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Mo CC, Richardson E, Calabretta E, Corrado F, Kocoglu MH, Baron RM, Connors JM, Iacobelli M, Wei LJ, Rapoport AP, Díaz-Ricart M, Moraleda JM, Carlo-Stella C, Richardson PG. Endothelial injury and dysfunction with emerging immunotherapies in multiple myeloma, the impact of COVID-19, and endothelial protection with a focus on the evolving role of defibrotide. Blood Rev 2024; 66:101218. [PMID: 38852017 DOI: 10.1016/j.blre.2024.101218] [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] [Received: 05/01/2024] [Revised: 05/31/2024] [Accepted: 05/31/2024] [Indexed: 06/10/2024]
Abstract
Patients with multiple myeloma (MM) were among the groups impacted more severely by the COVID-19 pandemic, with higher rates of severe disease and COVID-19-related mortality. MM and COVID-19, plus post-acute sequelae of SARS-CoV-2 infection, are associated with endothelial dysfunction and injury, with overlapping inflammatory pathways and coagulopathies. Existing treatment options for MM, notably high-dose therapy with autologous stem cell transplantation and novel chimeric antigen receptor (CAR) T-cell therapies and bispecific T-cell engaging antibodies, are also associated with endothelial cell injury and mechanism-related toxicities. These pathologies include cytokine release syndrome (CRS) and neurotoxicity that may be exacerbated by underlying endotheliopathies. In the context of these overlapping risks, prophylaxis and treatment approaches mitigating the inflammatory and pro-coagulant effects of endothelial injury are important considerations for patient management, including cytokine receptor antagonists, thromboprophylaxis with low-molecular-weight heparin and direct oral anticoagulants, and direct endothelial protection with defibrotide in the appropriate clinical settings.
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Affiliation(s)
- Clifton C Mo
- Department of Medical Oncology, Dana-Farber Cancer Institute, Jerome Lipper Center for Multiple Myeloma Research, Harvard Medical School, Boston, MA, USA
| | - Edward Richardson
- Department of Medicine, Warren Alpert Medical School at Brown University, Providence, RI, USA
| | - Eleonora Calabretta
- Department of Biomedical Sciences, Humanitas University, and IRCCS Humanitas Research Hospital, Milan, Italy; Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Francesco Corrado
- Department of Medical Oncology, Dana-Farber Cancer Institute, Jerome Lipper Center for Multiple Myeloma Research, Harvard Medical School, Boston, MA, USA; Department of Biomedical Sciences, Humanitas University, and IRCCS Humanitas Research Hospital, Milan, Italy; Broad Institute of Massachusetts Institute of Technology (MIT) and Harvard, Cambridge, MA, USA
| | - Mehmet H Kocoglu
- Department of Medicine, University of Maryland School of Medicine, and Transplant and Cellular Therapy Program, University of Maryland Greenebaum Comprehensive Cancer Center, Baltimore, MD, USA
| | - Rebecca M Baron
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | | | - Lee-Jen Wei
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Aaron P Rapoport
- Department of Medicine, University of Maryland School of Medicine, and Transplant and Cellular Therapy Program, University of Maryland Greenebaum Comprehensive Cancer Center, Baltimore, MD, USA
| | - Maribel Díaz-Ricart
- Hematopathology, Pathology Department, CDB, Hospital Clinic, and IDIBAPS, Barcelona, Spain, and Barcelona Endothelium Team, Barcelona, Spain
| | - José M Moraleda
- Department of Medicine, Faculty of Medicine, Institute of Biomedical Research (IMIB-Pascual Parrilla), University of Murcia, Murcia, Spain
| | - Carmelo Carlo-Stella
- Department of Biomedical Sciences, Humanitas University, and IRCCS Humanitas Research Hospital, Milan, Italy
| | - Paul G Richardson
- Department of Medical Oncology, Dana-Farber Cancer Institute, Jerome Lipper Center for Multiple Myeloma Research, Harvard Medical School, Boston, MA, USA.
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2
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Fang W, Sun W, Fang W, Zhao S, Wang C. Clinical features, treatment, and outcomes of patients with carfilzomib induced thrombotic microangiopathy. Int Immunopharmacol 2024; 134:112178. [PMID: 38728883 DOI: 10.1016/j.intimp.2024.112178] [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] [Received: 02/15/2024] [Revised: 04/25/2024] [Accepted: 04/27/2024] [Indexed: 05/12/2024]
Abstract
BACKGROUND Thrombotic microangiopathy (TMA) is associated with carfilzomib, and knowledge of carfilzomib-induced TMA is based mainly on case reports. This study investigated the clinical characteristics of patients with carfilzomib-induced TMA and provided a reference for the rational use of carfilzomib. METHODS Reports of carfilzomib-induced TMA were collected for retrospective analysis by searching the Chinese and English databases from inception to January 31, 2024. RESULTS Sixty-six patients were included, with a median age of 63 years (range 39, 85). The median time to onset of TMA was 42 days (range 1, 1825) from initial administration, and the median number of cycles was 3 cycles (range 1, 15). Hemolytic anemia was recorded in 64 patients, with a median of 8.3 g/dL (range 4.6, 13). Sixty-three patients had thrombocytopenia with a median of 18 × 109/L (range 1, 139). The median value of increased LDH was 1192 IU/L (range 141, 5378). ADAMTS13 activity was normal in 41 (62.1 %) of the 42 patients. Mutations were found in 9 (13.6 %) of the 15 patients. Fifty-seven patients achieved a clinical response after discontinuing carfilzomib and receiving therapeutic plasma exchange (53.0 %), eculizumab (24.2 %), or hemodialysis (39.4 %). CONCLUSION Carfilzomib-induced TMA is an important adverse event that should be considered in patients receiving carfilzomib for multiple myeloma with anemia, thrombocytopenia, and acute kidney injury. Withdrawal of carfilzomib and treatment with eculizumab have proven successful in some patients.
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Affiliation(s)
- Weilun Fang
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, Hunan 410013, China; College of Pharmacy, Changsha Medical University, Changsha, Hunan 410219, China
| | - Wei Sun
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, Hunan 410013, China
| | - Weijin Fang
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, Hunan 410013, China
| | - Shaoli Zhao
- Department of Endocrinology, The Third Xiangya Hospital, Central South University, China
| | - Chunjiang Wang
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, Hunan 410013, China.
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3
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Gork I, Xiong F, Kitchlu A. Cancer drugs and acute kidney injury: new therapies and new challenges. Curr Opin Nephrol Hypertens 2024:00041552-990000000-00164. [PMID: 38712677 DOI: 10.1097/mnh.0000000000001001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/08/2024]
Abstract
PURPOSE OF REVIEW Cancer therapies continue to evolve at a rapid pace and although novel treatments, including immunotherapies and targeted therapies have allowed for substantial improvements in cancer survival, they carry associated risks of acute kidney injury (AKI). We aim to summarize the existing literature on AKI associated with the spectrum of systemic cancer treatments, including conventional chemotherapies, newer immunotherapies, and the growing number of targeted cancer therapies, which may be associated with both AKI and 'pseudo-AKI'. RECENT FINDINGS Conventional cytotoxic chemotherapies (e.g. cisplatin and other platinum-based agents, methotrexate, pemetrexed, ifosfamide, etc.) with well recognized nephrotoxicities (predominantly tubulointerstitial injury) remain in widespread use. Immunotherapies (e.g., immune checkpoint inhibitors and CAR-T therapies) may be associated with kidney immune-related adverse events, most often acute interstitial nephritis, and rarely, glomerular disease. Recently, multiple targeted cancer therapies have been associated with reduced renal tubular secretion of creatinine, causing elevations in serum creatinine and apparent 'pseudo-AKI'. To complicate matters further, these agents have had biopsy-proven, 'true' kidney injury attributed to them in numerous case reports. SUMMARY Clinicians in nephrology and oncology must be aware of the various potential kidney risks with these agents and recognize those with clinically meaningful impact on both cancer and kidney outcomes.
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Affiliation(s)
- Ittamar Gork
- Department of Medicine, Division of Nephrology, University Health Network, University of Toronto, Toronto, Ontario, Canada
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4
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Ho PJ, Spencer A, Mollee P, Bryant CE, Enjeti AK, Horvath N, Butcher BE, Trotman J, Gibbs S, Joshua DE. Serum Free Light Chain Kinetics Is Predictive of Renal Response in Myeloma Patients With Renal Impairment-An ALLG Trial of Carfilzomib-Dexamethasone Therapy in Frontline and Relapse. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2024:S2152-2650(24)00149-6. [PMID: 38702217 DOI: 10.1016/j.clml.2024.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Revised: 03/22/2024] [Accepted: 04/04/2024] [Indexed: 05/06/2024]
Abstract
BACKGROUND AND PURPOSE Renal impairment (RI) confers adverse prognosis in myeloma; its reversal and avoidance of dialysis are crucial. We investigated whether serum free light chain (SFLC) measurements can predict renal outcome, to enable change in therapy to optimize prognosis and avoid dialysis. PATIENTS AND METHODS We investigated 36 myeloma patients (17 newly diagnosed [ND]; 19 relapsed refractory [RR]; with median of 5 prior lines) with eGFR 15-40 ml/min treated with carfilzomib (Cfz)-dexamethasone to determine whether SFLC kinetics can predict renal outcomes, and assess efficacy and tolerability. RESULTS The change in involved SFLC at Cycle 2 Day 1 was significantly correlated with renal function; for every one log10 reduction in involved SFLC, eGFR increased by 9.0-15.0 mL/min at cycles 2-4, with SFLC reduction of 54%-78%. At a median follow-up of 30.6 months, renal outcomes were favorable-CRrenal 25%, MRrenal 36%. Disease responses (ND 100%, RR 75%), progression-free survival (ND 32.2 months, RR 11.1 months) and overall survival (ND not reached, RR 42.0 months) were comparable to patients without RI. There was significant toxicity, including Cfz-related cardiac impairment of 20% within a cohort with high co-morbidity, and a high incidence of infections. CONCLUSION We propose that one log10 reduction in involved SFLC at Cycle 2 Day 1 is an appropriate target for reducing the risk of dialysis in myeloma patients with RI; below this threshold patients may benefit from a change in therapy. While Cfz-dexamethasone achieved favorable renal and disease outcomes, toxicity can be significant in this vulnerable cohort.
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Affiliation(s)
- P Joy Ho
- Institute of Haematology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia; University of Sydney, Sydney, New South Wales, Australia.
| | - Andrew Spencer
- Department of Haematology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Peter Mollee
- Haematology Department, Princess Alexandra Hospital, Brisbane, Queensland, Australia; School of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Christian E Bryant
- Institute of Haematology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia; University of Sydney, Sydney, New South Wales, Australia
| | - Anoop K Enjeti
- Department of Haematology, Calvary Mater Newcastle Hospital, Waratah, New South Wales, Australia; NSW Health Pathology, John Hunter Hospital, New Lambton Heights, New South Wales, Australia; Precision Medicine Program, Hunter Medical Research Institute and University of Newcastle, New South Wales, Australia
| | | | - Belinda E Butcher
- Biostatistics, WriteSource Medical, Lane Cove, New South Wales, Australia; School of Biomedical Sciences, University of New South Wales, Sydney, New South Wales, Australia
| | - Judith Trotman
- University of Sydney, Sydney, New South Wales, Australia; Concord Repatriation General Hospital, Concord, New South Wales, Australia
| | - Simon Gibbs
- Box Hill Hospital, Melbourne, Victoria, Australia
| | - Douglas E Joshua
- Institute of Haematology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia; University of Sydney, Sydney, New South Wales, Australia
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5
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Klomjit N, Evans R, Le TK, Wells SL, Ortega J, Green-Lingren O, Mazepa M, Sise ME, Jhaveri KD, Gupta S. Frequency and characteristics of chemotherapy-associated thrombotic microangiopathy: Analysis from a large pharmacovigilance database. Am J Hematol 2023; 98:E369-E372. [PMID: 37740927 PMCID: PMC10844958 DOI: 10.1002/ajh.27101] [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: 07/16/2023] [Revised: 08/30/2023] [Accepted: 09/09/2023] [Indexed: 09/25/2023]
Abstract
We used the information component (IC), a disproportionate Bayesian analysis comparing the number of observed versus expected adverse drug reactions, to determine the potential association between anti-neoplastic agents and thrombotic microangiopathy (TMA). The IC025 indicates the lower end of 95% of IC, in which a value >0 suggests a disproportionality signal between the drug of interest and the adverse drug reaction. Carfilzomib had the highest IC025 for TMA among all studied chemotherapies followed by gemcitabine, mitomycin, bevacizumab, and bortezomib.
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Affiliation(s)
- Nattawat Klomjit
- Division of Nephrology and Hypertension, Department of
Medicine, University of Minnesota, MN, USA
| | - Richard Evans
- Masonic Cancer Center, University of Minnesota, MN,
USA
| | - Thomas K. Le
- Department of Dermatology, University of Pittsburgh Medical
Center, Pittsburgh, PA
| | - Sophia L. Wells
- Division of Renal Medicine, Brigham and Women’s
Hospital, Boston, MA, USA
| | - Jessica Ortega
- Division of Renal Medicine, Brigham and Women’s
Hospital, Boston, MA, USA
| | | | - Marshall Mazepa
- Division of Hematology, Oncology and Transplantation,
Department of Medicine, University of Minnesota, MN, USA
| | - Meghan E. Sise
- Department of Medicine, Division of Nephrology,
Massachusetts General Hospital, Boston, MA, USA
| | - Kenar D. Jhaveri
- Division of Kidney Diseases and Hypertension, Donald and
Barbara Zucker School of Medicine, Great Neck, NY, USA
| | - Shruti Gupta
- Division of Renal Medicine, Brigham and Women’s
Hospital, Boston, MA, USA
- Adult Survivorship Program, Dana-Farber Cancer Institute,
Boston, MA, USA
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6
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Ponraj R, Bryant A, Dunlop L, Range H, Cobrador C, Ling S, Hsu D. Carfilzomib-induced thrombotic microangiopathy (TMA): an under-recognised spectrum of disease from microangiopathic haemolysis to subclinical TMA. Blood Cancer J 2023; 13:113. [PMID: 37495597 PMCID: PMC10371986 DOI: 10.1038/s41408-023-00885-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 07/01/2023] [Accepted: 07/13/2023] [Indexed: 07/28/2023] Open
Affiliation(s)
- Royston Ponraj
- Haematology Department, Liverpool Hospital, Sydney, Australia.
| | - Adam Bryant
- Haematology Department, Liverpool Hospital, Sydney, Australia
- School of Medicine, University of New South Wales, Sydney, Australia
| | - Lindsay Dunlop
- Haematology Department, Liverpool Hospital, Sydney, Australia
- School of Medicine, University of New South Wales, Sydney, Australia
- School of Medicine, Western Sydney University, Sydney, Australia
| | - Heather Range
- Department of Pharmacy, Liverpool Hospital, Sydney, Australia
| | - Cherry Cobrador
- Department of Pharmacy, Liverpool Hospital, Sydney, Australia
| | - Silvia Ling
- Haematology Department, Liverpool Hospital, Sydney, Australia
- School of Medicine, University of New South Wales, Sydney, Australia
- School of Medicine, Western Sydney University, Sydney, Australia
| | - Danny Hsu
- Haematology Department, Liverpool Hospital, Sydney, Australia
- School of Medicine, University of New South Wales, Sydney, Australia
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7
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Dabour MS, Abdelgawad IY, Grant MKO, El-Sawaf ES, Zordoky BN. Canagliflozin mitigates carfilzomib-induced endothelial apoptosis via an AMPK-dependent pathway. Biomed Pharmacother 2023; 164:114907. [PMID: 37247463 DOI: 10.1016/j.biopha.2023.114907] [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: 02/28/2023] [Revised: 05/05/2023] [Accepted: 05/16/2023] [Indexed: 05/31/2023] Open
Abstract
Carfilzomib (CFZ) is a proteasome inhibitor approved for relapsed/refractory multiple myeloma (MM) but its clinical use is limited by cardiovascular toxicity. The mechanisms of CFZ-induced cardiovascular toxicity are not fully understood but endothelial dysfunction may be a common denominator. Here, we first characterized the direct toxic effects of CFZ on endothelial cells (HUVECs and EA.hy926 cells) and tested whether SGLT2 inhibitors, known to have cardioprotective effects, can protect against CFZ-induced toxicity. To determine the chemotherapeutic effect of CFZ in the presence of SGLT2 inhibitors, MM and lymphoma cells were treated with CFZ with or without canagliflozin. CFZ decreased cell viability and induced apoptotic cell death in endothelial cells in a concentration-dependent manner. CFZ also upregulated ICAM-1 and VCAM-1 and downregulated VEGFR-2. These effects were associated with the activation of Akt and MAPK pathways, inhibition of p70s6k, and downregulation of AMPK. Canagliflozin, but not empagliflozin or dapagliflozin, protected endothelial cells from CFZ-induced apoptosis. Mechanistically, canagliflozin abrogated CFZ-induced JNK activation and AMPK inhibition. AICAR (an AMPK activator) protected from CFZ-induced apoptosis, and compound C (an AMPK inhibitor) abrogated the protective effect of canagliflozin, strongly suggesting that AMPK mediates these effects. Canagliflozin did not interfere with the anticancer effect of CFZ in cancer cells. In conclusion, our findings demonstrate for the first time the direct toxic effects of CFZ in endothelial cells and the associated signaling changes. Canagliflozin abrogated the apoptotic effects of CFZ in endothelial cells in an AMPK-dependent mechanism, without interfering with its cytotoxicity in cancer cells.
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Affiliation(s)
- Mohamed S Dabour
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, MN 55455, USA; Department of Clinical Pharmacy, Faculty of Pharmacy, Tanta University, 31111 Tanta, Egypt
| | - Ibrahim Y Abdelgawad
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, MN 55455, USA
| | - Marianne K O Grant
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, MN 55455, USA
| | - Engie S El-Sawaf
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, MN 55455, USA; Department of Pharmacology, Toxicology, and Biochemistry, Faculty of Pharmacy, Future University in Egypt, Cairo, Egypt
| | - Beshay N Zordoky
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, MN 55455, USA.
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8
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Jindal N, Jandial A, Jain A, Lad D, Prakash G, Khadwal A, Nada R, Sethi J, Ahluwalia J, Malhotra P. Carfilzomib-induced Thrombotic Microangiopathy: A Case Based Review. Hematol Oncol Stem Cell Ther 2023; 16:426-431. [PMID: 32735793 DOI: 10.1016/j.hemonc.2020.07.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 07/08/2020] [Accepted: 07/11/2020] [Indexed: 11/16/2022] Open
Abstract
Carfilzomib is an irreversible proteasome inhibitor currently approved for the treatment of relapsed multiple myeloma. It has been implicated as a cause of thrombotic microangiopathy (TMA) in several case reports. The incidence, risk factors, and treatment of carfilzomib-related TMA remain unclear. Here we describe the clinical presentation and outcome of a 58-year-old man with biopsy-proven TMA that occurred following treatment with carfilzomib-based therapy. We also reviewed the published literature with regard to the incidence, risk factors, treatment options, and outcome of carfilzomib-related TMA.
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Affiliation(s)
- Nishant Jindal
- Department of Internal Medicine, 4th floor, Nehru Hospital, Post Graduate Institute of Medical Education and Research, Sector 12 Chandigarh (160012), India
| | - Aditya Jandial
- Department of Internal Medicine, 4th floor, Nehru Hospital, Post Graduate Institute of Medical Education and Research, Sector 12 Chandigarh (160012), India
| | - Arihant Jain
- Department of Internal Medicine, 4th floor, Nehru Hospital, Post Graduate Institute of Medical Education and Research, Sector 12 Chandigarh (160012), India
| | - Deepesh Lad
- Department of Internal Medicine, 4th floor, Nehru Hospital, Post Graduate Institute of Medical Education and Research, Sector 12 Chandigarh (160012), India
| | - Gaurav Prakash
- Department of Internal Medicine, 4th floor, Nehru Hospital, Post Graduate Institute of Medical Education and Research, Sector 12 Chandigarh (160012), India
| | - Alka Khadwal
- Department of Internal Medicine, 4th floor, Nehru Hospital, Post Graduate Institute of Medical Education and Research, Sector 12 Chandigarh (160012), India
| | - Ritambhra Nada
- Department of Histopathology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Jasmine Sethi
- Department of Nephrology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Jasmina Ahluwalia
- Department of Hematology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Pankaj Malhotra
- Department of Internal Medicine, 4th floor, Nehru Hospital, Post Graduate Institute of Medical Education and Research, Sector 12 Chandigarh (160012), India
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Zafar A, Lim MY, Abou-Ismail MY. Eculizumab in the management of drug-induced thrombotic microangiopathy: A scoping review of the literature. Thromb Res 2023; 224:73-79. [PMID: 36871347 DOI: 10.1016/j.thromres.2023.02.012] [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] [Received: 11/15/2022] [Revised: 01/16/2023] [Accepted: 02/23/2023] [Indexed: 03/06/2023]
Abstract
Drug-induced TMA (DI-TMA) is a thrombotic microangiopathy (TMA) caused by certain drugs, usually managed by drug discontinuation and supportive measures. Data on the use of complement-inhibition with eculizumab in DI-TMA is scarce, and its benefit in cases of severe or refractory DI-TMA is unclear. We conducted a comprehensive search in PubMed, Embase and MEDLINE databases (2007-2021). We included articles that reported on DI-TMA patients treated with eculizumab and its clinical outcomes. All other causes of TMA were excluded. We evaluated the outcomes of hematologic recovery, renal recovery, and a composite of both (complete TMA recovery). 35 studies fulfilled our search criteria, which included 69 individual cases of DI-TMA treated with eculizumab. Most cases were secondary to chemotherapeutic agents, and the most implicated drugs were gemcitabine (42/69), carfilzomib (11/69), and bevacizumab (5/69). The median number of eculizumab doses given was 6 (range 1-16). 55/69 (80 %) patients achieved renal recovery, after 28-35 days (5-6 doses). 13/22 (59 %) patients were able to discontinue hemodialysis. 50/68 (74 %) patients achieved complete hematologic recovery after 7-14 days (1-2 doses). 41/68 (60 %) patients met criteria for complete TMA recovery. Eculizumab was safely tolerated in all cases, and appeared to be effective in achieving both hematologic and renal recovery in DI-TMA refractory to drug discontinuation and supportive measures, or with severe manifestations associated with significant morbidity or mortality. Our findings suggest that eculizumab may be considered as a potential treatment for severe or refractory DI-TMA that does not improve after initial management, although larger studies are needed.
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Affiliation(s)
- Aneeqa Zafar
- Division of Hematology, Bone Marrow Transplant and Cellular Therapy, Department of Internal Medicine, University of California, San Francisco, United States of America
| | - Ming Yeong Lim
- Division of Hematology and Hematologic Malignancies, Department of Internal Medicine, University of Utah Health Sciences Center, United States of America
| | - Mouhamed Yazan Abou-Ismail
- Division of Hematology and Hematologic Malignancies, Department of Internal Medicine, University of Utah Health Sciences Center, United States of America.
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10
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Leung N, Rajkumar SV. Multiple myeloma with acute light chain cast nephropathy. Blood Cancer J 2023; 13:46. [PMID: 36990996 PMCID: PMC10060259 DOI: 10.1038/s41408-023-00806-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 02/21/2023] [Accepted: 02/27/2023] [Indexed: 03/31/2023] Open
Abstract
Light chain cast nephropathy (LCCN) is a leading cause of acute kidney injury (AKI) in patients with multiple myeloma (MM) and is now defined as a myeloma defining event. While the long-term prognosis has improved with novel agents, short-term mortality remains significantly higher in patients with LCCN especially if the renal failure is not reversed. Recovery of renal function requires a rapid and significant reduction of the involved serum free light chain. Therefore, proper treatment of these patients is of the utmost importance. In this paper, we provide an algorithm for treatment of MM patients who present with biopsy-proven LCCN or in those where other causes of AKI have been ruled out. The algorithm is based on data from randomized trial whenever possible. When trial data is not available, our recommendations is based on non-randomized data and expert opinions on best practices. We recommend that all patients should enroll in a clinical trial if available prior to resorting to the treatment algorithm we outlined.
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Affiliation(s)
- Nelson Leung
- Division of Hematology, Mayo Clinic, Rochester, MN, USA.
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA.
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11
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Moscvin M, Liacos CI, Chen T, Theodorakakou F, Fotiou D, Hossain S, Rowell S, Leblebjian H, Regan E, Czarnecki P, Bagnoli F, Bolli N, Richardson P, Rennke HG, Dimopoulos MA, Kastritis E, Bianchi G. Mutations in the alternative complement pathway in multiple myeloma patients with carfilzomib-induced thrombotic microangiopathy. Blood Cancer J 2023; 13:31. [PMID: 36849497 PMCID: PMC9971259 DOI: 10.1038/s41408-023-00802-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 02/09/2023] [Accepted: 02/15/2023] [Indexed: 02/28/2023] Open
Abstract
Thrombotic microangiopathy (TMA) has been reported to occur in multiple myeloma (MM) patients in association with treatment with carfilzomib, an irreversible proteasome inhibitor (PI). The hallmark of TMA is vascular endothelial damage leading to microangiopathic hemolytic anemia, platelet consumption, fibrin deposition and small-vessel thrombosis with resultant tissue ischemia. The molecular mechanisms underlying carfilzomib-associated TMA are not known. Germline mutations in the complement alternative pathway have been recently shown to portend increased risk for the development of atypical hemolytic uremic syndrome (aHUS) and TMA in the setting of allogeneic stem cell transplant in pediatric patients. We hypothesized that germline mutations in the complement alternative pathway may similarly predispose MM patients to carfilzomib-associated TMA. We identified 10 MM patients with a clinical diagnosis of TMA in the context of carfilzomib treatment and assessed for the presence of germline mutations in the complement alternative pathway. Ten, matched MM patients exposed to carfilzomib but without clinical TMA were used as negative controls. We identified a frequency of deletions in the complement Factor H genes 3 and 1 (delCFHR3-CFHR1) and genes 1 and 4 (delCFHR1-CFHR4) in MM patients with carfilzomib-associated TMA that was higher as compared to the general population and matched controls. Our data suggest that complement alternative pathway dysregulation may confer susceptibility to vascular endothelial injury in MM patients and predispose to development of carfilzomib-associated TMA. Larger, retrospective studies are needed to evaluate whether screening for complement mutations may be indicated to properly counsel patients about TMA risk with carfilzomib use.
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Affiliation(s)
- Maria Moscvin
- Amyloidosis Program, Division of Hematology, Brigham and Women's Hospital, Boston, MA, USA
- Stanford Health Care, Stanford, CA, USA
| | - Christine Ivy Liacos
- Department of Clinical Therapeutics, National Kapodistrian University of Athens, Athens, Greece
| | - Tianzeng Chen
- Amyloidosis Program, Division of Hematology, Brigham and Women's Hospital, Boston, MA, USA
| | - Foteini Theodorakakou
- Department of Clinical Therapeutics, National Kapodistrian University of Athens, Athens, Greece
| | - Despina Fotiou
- Department of Clinical Therapeutics, National Kapodistrian University of Athens, Athens, Greece
| | - Shahrier Hossain
- Department of Clinical Therapeutics, National Kapodistrian University of Athens, Athens, Greece
| | - Sean Rowell
- Jerome Lipper Multiple Myeloma Center, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Houry Leblebjian
- Jerome Lipper Multiple Myeloma Center, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Eileen Regan
- Jerome Lipper Multiple Myeloma Center, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Peter Czarnecki
- Renal Division, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Filippo Bagnoli
- Department of Oncology and Onco-Hematology, University of Milan, Milan, Italy
- Hematology Division, Fondazione IRCCS Ca' Grande Ospedale Maggiore Policlinico, Milan, Italy
| | - Niccolo' Bolli
- Department of Oncology and Onco-Hematology, University of Milan, Milan, Italy
- Hematology Division, Fondazione IRCCS Ca' Grande Ospedale Maggiore Policlinico, Milan, Italy
| | - Paul Richardson
- Jerome Lipper Multiple Myeloma Center, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Helmut G Rennke
- Amyloidosis Program, Division of Hematology, Brigham and Women's Hospital, Boston, MA, USA
| | - Meletios A Dimopoulos
- Department of Clinical Therapeutics, National Kapodistrian University of Athens, Athens, Greece
| | - Efstathios Kastritis
- Department of Clinical Therapeutics, National Kapodistrian University of Athens, Athens, Greece
| | - Giada Bianchi
- Amyloidosis Program, Division of Hematology, Brigham and Women's Hospital, Boston, MA, USA.
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12
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Mescherina NS, Stepchenko MA, Leontieva TS, Khardikova EM, Mikhailenko TS. Approaches to early diagnosis and prevention of cardiovascular toxicity induced by targeted drugs and immune checkpoint inhibitors in oncohematology: a literature review. КАРДИОВАСКУЛЯРНАЯ ТЕРАПИЯ И ПРОФИЛАКТИКА 2023. [DOI: 10.15829/1728-8800-2023-3337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023] Open
Abstract
The development of targeted drugs and immune checkpoint inhibitors (ICIs), as well as their implementation into clinical practice has allowed increasing the overall and event-free survival of oncohematological patients. Currently, assessment of the efficacy of a therapeutic strategy in each specific case includes the evaluation of an acceptable tolerability profile. The subject of discussion includes cardiovascular complications induced by target drugs and ICIs. The review mainly presents the issues of cardiovascular toxicity (CVT) in certain groups of oncohematological patients (with chronic lymphocytic leukemia, chronic myeloid leukemia, multiple myeloma). The spectrum of cardiovascular adverse effects associated with targeted and ICI therapy in oncohematological practice is quite wide — coronary artery disease, peripheral arterial disease, myocarditis, heart failure, arrhythmias, hypertension. The high importance of the problem of using targeted and immunosuppressive therapy dictates the need to predict adverse effects. The diagnosis of heart failure (one of CVT manifestations) is based on determining the decreased left ventricular ejection fraction during echocardiography, less often — during cardiac magnetic resonance imaging; global longitudinal myocardial strain is a significant parameter of preclinical heart failure, which is determined using the speckle tracking technique. To determine vascular toxicity, a special attention is paid to the vascular wall structure and microcirculation parameters — capillary density at rest, percentage of capillary recovery and perfused capillaries, stiffness index for large blood vessels, reflection index for small arteries, laboratory markers of inflammation and endothelial dysfunction (C-reactive protein, fibrinogen, homocysteine, endothelin 1, vascular endothelial growth factor). CVT prevention presumes the determination of the risk group, correction of risk factors, and administration of protective therapy to very high and high-risk patients. One of the promising directions for preventing vascular toxicity is the use of sodium-glucose linked transporter-2 inhibitors.
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13
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Georgoulis V, Haidich AB, Bougioukas KI, Hatzimichael E. Efficacy and safety of carfilzomib for the treatment of multiple myeloma: An overview of systematic reviews. Crit Rev Oncol Hematol 2022; 180:103842. [DOI: 10.1016/j.critrevonc.2022.103842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Revised: 10/04/2022] [Accepted: 10/11/2022] [Indexed: 11/24/2022] Open
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14
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Gilles F. [What a cardiologist needs to know about managing a patient with multiple myeloma]. Ann Cardiol Angeiol (Paris) 2022; 71:309-316. [PMID: 35963791 DOI: 10.1016/j.ancard.2022.07.001] [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: 06/15/2023]
Abstract
Multiple myeloma is one of the most frequent hematological malignancies in the elderly and corresponds to the presence of a plasma cell clone. Antitumor treatment combines different therapeutics, including alkylating agents, high-dose corticosteroids, immunomodulators and proteasome inhibitors. These treatments can have cardiovascular side effects that are important to be aware of. The role of the cardiologist is essential in preventing, detecting and managing these effects properly in order to improve the cardiological and oncological prognosis of patients.
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Affiliation(s)
- F Gilles
- Service de cardiologie, Centre Hospitalier de Versailles, André Mignot, 177 rue de Versailles 78150 Le Chesnay, France.
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15
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Giannese D, Bonadio AG, Del Giudice ML, Cupisti A, Buda G. Carfilzomib-related glomerular and tubular injury in a patient with Multiple Myeloma. J Nephrol 2022; 35:2131-2134. [PMID: 35763255 DOI: 10.1007/s40620-022-01367-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 05/23/2022] [Indexed: 10/17/2022]
Affiliation(s)
- Domenico Giannese
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy.
| | - Angelo Giovanni Bonadio
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | | | - Adamasco Cupisti
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Gabriele Buda
- Department of Clinical and Experimental Medicine, Hematology Unit, University of Pisa, Pisa, Italy
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16
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Jang HY, Lee HK, Kim CJ, Yoon SS, Kim IW, Oh JM. Carfilzomib's Real-World Safety Outcomes in Korea: Target Trial Emulation Study Using Electronic Health Records. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:13560. [PMID: 36294140 PMCID: PMC9603615 DOI: 10.3390/ijerph192013560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 10/13/2022] [Accepted: 10/17/2022] [Indexed: 06/16/2023]
Abstract
Carfilzomib is a promising anticancer drug for relapsed/refractory multiple myeloma (RRMM). However, real-world evidence has only investigated the cardiovascular safety of carfilzomib, and there is a high demand for thorough safety evaluations. We aimed to comprehensively evaluate the risk of adverse events associated with carfilzomib in Korean patients with RRMM. We followed up with 138 matched patients with RRMM (69 KRd (carfilzomib, lenalidomide, and dexamethasone) and 69 Rd (lenalidomide and dexamethasone) users). A total of 12 adverse events were evaluated. More than 75% of adverse events occurred during the early cycle (1-6 cycles), and the incidence rate showed a tendency to decrease in the later cycle (7-12 and 13-18 cycles). Severities of most adverse events were evaluated as grade 1-2. The KRd regimen were related with significantly increased risks of dyspnea (adjusted HR (aHR) 2.27, 95% confidence interval (CI) 1.24-4.16), muscle spasm (aHR 5.12, 95% CI 1.05-24.9) and thrombocytopenia (aHR 1.84, 95% CI 1.10-3.06). Although the severities were low, carfilzomib has many side effects in treating RRMM; hence, findings on the patterns of its adverse events could lead to both effective and safe use of KRd therapy in real-world settings.
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Affiliation(s)
- Ha Young Jang
- College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, Seoul 08826, Korea
| | - Hyun Kyung Lee
- College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, Seoul 08826, Korea
| | - Chae Jeong Kim
- College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, Seoul 08826, Korea
| | - Sung-Soo Yoon
- Department of Internal Medicine, Seoul National University Hospital, 101, Daehak-ro, Jongro-gu, Seoul 03080, Korea
| | - In-Wha Kim
- College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, Seoul 08826, Korea
| | - Jung Mi Oh
- College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, Seoul 08826, Korea
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17
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Carfilzomib Induced Microangiopathy due to Accumulation With Paxlovid. Kidney Int Rep 2022; 7:2746-2749. [PMID: 36506224 PMCID: PMC9727521 DOI: 10.1016/j.ekir.2022.09.006] [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: 07/20/2022] [Revised: 08/31/2022] [Accepted: 09/05/2022] [Indexed: 12/15/2022] Open
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18
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Martins M, Bridoux F, Goujon JM, Meuleman MS, Ribes D, Rondeau E, Guerry MJ, Delmas Y, Levy B, Ducloux D, Kandel-Aznar C, Le Fur A, Garrouste C, Provot F, Gibier JB, Thervet E, Bruneval P, Rabant M, Karras A, Dragon Durey MA, Fremeaux-Bacchi V, Chauvet S. Complement Activation and Thrombotic Microangiopathy Associated With Monoclonal Gammopathy: A National French Case Series. Am J Kidney Dis 2022; 80:341-352. [PMID: 35217094 DOI: 10.1053/j.ajkd.2021.12.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 12/19/2021] [Indexed: 01/27/2023]
Abstract
RATIONALE & OBJECTIVE Hemolytic uremic syndrome (HUS), a thrombotic microangiopathy (TMA) with kidney involvement, is a rare condition in patients with monoclonal gammopathy. In the absence of known causes of TMA, the role of complement activation in endothelial injury in patients with monoclonal gammopathy remains unknown and was the focus of this investigation. STUDY DESIGN Case series. SETTING & PARTICIPANTS We studied the 24 patients in the French national registry of HUS between 2000 and 2020 who had monoclonal gammopathy without other causes of secondary TMA. We provide the clinical histories and complement studies of these patients. FINDINGS Monoclonal gammopathy-associated TMA with kidney involvement is estimated to be 10 times less frequent than adult atypical HUS (aHUS) in the French national registry. It is characterized by severe clinical features, with 17 of 24 patients requiring dialysis at disease onset, and with median renal survival of only 20 months. TMA-mediated extrarenal manifestations, particularly cutaneous and neurological involvement, were common and associated with poor overall prognosis. Complement studies identified low C3, normal C4, and high soluble C5b-9 levels in 33%, 100%, and 77% of tested patients, respectively, indicating a contribution of the alternative and terminal complement pathways in the pathophysiology of the disease. Genetic abnormalities in complement genes known to be associated with aHUS were found in only 3 of 17 (17%) who were tested. LIMITATIONS Retrospective study without comparison group; limited number of patients, limited available blood samples. CONCLUSIONS Within the spectrum of TMA, TMA associated with monoclonal gammopathy represents a distinct subset. Our findings suggest that HUS associated with monoclonal immunoglobulin is a complement-mediated disease akin to aHUS.
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Affiliation(s)
- Manon Martins
- Institut National de la Santé et de la Recherche Médicale Team 1138, Cordelier Research Center, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris; Departments of Nephrology, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris
| | - Frank Bridoux
- Departments of Nephrology, Centre Hospitalier Universitaire de Poitiers; Centre National de Référence Maladies Rares: Amylose AL et Autres Maladies à; Dépôts d'Immunoglobulines Monoclonales; Université de Poitiers, Poitiers
| | - Jean Michel Goujon
- Departments of Nephrology and Pathology, Centre Hospitalier Universitaire de Poitiers; Centre National de Référence Maladies Rares: Amylose AL et Autres Maladies à; Dépôts d'Immunoglobulines Monoclonales
| | - Marie Sophie Meuleman
- Institut National de la Santé et de la Recherche Médicale Team 1138, Cordelier Research Center, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris
| | - David Ribes
- Department of Nephrology, Centre Hospitalier Universitaire de Toulouse, Toulouse
| | - Eric Rondeau
- Department of Nephrology, Hôpital Tenon, Assistance Publique-Hôpitaux de Paris, Paris
| | - Mary-Jane Guerry
- Department of Nephrology, Centre Hospitalier de Valenciennes, Valenciennes
| | - Yahsou Delmas
- Department of Nephrology, Centre Hospitalier Universitaire de Bordeaux, Bordeaux
| | - Bénédicte Levy
- Department of Nephrology, Centre Hospitalier de Troyes, Troyes
| | - Didier Ducloux
- Department of Nephrology, Centre Hospitalier Universitaire de Besançon, Besançon
| | | | - Awena Le Fur
- Department of Nephrology, Centre Hospitalier Departemental de La Roche-sur-Yon, La Roche-sur-Yon
| | - Cyril Garrouste
- Department of Nephrology, Centre Hospitalier Universitaire de Clermont-Ferrand, Clermont-Ferrand
| | - François Provot
- Department of Nephrology, Centre Hospitalier Universitaire de Lille, Lille
| | | | - Eric Thervet
- Departments of Nephrology, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris; Université de Paris, Paris
| | - Patrick Bruneval
- Departments of Nephrology Pathology, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris
| | - Marion Rabant
- Department of Pathology, Hôpital Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris
| | - Alexandre Karras
- Departments of Nephrology, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris
| | - Marie Agnès Dragon Durey
- Departments of Nephrology Pathology, and Immunology, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris
| | - Veronique Fremeaux-Bacchi
- Departments of Nephrology Pathology, and Immunology, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris
| | - Sophie Chauvet
- Institut National de la Santé et de la Recherche Médicale Team 1138, Cordelier Research Center, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris; Departments of Nephrology, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris; Université de Paris, Paris.
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19
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Gupta S, Gudsoorkar P, Jhaveri KD. Acute Kidney Injury in Critically Ill Patients with Cancer. Clin J Am Soc Nephrol 2022; 17:1385-1398. [PMID: 35338071 PMCID: PMC9625110 DOI: 10.2215/cjn.15681221] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Advances in cancer therapy have significantly improved overall patient survival; however, AKI remains a common complication in patients with cancer, occurring in anywhere from 11% to 22% of patients, depending on patient-related or cancer-specific factors. Critically ill patients with cancer as well as patients with certain malignancies (e.g., leukemias, lymphomas, multiple myeloma, and renal cell carcinoma) are at highest risk of developing AKI. AKI may be a consequence of the underlying malignancy itself or from the wide array of therapies used to treat it. Cancer-associated AKI can affect virtually every compartment of the nephron and can present as subclinical AKI or as overt acute tubular injury, tubulointerstitial nephritis, or thrombotic microangiopathy, among others. AKI can have major repercussions for patients with cancer, potentially jeopardizing further eligibility for therapy and leading to greater morbidity and mortality. This review highlights the epidemiology of AKI in critically ill patients with cancer, risk factors for AKI, and common pathologies associated with certain cancer therapies, as well as the management of AKI in different clinical scenarios. It highlights gaps in our knowledge of AKI in patients with cancer, including the lack of validated biomarkers, as well as evidence-based therapies to prevent AKI and its deleterious consequences.
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Affiliation(s)
- Shruti Gupta
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Prakash Gudsoorkar
- Division of Nephrology & Kidney Clinical Advancement, Research & Education Program, University of Cincinnati, Cincinnati, Ohio
| | - Kenar D. Jhaveri
- Division of Kidney Diseases and Hypertension, Donald and Barbara Zucker School of Medicine, Great Neck, New York
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20
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Hamad CD, Hoelscher ZC, Tchakarov A, Kala J. Influenza-induced thrombotic microangiopathy in a patient with cancer on proteasome inhibitor: a diagnostic dilemma. CEN Case Rep 2022; 11:321-327. [PMID: 34997535 PMCID: PMC9343559 DOI: 10.1007/s13730-021-00681-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 12/23/2021] [Indexed: 11/25/2022] Open
Abstract
Thrombotic microangiopathy (TMA) in a cancer patient is a common complication of either cancer itself or anticancer therapy. Incidence of TMA from anticancer therapy was found to be > 15%, since the introduction of anti-angiogenic drugs like anti-vascular endothelial growth factor agents. It is, however, important to not ignore other causes of TMA such as bacteria, viruses, antiplatelet drugs, hereditary complement mutations, and autoimmune disorders. We present such a diagnostic dilemma in our patient who was admitted with influenza and was found to have TMA on renal biopsy, while on proteasome inhibitor (PI) therapy. With this case, we would like to highlight the importance of understanding the true cause of TMA to avoid unwarranted long-term discontinuation of life saving anti-cancer drugs after TMA resolution.
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Affiliation(s)
- Christopher D Hamad
- Division of Renal Diseases and Hypertension, Department of Internal Medicine, University of Texas Health Science Center-McGovern Medical School, 6410 Fannin St, Houston, TX, 77030, USA
| | - Zachary C Hoelscher
- Division of Renal Diseases and Hypertension, Department of Internal Medicine, University of Texas Health Science Center-McGovern Medical School, 6410 Fannin St, Houston, TX, 77030, USA
| | - Amanda Tchakarov
- Department of Pathology, The University of Texas Health Science Center-McGovern Medical School, Houston, TX, USA
| | - Jaya Kala
- Division of Renal Diseases and Hypertension, Department of Internal Medicine, University of Texas Health Science Center-McGovern Medical School, 6410 Fannin St, Houston, TX, 77030, USA.
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21
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Genetic and Functional Evidence of Complement Dysregulation in Multiple Myeloma Patients with Carfilzomib-Induced Thrombotic Microangiopathy Compared to Controls. J Clin Med 2022; 11:jcm11123355. [PMID: 35743426 PMCID: PMC9225266 DOI: 10.3390/jcm11123355] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 06/03/2022] [Accepted: 06/07/2022] [Indexed: 12/24/2022] Open
Abstract
Background: Carfilzomib, an irreversible proteasome inhibitor approved for the treatment of relapsed/refractory Multiple Myeloma (MM) has been associated with Thrombotic Microangiopathy (TMA). Several pathogenetic mechanisms of carfilzomib-induced TMA have been proposed; however, recently, there has been a shift of focus on the potential contribution of complement dysregulation. Our aim was to explore whether patients with carfilzomib-induced TMA harbor germline variants of complement-related genes, which have been characterized as risk factors for TMA. Methods: We retrospectively recruited consecutive MM patients with carfilzomib-induced TMA and compared them to MM patients who received ≥4 cycles of carfilzomib and did not develop signs/symptoms of TMA, in a 1:2 ratio. Genomic DNA from peripheral blood was analyzed using next generation sequencing (NGS) with a complement-related gene panel; ADAMTS13 activity and soluble C5b-9 were measured using ELISA. Results: Complement-related variants were more common in patients with carfilzomib-induced TMA compared to non-TMA controls, regardless of patient and treatment characteristics; ADAMTS13 activity and C5b-9 were compatible with the phenotype of complement-related TMA. Conclusions: We confirmed the previous findings that implicated complement-related genes in the pathogenesis of carfilzomib-induced TMA. Most importantly, by incorporating a control group of non-TMA MM patients treated with carfilzomib-based regimens and functional complement assays, we enhanced the credibility of our findings.
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22
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Terao T, Tsushima T, Miura D, Ikeda D, Fukumoto A, Kuzume A, Tabata R, Narita K, Takeuchi M, Matsue K. Carfilzomib-induced thrombotic microangiopathy is underestimated in clinical practice: A report of five patients and literature review. Leuk Lymphoma 2022; 63:1102-1110. [PMID: 35373680 DOI: 10.1080/10428194.2022.2057485] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Carfilzomib (Cfz) is widely used to treat multiple myeloma. However, real-world data of the incidence of thrombotic microangiopathy (TMA) caused by Cfz is inconsistent (<1-5%). We evaluated 96 consecutive patients who received Cfz to evaluate the incidence of TMA in clinical practice. TMA developed in five patients (5.2%) who were mainly receiving high-dose Cfz (≥56 mg/m2). Based on a literature review, precaution should be taken for Cfz-induced TMA in male patients receiving high-dose Cfz irrespective of the combination therapy, Cfz administration period, and complement level. In conclusion, Cfz-induced TMA might be underestimated in clinical practice, and early intervention should be considered.
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Affiliation(s)
- Toshiki Terao
- Division of Hematology/Oncology, Department of Internal Medicine, Kameda Medical Center, Kamogawa, Japan
| | - Takafumi Tsushima
- Division of Hematology/Oncology, Department of Internal Medicine, Kameda Medical Center, Kamogawa, Japan
| | - Daisuke Miura
- Division of Hematology/Oncology, Department of Internal Medicine, Kameda Medical Center, Kamogawa, Japan
| | - Daisuke Ikeda
- Division of Hematology/Oncology, Department of Internal Medicine, Kameda Medical Center, Kamogawa, Japan
| | - Ami Fukumoto
- Division of Hematology/Oncology, Department of Internal Medicine, Kameda Medical Center, Kamogawa, Japan
| | - Ayumi Kuzume
- Division of Hematology/Oncology, Department of Internal Medicine, Kameda Medical Center, Kamogawa, Japan
| | - Rikako Tabata
- Division of Hematology/Oncology, Department of Internal Medicine, Kameda Medical Center, Kamogawa, Japan
| | - Kentaro Narita
- Division of Hematology/Oncology, Department of Internal Medicine, Kameda Medical Center, Kamogawa, Japan
| | - Masami Takeuchi
- Division of Hematology/Oncology, Department of Internal Medicine, Kameda Medical Center, Kamogawa, Japan
| | - Kosei Matsue
- Division of Hematology/Oncology, Department of Internal Medicine, Kameda Medical Center, Kamogawa, Japan
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23
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Sterner RC, Rose WN. Unique Presentation of Bortezomib-Associated Thrombotic Microangiopathy Responsive to Therapeutic Plasma Exchange and Eculizumab Therapy. Hematol Rep 2022; 14:119-125. [PMID: 35466182 PMCID: PMC9036209 DOI: 10.3390/hematolrep14020018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 03/26/2022] [Accepted: 04/01/2022] [Indexed: 11/23/2022] Open
Abstract
Thrombotic microangiopathies (TMA) are a rare group of life-threatening hematological conditions characterized by thrombocytopenia and microangiopathic hemolytic anemia. Although our understanding of the pathophysiology and the availability of diagnostic testing has improved for primary TMAs, such as thrombotic thrombocytopenic purpura, the pathophysiology underlying secondary TMAs, including drug-induced TMAs (DITMAs), remains less clear. In this case report, we present the unique case of a patient with a history of multiple myeloma that presented four months after the initiation of bortezomib therapy with a bortezomib-associated TMA that responded to therapeutic plasma exchange (TPE) with plasma replacement and eculizumab therapy. This case demonstrates the possible utility of TPE with plasma replacement and eculizumab therapy in DITMA patients that fail to respond following a trial of holding the suspected medication.
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24
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Epstein M, Morrison C. Practical guidance for new multiple myeloma treatment regimens: A nursing perspective. Semin Oncol 2022; 49:103-117. [PMID: 35197198 PMCID: PMC9149030 DOI: 10.1053/j.seminoncol.2022.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 01/23/2022] [Indexed: 11/11/2022]
Abstract
As is the case for solid tumors, treatment paradigms have shifted from non-specific chemotherapeutic agents towards novel targeted drugs in the treatment of patients with multiple myeloma (MM). Currently, multiple targeted therapies are available to treat patients augmenting the arsenal of modalities which also includes chemotherapy, immunotherapy, radiation therapy, hematopoietic stem cell transplantation (HSCST) and chimeric antigen T-cell therapy (CAR-T). These novel, targeted agents have dramatically increased optimism for patients, who may now be treated over many years with successive regimens. As fortunate as we are to have these new therapies available for our patients, this advantage is juxtaposed with the challenges involved with delivering them safely. While each class of agents has demonstrated efficacy, in terms of response rates and survival, they also exert class effects which pose risks for toxicity. In addition, newer generation agents within the classes often have slightly different toxicity profiles than did their predecessors. These factors must be addressed, and their risks mitigated by the multidisciplinary team. This review presents a summary of the evolution of drug development for MM. For each targeted agent, the efficacy data from pivotal trials and highlights of the risks that were demonstrated in trials, as well as during post-marketing surveillance, are presented. Specific risks associated with agents within the classes, that are not shared with all new class members, are described. A table presenting these potential risks, with recommended nursing actions to mitigate toxicity, is provided as a quick reference that nurses may use during the planning, and provision, of patient care.
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Affiliation(s)
- Monica Epstein
- National Cancer Institute, Office of Research Nursing, Bethesda, MD.
| | - Candis Morrison
- United States Food and Drug Administration, 10903 New Hampshire Ave, Building 22 Room 2319 Silver Spring Maryland 20993
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25
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Scheggi V, Merilli I, Cesaroni E, Alterini B. Carfilzomib-induced thrombotic microangiopathy. A case report. J Oncol Pharm Pract 2021; 28:754-758. [PMID: 34904466 DOI: 10.1177/10781552211067433] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Drug-induced thrombotic microangiopathy (DITMA) is an acquired condition resulting from exposure to a drug that induces the formation of platelet-rich thrombi in small arterioles or capillaries secondary to drug-dependent antibodies or direct tissue toxicity. Carfilzomib is a selective proteasome inhibitor approved to treat selected patients with Multiple Myeloma (MM). It is one of the drugs with the strongest evidence for a causal association with non-antibody-mediated DITMA. CASE REPORT A 75-year-old man presented to the emergency department for the outbreak of vomit, asthenia, oliguria and dark stool emission. He was recently diagnosed with multiple myeloma, treated with lenalidomide, dexamethasone and carfilzomib. Laboratory exams were significant for microangiopathic haemolytic anaemia, thrombocytopenia and new-onset renal failure. ADAMTS-13 levels were in range, and no infectious signs were found both in blood nor in stool test. MANAGEMENT & OUTCOME A carfilzomib induced thrombotic microangiopathy was soon suspected. Thus, since daily haemodialysis and supportive care did not seem to get a fast enough recovery, the patient was treated with eculizumab with a good general outcome. DISCUSSION Drug-induced thrombotic microangiopathy is a rare and often life-threatening acquired condition whose diagnosis can be challenging and whose therapy is not always limited to supportive treatment and drug avoidance. Carfilzomib, along with other proteasome inhibitors, is one of the described potential drugs which can trigger such a manifestation.
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Affiliation(s)
- Valentina Scheggi
- Division of Cardiovascular and Perioperative Medicine, Cardiothoracovascular Department, Azienda Ospedaliero-Universitaria Careggi and University of Florence, Florence, Italy
| | - Irene Merilli
- Division of Cardiovascular and Perioperative Medicine, Cardiothoracovascular Department, Azienda Ospedaliero-Universitaria Careggi and University of Florence, Florence, Italy
| | - Edoardo Cesaroni
- Division of Cardiovascular and Perioperative Medicine, Cardiothoracovascular Department, Azienda Ospedaliero-Universitaria Careggi and University of Florence, Florence, Italy
| | - Bruno Alterini
- Division of Cardiovascular and Perioperative Medicine, Cardiothoracovascular Department, Azienda Ospedaliero-Universitaria Careggi and University of Florence, Florence, Italy
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Tonooka A, Ohashi R. Current trends of anti-cancer molecular targeted therapies: a narrative review focusing on renal complications and their histological features. J NIPPON MED SCH 2021; 89:128-138. [PMID: 34840210 DOI: 10.1272/jnms.jnms.2022_89-221] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Among the recent advancements in cancer treatment, the emergence of novel drugs targeting a specific molecule has considerably modulated the therapeutic strategies. Despite the efficacy, the associated renal complications distinct from conventional chemotherapeutic drugs have been reported. Targeted therapy drugs include monoclonal antibodies and small molecule agents. Bevacizumab is one of the monoclonal antibodies that targets vascular endothelial growth factor (VEGF) and blocks tumor angiogenesis. This anti-angiogenic effect causes endothelial injury, resulting in "thrombotic microangiopathy-like lesion" confined to the glomerulus. Segmental hyalinosis of the glomerular tuft is also observed. The small molecular agents, including tyrosine kinase inhibitors (TKIs), such as pazopanib, can cause endothelial injury and podocytopathy through blocking VEGF receptors and their downstream signaling. Minimal change nephrotic syndrome and focal segmental glomerulosclerosis are associated with TKIs-induced renal complications. Immune checkpoint inhibitors (ICIs), such as PD-1, CTLA-4 and PD-L1, are a novel form of immunotherapy against cancer, which modulates immune checkpoints. Owing to its unique function, ICIs cause inflammatory side effects referred to as immune-related adverse events (irAEs). irAEs in the kidney commonly include acute tubulointerstitial nephritis and tubulitis, occasionally accompanied by granuloma formation. The occurrence of vasculitis, thrombotic microangiopathy, and glomerulonephritis is also reported. Renal toxicity associated with other molecular drugs such as protease inhibitors and mammalian target of rapamycin inhibitors has also been documented. In this article, we review the clinico-histopathological aspects of renal complications associated with molecular targeted therapies, focusing on anti-VEGF agents and immune checkpoint inhibitors from the pathologists' viewpoint.
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Affiliation(s)
- Akiko Tonooka
- Division of Pathology, Cancer Institute, Japanese Foundation for Cancer Research.,Department of Pathology, Tokyo Metropolitan Cancer and Infectious Diseases Komagome Hospital
| | - Ryuji Ohashi
- Department of Integrated Diagnostic Pathology, Nippon Medical School
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The Proteasome Inhibitor Bortezomib Induces Apoptosis and Activation in Gel-Filtered Human Platelets. Int J Mol Sci 2021; 22:ijms22168955. [PMID: 34445660 PMCID: PMC8396574 DOI: 10.3390/ijms22168955] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 08/17/2021] [Accepted: 08/17/2021] [Indexed: 11/16/2022] Open
Abstract
Bortezomib (BTZ) has demonstrated its efficacy in several hematological disorders and has been associated with thrombocytopenia. There is controversy about the effect of BTZ on human platelets, so we set out to determine its effect on various types of platelet samples. Human platelets were investigated in platelet-rich plasma (PRP) and as gel-filtered platelets (GFPs). Mitochondrial inner membrane potential depolarization and phosphatidylserine (PS) and P-selectin expression levels were studied by flow cytometry, while thrombin generation was measured by a fluorescent method. In PRP, BTZ caused negligible PS expression after 60 min of treatment. However, in GFPs, PS expression was dose- and time-dependently increased in the BTZ-treated groups, as was P-selectin. The percentage of depolarized cells was also higher after BTZ pretreatment at both time points. Peak thrombin and velocity index increased significantly even with the lowest BTZ concentration (p = 0.0019; p = 0.0032) whereas time to peak and start tail parameters decreased (p = 0.0007; p = 0.0034). The difference between PRP and GFP results can be attributed to the presence of plasma proteins in PRP, as the PS-stimulating effect of BTZ could be attenuated by supplementing GFPs with purified human albumin. Overall, BTZ induces a procoagulant platelet phenotype in an experimental setting devoid of plasma proteins.
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28
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How I treat microangiopathic hemolytic anemia in patients with cancer. Blood 2021; 137:1310-1317. [PMID: 33512445 PMCID: PMC8555418 DOI: 10.1182/blood.2019003810] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 10/19/2020] [Indexed: 12/16/2022] Open
Abstract
Microangiopathic hemolytic anemia (MAHA) with thrombocytopenia, suggests a thrombotic microangiopathy (TMA), linked with thrombus formation affecting small or larger vessels. In cancer patients, it may be directly related to the underlying malignancy (initial presentation or progressive disease), to its treatment, or a separate incidental diagnosis. It is vital to differentiate incidental thrombotic thrombocytopenia purpura or atypical hemolytic uremic syndrome in cancer patients presenting with a TMA, as they have different treatment strategies, and prompt initiation of treatment impacts outcome. In the oncology patient, widespread microvascular metastases or extensive bone marrow involvement can cause MAHA and thrombocytopenia. A disseminated intravascular coagulation (DIC) picture may be precipitated by sepsis or driven by the cancer itself. Cancer therapies may cause a TMA, either dose-dependent toxicity, or an idiosyncratic immune-mediated reaction due to drug-dependent antibodies. Many causes of TMA seen in the oncology patient do not respond to plasma exchange and, where feasible, treatment of the underlying malignancy is important in controlling both cancer-TMA or DIC driven disease. Drug-induced TMA should be considered and any putative causal agent stopped. We will discuss the differential diagnosis and treatment of MAHA in patients with cancer using clinical cases to highlight management principles.
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Cervantes CE, Kant S, Atta MG. The Link Between Conventional and Novel Anti-Cancer Therapeutics with Thrombotic Microangiopathy. Drug Metab Lett 2021; 14:97-105. [PMID: 34279209 DOI: 10.2174/1872312814666210716141633] [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: 01/06/2021] [Revised: 04/28/2021] [Accepted: 05/09/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Kidney disease associated with cancer and anti-cancer therapies has been increasingly recognized in the field of onco-nephrology. In particular, drug-induced nephrotoxicity has important implications since most chemotherapeutic agents have a nephrotoxic potential. Also, standard creatinine clearance methods used for the measurement of kidney function have been questioned in cancer patients due to factors like low muscle mass and poor nutritional status. Overestimations of the glomerular filtration rate, not only can increase the nephrotoxic potential of different agents, but also further limit the use of first-line therapies. OBJECTIVE This review covers specifically the drug-induced thrombotic microangiopathy and its two pathophysiologic mechanisms which include immune or idiosyncratic reactions, and non-immune or dose-dependent ones. CONCLUSION As novel cancer therapies are developed, it is paramount to pursue a better understanding of conventional and novel chemotherapeutic agents and their role in kidney disease.
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Affiliation(s)
- Carmen E Cervantes
- Department of Medicine, Division of Nephrology, Johns Hopkins University, Baltimore, Maryland MD 21218, United States
| | - Sam Kant
- Department of Medicine, Division of Nephrology, Johns Hopkins University, Baltimore, Maryland MD 21218, United States
| | - Mohamed G Atta
- Department of Medicine, Division of Nephrology, Johns Hopkins University, Baltimore, Maryland MD 21218, United States
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30
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Freyer CW, Bange EM, Skuli S, Hsu M, Lin J, Cuker A, Cohen AD, Garfall A. Carfilzomib-Induced Atypical Hemolytic Uremic Syndrome in a Patient With Heterozygous CFHR3/CFHR1 Deletion Treated With Eculizumab. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2021; 21:e845-e849. [PMID: 34366267 DOI: 10.1016/j.clml.2021.06.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 06/15/2021] [Accepted: 06/22/2021] [Indexed: 11/19/2022]
Affiliation(s)
- Craig W Freyer
- Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Erin M Bange
- Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Sarah Skuli
- Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Miles Hsu
- Hospital of the University of Pennsylvania, Philadelphia, PA
| | - John Lin
- Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Adam Cuker
- Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Adam D Cohen
- Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Alfred Garfall
- Hospital of the University of Pennsylvania, Philadelphia, PA
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The Syndromes of Thrombotic Microangiopathy: A Critical Appraisal on Complement Dysregulation. J Clin Med 2021; 10:jcm10143034. [PMID: 34300201 PMCID: PMC8307963 DOI: 10.3390/jcm10143034] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 07/05/2021] [Accepted: 07/06/2021] [Indexed: 01/12/2023] Open
Abstract
Thrombotic microangiopathy (TMA) is a rare and potentially life-threatening condition that can be caused by a heterogeneous group of diseases, often affecting the brain and kidneys. TMAs should be classified according to etiology to indicate targets for treatment. Complement dysregulation is an important cause of TMA that defines cases not related to coexisting conditions, that is, primary atypical hemolytic uremic syndrome (HUS). Ever since the approval of therapeutic complement inhibition, the approach of TMA has focused on the recognition of primary atypical HUS. Recent advances, however, demonstrated the pivotal role of complement dysregulation in specific subtypes of patients considered to have secondary atypical HUS. This is particularly the case in patients presenting with coexisting hypertensive emergency, pregnancy, and kidney transplantation, shifting the paradigm of disease. In contrast, complement dysregulation is uncommon in patients with other coexisting conditions, such as bacterial infection, drug use, cancer, and autoimmunity, among other disorders. In this review, we performed a critical appraisal on complement dysregulation and the use of therapeutic complement inhibition in TMAs associated with coexisting conditions and outline a pragmatic approach to diagnosis and treatment. For future studies, we advocate the term complement-mediated TMA as opposed to the traditional atypical HUS-type classification.
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32
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Yee AJ. The role of carfilzomib in relapsed/refractory multiple myeloma. Ther Adv Hematol 2021; 12:20406207211019612. [PMID: 34163580 PMCID: PMC8191071 DOI: 10.1177/20406207211019612] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 05/04/2021] [Indexed: 12/20/2022] Open
Abstract
Carfilzomib is the second proteasome inhibitor approved for relapsed multiple myeloma. Since its approval in 2012, carfilzomib has been an active and versatile drug, based on its efficacy as a single agent; superiority as a doublet with dexamethasone compared with bortezomib and dexamethasone; and as a partner in diverse three drug combinations such as with lenalidomide or daratumumab. While it has an established place in relapsed disease, clinicians should be aware of its cardiovascular and renal adverse event profile, which is manageable, in order to optimize outcomes. This review will provide a perspective on the current and future role of carfilzomib in relapsed/refractory multiple myeloma.
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Affiliation(s)
- Andrew J. Yee
- Center for Multiple Myeloma, Massachusetts General Hospital Cancer Center, Harvard Medical
School, 55 Fruit St, Boston, MA 02114, USA
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Camilleri M, Cuadrado M, Phillips E, Wilson W, Jenner R, Pang G, Kamora S, Streetly M, Popat R, Bygrave C, Owen R, Cavenagh J, Chapman M, Sive J, Eccersley L, Sheaff M, Benjamin R, Ramasamy K, Cook G, Virchis A, Chavda SJ, Clifton-Hadley L, Scully MA, Yong K. Thrombotic microangiopathy in untreated myeloma patients receiving carfilzomib, cyclophosphamide and dexamethasone on the CARDAMON study. Br J Haematol 2021; 193:750-760. [PMID: 33650100 DOI: 10.1111/bjh.17377] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 02/02/2021] [Indexed: 11/29/2022]
Abstract
Proteasome inhibitors have been associated with thrombotic microangiopathy (TMA) - a group of disorders characterised by occlusive microvascular thrombosis causing microangiopathic haemolytic anaemia, thrombocytopenia and end-organ damage. To date, carfilzomib-associated TMA has predominantly been described in relapsed/refractory myeloma patients. We report eight patients with newly diagnosed myeloma who experienced TMA events while receiving carfilzomib on the phase II CARDAMON trial. The first three occurred during maintenance single-agent carfilzomib, two occurred at induction with carfilzomib given with cyclophosphamide and dexamethasone (KCd) and three occurred during KCd consolidation. At TMA presentation 6/8 were hypertensive; 7/8 had acute kidney injury and in three, renal impairment persisted after resolution of TMA in other respects. The mechanism of carfilzomib-associated TMA remains unclear, though patients with known hypertension seem particularly susceptible. Given the first three cases occurred during maintenance after a longer than five-week treatment break, a protocol amendment was instituted with: aggressive hypertension management, carfilzomib step-up dosing (20 mg/m2 on day 1) at start of maintenance before dose escalation to 56 mg/m2 maximum, and adding 10 mg dexamethasone as premedication to maintenance carfilzomib infusions. No further TMA events occurred during maintenance following this amendment and the TMA incidence reduced from 4·2 to 1·6 per 1 000 patient cycles.
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Affiliation(s)
- Marquita Camilleri
- Haematology Department, University College Hospitals, London, UK
- Cancer Institute, University College London, London, UK
| | - Maria Cuadrado
- Haematology Department, University College Hospitals, London, UK
| | - Elizabeth Phillips
- Division of Cancer Sciences, University of Manchester, Manchester Cancer Research Centre, Manchester, UK
| | - William Wilson
- Cancer Research UK and UCL Cancer Trials Centre, University College London, London, UK
| | - Richard Jenner
- Cancer Research UK and UCL Cancer Trials Centre, University College London, London, UK
| | - Gavin Pang
- Cancer Research UK and UCL Cancer Trials Centre, University College London, London, UK
| | - Sumaiya Kamora
- Cancer Research UK and UCL Cancer Trials Centre, University College London, London, UK
| | - Matthew Streetly
- Haematology Department, Guys and St Thomas' NHS Trust, London, UK
| | - Rakesh Popat
- Haematology Department, University College Hospitals, London, UK
- Cancer Institute, University College London, London, UK
| | | | - Roger Owen
- HMDS Laboratory, St James' Institute of Oncology, Leeds, UK
| | - James Cavenagh
- Haematology Department, Barts Health NHS Trust, London, UK
| | - Mike Chapman
- Haematology Department, Cambridge Institute for Medical Research, Cambridge, UK
| | - Jonathan Sive
- Haematology Department, University College Hospitals, London, UK
| | | | - Michael Sheaff
- Cellular Pathology Department, Barts Health NHS Trust, London, UK
| | | | - Karthik Ramasamy
- Haematology Department, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Gordon Cook
- Leeds Institute of Clinical Trial Research, University of Leeds, Leeds, UK
| | - Andres Virchis
- Haematology Department, Royal Free Hospitals NHS Trust, London, UK
| | - Selina J Chavda
- Haematology Department, University College Hospitals, London, UK
- Haematology Department, Guys and St Thomas' NHS Trust, London, UK
| | - Laura Clifton-Hadley
- Division of Cancer Sciences, University of Manchester, Manchester Cancer Research Centre, Manchester, UK
| | - Marie Anne Scully
- Haematology Department, University College Hospitals, London, UK
- Cardiometabolic Programme, NIHR UCLH/UCL Biomedical Research Centre, London, UK
| | - Kwee Yong
- Haematology Department, University College Hospitals, London, UK
- Haematology Department, Guys and St Thomas' NHS Trust, London, UK
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Mizuno S, Kitayama C, Sanada S, Sato T. Bortezomib-induced glomerular microangiopathy complicated with monoclonal immunoglobulin deposition disease. CEN Case Rep 2021; 10:537-542. [PMID: 33909224 DOI: 10.1007/s13730-021-00603-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 04/19/2021] [Indexed: 01/03/2023] Open
Abstract
A 75-year-old man admitted with IgG λ-type myeloma with creatinine level of 2.3 mg/dL. Serum lactate dehydrogenase level and platelet count were normal. Urinalysis demonstrated massive proteinuria dominated by albuminuria. Weekly bortezomib and dexamethasone therapy were started to treat myeloma but failed to be continued because of rapid deterioration of renal function and increase in proteinuria 1 week after the treatment. His renal function exacerbated to require hemodialysis for a month. There was no clinical evidence of tumor lysis syndrome or thrombocytopenia throughout the course of his acute kidney injury (AKI). After he became dialysis independent, a renal biopsy was performed to clarify myeloma-related renal involvement and the cause of AKI. As a result, IgG2-λ monoclonal immunoglobulin deposition disease (MIDD) and severe endothelial injury were revealed. There was no evidence of cast nephropathy. Bortezomib-induced glomerular microangiopathy (GMA) superimposed on MIDD. Bortezomib has a potential risk to cause drug-induced GMA without systemic thrombotic microangiopathy, in which vascular endothelial growth factor-nuclear factor-κ B pathway could be involved. This is the first case of biopsy-proven bortezomib-induced GMA. If proteinuria (mainly albuminuria) increases after using bortezomib, GMA should be suspected as an adverse effect of bortezomib even absent of clinical signs of systemic thrombotic microangiopathy.
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Affiliation(s)
- Shinichi Mizuno
- Department of Nephrology, Japan Community Health Care Organization Sendai Hospital, 3-16-1, Tsutsumimachi, Aoba-Ku, Sendai, Miyagi, 981-8501, Japan.
| | - Chigusa Kitayama
- Department of Nephrology, Japan Community Health Care Organization Sendai Hospital, 3-16-1, Tsutsumimachi, Aoba-Ku, Sendai, Miyagi, 981-8501, Japan
| | - Satoru Sanada
- Department of Nephrology, Japan Community Health Care Organization Sendai Hospital, 3-16-1, Tsutsumimachi, Aoba-Ku, Sendai, Miyagi, 981-8501, Japan
| | - Toshinobu Sato
- Department of Nephrology, Japan Community Health Care Organization Sendai Hospital, 3-16-1, Tsutsumimachi, Aoba-Ku, Sendai, Miyagi, 981-8501, Japan
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35
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Valério P, Barreto JP, Ferreira H, Chuva T, Paiva A, Costa JM. Thrombotic microangiopathy in oncology - a review. Transl Oncol 2021; 14:101081. [PMID: 33862523 PMCID: PMC8065296 DOI: 10.1016/j.tranon.2021.101081] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 03/18/2021] [Indexed: 12/31/2022] Open
Abstract
Thrombotic microangiopathy is a syndrome triggered by a wide spectrum of situations, some of which are specific to the Oncology setting. It is characterized by a Coombs-negative microangiopathic haemolytic anemia, thrombocytopenia and organ injury, with characteristic pathological features, resulting from platelet microvascular occlusion. TMA is rare and its cancer-related subset even more so. TMA triggered by drugs is the most common within this group, including classic chemotherapy and the latest targeted therapies. The neoplastic disease itself and hematopoietic stem-cell transplantation could also be potential triggers. Evidence-based medical guidance in the management of cancer-related TMA is scarce and the previous knowledge about primary TMA is valuable to understand the disease mechanisms and the potential treatments. Given the wide spectrum of potential causes for TMA in cancer patients, the aim of this review is to gather the vast information available. For each entity, pathophysiology, clinical features, therapeutic approaches and prognosis will be covered.
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Affiliation(s)
- Patrícia Valério
- Nephrology Department, Setúbal Hospital Center, Portugal Rua Camilo Castelo Branco 175, 2910-549 Setúbal, Portugal.
| | - João Pedro Barreto
- Laboratory Diagnosis Department, Portuguese Oncology Institute of Porto, Portugal Rua Dr. António Bernardino de Almeida, 4200-072 Porto, Portugal
| | - Hugo Ferreira
- Nephrology Department, Portuguese Oncology Institute of Porto, Portugal Rua Dr. António Bernardino de Almeida, 4200-072 Porto, Portugal
| | - Teresa Chuva
- Nephrology Department, Portuguese Oncology Institute of Porto, Portugal Rua Dr. António Bernardino de Almeida, 4200-072 Porto, Portugal
| | - Ana Paiva
- Nephrology Department, Portuguese Oncology Institute of Porto, Portugal Rua Dr. António Bernardino de Almeida, 4200-072 Porto, Portugal
| | - José Maximino Costa
- Nephrology Department, Portuguese Oncology Institute of Porto, Portugal Rua Dr. António Bernardino de Almeida, 4200-072 Porto, Portugal
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36
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El-Kadiry AEH, Merhi Y. The Role of the Proteasome in Platelet Function. Int J Mol Sci 2021; 22:ijms22083999. [PMID: 33924425 PMCID: PMC8069084 DOI: 10.3390/ijms22083999] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 04/06/2021] [Accepted: 04/08/2021] [Indexed: 02/06/2023] Open
Abstract
Platelets are megakaryocyte-derived acellular fragments prepped to maintain primary hemostasis and thrombosis by preserving vascular integrity. Although they lack nuclei, platelets harbor functional genomic mediators that bolster platelet activity in a signal-specific manner by performing limited de novo protein synthesis. Furthermore, despite their limited protein synthesis, platelets are equipped with multiple protein degradation mechanisms, such as the proteasome. In nucleated cells, the functions of the proteasome are well established and primarily include proteostasis among a myriad of other signaling processes. However, the role of proteasome-mediated protein degradation in platelets remains elusive. In this review article, we recapitulate the developing literature on the functions of the proteasome in platelets, discussing its emerging regulatory role in platelet viability and function and highlighting how its functional coupling with the transcription factor NF-κB constitutes a novel potential therapeutic target in atherothrombotic diseases.
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Affiliation(s)
- Abed El-Hakim El-Kadiry
- Laboratory of Thrombosis and Hemostasis, Montreal Heart Institute, Research Centre, Montreal, QC H1T 1C8, Canada;
- Biomedical Sciences Program, Faculty of Medicine, Université de Montréal, Montreal, QC H3T 1J4, Canada
| | - Yahye Merhi
- Laboratory of Thrombosis and Hemostasis, Montreal Heart Institute, Research Centre, Montreal, QC H1T 1C8, Canada;
- Biomedical Sciences Program, Faculty of Medicine, Université de Montréal, Montreal, QC H3T 1J4, Canada
- Correspondence: ; Tel.: +1-514-376-3330
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Bridoux F, Cockwell P, Glezerman I, Gutgarts V, Hogan JJ, Jhaveri KD, Joly F, Nasr SH, Sawinski D, Leung N. Kidney injury and disease in patients with haematological malignancies. Nat Rev Nephrol 2021; 17:386-401. [PMID: 33785910 DOI: 10.1038/s41581-021-00405-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/29/2021] [Indexed: 02/07/2023]
Abstract
Acute kidney injury (AKI) is common in patients with cancer, especially in those with haematological malignancies. Kidney injury might be a direct consequence of the underlying haematological condition. For example, in the case of lymphoma infiltration or extramedullary haematopoiesis, it might be caused by a tumour product; in the case of cast nephropathy it might be due to the presence of monoclonal immunoglobulin; or it might result from tumour complications, such as hypercalcaemia. Kidney injury might also be caused by cancer treatment, as many chemotherapeutic agents are nephrotoxic. High-intensity treatments, such as high-dose chemotherapy followed by haematopoietic stem cell transplantation, not only increase the risk of infection but can also cause AKI through various mechanisms, including viral nephropathies, engraftment syndrome and sinusoidal obstruction syndrome. Some conditions, such as thrombotic microangiopathy, might also result directly from the haematological condition or the treatment. Novel immunotherapies, such as immune checkpoint inhibitors and chimeric antigen receptor T cell therapy, can also be nephrotoxic. As new therapies for haematological malignancies with increased anti-tumour efficacy and reduced toxicity are developed, the number of patients receiving these treatments will increase. Clinicians must gain a good understanding of the different mechanisms of kidney injury associated with cancer to better care for these patients.
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Affiliation(s)
- Frank Bridoux
- Department of Nephrology, and Centre d'Investigation Clinique (CIC INSERM 1402), Centre Hospitalier Universitaire et Université de Poitiers, Poitiers, France.,CNRS, UMR7276, Limoges, France.,Centre de référence Amylose AL et autres maladies par dépôt d'immunoglobulines monoclonales, Poitiers, France
| | - Paul Cockwell
- Department of Nephrology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Ilya Glezerman
- Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Weill Cornell Medical College, New York, NY, USA
| | - Victoria Gutgarts
- Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Weill Cornell Medical College, New York, NY, USA
| | - Jonathan J Hogan
- Renal, Electrolyte and Hypertension Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Kenar D Jhaveri
- Division of Kidney Diseases and Hypertension, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Great Neck, NY, USA
| | - Florent Joly
- Department of Nephrology, and Centre d'Investigation Clinique (CIC INSERM 1402), Centre Hospitalier Universitaire et Université de Poitiers, Poitiers, France
| | - Samih H Nasr
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Deirdre Sawinski
- Renal, Electrolyte and Hypertension Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Nelson Leung
- Division of Nephrology and Hypertension, Division of Hematology, Mayo Clinic, Rochester, MN, USA.
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Darwin A, Malpica L, Dhanoa J, Hashmi H. Carfilzomib-induced atypical haemolytic uraemic syndrome: a diagnostic challenge and therapeutic success. BMJ Case Rep 2021; 14:14/2/e239091. [PMID: 33637496 PMCID: PMC7919563 DOI: 10.1136/bcr-2020-239091] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Haemolytic uraemic syndrome (HUS) is a thrombotic microangiopathy (TMA) that presents with renal insufficiency, thrombocytopaenia and microangiopathic haemolytic anaemia. Typical HUS is associated with Shiga toxin while atypical HUS (aHUS) is due to overactivation of the alternative complement pathway. aHUS has numerous causes, including drugs, with rare reports of carfilzomib, a proteasome inhibitor used in multiple myeloma, as causative agent. Cases vary in presentation, presenting a diagnostic challenge. Historically, TMAs were treated with plasma exchange. aHUS, however, is considered refractory to plasma exchange and best treated with eculizumab, a monoclonal antibody targeting C5, a terminal complement protein. We report a patient with history of multiple myeloma who presented with headaches, elevated blood pressure, petechiae, ecchymosis and haemolytic anaemia. His condition was determined to be carfilzomib-induced aHUS and he was successfully treated with eculizumab. Early detection and treatment of drug-induced aHUS is vital in reducing morbidity and mortality related to the condition.
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Affiliation(s)
- Alicia Darwin
- Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
| | - Leonger Malpica
- Department of Blood & Marrow Transplant and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, Florida, USA
| | - Jugraj Dhanoa
- Internal Medicine, University of Louisville, Louisville, Kentucky, USA
| | - Hamza Hashmi
- Department of Blood & Marrow Transplant and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, Florida, USA .,Department of Hematology Oncology, Medical University of South Carolina, Charleston, South Carolina, USA
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Kastritis E, Laina A, Georgiopoulos G, Gavriatopoulou M, Papanagnou ED, Eleutherakis-Papaiakovou E, Fotiou D, Kanellias N, Dialoupi I, Makris N, Manios E, Migkou M, Roussou M, Kotsopoulou M, Stellos K, Terpos E, Trougakos IP, Stamatelopoulos K, Dimopoulos MA. Carfilzomib-induced endothelial dysfunction, recovery of proteasome activity, and prediction of cardiovascular complications: a prospective study. Leukemia 2021; 35:1418-1427. [PMID: 33589757 DOI: 10.1038/s41375-021-01141-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 11/30/2020] [Accepted: 01/18/2021] [Indexed: 02/06/2023]
Abstract
Carfilzomib (CFZ) improves survival in relapsed/refractory multiple myeloma but is associated with cardiovascular adverse events (CVAEs). We prospectively investigated the effect of CFZ on endothelial function and associations with CVAEs. Forty-eight patients treated with Kd (CFZ 20/56 mg/m2 and dexamethasone) underwent serial endothelial function evaluation, using brachial artery flow-mediated dilatation (FMD) and 26S proteasome activity (PrA) measurement in PBMCs; patients were followed until disease progression or cycle 6 for a median of 10 months. FMD and PrA decreased acutely after the first dose (p < 0.01) and FMD decreased at cycles 3 and 6 compared to baseline (p ≤ 0.05). FMD changes were associated with CFZ-induced PrA changes (p < 0.05) and lower PrA recovery during first cycle was associated with more prominent FMD decrease (p = 0.034 for group interaction). During treatment, 25 patients developed Grade ≥3 CVAEs. Low baseline FMD (HR 2.57 lowest vs. higher tertiles, 95% CI 1.081-6.1) was an independent predictor of CVAEs. During treatment, an acute FMD decrease >40% at the end of first cycle was also independently associated with CVAEs (HR = 3.91, 95% CI 1.29-11.83). Kd treatment impairs endothelial function which is associated with PrA inhibition and recovery. Both pre- and posttreatment FMD predicted CFZ-related CVAEs supporting its role as a possible cardiovascular toxicity biomarker.
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Affiliation(s)
- Efstathios Kastritis
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.
| | - Ageliki Laina
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Georgios Georgiopoulos
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Maria Gavriatopoulou
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Eleni-Dimitra Papanagnou
- Department of Cell Biology and Biophysics, Faculty of Biology, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Despina Fotiou
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Nikolaos Kanellias
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Ioanna Dialoupi
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Nikolaos Makris
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Efstathios Manios
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Magdalini Migkou
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Maria Roussou
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Maria Kotsopoulou
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Konstantinos Stellos
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.,Biosciences Institute, Vascular Biology and Medicine Theme, Faculty of Medical Sciences, Newcastle University, Newcastle Upon Tyne, United Kingdom
| | - Evangelos Terpos
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Ioannis P Trougakos
- Department of Cell Biology and Biophysics, Faculty of Biology, National and Kapodistrian University of Athens, Athens, Greece
| | - Kimon Stamatelopoulos
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece. .,Biosciences Institute, Vascular Biology and Medicine Theme, Faculty of Medical Sciences, Newcastle University, Newcastle Upon Tyne, United Kingdom.
| | - Meletios A Dimopoulos
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
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Rassner M, Baur R, Wäsch R, Schiffer M, Schneider J, Mackensen A, Engelhardt M. Two cases of carfilzomib-induced thrombotic microangiopathy successfully treated with Eculizumab in multiple myeloma. BMC Nephrol 2021; 22:32. [PMID: 33461512 PMCID: PMC7814610 DOI: 10.1186/s12882-020-02226-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 12/25/2020] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Treatment with proteasome inhibitors like carfilzomib in patients with multiple myeloma (MM) can induce thrombotic microangiopathy (TMA) characterized by neurological symptoms, acute kidney injury, hemolysis and thrombocytopenia. Successful treatment with the monoclonal antibody eculizumab was described for these patients, but reports of ideal management and definitive treatment protocols are lacking. CASE PRESENTATION The first case describes a 43-years-old IgG-kappa-MM patient that developed TMA during the first course of carfilzomib-lenalidomide-dexamethasone (KRd) consolidation after autologous stem cell transplantation (ASCT). In the second case, a 59-years-old IgG-kappa-MM patient showed late-onset TMA during the fourth and last cycle of elotuzumab-KRd consolidation within the DSMM XVII study of the German study group MM (DSMM; clinicalTrials.gov Identifier: NCT03948035). Concurrently, he suffered from influenza A/B infection. Both patients had a high TMA-index for a poor prognosis of TMA. Therapeutically, in both patients plasma exchange (TPE) was initiated as soon as TMA was diagnosed. In patient #1, dialysis became necessary. For both patients, only when the complement inhibitor eculizumab was administered, kidney function and blood values impressively improved. CONCLUSION In this small case series, two patients with MM developed TMA due to carfilzomib treatment (CFZ-TMA), the second patient as a late-onset form. Even though TMA could have been elicited by influenza in the second patient and occurred after ASCT in both patients, with cases of TMA post-transplantation in MM being described, a relation of TMA and carfilzomib treatment was most likely. In both patients, treatment with eculizumab over two months efficiently treated TMA without recurrence and with both patients remaining responsive months after TMA onset. Taken together, we describe two cases of TMA in MM patients on carfilzomib-combination treatment, showing similar courses of this severe adverse reaction, with good responses to two months of eculizumab treatment.
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Affiliation(s)
- Michael Rassner
- Department of Medicine I (Hematology, Oncology and Stem Cell Transplantation), Medical Center, Faculty of Medicine, University of Freiburg, Hugstetter Strasse 53, D-79106, Freiburg, Germany
| | - Rebecca Baur
- Department of Internal Medicine 5 - Hematology/Oncology, University Hospital of Erlangen, Erlangen, Germany
| | - Ralph Wäsch
- Department of Medicine I (Hematology, Oncology and Stem Cell Transplantation), Medical Center, Faculty of Medicine, University of Freiburg, Hugstetter Strasse 53, D-79106, Freiburg, Germany
| | - Mario Schiffer
- Department of Internal Medicine 4 - Nephrology, University Hospital of Erlangen, Erlangen, Germany
| | - Johanna Schneider
- Department of Medicine IV, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Andreas Mackensen
- Department of Internal Medicine 5 - Hematology/Oncology, University Hospital of Erlangen, Erlangen, Germany
| | - Monika Engelhardt
- Department of Medicine I (Hematology, Oncology and Stem Cell Transplantation), Medical Center, Faculty of Medicine, University of Freiburg, Hugstetter Strasse 53, D-79106, Freiburg, Germany.
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Bridoux F, Leung N, Belmouaz M, Royal V, Ronco P, Nasr SH, Fermand JP. Management of acute kidney injury in symptomatic multiple myeloma. Kidney Int 2021; 99:570-580. [PMID: 33440212 DOI: 10.1016/j.kint.2020.11.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 10/23/2020] [Accepted: 11/03/2020] [Indexed: 01/15/2023]
Abstract
Symptomatic multiple myeloma is commonly complicated by acute kidney injury through various mechanisms. The most frequent is the precipitation of monoclonal free light chains with uromodulin in the distal tubules, defining light chain cast nephropathy. Early diagnosis and identification of the cause of acute kidney injury are required for optimizing management and avoiding chronic kidney injury that strongly affects quality of life and patient survival. In light chain cast nephropathy, often manifesting with severe acute kidney injury, renal recovery requires urgent intervention based on vigorous rehydration, correction of precipitating factors, and efficient anti-plasma cell chemotherapy to rapidly reduce the secretion of nephrotoxic free light chains. Currently, the association of the proteasome inhibitor bortezomib with high-dose dexamethasone is the standard regimen in newly diagnosed patients. The addition of another drug such as cyclophosphamide or an immunodulatory agent may improve free light chain response but raises tolerance concerns in frail patients. Further studies are warranted to confirm the role of anti-CD38 monoclonal antibodies, whose efficacy and tolerance have been documented in patients without renal impairment. Despite controversial results from randomized studies, recent data suggest that in patients with light chain cast nephropathy and acute kidney injury requiring dialysis, the combination of chemotherapy with free light chain removal through high-cutoff hemodialysis may increase renal response recovery rates. Kidney biopsy may be helpful in guiding management and assessing renal prognosis that appears to depend on the extent of cast formation and interstitial fibrosis/tubular atrophy. Because of continuous improvement in life expectancy of patients with multiple myeloma, renal transplantation is likely to be increasingly considered in selected candidates.
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Affiliation(s)
- Frank Bridoux
- Department of Nephrology, Dialysis, and Renal Transplantation, CIC INSERM 1402, CHU Poitiers, Poitiers, France; Centre national de référence Amylose AL & autres maladies par dépôts d'immunoglobulines monoclonales, CHU Poitiers, Poitiers, France; Centre National de la Recherche Scientifique UMR CNRS 7276/INSERM U1262, Université de Limoges, Limoges, France.
| | - Nelson Leung
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA; Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Mohamed Belmouaz
- Department of Nephrology, Dialysis, and Renal Transplantation, CIC INSERM 1402, CHU Poitiers, Poitiers, France; Centre national de référence Amylose AL & autres maladies par dépôts d'immunoglobulines monoclonales, CHU Poitiers, Poitiers, France
| | - Virginie Royal
- Division of Pathology, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montréal, Canada
| | - Pierre Ronco
- Nephrology Department, Assistance Publique - Hôpitaux de Paris, Hôpital Tenon, Paris, France; Sorbonne Université and Institut National de la Santé Et de la Recherche Médicale (INSERM), Unité Mixte de Recherche S 1135, Paris, France
| | - Samih H Nasr
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Jean Paul Fermand
- Department of Hematology and Immunology, Hôpital Saint Louis, Assistance Publique-Hôpitaux de Paris, INSERM UMR 1126, Paris, France; Intergroupe Francophone du Myélome (IFM), Paris, France
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Iacopo F, Branch M, Cardinale D, Middeldorp M, Sanders P, Cohen JB, Achirica MC, Jaiswal S, Brown SA. Preventive Cardio-Oncology: Cardiovascular Disease Prevention in Cancer Patients and Survivors. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2021. [DOI: 10.1007/s11936-020-00883-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Rosner MH, Jhaveri KD, McMahon BA, Perazella MA. Onconephrology: The intersections between the kidney and cancer. CA Cancer J Clin 2021; 71:47-77. [PMID: 32853404 DOI: 10.3322/caac.21636] [Citation(s) in RCA: 60] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 07/17/2020] [Accepted: 07/21/2020] [Indexed: 12/12/2022] Open
Abstract
Onconephrology is a new subspecialty of nephrology that recognizes the important intersections of kidney disease with cancer. This intersection takes many forms and includes drug-induced nephrotoxicity, electrolyte disorders, paraneoplastic glomerulonephritis, and the interactions of chronic kidney disease with cancer. Data clearly demonstrate that, when patients with cancer develop acute or chronic kidney disease, outcomes are inferior, and the promise of curative therapeutic regimens is lessened. This highlights the imperative for collaborative care between oncologists and nephrologists in recognizing and treating kidney disease in patients with cancer. In response to this need, specific training programs in onconephrology as well as dedicated onconephrology clinics have appeared. This comprehensive review covers many of the critical topics in onconephrology, with a focus on acute kidney injury, chronic kidney disease, drug-induced nephrotoxicity, kidney disease in stem cell transplantation, and electrolyte disorders in patients with cancer.
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Affiliation(s)
- Mitchell H Rosner
- Division of Nephrology, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Kenar D Jhaveri
- Division of Kidney Disease and Hypertension, Zucker School of Medicine at Hofstra University, Great Neck, New York
| | - Blaithin A McMahon
- Division of Nephrology. Medical, University of South Carolina, Charleston, South Carolina
| | - Mark A Perazella
- Division of Nephrology, Yale University School of Medicine, New Haven, Connecticut
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Fotiou D, Roussou M, Gakiopoulou C, Psimenou E, Gavriatopoulou M, Migkou M, Kanellias N, Dialoupi I, Eleutherakis-Papaiakovou E, Giannouli S, Delavinia C, Efstathiou K, Kontogiannis S, Terpos E, Dimopoulos MA, Kastritis E. Carfilzomib-associated renal toxicity is common and unpredictable: a comprehensive analysis of 114 multiple myeloma patients. Blood Cancer J 2020; 10:109. [PMID: 33149167 PMCID: PMC7642386 DOI: 10.1038/s41408-020-00381-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 06/03/2020] [Accepted: 06/08/2020] [Indexed: 11/24/2022] Open
Abstract
Carfilzomib (CFZ) is a non-reversible proteasome inhibitor approved for the treatment of patients with relapsed and refractory myeloma (RRMM). Its use has been associated with cardiovascular toxicity but although recently a signal of clinically significant renal complications has also been identified, it is less extensively investigated. We analyzed data of 114 consecutive patients with RRMM who received CFZ-based regimens. Renal complications not related to MM progression were observed in 19 (17%) patients; thrombotic microangiopathy (TMA) was seen in 6 (5%) patients, albuminuria >1 gr/day in 7 patients (6%) and at least grade 3 acute kidney injury (AKI) which could not be otherwise explained in 6 patients (5%). A total of 15 patients discontinued CFZ and dosing was reinitiated at a lower level in one patient with AKI. Albuminuria was associated with focal segmental glomerulosclerosis in the renal biopsy (performed in a total of 6 patients). Renal complications during CFZ therapy are common, occur mostly early and are unpredictable. A potential effect of CFZ on the renal endothelium could be implicated in the pathogenesis of these complications and may also share common pathophysiology with cardiovascular effects of CFZ.
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Affiliation(s)
- Despina Fotiou
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Maria Roussou
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Charikleia Gakiopoulou
- Fist Department of Pathology, National and Kapodistrian University of Athens, Athens, Greece
| | - Erasmia Psimenou
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Maria Gavriatopoulou
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Magdalini Migkou
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Nikolaos Kanellias
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Ioanna Dialoupi
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | | | - Stavroula Giannouli
- Second Department of Internal Medicine, Hematology Unit, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Christina Delavinia
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Kostantinos Efstathiou
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Sofoklis Kontogiannis
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Evangelos Terpos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Meletios A Dimopoulos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Efstathios Kastritis
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece.
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Monteith BE, Venner CP, Reece DE, Kew AK, Lalancette M, Garland JS, Shepherd LE, Pater JL, Hay AE. Drug-induced Thrombotic Microangiopathy with Concurrent Proteasome Inhibitor Use in the Treatment of Multiple Myeloma: A Case Series and Review of the Literature. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2020; 20:e791-e800. [DOI: 10.1016/j.clml.2020.04.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 04/17/2020] [Accepted: 04/22/2020] [Indexed: 01/29/2023]
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Pancheri E, Guglielmi V, Wilczynski GM, Malatesta M, Tonin P, Tomelleri G, Nowis D, Vattemi G. Non-Hematologic Toxicity of Bortezomib in Multiple Myeloma: The Neuromuscular and Cardiovascular Adverse Effects. Cancers (Basel) 2020; 12:cancers12092540. [PMID: 32906684 PMCID: PMC7563977 DOI: 10.3390/cancers12092540] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Revised: 09/02/2020] [Accepted: 09/04/2020] [Indexed: 12/13/2022] Open
Abstract
Simple Summary Multiple myeloma (MM) is a still uncurable tumor of mainly elderly patients originating from the terminally differentiated B cells. Introduction to the treatment of MM patients of a new class of drugs called proteasome inhibitors (bortezomib followed by carfilzomib and ixazomib) significantly improved disease control. Proteasome inhibitors interfere with the major mechanism of protein degradation in a cell leading to the severe imbalance in the protein turnover that is deadly to MM cells. Currently, these drugs are the mainstream of MM therapy but are also associated with an increased rate of the injuries to multiple organs and tissues. In this review, we summarize the current knowledge on the molecular mechanisms of the first-in-class proteasome inhibitor bortezomib-induced disturbances in the function of peripheral nerves and cardiac and skeletal muscle. Abstract The overall approach to the treatment of multiple myeloma (MM) has undergone several changes during the past decade. and proteasome inhibitors (PIs) including bortezomib, carfilzomib, and ixazomib have considerably improved the outcomes in affected patients. The first-in-class selective PI bortezomib has been initially approved for the refractory forms of the disease but has now become, in combination with other drugs, the backbone of the frontline therapy for newly diagnosed MM patients, as well as in the maintenance therapy and relapsed/refractory setting. Despite being among the most widely used and highly effective agents for MM, bortezomib can induce adverse events that potentially lead to early discontinuation of the therapy with negative effects on the quality of life and outcome of the patients. Although peripheral neuropathy and myelosuppression have been recognized as the most relevant bortezomib-related adverse effects, cardiac and skeletal muscle toxicities are relatively common in MM treated patients, but they have received much less attention. Here we review the neuromuscular and cardiovascular side effects of bortezomib. focusing on the molecular mechanisms underlying its toxicity. We also discuss our preliminary data on the effects of bortezomib on skeletal muscle tissue in mice receiving the drug.
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Affiliation(s)
- Elia Pancheri
- Department of Neurosciences, Biomedicine and Movement Sciences, Section of Clinical Neurology, University of Verona, 37134 Verona, Italy; (E.P.); (V.G.); (P.T.); (G.T.)
| | - Valeria Guglielmi
- Department of Neurosciences, Biomedicine and Movement Sciences, Section of Clinical Neurology, University of Verona, 37134 Verona, Italy; (E.P.); (V.G.); (P.T.); (G.T.)
| | - Grzegorz M. Wilczynski
- Laboratory of Molecular and Systemic Neuromorphology, Department of Neurophysiology Warsaw, Nencki Institute of Experimental Biology, 02-093 Warsaw, Poland;
| | - Manuela Malatesta
- Department of Neurosciences, Biomedicine and Movement Sciences, Section of Anatomy and Histology, University of Verona, 37134 Verona, Italy;
| | - Paola Tonin
- Department of Neurosciences, Biomedicine and Movement Sciences, Section of Clinical Neurology, University of Verona, 37134 Verona, Italy; (E.P.); (V.G.); (P.T.); (G.T.)
| | - Giuliano Tomelleri
- Department of Neurosciences, Biomedicine and Movement Sciences, Section of Clinical Neurology, University of Verona, 37134 Verona, Italy; (E.P.); (V.G.); (P.T.); (G.T.)
| | - Dominika Nowis
- Department of Immunology, Medical University of Warsaw, 02-093 Warsaw, Poland;
- Laboratory of Experimental Medicine, Medical University of Warsaw, 02-093 Warsaw, Poland
| | - Gaetano Vattemi
- Department of Neurosciences, Biomedicine and Movement Sciences, Section of Clinical Neurology, University of Verona, 37134 Verona, Italy; (E.P.); (V.G.); (P.T.); (G.T.)
- Correspondence:
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Nguyen MN, Nayernama A, Jones SC, Kanapuru B, Gormley N, Waldron PE. Proteasome inhibitor-associated thrombotic microangiopathy: A review of cases reported to the FDA adverse event reporting system and published in the literature. Am J Hematol 2020; 95:E218-E222. [PMID: 32291777 DOI: 10.1002/ajh.25832] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 04/08/2020] [Accepted: 04/09/2020] [Indexed: 11/06/2022]
Affiliation(s)
- Michelle Nadeau Nguyen
- Division of Pharmacovigilance Office of Surveillance and Epidemiology, U.S. Food and Drug Administration Silver Spring Maryland USA
| | - Afrouz Nayernama
- Division of Pharmacovigilance Office of Surveillance and Epidemiology, U.S. Food and Drug Administration Silver Spring Maryland USA
| | - S. Christopher Jones
- Division of Pharmacovigilance Office of Surveillance and Epidemiology, U.S. Food and Drug Administration Silver Spring Maryland USA
| | - Bindu Kanapuru
- Division of Hematologic Malignancies Office of Oncologic Diseases, U.S. Food and Drug Administration Silver Spring Maryland USA
| | - Nicole Gormley
- Division of Hematologic Malignancies Office of Oncologic Diseases, U.S. Food and Drug Administration Silver Spring Maryland USA
| | - Peter E. Waldron
- Division of Pharmacovigilance Office of Surveillance and Epidemiology, U.S. Food and Drug Administration Silver Spring Maryland USA
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Role of the Ubiquitin Proteasome System in the Regulation of Blood Pressure: A Review. Int J Mol Sci 2020; 21:ijms21155358. [PMID: 32731518 PMCID: PMC7432568 DOI: 10.3390/ijms21155358] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 07/24/2020] [Accepted: 07/24/2020] [Indexed: 12/18/2022] Open
Abstract
The kidney and the vasculature play crucial roles in regulating blood pressure. The ubiquitin proteasome system (UPS), a multienzyme process mediating covalent conjugation of the 76-amino acid polypeptide ubiquitin to a substrate protein followed by proteasomal degradation, is involved in multiple cellular processes by regulating protein turnover in various tissues. Increasing evidence demonstrates the roles of UPS in blood pressure regulation. In the kidney, filtered sodium is reabsorbed through diverse sodium transporters and channels along renal tubules, and studies conducted till date have provided insights into the complex molecular network through which ubiquitin ligases modulate sodium transport in different segments. Components of these pathways include ubiquitin ligase neuronal precursor cell-expressed developmentally downregulated 4-2, Cullin-3, and Kelch-like 3. Moreover, accumulating data indicate the roles of UPS in blood vessels, where it modulates nitric oxide bioavailability and vasoconstriction. Cullin-3 not only regulates renal salt reabsorption but also controls vascular tone using different adaptor proteins that target distinct substrates in vascular smooth muscle cells. In endothelial cells, UPS can also contribute to blood pressure regulation by modulating endothelial nitric oxide synthase. In this review, we summarize current knowledge regarding the role of UPS in blood pressure regulation, focusing on renal sodium reabsorption and vascular function.
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Rassner M, Jung J, Schneider J, Wäsch R, Engelhardt M. Dapsone-Induced Hemolytic Anemia in Multiple Myeloma: Case Report of Various Differential Diagnoses. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2020; 20:e821-e825. [PMID: 32753123 DOI: 10.1016/j.clml.2020.06.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 06/22/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Michael Rassner
- Department of Medicine I (Hematology, Oncology, and Stem Cell Transplantation), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Johannes Jung
- Department of Medicine I (Hematology, Oncology, and Stem Cell Transplantation), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Johanna Schneider
- Department of Medicine IV, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ralph Wäsch
- Department of Medicine I (Hematology, Oncology, and Stem Cell Transplantation), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Monika Engelhardt
- Department of Medicine I (Hematology, Oncology, and Stem Cell Transplantation), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
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Casiez C, Pica GM, Bally S. Syndrome hémolytique et urémique lié au carfilzomib: évolution favorable sous éculizumab. Nephrol Ther 2020; 16:221-224. [DOI: 10.1016/j.nephro.2020.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 02/09/2020] [Accepted: 03/10/2020] [Indexed: 10/24/2022]
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