Response of factor V inhibitor to rituximab in a patient who received liver transplantation for primary biliary cirrhosis

Systemic lupus erythematosus combined with Wilson's disease: a case report and literature review

BACKGROUND

Systemic lupus erythematosus (SLE) and Wilson's disease (WD) are both systemic diseases that can affect multiple organs in the body. The coexistence of SLE and WD is rarely encountered in clinical practice, making it challenging to diagnose.

CASE REPORT

We present the case of a 9-year-old girl who initially presented with proteinuria, haematuria, pancytopenia, hypocomplementemia, and positivity for multiple autoantibodies. She was diagnosed with SLE, and her blood biochemistry showed elevated liver enzymes at the time of diagnosis. Despite effective control of her symptoms, her liver enzymes remained elevated during regular follow-up. Laboratory tests revealed decreased serum copper and ceruloplasmin levels, along with elevated urinary copper. Liver biopsy revealed chronic active hepatitis, moderate inflammation, moderate-severe fibrosis, and a trend towards local cirrhosis. Genetic sequencing revealed compound heterozygous mutations in the ATP7B gene, confirming the diagnosis of SLE with WD. The girl received treatment with a high-zinc/low-copper diet, but her liver function did not improve. Upon recommendation following multidisciplinary consultation, she underwent liver transplantation. Unfortunately, she passed away on the fourth day after the surgery.

CONCLUSIONS

SLE and WD are diseases that involve multiple systems and organs in the body, and SLE complicated with WD is rarely encountered in the clinic; therefore, it is easy to misdiagnose. Because penicillamine can induce lupus, it is not recommended. Liver transplantation is indicated for patients with liver disease who do not respond to medical treatment with WD. However, further research is needed to determine the optimal timing of liver transplantation for patients with SLE complicated with WD.

Idiopathic factor V inhibitor in a patient starting haemodialysis

A 74-year-old Pacific Island man with end-stage renal failure planning to start haemodialysis presented with persistent bleeding after tunnelled dialysis catheter insertion. The laboratory findings revealed a prolonged activated partial thromboplastin time of 118 s, prothrombin ratio of 4.2, factor V activity of <2% and a factor V inhibitor of 40 Bethesda Units. No clear underlying aetiology was identified. The bleeding settled with conservative measures and the factor V inhibitor was successfully treated with oral cyclophosphamide for 6 weeks.

Liver Disease and Hemostasis (Review) Part 2. Cholestatic Liver Disease and Hemostasis

The presence or development of liver disorders can significantly complicate the course of critical illness and terminal conditions. Systemic hemostatic disorders are common in Intensive Care Units patients with cholestatic liver diseases, so the study of the mechanisms of their development can contribute to the understanding of the development of multiorgan failure in critical illness.

The review discusses current data on changes in hemostatic parameters in patients with cholestatic liver diseases, proposes a mechanism for the development of such disorders, which involve interactions of phospholipids with platelet and endotheliocyte membranes. It is suggested that a trend for thrombosis in patients with cholestatic liver disease is due to increased accumulation of bile acids in the systemic circulation. Available data demonstrate that the antiphospholipid syndrome may predispose to the formation of blood clots due to alterations of phospholipid composition of membranes of platelets and vascular endothelial cells by circulating antiphospholipid antibodies. Clarifying the mechanisms contributing to changes of the blood coagulation system parameters in liver disorders will aid to development of optimal correction of hemostatic disorders in patients with chronic liver diseases.

Rituximab in the Treatment of Acquired Hemophilia

Objective:

To review published literature evaluating the use of rituximab for treatment of acquired hemophilia.

Data Sources:

An English-language literature search was conducted using MEDLINE (1966–January 2006). References of identified articles were subsequently reviewed for additional data. Search terms included rituximab, acquired hemophilia, and inhibitors.

Data Synthesis:

Available data suggest that B-cell depletion by rituximab in patients with acquired hemophilia may contribute to the eradication of inhibitors to coagulation factors. B-cells have been shown to be essential in the development of autoimmunity or an acquired immune response. Beneficial effects of rituximab, after failure of established therapies, have been reported in case reports and one small, open-label trial.

Conclusions:

Although data are limited, administration of rituximab appears to be an effective option for treatment of patients with acquired hemophilia after established therapies have failed. Patients given rituximab experienced cessation of recurrent bleeding, normalization of factor VIII activity, and eradication of inhibitors. A complete response to rituximab (undetectable inhibitors, normalization of factor levels) generally occurred several weeks to months after initiation of therapy.

Acquired Factor V Inhibitors in a Patient with End-stage Renal Disease

We report a case of acquired factor V inhibitors (AFVIs) in a patient with end-stage renal disease receiving warfarin therapy for atrial fibrillation. A 72-year-old Japanese man was admitted to our hospital complaining of tarry stools and abdominal pain. The laboratory findings revealed eosinophilia (52.1%), prolonged activated partial thromboplastin time (APTT) (98 s), PT (84 s), a factor V (FV) activity of <3%, and an FV inhibitor level of 6 Bethesda units/mL. After administration of prednisolone was started, his coagulation findings improved. However, his renal failure progressed, and he ultimately required chronic hemodialysis. This is the first case of AFVIs in a patient starting hemodialysis for end-stage renal disease.

Acquired factor V inhibitor after liver transplantation

Acquired inhibitors against coagulation factor V (FV) occur rarely, the clinical symptoms vary to a great extent, from asymptomatic laboratory abnormalities to life-threatening bleeding. Coagulation factor V (FV) is a plasma-cofactor mostly existing in the plasma, and approximately 20-25% (Tracy et al. (1982), Kane (2006)) of FV exist in platelet granules. Patients' reaction is the prolonging of prothrombin time (PT) and activated partial thromboplastin time (APTT), but there is no exact reason, and that can not be corrected after normal plasma transfusion (Morris and Curris (2009), Lucia and Aguilar (2005)). We report here a case of the occurrence of FV inhibitors after orthotopic liver transplantation (OLT). With gastrointestinal bleeding, patient's haemostatic response was not achieved after using fresh frozenplasma (FFP), platelet concentrates (PC), prothrombin complex concentrates (PCC) or recombinant activated FVII (rFVIIa). After using high-dose intravenous immunoglobulin (IVIg) and change of immunosuppressant from tacrolimus (FK506) to cyclosporine, the bleeding stopped and better laboratory examination results was achieved thereafter.

Isolated factor V deficiency in a patient with elevated PT and aPTT during routine pre-operative laboratory screening

Isolated factor V (FV) deficiency is a rare disorder with approximately 150 cases reported in the literature since 1943. Bleeding symptoms from FV deficiency vary widely. FV deficiency usually manifests early in the life. We present a 59-year-old case with FV deficiency discovered during pre-operative laboratory screen.

Successful management of a possible antibiotic-related acquired factor V inhibitor: a case report and review of the literature

Acquired factor inhibitors are rare. We report a case of an elderly male who presented with a bleeding diathesis associated with an elevated prothrombin time and an activated partial thromboplastin time. Work-up revealed undetectable factor V activity and a factor V inhibitor level of >50 Bethesda units. The inhibitor may have been triggered by antibiotics. With a multimodality approach using steroids, platelet transfusions, intravenous immunoglobulin, factor VIII inhibitor bypass activity agent and cyclophosphamide, we successfully eliminated the inhibitor and controlled the bleeding.

Acquired factor V inhibitors: a systematic review

The occurrence of an inhibitor against coagulation factor V (FV) is a rare but challenging condition, which may span from asymptomatic laboratory abnormalities to potentially life-threatening bleeding. The onset of FV inhibitors has been associated most frequently in the past with the patients' exposure to topical bovine thrombin administered during surgery procedures. However, since this preparation is no longer used, in this systematic review we have only focused on non-bovine thrombin-related FV inhibitor cases.

Postoperative bleeding in an elderly patient from acquired factor V inhibitor: rapid response to immunosuppressive therapy

Acquired factor V inhibitor is a rare but potentially life-threatening hemorrhagic disorder caused by the development of autoantibodies directed against coagulation factor V. The management of acute bleeding and inhibitor eradication is the mainstay of the treatment. The authors report a case of a 79-year-old man who underwent right hip arthroplasty and postoperatively, when on Coumadin for deep venous thrombosis prophylaxis, developed bleeding from the surgical site with a hematoma and abnormal coagulation parameters. Further workup revealed an acquired factor V inhibitor. The approach to treat this rare and challenging disorder is discussed. The patient responded rapidly with disappearance of factor V inhibitor titers after initiation of treatment with rituximab, prednisone and cyclophosphamide.

Liver transplantation in systemic lupus erythematosus: case report and review of the literature

Severe liver involvement requiring liver transplantation is a rare complication in systemic lupus erythematosus (SLE), but very few cases have been reported. We describe a 39-year-old woman with SLE who underwent successful liver transplantation due to acute liver failure. The patient persisted without reactivation of SLE and with good long-term survival. Management and diagnosis considerations are reviewed.

Successful treatment with rituximab in a patient with an acquired factor V inhibitor

Rituximab has already been successfully used to treat immune-mediated bleeding disorders such as acquired factor VIII inhibitor. We report here a case of severe acquired factor V (FV) inhibitor deficiency due to FV inhibitor which has been dramatically improved after rituximab.

Rituximab in the treatment of anti-neutrophil cytoplasm antibody associated vasculitis and systemic lupus erythematosus: past, present and future

Nephritis is the most frequent severe manifestation of anti-neutrophil cytoplasm antibody associated (ANCA) systemic vasculitis (AASV) and systemic lupus erythematosus (SLE) and carries substantial morbidity. Although immunosuppressive medications and glucocorticoids are effective at inducing remission, patients still suffer from high relapse rates and experience significant treatment-related toxicity. Rituximab (RTX), a chimeric antibody directed against CD20, found on B lymphocytes, shows potential as a treatment for both AASV and SLE. Although direct comparisons with standard therapies are currently unavailable, patients in several studies of refractory and relapsing disease have achieved a remission despite the failure of standard therapies. These reports are supported by several lines of experimental evidence that underlie the rationale for using targeted B-cell therapies and have improved our understanding of the pathogenesis of these complex diseases. Future randomized control trials and long-term follow-up studies are required to confirm the role of RTX and other B-cell targeting therapies in AASV and SLE.

Failure of rituximab to induce immune tolerance in a boy with severe haemophilia A and an alloimmune factor VIII antibody: a case report and review of the literature

We report the use of rituximab (MabThera); Roche Grenzach-Wyhlen, Germany) in a 6-year-old boy with severe haemophilia A and a high titre alloimmune factor VIII (FVIII) antibody, which had failed to respond to standard immune tolerance therapy. Rituximab was administered in 4 weekly doses with concurrent high-dose i.v. immunoglobulin (Flebogamma); Grifols, Barcelona, Spain) followed by daily high-dose recombinant FVIII concentrate (Recombinate); Baxter, CA, USA). Despite a fall in CD20 positive cell count to undetectable levels the inhibitor persisted. We discuss the possible reasons for failure of immune tolerance induction and review the literature concerning the use of rituximab for this indication.

Acquired coagulation inhibitor-associated bleeding disorders: an update

Acquired blood coagulation inhibitors are circulating immunoglobulins that neutralize the activity of a specific coagulation protein or accelerate its clearance from the plasma, thus causing a bleeding tendency. In this review, we focus on the nonhemophilic inhibitors of coagulation, i.e. the autoantibodies occurring in individuals without a pre-existent coagulation defect, reporting the most recent advances in the pathophysiology, diagnosis and treatment of these rare acquired bleeding disorders.

Immunopathogenesis of primary Sjögren's syndrome: implications for disease management and therapy

PURPOSE OF REVIEW

Recent studies have broadened our understanding of the etiopathogenesis and immunopathology of primary Sjögren's syndrome. This review highlights recent advances in understanding the underlying mechanisms of the disease as well as their implications for clinical handling and therapeutic options.

RECENT FINDINGS

It becomes increasingly apparent that certain disturbances of the immune system (i.e. B-cell hyperreactivity and enhanced levels of B-cell-activating factor/B-lymphocyte stimulator) play a central role in this entity. Whether this is a primary abnormality or the result of predisposing factors or infectious, e.g. viral, agents remains uncertain. New insights into the pathogenesis also provide candidates for better diagnosis and classification of disease severity, such as flow cytometric analysis, measurement of soluble cell surface molecules, autoantibodies, cytokines, and ligands (B-cell-activating factor/B-lymphocyte stimulator). Whether B-cell-directed therapies (i.e. blocking B-cell-activating factor/B-lymphocyte stimulator, anti-CD20 therapy) will have an impact on primary Sjögren's syndrome needs to be shown in clinical trials. Alternative therapeutic approaches such as organ-targeted gene transfer are in development but must be carefully evaluated for safety and efficacy in preclinical models that resemble human primary Sjögren's syndrome.

SUMMARY

The pathogenesis of primary Sjögren's syndrome is complex and the factors initiating and driving autoimmunity in this entity are largely unknown. Recent studies provide new insights into potential pathogenetic mechanisms of the disease and, thereby, the chance for improved strategies in disease management and therapy.

Rituximab anti-B-cell therapy in systemic lupus erythematosus: pointing to the future

PURPOSE OF REVIEW

To discuss the clinical effects and the immunologic consequences of transient B-cell depletion using the anti-CD20 monoclonal antibody rituximab in systemic lupus erythematosus.

RECENT FINDINGS

A total of 100 rituximab-treated patients with severe disease, refractory to major immunosuppressive treatment, have been reported so far. Within a median follow-up period of 12 months rituximab was well tolerated, which is compatible with the experience accumulated from its use in more than 500 000 lymphoma patients. About 80% of patients achieved marked and rapid reductions in global disease activity. Because of the clinical heterogeneity, dosing differences, and concomitant treatments, including cyclophosphamide in 35% of patients, a proper evaluation of the clinical efficacy or rituximab is difficult. Variable degrees of clinical benefit have been reported for all clinical systemic lupus erythematosus manifestations, including active proliferative nephritis. Whereas 4-weekly infusions of 375 mg/m of rituximab result in complete B-cell depletion lasting most often from 3 to 8 months, a prolonged depletion does not always correlate with a more favorable clinical response. Total immunoglobulin levels and protective antibodies are preserved, but anti-dsDNA antibody titers decrease, often independently of the clinical response.

SUMMARY

The findings reviewed point to a growing optimism for targeting B cells in the treatment of systemic lupus erythematosus; therefore double-blind studies comparing rituximab with existing immunosuppressive therapies are needed. Moreover, careful assessments of the effects of transient B-cell depletion on distinct autoimmune pathogenetic processes will enable optimization of therapeutic single or combined therapeutic schemes.