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Bodó I, Amine I, Boban A, Bumbea H, Kulagin A, Lukina E, Piekarska A, Zupan IP, Sokol J, Windyga J, Cermak J. Complement Inhibition in Paroxysmal Nocturnal Hemoglobinuria (PNH): A Systematic Review and Expert Opinion from Central Europe on Special Patient Populations. Adv Ther 2023; 40:2752-2772. [PMID: 37072660 PMCID: PMC10112829 DOI: 10.1007/s12325-023-02510-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 03/28/2023] [Indexed: 04/20/2023]
Abstract
INTRODUCTION Hemolysis in paroxysmal nocturnal hemoglobinuria (PNH) is complement-mediated due to the lack of complement inhibitors in the hemopoietic cell membranes, making complement inhibition the best approach to manage PNH. Three complement inhibitors are approved by the European Medicines Agency as targeted therapy for PNH: eculizumab and ravulizumab, two humanized monoclonal antibodies targeting the same complement 5 (C5) epitope, approved in 2007 and 2019, respectively, and the more recently approved cyclic peptide, the complement 3 (C3) inhibitor pegcetacoplan. Although national and international PNH treatment guidelines exist, they do not take into consideration the latest clinical trial evidence. Given the lack of evidence-based data for some clinical situations encountered in real life, we identified specific populations of patients who may benefit from switching to proximal C3 from terminal C5 inhibition. METHODS The expert recommendations presented here were created using a Delphi-like process by a group of expert PNH specialists across Central Europe. Based on an initial advisory board meeting discussion, recommendations were prepared and reviewed as part of a Delphi survey to test agreement. RESULTS Using a systematic approach, literature databases were searched for relevant studies, and 50 articles were reviewed by the experts and included as supporting evidence. CONCLUSION Implementation of these recommendations uniformly across healthcare institutions will promote the best use of complement inhibition in managing PNH, and has the potential to positively impact patient outcomes in Central Europe and worldwide.
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Affiliation(s)
- Imre Bodó
- Department of Internal Medicine and Hematology, Semmelweis University, 46 Szentkirályi u., Budapest, 1088, Hungary.
| | - Ismail Amine
- Department of Hematology, Tokuda Hospital Sofia, Sofia, Bulgaria
| | - Ana Boban
- Division of Haematology, Department of Internal Medicine, University Hospital Center Zagreb, School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Horia Bumbea
- Bone Marrow Transplant Unit, Department of Hematology, Emergency University Hospital, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Alexander Kulagin
- RM Gorbacheva Research Institute, Pavlov University, St. Petersburg, Russia
| | - Elena Lukina
- Department of Orphan Diseases, National Research Medical Center for Hematology, Moscow, Russia
| | - Agnieszka Piekarska
- Department of Hematology and Transplantology Medical, University of Gdansk, Gdansk, Poland
| | - Irena Preloznik Zupan
- Department of Hematology, University Medical Centre Ljubljana, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Juraj Sokol
- Department of Hematology and Transfusion Medicine, Jessenius Medical Faculty in Martin, Comenius University in Bratislava, Martin, Slovakia
| | - Jerzy Windyga
- Department of Hemostasis Disorders and Internal Medicine, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Jaroslav Cermak
- Institute of Hematology and Blood Transfusion, Prague, Czech Republic
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Lazana I, Apap Mangion S, Babiker S, Large J, Trikha R, Zuckerman M, Gandhi S, Kulasekararaj AG. The Effect of Respiratory Viral Infections on Breakthrough Hemolysis in Patients with Paroxysmal Nocturnal Hemoglobinuria. Int J Mol Sci 2023; 24:ijms24119358. [PMID: 37298309 DOI: 10.3390/ijms24119358] [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: 02/15/2023] [Revised: 04/17/2023] [Accepted: 05/24/2023] [Indexed: 06/12/2023] Open
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) is characterized by hemolysis and thrombosis and is associated with significant morbidity and mortality. Although complement inhibitors have significantly changed the outcomes in PNH patients, breakthrough hemolysis (BTH) may still occur as a response to stress factors such as pregnancy, surgery, and infections. Despite the well-described association between bacterial infections and hemolysis in PNH patients, little is known about the effect of respiratory viruses on triggering hemolytic episodes. This is the first study, to our knowledge, addressing this question. We retrospectively analyzed 34 patients with PNH disease between 2016 and 2018, who were on eculizumab treatment and who presented with respiratory symptoms and were subsequently tested for 10 respiratory viruses (influenza A, influenza B, parainfluenza, respiratory syncytial virus, adenovirus, rhinovirus, and human metapneumovirus). NTS+ patients had higher inflammatory markers, with the majority requiring antibiotics. Acute hemolysis, along with a significant drop in hemoglobin, was noted in the NTS+ group, with three of them requiring a top-up transfusion and two requiring an extra dose of eculizumab. Furthermore, the time from the last eculizumab dose was longer in the NTS+ patients who had BTH, than those who did not. Our data indicate that respiratory virus infections pose a significant risk for BTH in PNH patients on complement inhibitor treatment, underlining the need for regular screening and close monitoring of patients with respiratory symptoms. Furthermore, it implies a higher risk for patients who are not established on complement inhibitors, suggesting the necessity for greater vigilance in these patients.
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Affiliation(s)
- Ioanna Lazana
- Department of Hematological Medicine, King's College Hospital-NHS Foundation Trust, London SE5 9RS, UK
- Cell and Gene Therapy Laboratory, Biomedical Research Foundation of the Academy of Athens, 115 27 Athens, Greece
| | - Sean Apap Mangion
- Department of Hematological Medicine, King's College Hospital-NHS Foundation Trust, London SE5 9RS, UK
| | - Selma Babiker
- Department of Hematological Medicine, King's College Hospital-NHS Foundation Trust, London SE5 9RS, UK
| | - Joanna Large
- Department of Hematological Medicine, King's College Hospital-NHS Foundation Trust, London SE5 9RS, UK
| | - Roochi Trikha
- Department of Hematological Medicine, King's College Hospital-NHS Foundation Trust, London SE5 9RS, UK
| | - Mark Zuckerman
- Department of Virology, King's College NHS Foundation Trust, London SE5 9RS, UK
| | - Shreyans Gandhi
- Department of Hematological Medicine, King's College Hospital-NHS Foundation Trust, London SE5 9RS, UK
- Faculty of Life Sciences and Medicine, King's College London, London WC2R 2LS, UK
| | - Austin G Kulasekararaj
- Department of Hematological Medicine, King's College Hospital-NHS Foundation Trust, London SE5 9RS, UK
- Faculty of Life Sciences and Medicine, King's College London, London WC2R 2LS, UK
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Basílio-Queirós D, Mischak-Weissinger E. Natural killer cells- from innate cells to the discovery of adaptability. Front Immunol 2023; 14:1172437. [PMID: 37275911 PMCID: PMC10232812 DOI: 10.3389/fimmu.2023.1172437] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 05/04/2023] [Indexed: 06/07/2023] Open
Abstract
Natural Killer (NK) cells have come a long way since their first description in the 1970's. The most recent reports of their adaptive-like behavior changed the way the immune system dichotomy is described. Adaptive NK cells present characteristics of both the innate and adaptive immune system. This NK cell subpopulation undergoes a clonal-like expansion in response to an antigen and secondary encounters with the same antigen result in an increased cytotoxic response. These characteristics can be of extreme importance in the clinical setting, especially as adoptive immunotherapies, since NK cells present several advantages compared other cell types. This review will focus on the discovery and the path to the current knowledge of the adaptive NK cell population.
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Sharma R, Ahmed S, Campagnari J, Huff W, Lloyd L. Embedding Patient-Centricity by Collaborating with Patients to Transform the Rare Disease Ecosystem. Pharmaceut Med 2023:10.1007/s40290-023-00474-y. [PMID: 37142887 DOI: 10.1007/s40290-023-00474-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2023] [Indexed: 05/06/2023]
Abstract
What is patient-centricity? In some contexts, it has been associated with targeting therapies based on biomarkers or enabling healthcare access. There has been a surge in patient-centricity publications, and in many cases for the biopharmaceutical industry, patient engagement is used to endorse pre-held assumptions at a specific moment in time. Rarely is patient engagement used to drive business decisions. Here we describe an innovative partnership between Alexion, AstraZeneca Rare Disease and patients that allowed a deeper understanding of the biopharmaceutical stakeholder ecosystem and an empathic understanding of each patient's and caregiver's lived experience. Alexion's decision to build patient-centricity frameworks resulted in the formation of two unique organisation design platforms: STAR (Solutions To Accelerate Results for patients) and LEAP (Learn, Evolve, Activate and deliver for Patients) Immersive Simulations. These interconnected programmes required cultural, global, and organisational shifts. STAR generates global patient insights that are embedded in drug candidate and product strategies while helping to establish enterprise foundational alignment and external stakeholder engagement plans. LEAP Immersive Simulations produce detailed country-level patient and stakeholder insights that contribute to an empathetic understanding of each patient's lived experience, support country medicine launches and provide ideas to have a positive impact along the patient journey. Combined, they deliver integrated, cross-functional insights, patient-centric decision making, an aligned patient journey, and 360° stakeholder activation. Throughout these processes, the patient is empowered to dictate their needs and validate the proposed solutions. This is not a patient engagement survey. This is a partnership where the patient co-authors strategies and solutions.
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Affiliation(s)
- Rohita Sharma
- Global Patient Insights and Solutions, Alexion, AstraZeneca Rare Disease, 1385 Craigleith Road, Oakville, Vaughan, Canada.
| | - Sumaira Ahmed
- Founder/Executive Director, The Sumaira Foundation, Boston, MA, USA
| | - Judy Campagnari
- Global Patient Insights and Solutions, Alexion, AstraZeneca Rare Disease, Boston, MA, USA
| | - Wendi Huff
- Vice President of Programs and Clinical Care, Myasthenia Gravis Foundation of America, Westborough, MA, USA
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Ariceta G. Pharmacological and clinical profile of ravulizumab 100 mg/mL formulation for paroxysmal nocturnal hemoglobinuria and atypical hemolytic uremic syndrome. Expert Rev Clin Pharmacol 2023; 16:401-410. [PMID: 37128905 DOI: 10.1080/17512433.2023.2209317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
INTRODUCTION Paroxysmal nocturnal hemoglobinuria (PNH) and atypical hemolytic uremic syndrome (aHUS) are two rare and severe conditions caused by chronic complement (C') system dysregulation. Treatment with eculizumab, a recombinant, humanized monoclonal antibody against complement C5, changed the natural history of both diseases inducing remission and improving patient outcome. Ravulizumab, a new long-acting next-generation C5 inhibitor has been recently approved for treatment of PNH and aHUS. AREAS COVERED Main characteristics of ravulizumab are described: composition, dosing, efficacy and safety profile. Further, an overview of seminal studies and clinical trials using ravulizumab to treat PNH and aHUS in children and adults is detailed. Literature review was performed using the following key words: paroxysmal nocturnal hemoglobinuria, atypical hemolytic uremic syndrome, and ravulizumab. EXPERT OPINION Ravulizumab profile to treat PNH and aHUS is equivalent to eculizumab in efficacy and safety but allows extended dosing interval to every 4-8 weeks based on patient weight, and requires reduced infusion time. Less travels to infusion centers and medical visits and decreasing job and school absences, significantly increases patient and families' QoL, while reducing cost. Further infusion time is reduced Ravulizumab will possibly become the treatment of choice for patients with PNH and aHUS on chronic C5 inhibition.
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Affiliation(s)
- Gema Ariceta
- Pediatric Nephrology, Hospital Universitari Vall d'Hebron. Universitat Autonoma Barcelona, Spain
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Begum F, Khan N, Boisclair S, Malieckal DA, Chitty D. Complement Inhibitors in the Management of Complement-Mediated Hemolytic Uremic Syndrome and Paroxysmal Nocturnal Hemoglobinuria. Am J Ther 2023; 30:e209-e219. [PMID: 37104648 DOI: 10.1097/mjt.0000000000001609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Abstract
BACKGROUND Complement-mediated HUS (CM-HUS) and paroxysmal nocturnal hemoglobinuria (PNH) are rare hematologic disorders that cause dysregulation and hyperactivation of the complement system. Historically, treatment of CM-HUS involved plasma exchange (PLEX), often with limited benefit and variable tolerance. Conversely, PNH was treated with supportive care or hemopoietic stem cell transplant. Within the last decade, monoclonal antibody therapies that block terminal complement pathway activation, have emerged as less invasive and more efficacious options for management of both disorders. This manuscript seeks to discuss a relevant clinical case of CM-HUS and the evolving landscape of complement inhibitor therapies for CM-HUS and PNH. AREAS OF UNCERTAINTY Eculizumab, the first humanized anti-C5 monoclonal antibody, has been the standard of care in treating CM-HUS and PNH for over a decade. Although eculizumab has remained an effective agent, the variability in ease and frequency of administration has remained an obstacle for patients. The development of novel complement inhibitor therapies with longer half-lives, has allowed for changes in frequency and route of administration, thus improving patient QOL. However, there are limited prospective clinical trial data given disease rarity, and limited information on variable infusion frequency and length of treatment. THERAPEUTIC ADVANCES Recently, there has been a push to formulate complement inhibitors that improve QOL while maintaining efficacy. Ravulizumab, a derivative of eculizumab, was developed to allow for less frequent administration, while remaining efficacious. In addition, the novel oral and subcutaneous therapies, danicopan and crovalimab, respectively, along with pegcetacoplan are currently undergoing active clinical trials, and poised to further reduce treatment burden. CONCLUSION Complement inhibitor therapies have changed the treatment landscape for CM-HUS and PNH. With a significant emphasis on patient QOL, novel therapies continue to emerge and require an in-depth review of their appropriate use and efficacy in these rare disorders. CLINICAL CASE A 47-year-old woman with hypertension and hyperlipidemia presented with shortness of breath and was found to have hypertensive emergency in the setting of acute renal failure. Her serum creatinine was 13.9 mg/dL; elevated from 1.43 mg/dL 2 years before. The differential diagnosis for her acute kidney injury (AKI) included infectious, autoimmune, and hematologic processes. Infectious work-up was negative. ADAMTS13 activity level was not low at 72.9%, ruling out thrombotic thrombocytopenic purpura (TTP). Patient underwent a renal biopsy, which revealed acute on chronic thrombotic microangiopathy (TMA). A trial of eculizumab was initiated with concurrent hemodialysis. The diagnosis of CM-HUS was later confirmed by a heterozygous mutation in complement factor I (CFI), resulting in increased membrane attack complex (MAC) cascade activation. The patient was maintained on biweekly eculizumab and was eventually transitioned to ravulizumab infusions as an outpatient. Her renal failure did not recover, and the patient remains on hemodialysis while awaiting kidney transplantation.
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Affiliation(s)
- Farhana Begum
- Department of Medicine, Zucker School of Medicine-Northwell NS/LIJ, Manhasset, NY 11030
| | - Nida Khan
- Department of Medicine, Zucker School of Medicine-Northwell NS/LIJ, Manhasset, NY 11030
| | - Stephanie Boisclair
- Department of Hematology and Oncology, Northwell Health Cancer Institute, Zucker School of Medicine-Northwell NS/LIJ, Manhasset, NY 11030; and
| | - Deepa A Malieckal
- Division of Kidney Diseases and Hypertension, Zucker School of Medicine-Northwell NS/LIJ, Manhasset, NY 11030
| | - David Chitty
- Department of Hematology and Oncology, Northwell Health Cancer Institute, Zucker School of Medicine-Northwell NS/LIJ, Manhasset, NY 11030; and
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Wong R, Fishman J, Wilson K, Yeh M, Al-Adhami M, Zion A, Yee CW, Huynh L, Duh MS. Comparative Effectiveness of Pegcetacoplan Versus Ravulizumab and Eculizumab in Complement Inhibitor-Naïve Patients with Paroxysmal Nocturnal Hemoglobinuria: A Matching-Adjusted Indirect Comparison. Adv Ther 2023; 40:1571-1589. [PMID: 36750531 PMCID: PMC10070304 DOI: 10.1007/s12325-023-02438-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 01/17/2023] [Indexed: 02/09/2023]
Abstract
INTRODUCTION In the absence of head-to-head trials, this study compared treatment outcomes with the C3 complement inhibitor pegcetacoplan versus the C5 complement inhibitor eculizumab or ravulizumab in complement inhibitor-naïve patients with paroxysmal nocturnal hemoglobinuria (PNH). METHODS A matching-adjusted indirect comparison was conducted using individual patient data from the pegcetacoplan arm of the PRINCE trial (NCT04085601; n = 34) and aggregate data from the ravulizumab (n = 125) and eculizumab (n = 121) arms of the ALXN1210-PNH-301 trial (NCT03056040). Clinical and quality of life endpoints were evaluated after matching patients in the two trials on baseline characteristics. The weighted Wald test with 95% confidence interval was used to compare categorical and continuous variables (i.e., weighted chi-squared and z tests, respectively). Bias factor analysis was performed to quantify the extent of residual bias from unmeasured confounders. RESULTS After weighting, treatment with pegcetacoplan was associated with statistically significant improvements in most clinical endpoints compared with ravulizumab or eculizumab treatment. These included: greater absolute and percent reductions in lactate dehydrogenase (LDH) level and increase in hemoglobin level from baseline; shorter time to first occurrence of LDH normalization; larger proportions of patients achieving hemoglobin stabilization and avoiding transfusion, with fewer packed red blood cell units transfused; and a smaller proportion of patients experiencing breakthrough hemolysis (all p < 0.05). Patients receiving pegcetacoplan also had a greater increase in general health status score from baseline compared with those receiving C5 complement inhibitors. CONCLUSION Pegcetacoplan provides clinical benefits as first-line treatment for complement inhibitor-naïve patients with PNH. TRIAL REGISTRATION ClinicalTrials.gov identifier, NCT04085601.
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Affiliation(s)
- Raymond Wong
- Sir Y.K. Pao Centre for Cancer and Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, 30-32 Ngan Shing Street, Shatin, New Territories, Hong Kong
| | - Jesse Fishman
- Apellis Pharmaceuticals, Inc., 100 5th Avenue, Waltham, MA, 02451, USA
| | - Koo Wilson
- Swedish Orphan Biovitrum AB, Tomtebodavägen 23a, Solna, 171 65, Stockholm, Sweden
| | - Michael Yeh
- Apellis Pharmaceuticals, Inc., 100 5th Avenue, Waltham, MA, 02451, USA
| | | | - Abigail Zion
- Analysis Group, Inc., 111 Huntington Avenue, 14th Floor, Boston, MA, 02199, USA
| | - Christopher W Yee
- Analysis Group, Inc., 111 Huntington Avenue, 14th Floor, Boston, MA, 02199, USA
| | - Lynn Huynh
- Analysis Group, Inc., 111 Huntington Avenue, 14th Floor, Boston, MA, 02199, USA.
| | - Mei Sheng Duh
- Analysis Group, Inc., 111 Huntington Avenue, 14th Floor, Boston, MA, 02199, USA
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de Boer ECW, Thielen AJF, Langereis JD, Kamp A, Brouwer MC, Oskam N, Jongsma ML, Baral AJ, Spaapen RM, Zeerleder S, Vidarsson G, Rispens T, Wouters D, Pouw RB, Jongerius I. The contribution of the alternative pathway in complement activation on cell surfaces depends on the strength of classical pathway initiation. Clin Transl Immunology 2023; 12:e1436. [PMID: 36721662 PMCID: PMC9881211 DOI: 10.1002/cti2.1436] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 10/31/2022] [Accepted: 12/23/2022] [Indexed: 01/28/2023] Open
Abstract
Objectives The complement system is an important component of innate immunity. The alternative pathway (AP) amplification loop is considered an essential feed forward mechanism for complement activation. However, the role of the AP in classical pathway (CP) activation has only been studied in ELISA settings. Here, we investigated its contribution on physiologically relevant surfaces of human cells and bacterial pathogens and in antibody-mediated complement activation, including in autoimmune haemolytic anaemia (AIHA) setting with autoantibodies against red blood cells (RBCs). Methods We evaluated the contribution of the AP to complement responses initiated through the CP on human RBCs by serum of AIHA patients and recombinant antibodies. Moreover, we studied complement activation on Neisseria meningitidis and Escherichia coli. The effect of the AP was examined using either AP-depleted sera or antibodies against factor B and factor D. Results We show that the amplification loop is redundant when efficient CP activation takes place. This is independent of the presence of membrane-bound complement regulators. The role of the AP may become significant when insufficient CP complement activation occurs, but this depends on antibody levels and (sub)class. Our data indicate that therapeutic intervention in the amplification loop will most likely not be effective to treat antibody-mediated diseases. Conclusion The AP can be bypassed through efficient CP activation. The AP amplification loop has a role in complement activation during conditions of modest activation via the CP, when it can allow for efficient complement-mediated killing.
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Affiliation(s)
- Esther CW de Boer
- Department of Immunopathology, Sanquin Research and Landsteiner LaboratoryAmsterdam Infection and Immunity Institute, Amsterdam University Medical CentreAmsterdamThe Netherlands,Department of Pediatric Immunology, Rheumatology, and Infectious Diseases, Emma Children's HospitalAmsterdam University Medical CentreAmsterdamThe Netherlands
| | - Astrid JF Thielen
- Department of Immunopathology, Sanquin Research and Landsteiner LaboratoryAmsterdam Infection and Immunity Institute, Amsterdam University Medical CentreAmsterdamThe Netherlands
| | - Jeroen D Langereis
- Laboratory of Medical Immunology, Radboud Institute for Molecular Life SciencesRadboudumcNijmegenThe Netherlands,Radboud Center for Infectious Diseases, RadboudumcNijmegenThe Netherlands
| | - Angela Kamp
- Department of Immunopathology, Sanquin Research and Landsteiner LaboratoryAmsterdam Infection and Immunity Institute, Amsterdam University Medical CentreAmsterdamThe Netherlands
| | - Mieke C Brouwer
- Department of Immunopathology, Sanquin Research and Landsteiner LaboratoryAmsterdam Infection and Immunity Institute, Amsterdam University Medical CentreAmsterdamThe Netherlands
| | - Nienke Oskam
- Department of Immunopathology, Sanquin Research and Landsteiner LaboratoryAmsterdam Infection and Immunity Institute, Amsterdam University Medical CentreAmsterdamThe Netherlands
| | - Marlieke L Jongsma
- Department of Immunopathology, Sanquin Research and Landsteiner LaboratoryAmsterdam Infection and Immunity Institute, Amsterdam University Medical CentreAmsterdamThe Netherlands
| | - April J Baral
- Translational and Clinical Research InstituteNewcastle upon TyneUK
| | - Robbert M Spaapen
- Department of Immunopathology, Sanquin Research and Landsteiner LaboratoryAmsterdam Infection and Immunity Institute, Amsterdam University Medical CentreAmsterdamThe Netherlands
| | - Sacha Zeerleder
- Department of Immunopathology, Sanquin Research and Landsteiner LaboratoryAmsterdam Infection and Immunity Institute, Amsterdam University Medical CentreAmsterdamThe Netherlands,Department of Hematology, Luzerner KantonsspitalLuzern and University of BernBernSwitzerland,Department for BioMedical ResearchUniversity of BernBernSwitzerland
| | - Gestur Vidarsson
- Department of Experimental Immunohematology, Sanquin Research, and Landsteiner LaboratoryAmsterdam University Medical CenterAmsterdamThe Netherlands
| | - Theo Rispens
- Department of Immunopathology, Sanquin Research and Landsteiner LaboratoryAmsterdam Infection and Immunity Institute, Amsterdam University Medical CentreAmsterdamThe Netherlands
| | - Diana Wouters
- Department of Immunopathology, Sanquin Research and Landsteiner LaboratoryAmsterdam Infection and Immunity Institute, Amsterdam University Medical CentreAmsterdamThe Netherlands,Centre for Infectious Disease ControlNational Institute for Public Health and the Environment (RIVM)BilthovenThe Netherlands
| | - Richard B Pouw
- Department of Immunopathology, Sanquin Research and Landsteiner LaboratoryAmsterdam Infection and Immunity Institute, Amsterdam University Medical CentreAmsterdamThe Netherlands,Sanquin Health SolutionsAmsterdamThe Netherlands
| | - Ilse Jongerius
- Department of Immunopathology, Sanquin Research and Landsteiner LaboratoryAmsterdam Infection and Immunity Institute, Amsterdam University Medical CentreAmsterdamThe Netherlands,Department of Pediatric Immunology, Rheumatology, and Infectious Diseases, Emma Children's HospitalAmsterdam University Medical CentreAmsterdamThe Netherlands
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Biomarkers and laboratory assessments for monitoring the treatment of patients with paroxysmal nocturnal hemoglobinuria: Differences between terminal and proximal complement inhibition. Blood Rev 2023; 59:101041. [PMID: 36732204 DOI: 10.1016/j.blre.2023.101041] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 12/15/2022] [Accepted: 01/09/2023] [Indexed: 01/15/2023]
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) is a rare, life-threatening, acquired disease in which blood cells lacking complement regulatory proteins are destroyed because of uncontrolled complement activity. Since 2007, terminal complement inhibitors have revolutionized the treatment of this disease. However, patients treated with these inhibitors can still experience anemia because of C3-mediated extravascular hemolysis and clinically relevant levels of breakthrough or residual intravascular hemolysis. Proximal complement inhibitors, which are only just beginning to emerge, have the potential to address this problem by targeting components of the pathway upstream of C5, thereby protecting patients against both intra- and extravascular hemolysis. In this review, we describe different biomarkers that can be used to monitor complement pathway blockade and discuss key laboratory assessments for evaluating treatment efficacy. We also consider how these assessments are affected by each class of inhibitor and highlight how evolving treatment goals may influence the relative importance of these assessments.
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Long noncoding RNA FAM157C contributes to clonal proliferation in paroxysmal nocturnal hemoglobinuria. Ann Hematol 2023; 102:299-309. [PMID: 36607351 PMCID: PMC9889514 DOI: 10.1007/s00277-022-05055-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 11/13/2022] [Indexed: 01/07/2023]
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) is a rare clonal disease of hematopoietic stem cells (HSCs). Long noncoding RNAs (lncRNAs) perform a wide range of biological functions, including the regulation of gene expression, cell differentiation, and proliferation, but their role in PNH remains unclear.CD59- and CD59+ granulocytes and monocytes from 35 PNH patients were sorted. High-throughput sequencing was analyzed in 5 PNH patients, and differentially expressed lncRNAs and mRNAs were identified. The mRNAs with fragments per kilobase of exon model per million mapped fragments (FPKM) > 10 in at least 3 patients were selected, and experiments were performed to identify their upstream regulatory lncRNAs. The expression of selected mRNAs and lncRNAs was verified by qRT‒PCR, and the correlation of these expression patterns with clinical data from other 30 PNH patients was analyzed. Then, the functions of the lncRNAs were studied in the PIGA-KO-THP-1 cell line.Transcription analysis revealed 742 upregulated and 1376 downregulated lncRNAs and 3276 upregulated and 213 downregulated mRNAs. After deep screening, 8 highly expressed mRNAs that were related to the NF-κB pathway were analyzed to determine coexpression patterns. LINC01002, FAM157C, CTD-2530H12.2, XLOC-064331 and XLOC-106677 were correlated with the 8 mRNAs. After measuring the expression of these molecules in 30 PNH patients by qRT‒PCR, lncRNA FAM157C was verified to be upregulated in the PNH clone, and its expression levels were positively correlated with the LDH levels and CD59- granulated and monocyte cell ratios. After knockdown of the FAM157C gene in the PIGA-KO-THP-1 cell line, we found that the cells were arrested in the G0/G1 phase and S phase, the apoptosis rate increased, and the cell proliferation decreased.LncRNA FAM157C was proven to promote PNH clone proliferation, and this is the first study to explore the role of lncRNAs in PNH.
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Yenerel MN, Sicre de Fontbrune F, Piatek C, Sahin F, Füreder W, Ortiz S, Ogawa M, Ozol-Godfrey A, Sierra JR, Szer J. Phase 3 Study of Subcutaneous Versus Intravenous Ravulizumab in Eculizumab-Experienced Adult Patients with PNH: Primary Analysis and 1-Year Follow-Up. Adv Ther 2023; 40:211-232. [PMID: 36272026 PMCID: PMC9589670 DOI: 10.1007/s12325-022-02339-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 09/26/2022] [Indexed: 01/28/2023]
Abstract
INTRODUCTION This study compared the pharmacokinetics (PK) of the ravulizumab on-body delivery system for subcutaneous (SUBQ) administration with intravenous (IV) ravulizumab in eculizumab-experienced patients with paroxysmal nocturnal hemoglobinuria (PNH). METHODS Patients with PNH received SUBQ ravulizumab (n = 90) or IV ravulizumab (n = 46) during the 10-week randomized treatment period; all patients then received SUBQ ravulizumab during an extension period (< 172 weeks; data cutoff 1 year). Primary endpoint was day 71 serum ravulizumab trough concentration (Ctrough). Secondary endpoints were ravulizumab Ctrough and free C5 over time. Efficacy endpoints included change in lactate dehydrogenase (LDH), breakthrough hemolysis (BTH), transfusion avoidance, stabilized hemoglobin, and Treatment Administration Satisfaction Questionnaire (TASQ) score. Safety, including adverse events (AEs) and adverse device effects (ADEs), was assessed until data cutoff. RESULTS SUBQ ravulizumab demonstrated PK non-inferiority with IV ravulizumab (day 71 SUBQ/IV geometric least-squares means ratio 1.257 [90% confidence interval 1.160-1.361; p < 0.0001]). Through 1 year of SUBQ administration, ravulizumab Ctrough values were > 175 μg/mL (PK threshold) and free C5 < 0.5 μg/mL (PD threshold). Efficacy endpoints remained stable: mean (standard deviation, SD) LDH percentage change was 0.9% (20.5%); BTH events, 5/128 patients (3.9%); 83.6% achieved transfusion avoidance; 79.7% achieved stabilized hemoglobin. Total TASQ score showed improved satisfaction with SUBQ ravulizumab compared with IV eculizumab (mean [SD] change at SUBQ day 351, - 69.3 [80.1]). The most common AEs during SUBQ treatment (excluding ADEs) were headache (14.1%), COVID-19 (14.1%), and pyrexia (10.9%); the most common ADE unrelated to a device product issue was injection site reaction (4.7%). Although many patients had ≥ 1 device issue-related ADE, full SUBQ dose administration was achieved in 99.9% of attempts. CONCLUSIONS SUBQ ravulizumab provides an additional treatment choice for patients with PNH. Patients may switch to SUBQ ravulizumab from IV eculizumab or ravulizumab without loss of efficacy. TRIAL REGISTRATION NCT03748823.
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Affiliation(s)
- Mustafa N Yenerel
- Division of Hematology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey.
| | - Flore Sicre de Fontbrune
- Hematology and Bone Marrow Transplant Unit, Assistance Publique Hôpitaux des Paris, Saint Louis Hospital, Paris, France
| | - Caroline Piatek
- Jane Anne Nohl Division of Hematology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Fahri Sahin
- Division of Hematology, Department of Internal Medicine, Ege University, Izmir, Turkey
| | - Wolfgang Füreder
- Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna, Austria
| | | | - Masayo Ogawa
- Alexion, AstraZeneca Rare Disease, Boston, MA, USA
| | | | | | - Jeff Szer
- Department of Clinical Haematology, Peter MacCallum Cancer Centre and The Royal Melbourne Hospital, Melbourne, VIC, Australia
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Chatzileontiadou S, Hatjiharissi E, Angelopoulou M, Asimakopoulos JV, Loutsidi NE, Chatzikonstantinou T, Zikos P, Bouchla A, Bezirgiannidou Z, Kouvata E, Frouzaki C, Chaloudis P, Sotiropoulos D, Douka V, Sirigou A, Mandala E, Psyllaki M, Papadaki HA, Marinakis T, Viniou NA, Kokkori S, Kontopidou F, Skepetari A, Vassilopoulos G, Kotsianidis I, Pappa V, Lalayanni C, Baltadakis I, Delimpassi S, Pagoni M, Papaioannou M. Thromboembolic events in patients with paroxysmal nocturnal hemoglobinuria (PNH): Real world data of a Greek nationwide multicenter retrospective study. Front Oncol 2023; 13:1128994. [PMID: 36959785 PMCID: PMC10028290 DOI: 10.3389/fonc.2023.1128994] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 02/07/2023] [Indexed: 03/09/2023] Open
Abstract
Thrombosis is the most common and a life-threatening complication in patients with Paroxysmal Nocturnal Hemoglobinuria. One-third of patients with PNH experience at least one thromboembolic event during the course of the disease, with thrombosis being the most common cause of death in these patients. The mechanism of thrombosis in PNH is complex and continues to be of great research interest. Since the introduction of C5 complement inhibitors in the treatment of PNH, the incidence of thromboembolic events has decreased substantially. We retrospectively analyzed data concerning the thrombotic episodes of 41 patients with PNH from 14 different national hematology centers in Greece. Sixteen patients (39%) experienced at least one episode of thrombosis, including, seven (43.8%) at diagnosis, seven (43.8%) during the course of the disease and two (12.5%) patients prior to PNH diagnosis. Nearly half of these individuals (n=7, 43.8%) had multiple episodes of thrombosis during the course of their disease. The most common sites of thrombosis were intra-abdominal veins. Three out of 26 patients developed thrombosis while on eculizumab. In none of the 16 patients, the thrombotic event was fatal. Our findings, despite the small number of patients, confirmed that thrombosis continues to be a significant complication of PNH affecting more than one third of the patients.
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Affiliation(s)
- S. Chatzileontiadou
- Hematology Unit, 1st Department of Internal Medicine, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - E. Hatjiharissi
- Hematology Unit, 1st Department of Internal Medicine, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - M. Angelopoulou
- Department of Hematology, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - J. V. Asimakopoulos
- Department of Hematology, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - N. E. Loutsidi
- Hematology - Lymphomas Department and Bone Marrow Transplant Unit, Evangelismos General Hospital, Athens, Greece
| | - T. Chatzikonstantinou
- Department of Hematology, Bone Marrow Transplantation Unit, G. Papanicolaou Hospital, Thessaloniki, Greece
| | - P. Zikos
- Department of Hematology, General Hospital of Patras “Aghios Andreas”, Patras, Greece
| | - A. Bouchla
- Second Department of Internal Medicine and Research Unit, Hematology Unit, University General Hospital, “Attikon”, Athens, Greece
| | - Z. Bezirgiannidou
- Department of Hematology, University Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece
| | - E. Kouvata
- Department of Hematology, University Hospital of Larissa, Larissa, Greece
| | - C. Frouzaki
- Hematology Unit, 1st Department of Internal Medicine, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - P. Chaloudis
- Hematology Unit, 1st Department of Internal Medicine, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - D. Sotiropoulos
- Department of Hematology, Bone Marrow Transplantation Unit, G. Papanicolaou Hospital, Thessaloniki, Greece
| | - V. Douka
- Department of Hematology, Bone Marrow Transplantation Unit, G. Papanicolaou Hospital, Thessaloniki, Greece
| | - A. Sirigou
- Department of Hematology, Bone Marrow Transplantation Unit, G. Papanicolaou Hospital, Thessaloniki, Greece
| | - E. Mandala
- Forth Department of Medicine, Aristotle University of Thessaloniki, “Hippokration” Hospital, Thessaloniki, Greece
| | - M. Psyllaki
- Department of Hematology, University of Crete School of Medicine, University Hospital of Heraklion, Heraklion, Greece
| | - H. A. Papadaki
- Department of Hematology, University of Crete School of Medicine, University Hospital of Heraklion, Heraklion, Greece
| | - T. Marinakis
- Department of Hematology, “G. Gennimatas” General Hospital, Athens, Greece
| | - N. A. Viniou
- Hematology Unit, First Department of Internal Medicine, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - S. Kokkori
- Hematology Laboratory, University General Hospital “Attikon”, Athens, Greece
| | - F. Kontopidou
- 2nd Department of Internal Medicine, Medical School, University of Athens, Hippokration General Hospital, Athens, Greece
| | - A. Skepetari
- 2nd Department of Internal Medicine, Medical School, University of Athens, Hippokration General Hospital, Athens, Greece
| | - G. Vassilopoulos
- Department of Hematology, University Hospital of Larissa, Larissa, Greece
| | - I. Kotsianidis
- Department of Hematology, University Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece
| | - V. Pappa
- Second Department of Internal Medicine and Research Unit, Hematology Unit, University General Hospital, “Attikon”, Athens, Greece
| | - C. Lalayanni
- Department of Hematology, Bone Marrow Transplantation Unit, G. Papanicolaou Hospital, Thessaloniki, Greece
| | - I. Baltadakis
- Hematology - Lymphomas Department and Bone Marrow Transplant Unit, Evangelismos General Hospital, Athens, Greece
| | - S. Delimpassi
- Hematology - Lymphomas Department and Bone Marrow Transplant Unit, Evangelismos General Hospital, Athens, Greece
| | - M. Pagoni
- Hematology - Lymphomas Department and Bone Marrow Transplant Unit, Evangelismos General Hospital, Athens, Greece
| | - M. Papaioannou
- Hematology Unit, 1st Department of Internal Medicine, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
- *Correspondence: M. Papaioannou,
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Sadeghalvad M, Rezaei N. Immunodeficiencies. Clin Immunol 2023. [DOI: 10.1016/b978-0-12-818006-8.00004-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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Zarantonello A, Revel M, Grunenwald A, Roumenina LT. C3-dependent effector functions of complement. Immunol Rev 2023; 313:120-138. [PMID: 36271889 PMCID: PMC10092904 DOI: 10.1111/imr.13147] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
C3 is the central effector molecule of the complement system, mediating its multiple functions through different binding sites and their corresponding receptors. We will introduce the C3 forms (native C3, C3 [H2 O], and intracellular C3), the C3 fragments C3a, C3b, iC3b, and C3dg/C3d, and the C3 expression sites. To highlight the important role that C3 plays in human biological processes, we will give an overview of the diseases linked to C3 deficiency and to uncontrolled C3 activation. Next, we will present a structural description of C3 activation and of the C3 fragments generated by complement regulation. We will proceed by describing the C3a interaction with the anaphylatoxin receptor, followed by the interactions of opsonins (C3b, iC3b, and C3dg/C3d) with complement receptors, divided into two groups: receptors bearing complement regulatory functions and the effector receptors without complement regulatory activity. We outline the molecular architecture of the receptors, their binding sites on the C3 activation fragments, the cells expressing them, the diversity of their functions, and recent advances. With this review, we aim to give an up-to-date analysis of the processes triggered by C3 activation fragments on different cell types in health and disease contexts.
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Affiliation(s)
- Alessandra Zarantonello
- Centre de Recherche des Cordeliers, INSERM, Sorbonne Université, Université de Paris, Paris, France
| | - Margot Revel
- Centre de Recherche des Cordeliers, INSERM, Sorbonne Université, Université de Paris, Paris, France
| | - Anne Grunenwald
- Centre de Recherche des Cordeliers, INSERM, Sorbonne Université, Université de Paris, Paris, France
| | - Lubka T Roumenina
- Centre de Recherche des Cordeliers, INSERM, Sorbonne Université, Université de Paris, Paris, France
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Paroxysmal nocturnal hemoglobinuria: A rare case of recurrent episodes of icterus. ACTA MEDICA MARTINIANA 2022. [DOI: 10.2478/acm-2022-0014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Abstract
In this work we describe a rare case of a patient with paroxysmal nocturnal hemoglobinuria (PNH) developed on the background of specific medical history of morbus Gilbert with chronically elevated bilirubin and recurrent attacks of macroscopic haematuria. We focus on a differential diagnosis of the disease, its obstacles, and treatment options.
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66
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Sicre de Fontbrune F, Burmester P, Piggin M, Matos JE, Costantino H, Wilson K, Hakimi Z, Nazir J, Desgraz R, Fishman J, Persson E, Panse J. The burden of illness of patients with paroxysmal nocturnal haemoglobinuria receiving C5 inhibitors: clinical outcomes and medical encounters from the patient perspective. Hematology 2022; 27:1140-1151. [PMID: 36165770 DOI: 10.1080/16078454.2022.2127630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023] Open
Abstract
OBJECTIVES To assess the clinical and healthcare resource burden among C5 inhibitor (C5i)-treated patients with paroxysmal nocturnal haemoglobinuria (PNH), using patient-reported data. METHODS This web-based, cross-sectional survey (01FEB2021-31MAR2021) of adults with PNH treated with eculizumab (France, Germany, UK) or ravulizumab (Germany) included: patient characteristics; treatment patterns/dosage; haematological outcomes (haemoglobin [Hb] levels, transfusions, thrombotic events, breakthrough haemolysis); and medical encounters. Treatment and Hb-level subgroup differences were assessed with statistical significance tests. RESULTS Among 71 patients, 98.6% were C5i-treated for ≥3 months. The majority (with reported Hb levels) had levels ≤12.0 g/dL (85.7%; n = 54/63). The mean Hb level was 10.2 g/dL (standard deviation [SD]: 2.0; median 10.0 g/dL). Treatment with above label-recommended doses was reported by 30.4% (eculizumab) and 5.3% (ravulizumab) of patients. Within the past 12 months among patients treated with C5i for ≥1 year: 24.1% had ≥1 transfusion; 3.2% had ≥1 thrombosis; and 28.6% had ≥1 breakthrough haemolysis. Among all patients, 26.8% and 31.0% reported emergency department/room [ER] and inpatient visits, respectively. Mean annual, per-patient all-cause medical encounters were: 0.5 (ER); 1.9 (inpatient); and overall outpatient visits ranged by setting from 2.0 to 6.4. Most encounters were PNH-related, with means of 0.4 (ER); 1.8 (inpatient); and 1.6-5.4 (outpatient). Primary haematological and medical encounter outcomes were similar between treatment as well as Hb-level subgroups, with almost no statistically significant differences. CONCLUSIONS Despite at least 3 months of C5i treatment, high proportions of patients with PNH reported low haemoglobin levels and required transfusions and hospitalizations, which suggests remaining unmet needs.
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Affiliation(s)
- Flore Sicre de Fontbrune
- Hematology transplant Unit - French Reference Center for Aplastic Anemia, Hôpital Saint-Louis, Paris, France
| | | | | | - Joana E Matos
- Employee of Kantar Health, New York, NY, USA at the time of the study
| | | | - Koo Wilson
- Swedish Orphan Biovitrum AB, Stockholm, Sweden
| | | | | | | | | | | | - Jens Panse
- Department of Oncology, Hematology, Hemostaseology and Stem Cell Transplantation, University Hospital RWTH Aachen, Aachen, Germany
- Center for Integrated Oncology (CIO) Aachen, Bonn, Cologne, Duesseldorf
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The Effect of Sample Glucose Content on PNGase F-Mediated N-Glycan Release Analyzed by Capillary Electrophoresis. MOLECULES (BASEL, SWITZERLAND) 2022; 27:molecules27238192. [PMID: 36500281 PMCID: PMC9740771 DOI: 10.3390/molecules27238192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 11/18/2022] [Accepted: 11/21/2022] [Indexed: 11/27/2022]
Abstract
Protein therapeutics have recently gained high importance in general health care along with applied clinical research. Therefore, it is important to understand the structure-function relationship of these new generation drugs. Asparagine-bound carbohydrates represent an important critical quality attribute of therapeutic glycoproteins, reportedly impacting the efficacy, immunogenicity, clearance rate, stability, solubility, pharmacokinetics and mode of action of the product. In most instances, these linked N-glycans are analyzed in their unconjugated form after endoglycosidase-mediated release, e.g., PNGase F-mediated liberation. In this paper, first, N-glycan release kinetics were evaluated using our previously reported in-house produced 6His-PNGase F enzyme. The resulting deglycosylation products were quantified by sodium dodecyl sulfate capillary gel electrophoresis to determine the optimal digestion time. Next, the effect of sample glucose content was investigated as a potential endoglycosidase activity modifier. A comparative Michaelis-Menten kinetics study was performed between the 6His-PNGase F and a frequently employed commercial PNGase F product with and without the presence of glucose in the digestion reaction mixture. It was found that 1 mg/mL glucose in the sample activated the 6His-PNGase F enzyme, while did not affect the release efficiency of the commercial PNGase F. Capillary isoelectric focusing revealed subtle charge heterogeneity differences between the two endoglycosidases, manifested by the lack of extra acidic charge variants in the cIEF trace of the 6His-PNGase F enzyme, which might have possibly influenced the glucose-mediated enzyme activity differences.
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Zhang W, Wu M, Vadlakonda S, Juarez L, Cheng X, Muppa S, Chintareddy V, Vogeti L, Kellogg-Yelder D, Williams J, Polach K, Chen X, Raman K, Babu Y, Kotian P. Scaffold hopping via ring opening enables identification of acyclic compounds as new complement Factor D inhibitors. Bioorg Med Chem 2022; 74:117034. [DOI: 10.1016/j.bmc.2022.117034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 09/21/2022] [Accepted: 09/22/2022] [Indexed: 11/26/2022]
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Lægreid IJ, Wilson T, Næss KH, Ernstsen SL, Schou V, Arsenovic MG. Whole blood transfusion and paroxysmal nocturnal haemoglobinuria meet again: Minor incompatibility, major trouble. Vox Sang 2022; 117:1323-1326. [PMID: 36102159 PMCID: PMC9826352 DOI: 10.1111/vox.13354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 08/10/2022] [Accepted: 08/10/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND AND OBJECTIVES The field of transfusion medicine started out with whole blood transfusion to treat severe anaemia and other deficiencies, and then transitioned to component therapy, largely leaving the practice, and experiences, of whole blood transfusions behind. Currently, the field is circling back and whole blood is gaining ground as an alternative to massive transfusion protocols. MATERIALS AND METHODS Herein we describe a severely anaemic paroxysmal nocturnal haemoglobinuria (PNH) patient initially suspected of suffering from renal haemorrhage, receiving a standard low-titre group O whole blood transfusion during pre-hospital transportation. RESULTS Following the transfusion, the patient suffered a clinically unmistakable haemolytic transfusion reaction requiring supportive treatment in the intensive care unit. Clinical observations are consistent with an acute haemolytic reaction. The haemolysis was likely due to minor incompatibility between the plasma from the transfused whole blood and the patient's PNH red cells. Recovery was uneventful. CONCLUSION This revealed an unappreciated contraindication to minor incompatible whole blood transfusion, and prompted a discussion on the distinction between whole blood and erythrocyte concentrates, the different indications for use and the importance of emphasizing these differences. It also calls attention to patient groups where minor incompatibility can be of major importance.
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Affiliation(s)
- Ingvild Jenssen Lægreid
- Department of Laboratory Medicine, Division of Diagnostic servicesUniversity Hospital of North NorwayTromsøNorway
| | - Thomas Wilson
- Division of Prehospital servicesFinnmark Hospital TrustKirkenesNorway
| | | | - Siw Leiknes Ernstsen
- Department of Laboratory Medicine, Division of Diagnostic servicesUniversity Hospital of North NorwayTromsøNorway
| | - Vibeke Schou
- Department of Anesthesia and Intensive CareKirkenes Hospital, Finnmark Hospital TrustKirkenesNorway
| | - Mirjana Grujic Arsenovic
- Department of Laboratory Medicine, Division of Diagnostic servicesUniversity Hospital of North NorwayTromsøNorway
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Savchenko VG, Lukina EA, Mikhaylova EA, Tsvetaeva NV, Latyshev VD, Lukina KA, Fidarova ZT, Galtseva IV, Dvirnik VN, Ptushkin VV, Afanasyev BV, Kulagin AD, Shilova ER, Maschan AA, Smetanina NS, Lugovskaya SA. Clinical guidelines for the management of patients with paroxysmal nocturnal hemoglobinuria. RUSSIAN JOURNAL OF HEMATOLOGY AND TRANSFUSIOLOGY 2022. [DOI: 10.35754/0234-5730-2022-67-3-426-439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/11/2023]
Abstract
Introduction. Paroxysmal nocturnal hemoglobinuria (PNH) is a rare acquired clonal disease of the blood system characterized by intravascular hemolysis, bone marrow dysfunction and an increased risk of thrombotic and organ complications.Aim — to provide relevant clinical recommendations for the provision of medical care to adults and children with PNH.Basic information. Experts from the National Hematological Society association which is focused on the promotion of hematology, transfusiology and bone marrow transplantation along with experts from the public organization, National Society of Pediatric Hematologists and Oncologists, have developed current clinical recommendations for providing medical care to adults and children with PNH. The recommendations address in detail the issues of etiology, pathogenesis, epidemiology, and clinical manifestations of the disease. Special attention is paid to the diagnosis, differential diagnosis, and treatment of PNH based on the principles of evidence.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - V. V. Ptushkin
- Botkin City Clinical Hospital of the Moscow Health Department
| | - B. V. Afanasyev
- Raisa Gorbacheva Memorial Research Institute of Children Oncology, Hematology and Transplantation, Pavlov First State Medical University of St. Petersburg
| | - A. D. Kulagin
- Raisa Gorbacheva Memorial Research Institute of Children Oncology, Hematology and Transplantation, Pavlov First State Medical University of St. Petersburg
| | - E. R. Shilova
- Russian Research Institute of Hematology and Transfusiology of the Federal Medical and Biological Agency
| | - A. A. Maschan
- Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology
| | - N. S. Smetanina
- Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology
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Kawahara H, Watanabe N, Endo A, Yoshitomi H, Tanabe K. Subacute stent thrombosis with spontaneously resolved secondary thrombi in paroxysmal nocturnal hemoglobinuria: a case report. BMC Cardiovasc Disord 2022; 22:408. [PMID: 36096718 PMCID: PMC9469620 DOI: 10.1186/s12872-022-02850-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Accepted: 09/07/2022] [Indexed: 11/15/2022] Open
Abstract
Background Stent thrombosis (ST) is a serious complication; however, a method to prevent ST in patients with thrombophilic diseases has not been established. Case presentation We report a case of subacute ST in a patient with paroxysmal nocturnal hemoglobinuria (PNH) who was receiving continuous heparin treatment in addition to the usual dual antiplatelet therapy for contrast defects at the proximal site of the occluded right coronary artery and the proximal site of the left circumflex artery. Despite the resolution of thrombi in secondary lesions, subacute ST occurred. After percutaneous coronary intervention for ST, triple therapy, including oral anticoagulation for PNH-related thrombosis, was initiated. The patient subsequently underwent craniotomy hematoma removal for hemorrhagic cerebral infarction. Conclusions Reported cases of ST in patients with PNH are very few, and this case adds evidence with respect to antithrombotic therapy in patients with thrombotic tendencies. Both thrombosis and bleeding should be considered when administering antithrombotic therapy to patients with thrombotic diseases. If there are specific treatments for thrombophilic diseases, they should be initiated early.
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Affiliation(s)
- Hiroshi Kawahara
- Division of Cardiology, Faculty of Medicine, Shimane University, 89-1 Enya-cho, Izumo, 693-8501, Japan.
| | - Nobuhide Watanabe
- Division of Cardiology, Faculty of Medicine, Shimane University, 89-1 Enya-cho, Izumo, 693-8501, Japan
| | - Akihiro Endo
- Division of Cardiology, Faculty of Medicine, Shimane University, 89-1 Enya-cho, Izumo, 693-8501, Japan
| | - Hiroyuki Yoshitomi
- Clinical Laboratory Division, Faculty of Medicine, Shimane University, 89-1 Enya-cho, Izumo, 693-8501, Japan
| | - Kazuaki Tanabe
- Division of Cardiology, Faculty of Medicine, Shimane University, 89-1 Enya-cho, Izumo, 693-8501, Japan
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Wang R, Guo X, Tang Y, Qi X. Portal vein thrombosis as the first presentation of paroxysmal nocturnal hemoglobinuria. Drug Discov Ther 2022; 16:200-203. [PMID: 35989282 DOI: 10.5582/ddt.2022.01033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) is a rare, acquired clonal hematopoietic stem cell disorder, characterized by hemolytic anemia, bone marrow failure and thrombosis. Portal vein thrombosis (PVT) is relatively rare in patients with PNH. In this paper, we reported PVT as the first clinical presentation of PNH in a female patient. PVT related symptoms resolved after anticoagulation therapy.
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Affiliation(s)
- Ran Wang
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
| | - Xiaozhong Guo
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
| | - Yufu Tang
- Department of Hepatobiliary Surgery, General Hospital of Northern Theater Command, Shenyang, China
| | - Xingshun Qi
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
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Shammo J, Gajra A, Patel Y, Tomazos I, Kish J, Hill A, Sierra JR, Araten D. Low Rate of Clinically Evident Extravascular Hemolysis in Patients with Paroxysmal Nocturnal Hemoglobinuria Treated with a Complement C5 Inhibitor: Results from a Large, Multicenter, US Real-World Study. J Blood Med 2022; 13:425-437. [PMID: 35983240 PMCID: PMC9380823 DOI: 10.2147/jbm.s361863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 06/29/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose Most patients with paroxysmal nocturnal hemoglobinuria (PNH) treated with a complement protein 5 (C5) inhibitor achieve full control of terminal complement activity and intravascular hemolysis. The minority remains anemic and transfusion dependent despite this control. Etiology for ongoing anemia is multifactorial and includes bone marrow failure, breakthrough hemolysis, extravascular hemolysis (EVH) and nutritional deficiencies. Patients and Methods To evaluate the potential etiologies of hemoglobin levels <10 g/dL despite receiving C5 inhibitor therapy, we performed a retrospective US chart review of adult patients with PNH and treated for at least 12 months with eculizumab (n=53), ravulizumab (n=32), or eculizumab followed by ravulizumab (n=15). Clinically evident EVH was defined as at least one transfusion, reticulocyte count ≥120×109/L and hemoglobin level ≤9.5 g/dL. Safety data were not collected. Mean treatment duration was 26.5±17.2 months. Results Treatment with C5 inhibitors significantly improved hemoglobin, lactate dehydrogenase, and number of transfusions versus baseline. Among the patients with hemoglobin <10 g/dL during the last 6 months of treatment (n=38), one patient (eculizumab) had clinically evident EVH, and 10 patients had active concomitant bone marrow failure. Bone marrow failure was a major contributor to hemoglobin <10 g/dL and transfusion dependence; clinically evident EVH was uncommon. Conclusion A range of hematologic causes need to be considered when evaluating anemia in the presence of treatment with a C5 inhibitor.
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Affiliation(s)
- Jamile Shammo
- Rush Hematology, Oncology and Cell Therapy, Rush University Medical Center, Chicago, IL, USA
| | | | - Yogesh Patel
- Alexion, AstraZeneca Rare Disease, Boston, MA, USA
| | | | | | - Anita Hill
- Alexion, AstraZeneca Rare Disease, Inc., Leeds, UK
| | | | - David Araten
- Division of Hematology, New York University School of Medicine, New York, NY, USA
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Lee JW, Brodsky RA, Nishimura JI, Kulasekararaj AG. The role of the alternative pathway in paroxysmal nocturnal hemoglobinuria and emerging treatments. Expert Rev Clin Pharmacol 2022; 15:851-861. [PMID: 35980222 DOI: 10.1080/17512433.2022.2109462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Paroxysmal nocturnal hemoglobinuria (PNH) is characterized by uncontrolled activation of the terminal complement pathway, leading to intravascular hemolysis (IVH) and a prothrombotic state. Treatment with terminal complement (C5) inhibitors, the current standard of care, suppresses IVH and reduces the risk of thrombosis and the associated morbidity and mortality. Opportunities exist to further improve care by alternative modes of administration and the reduction of clinically significant anemia and transfusion dependence caused by extravascular hemolysis in some patients. AREAS COVERED This review describes the pathophysiology of PNH, provides an overview of the current standard of care, and discusses potential avenues for enhancing patient care, with a focus on the literature describing new and emerging treatments that target the alternative pathway. Emerging treatments include biosimilars and novel C5 inhibitors as well as agents with novel mechanisms of action that target the proximal complement pathways (C3 inhibitors, factor B inhibitors, and factor D inhibitors). EXPERT OPINION Alternative complement pathway inhibitors may offer further benefit as long as terminal complement is completely inhibited to reduce IVH and disease activity. This may lead to improvements in adherence and health-related quality of life for patients with PNH.
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Affiliation(s)
- Jong Wook Lee
- Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Robert A Brodsky
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jun-Ichi Nishimura
- Department of Hematology and Oncology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Austin G Kulasekararaj
- King's College Hospital-NHS Foundation Trust, NIHR/Wellcome King's Clinical Research Facility, UK & King's College London, London, UK
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75
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Neutrophils activated by membrane attack complexes increase the permeability of melanoma blood vessels. Proc Natl Acad Sci U S A 2022; 119:e2122716119. [PMID: 35960843 PMCID: PMC9388087 DOI: 10.1073/pnas.2122716119] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Cancer cell dissemination is the seed for metastasis and adversely linked to patients’ benefit. Critical for hematogenous dissemination is the entrance of the cancer cell into the circulation, which is regulated by vascular permeability within the primary tumor. Here, we describe pathophysiological communication between endothelial cells, tumor infiltrating neutrophils, and the complement system, with implications for vascular barrier opening and melanoma cell dissemination. Experiments in complement-deficient animals indicate that interference with complement-mediated activation of neutrophils stabilizes blood vessel integrity and abolishes the systemic spread of melanoma cells. The microenvironment of malignant melanomas defines the properties of tumor blood vessels and regulates infiltration and vascular dissemination of immune and cancer cells, respectively. Previous research in other cancer entities suggested the complement system as an essential part of the tumor microenvironment. Here, we confirm activation of the complement system in samples of melanoma patients and murine melanomas. We identified the tumor endothelium as the starting point of the complement cascade. Generation of complement-derived C5a promoted the recruitment of neutrophils. Upon contact with the vascular endothelium, neutrophils were further activated by complement membrane attack complexes (MACs). MAC-activated neutrophils release neutrophil extracellular traps (NETs). Close to the blood vessel wall, NETs opened the endothelial barrier as indicated by an enhanced vascular leakage. This facilitated the entrance of melanoma cells into the circulation and their systemic spread. Depletion of neutrophils or lack of MAC formation in complement component 6 (C6)–deficient animals protected the vascular endothelium and prevented vascular intravasation of melanoma cells. Our data suggest that inhibition of MAC-mediated neutrophil activation is a potent strategy to abolish hematogenous dissemination in melanoma.
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Han B, Ji J, Zhang B, Bai H, Zhou D, Feng F, Huang Y, Zhu H, Chen L, Wu Z, Jiang X, Li X, Jia Q, Chang Q, Pan H, Peng H, Zheng W, Huang H, Chen Z, Yang C, Chen M, Du B, Zhang S. The first successful expanded compassionate use of Iptacopan in a patient with paroxysmal nocturnal hemoglobinuria. Ann Hematol 2022; 101:2537-2539. [PMID: 35965286 PMCID: PMC9376122 DOI: 10.1007/s00277-022-04933-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 07/23/2022] [Indexed: 11/24/2022]
Affiliation(s)
- Bing Han
- Peking Union Medical College Hospital, Beijing, China
| | - Jiang Ji
- Peking Union Medical College Hospital, Beijing, China
| | - Bo Zhang
- Peking Union Medical College Hospital, Beijing, China
| | - Hua Bai
- Peking Union Medical College Hospital, Beijing, China
| | - Daobin Zhou
- Peking Union Medical College Hospital, Beijing, China
| | - Feng Feng
- Peking Union Medical College Hospital, Beijing, China
| | - Yan Huang
- Peking Union Medical College Hospital, Beijing, China
| | - Huijuan Zhu
- Peking Union Medical College Hospital, Beijing, China
| | - Limeng Chen
- Peking Union Medical College Hospital, Beijing, China
| | - Zhihong Wu
- Peking Union Medical College Hospital, Beijing, China
| | - Xiuchun Jiang
- Peking Union Medical College Hospital, Beijing, China
| | - Xuemei Li
- Peking Union Medical College Hospital, Beijing, China
| | - Qing Jia
- Peking Union Medical College Hospital, Beijing, China
| | - Qing Chang
- Peking Union Medical College Hospital, Beijing, China
| | - Hui Pan
- Peking Union Medical College Hospital, Beijing, China
| | - Hua Peng
- Peking Union Medical College Hospital, Beijing, China
| | - Wenting Zheng
- Peking Union Medical College Hospital, Beijing, China
| | - Hui Huang
- Peking Union Medical College Hospital, Beijing, China
| | - Zheng Chen
- Peking Union Medical College Hospital, Beijing, China
| | - Chen Yang
- Peking Union Medical College Hospital, Beijing, China
| | - Miao Chen
- Peking Union Medical College Hospital, Beijing, China
| | - Bin Du
- Peking Union Medical College Hospital, Beijing, China
| | - Shuyang Zhang
- Peking Union Medical College Hospital, Beijing, China.
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Jiandong B, Yunxiao Z, Zuhua W, Yan H, Shuangshuang G, Junke L, Hongwei W, Hua X. Generalized pulp canal obliteration in a patient on long-term glucocorticoids: a case report and literature review. BMC Oral Health 2022; 22:352. [PMID: 35971099 PMCID: PMC9380356 DOI: 10.1186/s12903-022-02387-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 08/10/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The calcification of the tooth pulp is a pathological condition that occurs in response to various factors. A uncommon haematological condition known as paroxysmal nocturnal haemoglobinuria (PNH) is characterized by bouts of haemolysis, and it requires long-term use of glucocorticoids (GCs). CASE PRESENTATION A female patient who was diagnosed with PNH and had a history of long-term use of GCs came to our department for root canal therapy (RCT) for teeth 25, 26, and 27. The radiographs showed generalized pulp canal obliteration (PCO) in most of the patients. None of these teeth (25, 26, or 27) were sensitive to percussion, and they did not respond to thermal or electrical sensitivity tests. A diagnose of pulp necrosis was made for these teeth. RCT was carried out with the help of an oral microscope, and then a prosthodontic procedure was created for the teeth. CONCLUSIONS Based on the patient's long history use of GCs and a series of related studies, we conclude that the long-term usage of GCs contributes significantly to the onset of PCO.
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Affiliation(s)
- Ban Jiandong
- Department of Stomatology, Hebei Eye Hospital, Xingtai, 054000, China
| | - Zhang Yunxiao
- Department of Haematology, The First Affiliated Hospital of Xingtai Medical College, Xingtai, 054000, China
| | - Wang Zuhua
- Department of Endodontics, Stomatological Hospital of Peking University, Beijing, 100010, China
| | - Hou Yan
- Department of Stomatology, Hebei Eye Hospital, Xingtai, 054000, China
| | - Geng Shuangshuang
- Department of Stomatology, Hebei Eye Hospital, Xingtai, 054000, China
| | - Li Junke
- Department of Stomatology, Hebei Eye Hospital, Xingtai, 054000, China
| | - Wang Hongwei
- Department of Stomatology, Hebei Eye Hospital, Xingtai, 054000, China
| | - Xu Hua
- Department of Stomatology, Hebei Eye Hospital, Xingtai, 054000, China.
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Todisco G, Moura PL, Hellström-Lindberg E. Clinical manifestations of clonal hematopoiesis: What has SF3B1-mutant MDS taught us? Semin Hematol 2022; 59:150-155. [DOI: 10.1053/j.seminhematol.2022.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 08/02/2022] [Accepted: 08/08/2022] [Indexed: 12/17/2022]
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Hosokawa K, Nakao S. Somatic mutations and clonal expansions in paroxysmal nocturnal hemoglobinuria. Semin Hematol 2022; 59:143-149. [DOI: 10.1053/j.seminhematol.2022.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 08/17/2022] [Accepted: 08/17/2022] [Indexed: 01/02/2023]
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Wong RS. Safety and efficacy of pegcetacoplan in paroxysmal nocturnal hemoglobinuria. Ther Adv Hematol 2022; 13:20406207221114673. [PMID: 35923770 PMCID: PMC9340389 DOI: 10.1177/20406207221114673] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 07/04/2022] [Indexed: 11/15/2022] Open
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) is a rare, acquired, hematologic disease characterized by complement-mediated hemolysis, thrombosis, and various degrees of bone marrow dysfunction. Until recently, C5 inhibition with eculizumab or ravulizumab represented the only therapies approved for patients with PNH by the United States Food and Drug Administration (US FDA). Although C5-inhibitors reduce PNH-related signs and symptoms, many patients continue to exhibit persistent anemia and require frequent blood transfusions. In May 2021, pegcetacoplan became the third US FDA-approved treatment for adults with PNH, and the first to target C3, a complement component upstream of C5. The novel strategy of inhibiting proximal complement activity with pegcetacoplan controls C5-mediated intravascular hemolysis and prevents C3-mediated extravascular hemolysis. Here, we review the results from multiple pegcetacoplan clinical studies on the efficacy and safety of pegcetacoplan treatment in adults with PNH. This review summarizes findings from three studies in complement-inhibitor-naïve patients with PNH (PADDOCK [phase Ib], PALOMINO [phase IIa], PRINCE [phase III; pegcetacoplan versus standard treatment excluding complement-inhibitors]), and one phase III study (PEGASUS) that compared eculizumab to pegcetacoplan in patients who remained anemic (hemoglobin levels < 10.5 g/dL) despite stable eculizumab treatment (⩾3 months). These studies found that pegcetacoplan contributed to superior improvements in primary and secondary endpoints related to hemoglobin levels and other hematologic parameters and provided effective management of anemia and anemia-related complications (i.e. transfusion burden, reticulocyte production, and fatigue). Furthermore, we summarize results from the 32-week open-label period from the PEGASUS trial, which confirmed the long-term safety and durable efficacy of pegcetacoplan as demonstrated by sustained improvements in clinical and hematologic outcomes in pegcetacoplan-treated patients. Pegcetacoplan is approved for the treatment of adults with PNH in the United States (Empaveli™) and for adult patients who remain anemic after at least 3 months of stable C5-inhibitor therapy in the European Union (Aspaveli®) and Australia (Empaveli; also approved for patients intolerant to C5-inhibitors).
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Affiliation(s)
- Raymond S.M. Wong
- Sir Y.K. Pao Centre for Cancer and Department
of Medicine & Therapeutics, Prince of Wales Hospital, The Chinese
University of Hong Kong, 30-32 Ngan Shing Street, Shatin, Hong Kong
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Changes in hemoglobin and clinical outcomes drive improvements in fatigue, quality of life, and physical function in patients with paroxysmal nocturnal hemoglobinuria: post hoc analyses from the phase III PEGASUS study. Ann Hematol 2022; 101:1905-1914. [PMID: 35869984 PMCID: PMC9375756 DOI: 10.1007/s00277-022-04887-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 06/05/2022] [Indexed: 11/12/2022]
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) is a rare, chronic, acquired, hematologic, life-threatening disease characterized by thrombosis, impaired bone marrow function, and complement-mediated hemolysis. The PEGASUS phase III clinical trial demonstrated superiority of pegcetacoplan over eculizumab regarding improvements in hemoglobin levels in patients with suboptimal response to prior eculizumab treatment. The objective of this post hoc analysis was to compare the patient-reported outcome (PRO) response rates observed among PEGASUS participants and the relationships between their PRO scores with clinical and hematological parameters. Data from the 16-week randomized, controlled (1:1 to pegcetacoplan or eculizumab) period of the PEGASUS trial included comparisons of weekly PRO measurements taken using the Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F) scale and the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core-30 (EORTC QLQ-C30) scales. A clinically meaningful FACIT-F response was defined as an increase from baseline of ≥5 points. Convergent validity was assessed using conventional threshold correlations between FACIT-F, EORTC QLQ-C30, and laboratory parameters. A clinically meaningful improvement in FACIT-F score was seen in 72.2% of pegcetacoplan-treated patients compared to 22.9% of eculizumab-treated patients. At week 16, the FACIT-F total score correlated with hemoglobin levels (r=0.47, p< 0.0001), absolute reticulocyte count (r=−0.37, p<0.01), and indirect bilirubin levels (r=−0.25, p<0.05). Clinically meaningful improvements in pegcetacoplan-treated patients were also observed for multiple EORTC scales. Fatigue and other self-reported outcomes were correlated with clinically meaningful improvements in clinical and hematological parameters. Clinical trial registration: NCT03500549
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Al-Riyami AZ, Al-Kindi Y, Al-Qassabi J, Al-Mamari S, Fawaz N, Al-Khabori M, Al-Huneini M, Al Kindi S. Clinicopathological Profile of Paroxysmal Nocturnal Hemoglobinuria among Omani Patients: A Case Series. Oman Med J 2022; 37:e405. [PMID: 35949713 PMCID: PMC9357272 DOI: 10.5001/omj.2022.13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 12/23/2020] [Indexed: 11/03/2022] Open
Abstract
We aimed to estimate the nature and prevalence of paroxysmal nocturnal hemoglobinuria (PNH) among Omani patients. We performed a retrospective review of all patients who were tested for PNH by flow cytometry at the Sultan Qaboos University Hospital, Muscat, between 2012 and 2019. Manifestations, treatment modalities, and outcomes were assessed. A total of 10 patients were diagnosed or were on follow-up for PNH (median age 22.5 years). Clinical manifestations included fatigue (80%) and anemia (70%). Six patients had classical PNH with hemolysis, three had PNH in the context of aplastic anemia, and one patient had subclinical PNH. The median total clone size (type II + III) for neutrophils was 95.5 (range: 1.5-97) (FLAER/CD24) and for monocytes was 91.6 (range = 0.04-99) (FLAER/CD14). Four patients had clone sizes > 50% at the time of diagnosis. The median follow-up period of the patients was 62 months (range = 8-204 months). One patient suffered thrombosis. Three patients were on immunosuppressant agents, five were initiated on eculizumab, and four had a bone marrow transplant. No deaths were reported in the cohort. The estimated average incidence of PNH among Omani patients was 1.5 per 5 000 000. PNH is rare in the Omani population. The predominant presentation is hemolytic anemia.
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Affiliation(s)
- Arwa Z Al-Riyami
- Department of Hematology, Sultan Qaboos University Hospital, Muscat, Oman
| | - Yahya Al-Kindi
- College of Medicine and Health Sciences, Sultan Qaboos University, Muscat, Oman
| | - Jamal Al-Qassabi
- Department of Hematology, Sultan Qaboos University Hospital, Muscat, Oman
| | - Sahimah Al-Mamari
- Department of Hematology, Sultan Qaboos University Hospital, Muscat, Oman
| | - Naglaa Fawaz
- Department of Hematology, Sultan Qaboos University Hospital, Muscat, Oman
| | | | | | - Salam Al Kindi
- Department of Hematology, College of Medicine and Health Sciences, Sultan Qaboos University, Muscat, Oman
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83
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Liu L, Wang S, Jiang E, Zhang Y, Li J, Fu Y, Lei M, Xu K, Yang M, Lu Y, Miao M, Wu D. Haploidentical vs matched sibling donor transplant for paroxysmal nocturnal haemoglobinuria: A multicenter study. Blood Cancer J 2022; 12:92. [PMID: 35750668 PMCID: PMC9232486 DOI: 10.1038/s41408-022-00682-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 03/02/2022] [Accepted: 05/19/2022] [Indexed: 12/02/2022] Open
Affiliation(s)
- Limin Liu
- National Clinical Research Center for Hematologic Diseases, The First Affiliated Hospital of Soochow University, Jiangsu Institute of Hematology, Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Collaborative Innovation Center of Hematology, Suzhou, China
| | - Shunqing Wang
- Department of Hematology, Guangzhou First People's Hospital, Guangzhou Medical University, Guangzhou, China
| | - Erlie Jiang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Yanming Zhang
- Department of hematology, The Affiliated Huai'an Hospital of Xuzhou Medical University and The Second People's Hospital of Huai'an, Huai'an, China
| | - Jianyong Li
- Department of hematology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yuewen Fu
- Department of hematology, Affiliated Cancer Hospital Zhengzhou University, Henan Tumor Hospital, Institute of Hematology, Zhengzhou, China
| | - Meiqing Lei
- Department of hematology, Haikou Municipal People's Hospital, Affiliated Haikou Hospital Xiangya School of Medicine Central South University, Haikou, China
| | - Kailin Xu
- Department of hematology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Mingzhen Yang
- Department of hematology, The Fourth Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Yinghao Lu
- Department of hematology, The Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Miao Miao
- National Clinical Research Center for Hematologic Diseases, The First Affiliated Hospital of Soochow University, Jiangsu Institute of Hematology, Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Collaborative Innovation Center of Hematology, Suzhou, China.
| | - Depei Wu
- National Clinical Research Center for Hematologic Diseases, The First Affiliated Hospital of Soochow University, Jiangsu Institute of Hematology, Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Collaborative Innovation Center of Hematology, Suzhou, China.
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Pharmacokinetics and pharmacodynamics of pozelimab alone or in combination with cemdisiran in non-human primates. PLoS One 2022; 17:e0269749. [PMID: 35709087 PMCID: PMC9202903 DOI: 10.1371/journal.pone.0269749] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 05/26/2022] [Indexed: 12/02/2022] Open
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) is a rare disease caused by uncontrolled complement activation; effective and approved treatments include terminal complement inhibition. This study assessed whether combination cemdisiran (an investigational N-acetylgalactosamine-conjugated RNAi therapeutic that suppresses liver production of complement component C5) and pozelimab (an investigational fully human monoclonal antibody against C5) results in more effective and durable complement activity inhibition than the individual agents alone in non-human primates. Cynomolgus monkeys received a single subcutaneous injection of cemdisiran (5 or 25 mg/kg), pozelimab (5 or 10 mg/kg), or combination cemdisiran and pozelimab (5+5 mg/kg, 5+10 mg/kg, or 25+10 mg/kg, respectively). When given in combination, pozelimab was administered 2 weeks after cemdisiran dosing. Pharmacokinetics and ex vivo pharmacodynamic properties were assessed. The half-life of pozelimab alone was 12.9–13.3 days; this increased to 19.6–21.1 days for pozelimab administered in combination with cemdisiran. In ex vivo classical pathway hemolysis assays (CH50), pozelimab + cemdisiran combinations achieved durable and more complete suppression of complement activity (8–13 weeks) vs monotherapy of either agent. Cemdisiran monotherapy demonstrated dose-dependent suppression of total C5 concentrations, with the higher dose (25 mg/kg) achieving >90% maximum suppression. Total C5 concentrations after administration of pozelimab + cemdisiran combinations were similar compared with administration of cemdisiran alone. The combination of pozelimab + cemdisiran mediates complement activity inhibition more efficiently than either pozelimab or cemdisiran administered alone. The pharmacokinetic/pharmacodynamic profile of combination pozelimab + cemdisiran in non-human primates appears suitable for further clinical investigation as a potential long-acting treatment for PNH and other complement-mediated diseases.
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85
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Kamura Y, Sakamoto T, Yokoyama Y, Nishikii H, Sakata-Yanagimoto M, Chiba S, Obara N. Hemolysis induced by SARS-CoV-2 mRNA vaccination in patients with paroxysmal nocturnal hemoglobinuria. Int J Hematol 2022; 116:55-59. [PMID: 35668275 PMCID: PMC9169953 DOI: 10.1007/s12185-022-03387-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 05/06/2022] [Accepted: 05/09/2022] [Indexed: 11/27/2022]
Abstract
Autoimmune and complement-related hematological side effects have been observed with messenger ribonucleic acid (mRNA) vaccines. Here, we report the incidence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccine-induced hemolysis in patients with paroxysmal nocturnal hemoglobinuria (PNH). We reviewed the medical records of seventeen patients with PNH visiting the University of Tsukuba Hospital who had received two doses of the SARS-CoV-2 mRNA vaccine between May 2021 and November 2021. Twelve patients were being treated with complement inhibitors. The median age of all patients was 62 years (range 29–89 years).; six were males and eleven were females. Fourteen patients received the BNT162b2 vaccine (Pfizer/BioNTech) and three received the mRNA-1273 vaccine (Moderna). The median percentages of PNH clones in erythrocytes and granulocytes were 37.61% (range 8.11–85.71%) and 59.73% (range 3.76–97.82%), respectively. Of the twelve patients receiving complement inhibitors, only one had a hemolytic reaction after vaccination, but it did not meet the definition of breakthrough hemolysis. By contrast, hemolytic attacks were observed in two of the five untreated patients with PNH, and one of them required a blood transfusion. Appropriate administration of complement inhibitors to patients with PNH may prevent hemolysis induced by SARS-CoV-2 mRNA vaccination.
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Affiliation(s)
- Yuya Kamura
- Department of Hematology, University of Tsukuba Hospital, Ibaraki, Japan
| | - Tatsuhiro Sakamoto
- Department of Hematology, University of Tsukuba Hospital, Ibaraki, Japan
- Department of Hematology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Yasuhisa Yokoyama
- Department of Hematology, University of Tsukuba Hospital, Ibaraki, Japan
- Department of Hematology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Hidekazu Nishikii
- Department of Hematology, University of Tsukuba Hospital, Ibaraki, Japan
- Department of Hematology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Mamiko Sakata-Yanagimoto
- Department of Hematology, University of Tsukuba Hospital, Ibaraki, Japan
- Department of Hematology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
- Division of Advanced Hemato-Oncology, Transborder Medical Research Center, University of Tsukuba, Ibaraki, Japan
| | - Shigeru Chiba
- Department of Hematology, University of Tsukuba Hospital, Ibaraki, Japan
- Department of Hematology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Naoshi Obara
- Department of Hematology, University of Tsukuba Hospital, Ibaraki, Japan.
- Department of Medical Sciences, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan.
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Nishimura JI, Ando K, Masuko M, Noji H, Ito Y, Mayer J, Griskevicius L, Bucher C, Müllershausen F, Gergely P, Rozenberg I, Schubart A, Chawla R, Rondeau JM, Roguska M, Splawski I, Keating MT, Johnson L, Danekula R, Bagger M, Watanabe Y, Haraldsson B, Kanakura Y. Tesidolumab (LFG316) for treatment of C5-variant patients with paroxysmal nocturnal hemoglobinuria. Haematologica 2022; 107:1483-1488. [PMID: 35263983 PMCID: PMC9152970 DOI: 10.3324/haematol.2020.265868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 03/01/2022] [Indexed: 12/03/2022] Open
Affiliation(s)
- Jun-Ichi Nishimura
- Department of Hematology and Oncology, Osaka University Graduate School of Medicine, Suita.
| | - Kiyoshi Ando
- Department of Hematology and Oncology, Tokai University, Isehara
| | - Masayoshi Masuko
- Department of Hematology, Endocrinology and Metabolism, Niigata University Medical and Dental Hospital, Niigata
| | - Hideyoshi Noji
- Department of Cardiology and Hematology, Fukushima Medical University, Fukushima
| | - Yoshikazu Ito
- Department of Hematology, Tokyo Medical University, Shinjuku-ku, Tokyo
| | - Jiri Mayer
- Department of Internal Medicine, Hematology and Oncology, Masaryk University Hospital and Faculty of Medicine, Brno, Czech Republic
| | - Laimonas Griskevicius
- Hematology, Oncology and Transfusion Medicine Center, Vilnius University Hospital Santaros Klinikos and Institute of Clinical Medicine, Vilnius University, Vilnius
| | - Christoph Bucher
- Novartis Institutes for BioMedical Research, Basel, Switzerland, Cambridge, USA, and Novartis Pharma KK, Toranomon Minato-ku, Tokyo
| | - Florian Müllershausen
- Novartis Institutes for BioMedical Research, Basel, Switzerland, Cambridge, USA, and Novartis Pharma KK, Toranomon Minato-ku, Tokyo
| | - Peter Gergely
- Novartis Institutes for BioMedical Research, Basel, Switzerland, Cambridge, USA, and Novartis Pharma KK, Toranomon Minato-ku, Tokyo
| | - Izabela Rozenberg
- Novartis Institutes for BioMedical Research, Basel, Switzerland, Cambridge, USA, and Novartis Pharma KK, Toranomon Minato-ku, Tokyo
| | - Anna Schubart
- Novartis Institutes for BioMedical Research, Basel, Switzerland, Cambridge, USA, and Novartis Pharma KK, Toranomon Minato-ku, Tokyo
| | - Raghav Chawla
- Novartis Institutes for BioMedical Research, Basel, Switzerland, Cambridge, USA, and Novartis Pharma KK, Toranomon Minato-ku, Tokyo
| | - Jean-Michel Rondeau
- Novartis Institutes for BioMedical Research, Basel, Switzerland, Cambridge, USA, and Novartis Pharma KK, Toranomon Minato-ku, Tokyo
| | - Michael Roguska
- Novartis Institutes for BioMedical Research, Basel, Switzerland, Cambridge, USA, and Novartis Pharma KK, Toranomon Minato-ku, Tokyo
| | - Igor Splawski
- Novartis Institutes for BioMedical Research, Basel, Switzerland, Cambridge, USA, and Novartis Pharma KK, Toranomon Minato-ku, Tokyo
| | - Mark T Keating
- Novartis Institutes for BioMedical Research, Basel, Switzerland, Cambridge, USA, and Novartis Pharma KK, Toranomon Minato-ku, Tokyo
| | - Leslie Johnson
- Novartis Institutes for BioMedical Research, Basel, Switzerland, Cambridge, USA, and Novartis Pharma KK, Toranomon Minato-ku, Tokyo
| | - Rambabu Danekula
- Novartis Institutes for BioMedical Research, Basel, Switzerland, Cambridge, USA, and Novartis Pharma KK, Toranomon Minato-ku, Tokyo
| | - Morten Bagger
- Novartis Institutes for BioMedical Research, Basel, Switzerland, Cambridge, USA, and Novartis Pharma KK, Toranomon Minato-ku, Tokyo
| | - Yoko Watanabe
- Novartis Institutes for BioMedical Research, Basel, Switzerland, Cambridge, USA, and Novartis Pharma KK, Toranomon Minato-ku, Tokyo
| | - Börje Haraldsson
- Novartis Institutes for BioMedical Research, Basel, Switzerland, Cambridge, USA, and Novartis Pharma KK, Toranomon Minato-ku, Tokyo
| | - Yuzuru Kanakura
- Department of Hematology and Oncology, Osaka University Graduate School of Medicine, Suita, Japan; Sumitomo Hospital, Osaka
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87
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Kulasekararaj AG, Brodsky RA, Nishimura JI, Patriquin CJ, Schrezenmeier H. The importance of terminal complement inhibition in paroxysmal nocturnal hemoglobinuria. Ther Adv Hematol 2022; 13:20406207221091046. [PMID: 35663504 PMCID: PMC9160915 DOI: 10.1177/20406207221091046] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 03/14/2022] [Indexed: 11/30/2022] Open
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) is a rare, chronic hematologic disorder associated with inappropriate terminal complement activity on blood cells that can result in intravascular hemolysis (IVH), thromboembolic events (TEs), and organ damage. Untreated individuals with PNH have an increased risk of morbidity and mortality. Patients with PNH experiencing IVH often present with an elevated lactate dehydrogenase (LDH; ⩾ 1.5 × the upper limit of normal) level which is associated with a significantly higher risk of TEs, one of the leading causes of death in PNH. LDH is therefore used as a biomarker for IVH in PNH. The main objective of PNH treatment should therefore be prevention of morbidity and mortality due to terminal complement activation, with the aim of improving patient outcomes. Approval of the first terminal complement inhibitor, eculizumab, greatly changed the treatment landscape of PNH by giving patients an effective therapy and demonstrated the critical role of terminal complement and the possibility of modulating it therapeutically. The current mainstays of treatment for PNH are the terminal complement component 5 (C5) inhibitors, eculizumab and ravulizumab, which have shown efficacy in controlling terminal complement-mediated IVH, reducing TEs and organ damage, and improving health-related quality of life in patients with PNH since their approval by the United States Food and Drug Administration in 2007 and 2018, respectively. Moreover, the use of eculizumab has been shown to reduce mortality due to PNH. More recently, interest has arisen in developing additional complement inhibitors with different modes of administration and therapeutics targeting other components of the complement cascade. This review focuses on the pathophysiology of clinical complications in PNH and explores why sustained inhibition of terminal complement activity through the use of complement inhibitors is essential for the management of patients with this chronic and debilitating disease.
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Affiliation(s)
- Austin G. Kulasekararaj
- Department of Haematological Medicine, King’s College Hospital, Denmark Hill, London SE5 9RS, UK
- National Institute of Health Research/Wellcome King’s Clinical Research Facility and King’s College London, London, UK
| | | | - Jun-ichi Nishimura
- Department of Hematology and Oncology, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Christopher J. Patriquin
- Division of Medical Oncology & Hematology, University Health Network – Toronto General Hospital, University of Toronto, Toronto, ON, Canada
| | - Hubert Schrezenmeier
- Institute of Transfusion Medicine, University of Ulm, and Institute of Clinical Transfusion Medicine and Immunogenetics Ulm, German Red Cross Blood Transfusion Service, and University Hospital Ulm, Ulm, Germany
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88
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Indications for haematopoietic cell transplantation for haematological diseases, solid tumours and immune disorders: current practice in Europe, 2022. Bone Marrow Transplant 2022; 57:1217-1239. [PMID: 35589997 PMCID: PMC9119216 DOI: 10.1038/s41409-022-01691-w] [Citation(s) in RCA: 117] [Impact Index Per Article: 58.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 04/15/2022] [Accepted: 04/20/2022] [Indexed: 12/17/2022]
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89
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Fabian E, Stadlbauer V, Keil F, Hegenbarth K, Beubler E, Krejs GJ. Clinical-Pathological Conference Series from the Medical University of Graz : Case No 125: A 42-year-old man with loss of appetite, vomiting and stabbing abdominal pain. Wien Klin Wochenschr 2022; 134:487-496. [PMID: 35543823 PMCID: PMC9213354 DOI: 10.1007/s00508-022-02025-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/04/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Elisabeth Fabian
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Vanessa Stadlbauer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 15, 8036, Graz, Austria
| | - Felix Keil
- Department of Internal Medicine 3, Hematology and Oncology, Hanusch Hospital, Vienna, Austria
| | | | - Eckhard Beubler
- Department of Clinical Pharmacology and Toxicology, Medical University of Graz, Graz, Austria
| | - Guenter J Krejs
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 15, 8036, Graz, Austria.
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90
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Bansal L, Nichols EM, Howsmon DP, Neisen J, Bessant CM, Cunningham F, Petit-Frere S, Ludbrook S, Damian V. Mathematical Modeling of Complement Pathway Dynamics for Target Validation and Selection of Drug Modalities for Complement Therapies. Front Pharmacol 2022; 13:855743. [PMID: 35517827 PMCID: PMC9061988 DOI: 10.3389/fphar.2022.855743] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 03/14/2022] [Indexed: 11/13/2022] Open
Abstract
Motivation: The complement pathway plays a critical role in innate immune defense against infections. Dysregulation between activation and regulation of the complement pathway is widely known to contribute to several diseases. Nevertheless, very few drugs that target complement proteins have made it to the final regulatory approval because of factors such as high concentrations and dosing requirements for complement proteins and serious side effects from complement inhibition. Methods: A quantitative systems pharmacology (QSP) model of the complement pathway has been developed to evaluate potential drug targets to inhibit complement activation in autoimmune diseases. The model describes complement activation via the alternative and terminal pathways as well as the dynamics of several regulatory proteins. The QSP model has been used to evaluate the effect of inhibiting complement targets on reducing pathway activation caused by deficiency in factor H and CD59. The model also informed the feasibility of developing small-molecule or large-molecule antibody drugs by predicting the drug dosing and affinity requirements for potential complement targets. Results: Inhibition of several complement proteins was predicted to lead to a significant reduction in complement activation and cell lysis. The complement proteins that are present in very high concentrations or have high turnover rates (C3, factor B, factor D, and C6) were predicted to be challenging to engage with feasible doses of large-molecule antibody compounds (≤20 mg/kg). Alternatively, complement fragments that have a short half-life (C3b, C3bB, and C3bBb) were predicted to be challenging or infeasible to engage with small-molecule compounds because of high drug affinity requirements (>1 nM) for the inhibition of downstream processes. The drug affinity requirements for disease severity reduction were predicted to differ more than one to two orders of magnitude than affinities needed for the conventional 90% target engagement (TE) for several proteins. Thus, the QSP model analyses indicate the importance for accounting for TE requirements for achieving reduction in disease severity endpoints during the lead optimization stage.
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Affiliation(s)
- Loveleena Bansal
- Systems Modeling and Translational Biology, Computational Sciences, GSK, Upper Providence, Collegeville, PA, United States
| | | | - Daniel P Howsmon
- Department of Chemical and Biological Engineering, Rensselaer Polytechnic Institute, Troy, NY, United States
| | - Jessica Neisen
- Immunology Research Unit, GSK, Stevenage, United Kingdom
| | | | | | | | - Steve Ludbrook
- Immunology Research Unit, GSK, Stevenage, United Kingdom
| | - Valeriu Damian
- Systems Modeling and Translational Biology, Computational Sciences, GSK, Upper Providence, Collegeville, PA, United States
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91
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Meuleman MS, Duval A, Fremeaux-Bacchi V, Roumenina LT, Chauvet S. Ex Vivo Test for Measuring Complement Attack on Endothelial Cells: From Research to Bedside. Front Immunol 2022; 13:860689. [PMID: 35493497 PMCID: PMC9041553 DOI: 10.3389/fimmu.2022.860689] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 03/21/2022] [Indexed: 01/04/2023] Open
Abstract
As part of the innate immune system, the complement system plays a key role in defense against pathogens and in host cell homeostasis. This enzymatic cascade is rapidly triggered in the presence of activating surfaces. Physiologically, it is tightly regulated on host cells to avoid uncontrolled activation and self-damage. In cases of abnormal complement dysregulation/overactivation, the endothelium is one of the primary targets. Complement has gained momentum as a research interest in the last decade because its dysregulation has been implicated in the pathophysiology of many human diseases. Thus, it appears to be a promising candidate for therapeutic intervention. However, detecting abnormal complement activation is challenging. In many pathological conditions, complement activation occurs locally in tissues. Standard routine exploration of the plasma concentration of the complement components shows values in the normal range. The available tests to demonstrate such dysregulation with diagnostic, prognostic, and therapeutic implications are limited. There is a real need to develop tools to demonstrate the implications of complement in diseases and to explore the complex interplay between complement activation and regulation on human cells. The analysis of complement deposits on cultured endothelial cells incubated with pathologic human serum holds promise as a reference assay. This ex vivo assay most closely resembles the physiological context. It has been used to explore complement activation from sera of patients with atypical hemolytic uremic syndrome, malignant hypertension, elevated liver enzymes low platelet syndrome, sickle cell disease, pre-eclampsia, and others. In some cases, it is used to adjust the therapeutic regimen with a complement-blocking drug. Nevertheless, an international standard is lacking, and the mechanism by which complement is activated in this assay is not fully understood. Moreover, primary cell culture remains difficult to perform, which probably explains why no standardized or commercialized assay has been proposed. Here, we review the diseases for which endothelial assays have been applied. We also compare this test with others currently available to explore complement overactivation. Finally, we discuss the unanswered questions and challenges to overcome for validating the assays as a tool in routine clinical practice.
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Affiliation(s)
- Marie-Sophie Meuleman
- Centre de Recherche des Cordeliers, INSERM, Sorbonne Université, Université de Paris, Paris, France
| | - Anna Duval
- Centre de Recherche des Cordeliers, INSERM, Sorbonne Université, Université de Paris, Paris, France
| | | | - Lubka T Roumenina
- Centre de Recherche des Cordeliers, INSERM, Sorbonne Université, Université de Paris, Paris, France
| | - Sophie Chauvet
- Centre de Recherche des Cordeliers, INSERM, Sorbonne Université, Université de Paris, Paris, France
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92
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Kulasekararaj AG, Griffin M, Langemeijer S, Usuki K, Kulagin A, Ogawa M, Yu J, Mujeebuddin A, Nishimura JI, Lee JW, Peffault de Latour R. Long-term safety and efficacy of ravulizumab in patients with paroxysmal nocturnal hemoglobinuria: 2-year results from two pivotal phase 3 studies. Eur J Haematol 2022; 109:205-214. [PMID: 35502600 PMCID: PMC9546219 DOI: 10.1111/ejh.13783] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 04/21/2022] [Accepted: 04/25/2022] [Indexed: 12/01/2022]
Abstract
OBJECTIVES The complement component 5 (C5) inhibitor ravulizumab demonstrated non-inferiority to eculizumab following 26 weeks of treatment in complement inhibitor-naïve and complement inhibitor-experienced patients with paroxysmal nocturnal hemoglobinuria (PNH; studies 301 and 302, respectively). This study aims to describe the results of both studies from 27 weeks to 2 years. METHODS Patients (N = 441) continued to receive ravulizumab throughout the extension period. Efficacy endpoints included lactate dehydrogenase (LDH) normalization, transfusion avoidance and fatigue score (FACIT-F). Safety analyses were also performed. RESULTS From 27 weeks to 2 years, improvements in LDH levels were maintained in both study populations. Transfusion avoidance was maintained in 81.9% (study 301) and 85.6% (study 302) of patients, and FACIT-F scores remained stable. Ravulizumab was well tolerated, and the incidence of adverse events (AEs) were similar between patients of both studies. Incidence of serious AEs deemed related to ravulizumab treatment was low (<3%). CONCLUSIONS This study reports, to date, the longest period of follow-up in over 400 patients with PNH treated with ravulizumab (662 patient-years). Long-term, ravulizumab demonstrated durable efficacy and was well tolerated, highlighting the importance of C5 inhibitors as the mainstay of PNH treatment.
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Affiliation(s)
- Austin G Kulasekararaj
- Department of Haematological Medicine, King's College Hospital, National Institute for Health Research and Wellcome King's Clinical Research Facility and King's College London, London, UK
| | | | | | | | - Alexander Kulagin
- RM Gorbacheva Research Institute, Pavlov University, St Petersburg, Russia
| | - Masayo Ogawa
- Alexion, AstraZeneca Rare Disease, Boston, Massachusetts, USA
| | - Ji Yu
- Alexion, AstraZeneca Rare Disease, Boston, Massachusetts, USA
| | | | | | - Jong Wook Lee
- Department of Hematology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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93
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Kulasekararaj A, Glasmacher A, Liu P, Szer J, Araten D, Rauch G, Gwaltney C, Sierra JR, Lee JW. Composite endpoint to evaluate complement inhibition therapy in patients with paroxysmal nocturnal hemoglobinuria. Eur J Haematol Suppl 2022; 108:391-402. [PMID: 35100459 PMCID: PMC9311164 DOI: 10.1111/ejh.13746] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 01/20/2022] [Accepted: 01/21/2022] [Indexed: 12/16/2022]
Abstract
This study developed and explored a novel composite endpoint to assess the overall impact that treatment can have on patients living with paroxysmal nocturnal hemoglobinuria (PNH). Candidate composite endpoint variables were selected by a group of experts and included: lactate dehydrogenase levels as a measure of intravascular hemolysis; complete terminal complement inhibition; absence of major adverse vascular events, including thrombosis; absence of any adverse events leading to death or discontinuation of study treatment; transfusion avoidance; and improvements in fatigue‐related quality of life as determined by the Functional Assessment of Chronic Illness Therapy (FACIT)‐Fatigue score. From these variables, a novel composite endpoint was constructed and explored using data collected in the ravulizumab PNH Study 301 (NCT02946463). Thresholds were defined and reported for each candidate variable. Five of the six candidate variables were included in the final composite endpoint; the FACIT‐Fatigue score was excluded. Composite endpoint criterion was defined as patients meeting all five selected individual component thresholds. All patients in the ravulizumab arm achieved complete terminal complement inhibition and a reduction in lactate dehydrogenase levels; 51.2% and 41.3% of patients in the ravulizumab arm and eculizumab arm, respectively, achieved all composite endpoint component thresholds (treatment difference: 9.4%; 95% confidence interval: −3.0, 21.5). The composite endpoint provided a single and simultaneous measurement of overall benefit for patients receiving treatment for PNH. Use of the composite endpoint in future PNH research is recommended to determine clinical benefit, and its use in health technology assessments should be evaluated.
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Affiliation(s)
- Austin Kulasekararaj
- King's College Hospital, King's College London, and NIHR/Wellcome Trust King's Clinical Research Facility, London, UK
| | - Axel Glasmacher
- AG Life Science Consulting, Alfter, Germany.,Department of Medicine III, University of Bonn, Bonn, Germany
| | - Peng Liu
- Alexion Pharmaceuticals, Inc., Boston, Massachusetts, USA
| | - Jeff Szer
- Peter MacCallum Cancer Centre and The Royal Melbourne Hospital, Melbourne, Australia
| | - David Araten
- New York University Grossman School of Medicine, New York, New York, USA
| | - Geraldine Rauch
- Institute of Biometry and Clinical Epidemiology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Chad Gwaltney
- Gwaltney Consulting, Westerly, Rhode Island, USA.,Brown University, Providence, Rhode Island, USA
| | | | - Jong Wook Lee
- Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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94
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Jahangirpour M, Vahedi A, Baghdadi H, Madani T, Behvarmanesh A, Alidadi M, Boroojerdi MH, Mohammaei S, Poopak P, Poopak A, Pour GK, Poopak B. Paroxysmal nocturnal haemoglobinuria, diagnosis and haematological findings, first report from Iran, model for developing countries. EJHAEM 2022; 3:335-340. [PMID: 35846057 PMCID: PMC9176096 DOI: 10.1002/jha2.410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 02/14/2022] [Accepted: 02/21/2022] [Indexed: 11/10/2022]
Affiliation(s)
| | | | - Hamed Baghdadi
- Payvand Clinical and Specialty Laboratory Tehran Iran
- Department of Hematology Faculty of Medical Sciences Tarbiat Modares University Tehran Iran
| | | | - Ali Behvarmanesh
- Department of Biochemistry and Centre de Recherche en Biologie Structurale McGill University Montreal Quebec Canada
| | - Mohammad Alidadi
- In Vitro Medical Device Department National Medical Device Directorate Food And Drug Administration Tehran Iran
| | - Mohadese Hashem Boroojerdi
- Payvand Clinical and Specialty Laboratory Tehran Iran
- Department of Medical Biotechnology, Medical Faculty, Tarbiat Modares University Tehran Iran
| | | | | | - Amirhossein Poopak
- Tehran University of Medical Sciences Tehran Iran
- Students’ Scientific Research Centre Tehran University of Medical Sciences Tehran Iran
| | | | - Behzad Poopak
- Payvand Clinical and Specialty Laboratory Tehran Iran
- Islamic Azad University Tehran Medical Sciences Branch Tehran Iran
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95
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Krishnan S, Sarda S, Kunzweiler C, Wu M, Sundaresan S, Huynh L, Duh MS, Escalante CP. Literature Review of Fatigue Scales and Association with Clinically Meaningful Improvements in Outcomes Among Patients With and Without Paroxysmal Nocturnal Hemoglobinuria. Adv Ther 2022; 39:1959-1975. [PMID: 35316499 PMCID: PMC9056457 DOI: 10.1007/s12325-022-02111-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Accepted: 03/02/2022] [Indexed: 11/15/2022]
Abstract
Introduction Paroxysmal nocturnal hemoglobinuria (PNH) is a rare blood disorder characterized by anemia and debilitating fatigue. Limited evidence characterizes the association between hemoglobin, an indicator of anemia and disease activity, and patient-reported fatigue scales. This review identifies benchmarks for clinically meaningful improvements in patients with and without PNH. Methods MEDLINE, Embase, Cochrane, and PsycINFO databases were searched along with Google Scholar to identify publications for patients with and without PNH. Full-text articles and conference abstracts of clinical trials or observational studies that examined patient-reported fatigue or associations between fatigue and hemoglobin were included. Results Fourteen publications were included in this study. Four clinical trials conducted in patients with PNH reported that patients achieved and sustained clinically meaningful improvements in fatigue. However, these studies did not examine the association between fatigue and hemoglobin. Ten studies conducted in patients with cancer and anemia (with or without chemotherapy) demonstrated an association between increased hemoglobin and improvements in fatigue (P < 0.05). The greatest incremental gain in fatigue improvement was observed when hemoglobin increased from 11 to 12 g/dL. Conclusion Evidence among patients with cancer without PNH demonstrates that increased hemoglobin levels are associated with clinically significant improvements in fatigue. Future studies should validate this relationship among patients with PNH. Supplementary Information The online version contains supplementary material available at 10.1007/s12325-022-02111-7.
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96
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Cheng WY, Sarda SP, Mody-Patel N, Krishnan S, Yenikomshian M, Kunzweiler C, Vu JD, Cheung HC, Duh MS. Real-World Eculizumab Dosing Patterns Among Patients with Paroxysmal Nocturnal Hemoglobinuria in a US Population. CLINICOECONOMICS AND OUTCOMES RESEARCH 2022; 14:357-369. [PMID: 35535299 PMCID: PMC9078865 DOI: 10.2147/ceor.s346816] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Accepted: 04/12/2022] [Indexed: 01/01/2023] Open
Abstract
Purpose Current pharmacologic management of paroxysmal nocturnal hemoglobinuria (PNH) consists of C5 inhibitors, eculizumab and ravulizumab; however, because patients experience incomplete symptom control, off-label doses may be utilized. We conducted a retrospective, longitudinal cohort study of provider-based claims data to assess the real-world eculizumab dosing patterns in PNH patients. Patients and Methods Patients were ≥12 years, received ≥2 eculizumab infusions between January 1, 2015 and September 30, 2019, and had ≥3 months of continuous clinical activity prior to index. The index date was the first claim for eculizumab. Patients with ≥1 diagnosis of another indication for eculizumab were excluded. Treatment patterns including the proportion with high, label-recommended, and low dosages during induction (first 28 days) and maintenance (beginning day 29) phases were described. The proportion and time-to-first dose escalation, defined as an increase in dose or frequency of infusion, were assessed among a subset of patients (ie, escalation analysis cohort). Results A total of 707 patients were examined. Mean (standard deviation [SD]) starting dose was 862mg (412mg) and was higher than label-recommended 600mg for 64% of the patients. Mean (SD) dose per infusion was 859mg (391mg) during the induction phase; average dose was higher than label-recommended 600mg for 68%. Mean (SD) dose per infusion during the maintenance phase was 1005mg (335mg); average dose was higher than label-recommended 900mg for 43%. Dose escalation occurred in 40/121 escalation analysis cohort patients. Median time-to-first dose escalation was ~12 months. Conclusion Results suggest that deviations from label-recommended dosing patterns were common. Future budget impact assessments of eculizumab should account for real-world dosing patterns to comprehensively assess costs and benefits.
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Affiliation(s)
- Wendy Y Cheng
- Analysis Group, Inc., Boston, MA, USA
- Correspondence: Wendy Y Cheng, Analysis Group, Inc., 111 Huntington Ave, 14th Floor, Boston, MA, 02199, USA, Tel +1 617 425 8219, Fax +1 617 425 8000, Email
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97
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Höchsmann B, de Fontbrune FS, Lee JW, Kulagin AD, Hillmen P, Wilson A, Marantz JL, Schrezenmeier H. Effect of eculizumab treatment in patients with paroxysmal nocturnal hemoglobinuria with or without high disease activity: Real-world findings from the International Paroxysmal Nocturnal Hemoglobinuria Registry. Eur J Haematol 2022; 109:197-204. [PMID: 35390189 DOI: 10.1111/ejh.13773] [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: 08/09/2021] [Revised: 03/28/2022] [Accepted: 03/30/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND The effects of eculizumab treatment in paroxysmal nocturnal hemoglobinuria (PNH) patients with or without high-disease activity (HDA), defined by LDH ≥ 1.5 × ULN and history of major adverse vascular events (MAVEs; including thrombotic events [TEs]); anemia; and/or physician-reported abdominal pain, dyspnea, dysphagia, erectile dysfunction, fatigue, and/or hemoglobinuria, in the International PNH Registry were evaluated. METHODS Registry patients were stratified by baseline HDA and eculizumab-treatment status. Longitudinal changes in laboratory and clinical PNH-related endpoints were evaluated using linear mixed models (continuous variables) or Poisson regression (incidence rates). RESULTS As of May 1, 2017, 3009 patients (HDA/eculizumab-treated, n = 913; HDA/never-treated, n = 651; no-HDA/eculizumab-treated, n = 173; no-HDA/never-treated, n = 1272) were analyzed. Higher proportions of eculizumab-treated patients had HDA and history of MAVEs. In patients with and without HDA, respectively, eculizumab treatment resulted in reductions from baseline for (1) LDH ratio (mean [SD]: -5.3 [4.0] and -2.3 [3.8]); (2) incidence rate ratio (IRR) for MAVEs (-80% and -70%); (3) IRR for TEs (-80% for both); and (4) units of red blood cell transfusions per year (from 6.8 to 2.8 and 3.6 to 2.5 units). CONCLUSIONS Eculizumab treatment in a real-world setting improved outcomes, including substantial decreases in hemolysis, MAVE rates, TEs, and transfusions in PNH patients regardless of HDA.
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Affiliation(s)
- Britta Höchsmann
- Institute of Transfusion Medicine, University of Ulm, and Institute for Clinical Transfusion Medicine and Immunogenetics, German Red Cross Blood Transfusion Service Baden-Württemberg-Hessen and University Hospital Ulm, Ulm, Germany
| | | | - Jong Wook Lee
- Department of Hematology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Alexander D Kulagin
- Pavlov First Saint Petersburg State Medical University, St. Petersburg, Russia
| | | | - Amanda Wilson
- Alexion, AstraZeneca Rare Disease, Boston, Massachusetts, USA
| | - Jing L Marantz
- Alexion, AstraZeneca Rare Disease, Boston, Massachusetts, USA
| | - Hubert Schrezenmeier
- Institute of Transfusion Medicine, University of Ulm, and Institute for Clinical Transfusion Medicine and Immunogenetics, German Red Cross Blood Transfusion Service Baden-Württemberg-Hessen and University Hospital Ulm, Ulm, Germany
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98
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Saad AA. Targeting cancer-associated glycans as a therapeutic strategy in leukemia. ALL LIFE 2022. [DOI: 10.1080/26895293.2022.2049901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Affiliation(s)
- Ashraf Abdullah Saad
- Unit of Pediatric Hematologic Oncology and BMT, Sultan Qaboos University Hospital, Muscat, Oman
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99
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Khalil A, Kanitra JJ, Lorelli D. Non-diseased aortic mural thrombus presenting with acute limb ischaemia. BMJ Case Rep 2022; 15:e247297. [PMID: 35332004 PMCID: PMC8948415 DOI: 10.1136/bcr-2021-247297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/13/2022] [Indexed: 11/07/2022] Open
Abstract
We present a case of a thoracic aortic mural thrombus (AMT) in a non-atherosclerotic and non-aneurysmal aorta that presented with acute limb ischaemia. AMT in a non-diseased aorta without an underlying hypercoagulable disorder is rare. The AMT in our patient was managed with anticoagulation, which resolved on a 5-month follow-up CT scan. This provided us an opportunity to discuss the successful medical management of an AMT, to review the literature on the management of AMT and to add to the literature on a rare presentation of an AMT.
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Affiliation(s)
- Ali Khalil
- School of Medicine, St George's University, St George's, Grenada
| | - John J Kanitra
- Department of Surgery, Ascension St John Hospital, Detroit, Michigan, USA
| | - David Lorelli
- Department of Surgery, Ascension St John Hospital, Detroit, Michigan, USA
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100
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New insights into Human Hematopoietic Stem and Progenitor Cells via Single-Cell Omics. Stem Cell Rev Rep 2022; 18:1322-1336. [PMID: 35318612 PMCID: PMC8939482 DOI: 10.1007/s12015-022-10330-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/09/2022] [Indexed: 10/25/2022]
Abstract
Residing at the apex of the hematopoietic hierarchy, hematopoietic stem and progenitor cells (HSPCs) give rise to all mature blood cells. In the last decade, significant progress has been made in single-cell RNA sequencing as well as multi-omics technologies that have facilitated elucidation of the heterogeneity of previously defined human HSPCs. From the embryonic stage through the adult stage to aging, single-cell studies have enabled us to trace the origins of hematopoietic stem cells (HSCs), demonstrating different hematopoietic differentiation during development, as well as identifying novel cell populations. In both hematological benign diseases and malignancies, single-cell omics technologies have begun to reveal tissue heterogeneity and have permitted mapping of microenvironmental ecosystems and tracking of cell subclones, thereby greatly broadening our understanding of disease development. Furthermore, advances have also been made in elucidating the molecular mechanisms for relapse and identifying therapeutic targets of hematological disorders and other non-hematological diseases. Extensive exploration of hematopoiesis at the single-cell level may thus have great potential for broad clinical applications of HSPCs, as well as disease prognosis.
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