Hambleton S, Cant AJ, Gilmour K, Adams S, Ahsan G, Barge D, Gennery AR, Qasim W, Slatter M, Veys P. New graft manipulation strategies improve the outcome of mismatched stem cell transplantation in children with primary immunodeficiencies. J Allergy Clin Immunol 2019; 144:280-293. [PMID: 30731121 DOI: 10.1016/j.jaci.2019.01.030] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2018] [Revised: 01/11/2019] [Accepted: 01/17/2019] [Indexed: 01/04/2023]
Abstract
BACKGROUND Mismatched stem cell transplantation is associated with a high risk of graft loss, graft-versus-host disease (GvHD), and transplant-related mortality. Alternative graft manipulation strategies have been used over the last 11 years to reduce these risks. OBJECTIVE We investigated the outcome of using different graft manipulation strategies among children with primary immunodeficiencies. METHODS Between 2006 and 2017, 147 patients with primary immunodeficiencies received 155 mismatched grafts: 30 T-cell receptor (TCR) αβ/CD19-depleted grafts, 43 cord blood (CB) grafts (72% with no serotherapy), 17 CD34+ selection with T-cell add-back grafts, and 65 unmanipulated grafts. RESULTS The estimated 8-year survival of the entire cohort was 79%, transplant-related mortality was 21.7%, and the graft failure rate was 6.7%. Posttransplantation viral reactivation, grade II to IV acute graft-versus-host disease (aGvHD), and chronic graft-versus-host disease (cGvHD) complicated 49.6%, 35%, and 15% of transplantations, respectively. Use of TCRαβ/CD19 depletion was associated with a significantly lower incidence of grade II to IV aGvHD (11.5%) and cGvHD (0%), although with a greater incidence of viral reactivation (70%) in comparison with other grafts. T-cell immune reconstitution was robust among CB transplants, although with a high incidence (56.7%) of grade II to IV aGvHD. Stable full donor engraftment was significantly greater at 80% among TCRαβ+/CD19+-depleted and CB transplants versus 40% to 60% among the other groups. CONCLUSIONS Rapidly accessible CB and haploidentical grafts are suitable alternatives for patients with no HLA-matched donor. Cord transplantation without serotherapy and TCRαβ+/CD19+-depleted grafts produced comparable survival rates of around 80%, although with a high rate of aGvHD with the former and a high risk of viral reactivation with the latter that need to be addressed.
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Affiliation(s)
- Reem Elfeky
- Molecular and Cellular Immunology Unit, University College London (UCL) Great Ormond Street Institute of Child Health, London, United Kingdom; Department of Paediatric Allergy and Immunology, Ain Shams University, Cairo, Egypt.
| | - Ravi M Shah
- Blood and Bone Marrow Transplant Unit, Great Ormond Street Hospital, London, United Kingdom; Department of Paediatric Oncology and BMT, Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Mohamed N M Unni
- Host Defence Unit, Great North Children's Hospital, Newcastle Upon Tyne, United Kingdom
| | - Giorgio Ottaviano
- Department of Paediatrics, Fondazione MBBM University of Milan-Bicocca, Monza, Italy
| | - Kanchan Rao
- Blood and Bone Marrow Transplant Unit, Great Ormond Street Hospital, London, United Kingdom
| | - Robert Chiesa
- Blood and Bone Marrow Transplant Unit, Great Ormond Street Hospital, London, United Kingdom
| | - Persis Amrolia
- Molecular and Cellular Immunology Unit, University College London (UCL) Great Ormond Street Institute of Child Health, London, United Kingdom; Blood and Bone Marrow Transplant Unit, Great Ormond Street Hospital, London, United Kingdom
| | - Austen Worth
- Blood and Bone Marrow Transplant Unit, Great Ormond Street Hospital, London, United Kingdom
| | - Terry Flood
- Host Defence Unit, Great North Children's Hospital, Newcastle Upon Tyne, United Kingdom
| | - Mario Abinun
- Host Defence Unit, Great North Children's Hospital, Newcastle Upon Tyne, United Kingdom
| | - Sophie Hambleton
- Host Defence Unit, Great North Children's Hospital, Newcastle Upon Tyne, United Kingdom
| | - Andrew J Cant
- Host Defence Unit, Great North Children's Hospital, Newcastle Upon Tyne, United Kingdom
| | - Kimberly Gilmour
- Blood and Bone Marrow Transplant Unit, Great Ormond Street Hospital, London, United Kingdom
| | - Stuart Adams
- Blood and Bone Marrow Transplant Unit, Great Ormond Street Hospital, London, United Kingdom
| | - Gul Ahsan
- Blood and Bone Marrow Transplant Unit, Great Ormond Street Hospital, London, United Kingdom
| | - Dawn Barge
- Host Defence Unit, Great North Children's Hospital, Newcastle Upon Tyne, United Kingdom
| | - Andrew R Gennery
- Host Defence Unit, Great North Children's Hospital, Newcastle Upon Tyne, United Kingdom
| | - Waseem Qasim
- Molecular and Cellular Immunology Unit, University College London (UCL) Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Mary Slatter
- Host Defence Unit, Great North Children's Hospital, Newcastle Upon Tyne, United Kingdom
| | - Paul Veys
- Molecular and Cellular Immunology Unit, University College London (UCL) Great Ormond Street Institute of Child Health, London, United Kingdom; Blood and Bone Marrow Transplant Unit, Great Ormond Street Hospital, London, United Kingdom
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97
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Dvorak CC, Higham C, Shimano KA. Transplant-Associated Thrombotic Microangiopathy in Pediatric Hematopoietic Cell Transplant Recipients: A Practical Approach to Diagnosis and Management. Front Pediatr 2019; 7:133. [PMID: 31024873 PMCID: PMC6465621 DOI: 10.3389/fped.2019.00133] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 03/21/2019] [Indexed: 01/04/2023] Open
Abstract
Transplant-associated thrombotic microangiopathy (TA-TMA) is an endothelial damage syndrome that is increasingly identified as a complication of both autologous and allogeneic hematopoietic cell transplantation (HCT) in children. If not promptly diagnosed and treated, TA-TMA can lead to significant morbidity (e.g., permanent renal injury) or mortality. However, as the recognition of the early stages of TA-TMA may be difficult, we propose a TA-TMA "triad" of hypertension, thrombocytopenia (or platelet transfusion refractoriness), and elevated lactate dehydrogenase (LDH). While not diagnostic, this triad should prompt further evaluation for TA-TMA. There is increased understanding of the risk factors for the development of TA-TMA, including those which are inherent (e.g., race, genetics), transplant approach-related (e.g., second HCT, use of HLA-mismatched donors), and related to post-transplant events (e.g., receipt of calcineurin inhibitors, development of graft-vs. -host-disease, or certain infections). This understanding should lead to enhanced screening for TA-TMA signs and symptoms in high-risk patients. The pathophysiology of TA-TMA is complex, resulting from a cycle of activation of endothelial cells to produce a pro-coagulant state, along with activation of antigen-presenting cells and lymphocytes, as well as activation of the complement cascade and microthrombi formation. This has led to the formulation of a "Three-Hit Hypothesis" in which patients with either an underlying predisposition to complement activation or pre-existing endothelial injury (Hit 1) undergo a toxic conditioning regimen causing endothelial injury (Hit 2), and then additional insults are triggered by medications, alloreactivity, infections, and/or antibodies (Hit 3). Understanding this cycle of injury permits the development of a specific TA-TMA treatment algorithm designed to treat both the triggers and the drivers of the endothelial injury. Finally, several intriguing approaches to TA-TMA prophylaxis have been identified. Future work on the development of a single diagnostic test with high specificity and sensitivity, and the development of a robust risk-scoring system, will further improve the management of this serious post-transplant complication.
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Affiliation(s)
- Christopher C Dvorak
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplant, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA, United States
| | - Christine Higham
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplant, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA, United States
| | - Kristin A Shimano
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplant, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA, United States
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98
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Sartain S, Shubert S, Wu MF, Srivaths P, Teruya J, Krance R, Martinez C. Therapeutic Plasma Exchange does not Improve Renal Function in Hematopoietic Stem Cell Transplantation–Associated Thrombotic Microangiopathy: An Institutional Experience. Biol Blood Marrow Transplant 2019; 25:157-162. [DOI: 10.1016/j.bbmt.2018.08.016] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Accepted: 08/13/2018] [Indexed: 01/27/2023]
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99
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A Heterozygous CFHR3-CFHR1 Gene Deletion in a Pediatric Patient With Transplant-associated Thrombotic Microangiopathy Who was Treated With Eculizumab. J Pediatr Hematol Oncol 2018; 40:e544-e546. [PMID: 28991129 DOI: 10.1097/mph.0000000000000986] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Complement system dysregulation, such as complement Factor H (CFH) autoantibodies and deletions in CFH-related (CFHR) genes 3 and 1, might cause transplant-associated thrombotic microangiopathy (TA-TMA). The use of eculizumab, a terminal complement inhibitor, could be a targeted therapy for TA-TMA. We report a 1-year-old girl who developed TA-TMA, just after autologous peripheral blood stem cell transplantation in neuroblastoma therapy. Eculizumab improved TA-TMA. Investigation for the complement alternative pathway showed a heterozygous CFHR3-CFHR1 gene deletion, which is involved in complement activation. The patient might develop TA-TMA as a result of complement regulatory gene mutation.
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100
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Moiseev IS, Tsvetkova T, Aljurf M, Alnounou RM, Bogardt J, Chalandon Y, Drokov MY, Dvirnyk V, Faraci M, Friis LS, Giglio F, Greinix HT, Kornblit BT, Koelper C, Koenecke C, Lewandowski K, Niederwieser D, Passweg JR, Peczynski C, Penack O, Peric Z, Piekarska A, Ronchi PE, Rovo A, Rzepecki P, Scuderi F, Sigrist D, Siitonen SM, Stoelzel F, Sulek K, Tsakiris DA, Wilkowojska U, Duarte RF, Ruutu T, Basak GW. Clinical and morphological practices in the diagnosis of transplant-associated microangiopathy: a study on behalf of Transplant Complications Working Party of the EBMT. Bone Marrow Transplant 2018; 54:1022-1028. [DOI: 10.1038/s41409-018-0374-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 09/25/2018] [Accepted: 10/02/2018] [Indexed: 11/09/2022]
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