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Zhang C, Charland D, O'Hearn K, Steele M, Klaassen RJ, Speckert M. Childhood autoimmune hemolytic anemia: A scoping review. Eur J Haematol 2024. [PMID: 38894537 DOI: 10.1111/ejh.14253] [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: 04/15/2024] [Revised: 05/24/2024] [Accepted: 06/04/2024] [Indexed: 06/21/2024]
Abstract
BACKGROUND AND OBJECTIVE Autoimmune hemolytic anemia (AIHA) is a rare but important cause of morbidity in pediatric hematology patients. Given its rarity, there is little high-quality evidence on which to base the investigation and management of pediatric AIHA. This scoping review aims to summarize the current evidence and highlight key gaps to inform future studies. METHODS This review searched MEDLINE and the Cochrane CENTRAL Trials Register from 2000 to November 03, 2023. Experimental and observational studies reporting AIHA diagnostic criteria, laboratory workup, or treatment/management in populations with at least 20% of patients ≤18 years were included. RESULTS Forty-three studies were included, with no randomized controlled trials identified. AIHA diagnostic criteria, diagnostic tests, and treatments were highly variable. First-line treatment approaches include corticosteroids, intravenous immunoglobulin, or both. Approaches to AIHA resistance to first-line therapy were widely variable between studies, but most commonly included rituximab and/or cyclosporine. CONCLUSIONS We identify a heterogenous group of observational studies into this complex, immune-mediated disorder. Standardized definitions and classifications are needed to guide collaborative efforts needed to study this rare disease. The work done by the CEREVANCE group provides an important paradigm for future studies.
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Affiliation(s)
- Caseng Zhang
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Danielle Charland
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Katie O'Hearn
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - MacGregor Steele
- Department of Pediatrics, Section of Pediatric Hematology, Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada
| | - Robert J Klaassen
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
- Division of Hematology Oncology, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Matthew Speckert
- Division of Hematology Oncology, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
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Michel M, Saïr M, Rivière E, Moulis G, Comont T, Costedoat-Chalumeau N, Pouchelon C, Boutboul D, Benyamine A, Bert A, Jeandel PY, Hamrouni S, Belfeki N, Lobbes H, Dossier A, Gobert D, Mahevas M, Godeau B, Gallien Y, Ebbo M. Intravenous immunoglobulin as a rescue therapy for severe adult autoimmune hemolytic anemia: Results from a French multicenter observational study. Am J Hematol 2024. [PMID: 38742870 DOI: 10.1002/ajh.27361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Revised: 04/17/2024] [Accepted: 04/26/2024] [Indexed: 05/16/2024]
Affiliation(s)
- M Michel
- Department of Internal Medicine and Clinical Immunology, French National Reference Center for Adult' Immune Cytopenias, Henri-Mondor University Hospital, Assistance Publique Hôpitaux de Paris, Université Paris-Est Créteil, Créteil, France
| | - M Saïr
- Department of Internal Medicine and Clinical Immunology, Aix Marseille Univ, APHM, La Timone Hospital, Marseille, France
| | - E Rivière
- Department of Internal Medicine and Clinical Immunology, Bordeaux University Hospital, Bordeaux, France
| | - G Moulis
- Department of Internal Medicine and Clinical Immunology & Clinical Investigation Center 1436, Purpan Hospital, Toulouse University Hospital, Toulouse, France
| | - T Comont
- Department of Internal Medicine and Clinical Immunology, Oncopole Hospital, Toulouse University Hospital, Toulouse, France
| | - N Costedoat-Chalumeau
- Department of Internal Medicine and Clinical Immunology, Assistance Publique Hôpitaux de Paris, APHP, Cochin University Hospital, Créteil, France
| | - C Pouchelon
- Department of Internal Medicine and Clinical Immunology, French National Reference Center for Adult' Immune Cytopenias, Henri-Mondor University Hospital, Assistance Publique Hôpitaux de Paris, Université Paris-Est Créteil, Créteil, France
| | - D Boutboul
- Department of Internal Medicine and Clinical Immunology, Assistance Publique Hôpitaux de Paris, APHP, St Louis Hospital, Paris, France
| | - A Benyamine
- Department of Internal Medicine and Clinical Immunology, Aix Marseille Univ, APHM, Hopital Nord, Marseille, France
| | - A Bert
- Department of Internal Medicine and Clinical Immunology, CHU de Lyon, Hospices Civils, Lyon, France
| | - P-Y Jeandel
- Department of Internal Medicine and Clinical Immunology, CHU de Nice, l'Archer Hospital, Nice, France
| | - S Hamrouni
- Department of Internal Medicine and Clinical Immunology, Groupe Hospitalier Sud, CH de Melun, Melun, France
| | - N Belfeki
- Department of Internal Medicine and Clinical Immunology, Groupe Hospitalier Sud, CH de Melun, Melun, France
| | - H Lobbes
- Department of Internal Medicine and Clinical Immunology, CHU de Clermont Ferrand, Clermont Ferrand, France
| | - A Dossier
- Department of Internal Medicine and Clinical Immunology, Assistance Publique Hôpitaux de Paris, APHP, Bichat Hospital, Paris, France
| | - D Gobert
- Department of Internal Medicine and Clinical Immunology, Assistance Publique Hôpitaux de Paris, APHP, St Antoine Hospital, Paris, France
| | - M Mahevas
- Department of Internal Medicine and Clinical Immunology, French National Reference Center for Adult' Immune Cytopenias, Henri-Mondor University Hospital, Assistance Publique Hôpitaux de Paris, Université Paris-Est Créteil, Créteil, France
| | - B Godeau
- Department of Internal Medicine and Clinical Immunology, French National Reference Center for Adult' Immune Cytopenias, Henri-Mondor University Hospital, Assistance Publique Hôpitaux de Paris, Université Paris-Est Créteil, Créteil, France
| | - Y Gallien
- Santé Publique, Agence Régionale de Santé, Ile de France, Saint Denis, France
| | - M Ebbo
- Department of Internal Medicine and Clinical Immunology, Aix Marseille Univ, APHM, La Timone Hospital, Marseille, France
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3
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Zhang Z, Hu Q, Yang C, Chen M, Han B. Sirolimus is effective for primary refractory/relapsed warm autoimmune haemolytic anaemia/Evans syndrome: a retrospective single-center study. Ann Med 2023; 55:2282180. [PMID: 37967535 PMCID: PMC10653746 DOI: 10.1080/07853890.2023.2282180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 10/31/2023] [Indexed: 11/17/2023] Open
Abstract
BACKGROUND Some patients with warm autoimmune haemolytic anaemia (wAIHA) or Evans syndrome (ES) have no response to glucocorticoid or relapse. Recent studies found that sirolimus was effective in autoimmune cytopenia with a low relapse rate. METHODS Data from patients with refractory/relapsed wAIHA and ES in Peking Union Medical College Hospital from July 2016 to May 2022 who had been treated with sirolimus for at least 6 months and followed up for at least 12 months were collected retrospectively. Baseline and follow-up clinical data were recorded and the rate of complete response (CR), partial response (PR) at different time points, adverse events, relapse, outcomes, and factors that may affect the efficacy and relapse were analyzed. RESULTS There were 44 patients enrolled, with 9 (20.5%) males and a median age of 44 (range: 18-86) years. 37 (84.1%) patients were diagnosed as wAIHA, and 7 (15.9%) as ES. Patients were treated with sirolimus for a median of 23 (range: 6-80) months and followed up for a median of 25 (range: 12-80) months. 35 (79.5%) patients responded to sirolimus, and 25 (56.8%) patients achieved an optimal response of CR. Mucositis (11.4%), infection (9.1%), and alanine aminotransferase elevation (9.1%) were the most common adverse events. 5/35 patients (14.3%) relapsed at a median of 19 (range: 15-50) months. Patients with a higher sirolimus plasma trough concentration had a higher overall response (OR) and CR rate (p = 0.009, 0.011, respectively). At the time of enrolment, patients were divided into two subgroups that relapsed or refractory to glucocorticoid, and the former had poorer relapse-free survival (p = 0.032) than the other group. CONCLUSION Sirolimus is effective for patients with primary refractory/relapsed wAIHA and ES, with a low relapse rate and mild side effects. Patients with a higher sirolimus plasma trough concentration had a higher OR and CR rate, and patients who relapsed to glucocorticoid treatment had poorer relapse-free survival than those who were refractory.
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Affiliation(s)
- Zhuxin Zhang
- Department of Hematology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Science, Beijing, China
| | - Qinglin Hu
- Department of Hematology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Science, Beijing, China
| | - Chen Yang
- Department of Hematology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Science, Beijing, China
| | - Miao Chen
- Department of Hematology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Science, Beijing, China
| | - Bing Han
- Department of Hematology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Science, Beijing, China
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4
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Conti F, Moratti M, Leonardi L, Catelli A, Bortolamedi E, Filice E, Fetta A, Fabi M, Facchini E, Cantarini ME, Miniaci A, Cordelli DM, Lanari M, Pession A, Zama D. Anti-Inflammatory and Immunomodulatory Effect of High-Dose Immunoglobulins in Children: From Approved Indications to Off-Label Use. Cells 2023; 12:2417. [PMID: 37830631 PMCID: PMC10572613 DOI: 10.3390/cells12192417] [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: 08/07/2023] [Revised: 09/23/2023] [Accepted: 10/05/2023] [Indexed: 10/14/2023] Open
Abstract
BACKGROUND The large-scale utilization of immunoglobulins in patients with inborn errors of immunity (IEIs) since 1952 prompted the discovery of their key role at high doses as immunomodulatory and anti-inflammatory therapy, in the treatment of IEI-related immune dysregulation disorders, according to labelled and off-label indications. Recent years have been dominated by a progressive imbalance between the gradual but constant increase in the use of immunoglobulins and their availability, exacerbated by the SARS-CoV-2 pandemic. OBJECTIVES To provide pragmatic indications for a need-based application of high-dose immunoglobulins in the pediatric context. SOURCES A literature search was performed using PubMed, from inception until 1st August 2023, including the following keywords: anti-inflammatory; children; high dose gammaglobulin; high dose immunoglobulin; immune dysregulation; immunomodulation; immunomodulatory; inflammation; intravenous gammaglobulin; intravenous immunoglobulin; off-label; pediatric; subcutaneous gammaglobulin; subcutaneous immunoglobulin. All article types were considered. IMPLICATIONS In the light of the current imbalance between gammaglobulins' demand and availability, this review advocates the urgency of a more conscious utilization of this medical product, giving indications about benefits, risks, cost-effectiveness, and administration routes of high-dose immunoglobulins in children with hematologic, neurologic, and inflammatory immune dysregulation disorders, prompting further research towards a responsible employment of gammaglobulins and improving the therapeutical decisional process.
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Affiliation(s)
- Francesca Conti
- Pediatric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (F.C.); (A.M.); (A.P.)
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, 40138 Bologna, Italy; (A.F.); (D.M.C.); (M.L.); (D.Z.)
| | - Mattia Moratti
- Specialty School of Paediatrics, University of Bologna, 40138 Bologna, Italy; (A.C.); (E.B.)
| | - Lucia Leonardi
- Department of Maternal Infantile and Urological Sciences, Sapienza University of Rome, 00185 Rome, Italy;
| | - Arianna Catelli
- Specialty School of Paediatrics, University of Bologna, 40138 Bologna, Italy; (A.C.); (E.B.)
| | - Elisa Bortolamedi
- Specialty School of Paediatrics, University of Bologna, 40138 Bologna, Italy; (A.C.); (E.B.)
| | - Emanuele Filice
- Department of Pediatrics, Maggiore Hospital, 40133 Bologna, Italy;
| | - Anna Fetta
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, 40138 Bologna, Italy; (A.F.); (D.M.C.); (M.L.); (D.Z.)
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Neuropsichiatria dell’Età Pediatrica, 40139 Bologna, Italy
| | - Marianna Fabi
- Paediatric Emergency Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy;
| | - Elena Facchini
- Pediatric Oncology and Hematology Unit “Lalla Seràgnoli”, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (E.F.); (M.E.C.)
| | - Maria Elena Cantarini
- Pediatric Oncology and Hematology Unit “Lalla Seràgnoli”, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (E.F.); (M.E.C.)
| | - Angela Miniaci
- Pediatric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (F.C.); (A.M.); (A.P.)
| | - Duccio Maria Cordelli
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, 40138 Bologna, Italy; (A.F.); (D.M.C.); (M.L.); (D.Z.)
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Neuropsichiatria dell’Età Pediatrica, 40139 Bologna, Italy
| | - Marcello Lanari
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, 40138 Bologna, Italy; (A.F.); (D.M.C.); (M.L.); (D.Z.)
- Paediatric Emergency Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy;
| | - Andrea Pession
- Pediatric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (F.C.); (A.M.); (A.P.)
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, 40138 Bologna, Italy; (A.F.); (D.M.C.); (M.L.); (D.Z.)
| | - Daniele Zama
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, 40138 Bologna, Italy; (A.F.); (D.M.C.); (M.L.); (D.Z.)
- Paediatric Emergency Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy;
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Mulder FVM, Evers D, de Haas M, Cruijsen MJ, Bernelot Moens SJ, Barcellini W, Fattizzo B, Vos JMI. Severe autoimmune hemolytic anemia; epidemiology, clinical management, outcomes and knowledge gaps. Front Immunol 2023; 14:1228142. [PMID: 37795092 PMCID: PMC10545865 DOI: 10.3389/fimmu.2023.1228142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 08/28/2023] [Indexed: 10/06/2023] Open
Abstract
Autoimmune hemolytic anemia (AIHA) is an acquired hemolytic disorder, mediated by auto-antibodies, and has a variable clinical course ranging from fully compensated low grade hemolysis to severe life-threatening cases. The rarity, heterogeneity and incomplete understanding of severe AIHA complicate the recognition and management of severe cases. In this review, we describe how severe AIHA can be defined and what is currently known of the severity and outcome of AIHA. There are no validated predictors for severe clinical course, but certain risk factors for poor outcomes (hospitalisation, transfusion need and mortality) can aid in recognizing severe cases. Some serological subtypes of AIHA (warm AIHA with complement positive DAT, mixed, atypical) are associated with lower hemoglobin levels, higher transfusion need and mortality. Currently, there is no evidence-based therapeutic approach for severe AIHA. We provide a general approach for the management of severe AIHA patients, incorporating monitoring, supportive measures and therapeutic options based on expert opinion. In cases where steroids fail, there is a lack of rapidly effective therapeutic options. In this era, numerous novel therapies are emerging for AIHA, including novel complement inhibitors, such as sutimlimab. Their potential in severe AIHA is discussed. Future research efforts are needed to gain a clearer picture of severe AIHA and develop prediction models for severe disease course. It is crucial to incorporate not only clinical characteristics but also biomarkers that are associated with pathophysiological differences and severity, to enhance the accuracy of prediction models and facilitate the selection of the optimal therapeutic approach. Future clinical trials should prioritize the inclusion of severe AIHA patients, particularly in the quest for rapidly acting novel agents.
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Affiliation(s)
- Femke V. M. Mulder
- Sanquin Research and Landsteiner Laboratory, Translational Immunohematology, Amsterdam UMC, Amsterdam, Netherlands
- Department of Hematology, Leiden University Medical Center, Leiden, Netherlands
| | - Dorothea Evers
- Department of Hematology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Masja de Haas
- Sanquin Research and Landsteiner Laboratory, Translational Immunohematology, Amsterdam UMC, Amsterdam, Netherlands
- Department of Hematology, Leiden University Medical Center, Leiden, Netherlands
- Department of Immunohematology Diagnostics, Sanquin Diagnostic Services, Amsterdam, Netherlands
| | | | - Sophie J. Bernelot Moens
- Department of Hematology and Amsterdam Institute for Infection and Immunity, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Wilma Barcellini
- Department of Hematology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Bruno Fattizzo
- Department of Hematology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Josephine M. I. Vos
- Department of Immunohematology Diagnostics, Sanquin Diagnostic Services, Amsterdam, Netherlands
- Department of Hematology and Amsterdam Institute for Infection and Immunity, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
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Berentsen S, Fattizzo B, Barcellini W. The choice of new treatments in autoimmune hemolytic anemia: how to pick from the basket? Front Immunol 2023; 14:1180509. [PMID: 37168855 PMCID: PMC10165002 DOI: 10.3389/fimmu.2023.1180509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 04/13/2023] [Indexed: 05/13/2023] Open
Abstract
Autoimmune hemolytic anemia (AIHA) is defined by increased erythrocyte turnover mediated by autoimmune mechanisms. While corticosteroids remain first-line therapy in most cases of warm-antibody AIHA, cold agglutinin disease is treated by targeting the underlying clonal B-cell proliferation or the classical complement activation pathway. Several new established or investigational drugs and treatment regimens have appeared during the last 1-2 decades, resulting in an improvement of therapy options but also raising challenges on how to select the best treatment in individual patients. In severe warm-antibody AIHA, there is evidence for the upfront addition of rituximab to prednisolone in the first line. Novel agents targeting B-cells, extravascular hemolysis, or removing IgG will offer further options in the acute and relapsed/refractory settings. In cold agglutinin disease, the development of complement inhibitors and B-cell targeting agents makes it possible to individualize therapy, based on the disease profile and patient characteristics. For most AIHAs, the optimal treatment remains to be found, and there is still a need for more evidence-based therapies. Therefore, prospective clinical trials should be encouraged.
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Affiliation(s)
- Sigbjørn Berentsen
- Department of Research and Innovation, Haugesund Hospital, Helse Fonna Hospital Trust, Haugesund, Norway
- *Correspondence: Sigbjørn Berentsen,
| | - Bruno Fattizzo
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, and Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Wilma Barcellini
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
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7
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Cold AIHA and the best treatment strategies. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2022; 2022:90-95. [PMID: 36485161 PMCID: PMC9821124 DOI: 10.1182/hematology.2022000369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Cold-reactive autoimmune hemolytic anemia (AIHA) is rare among the hemolytic anemias. It results when 1 of a variety of processes causes the generation of immunoglobulin M (IgM) autoantibodies against endogenous erythrocytes, resulting in complement activation and predominantly intravascular hemolysis. Cold AIHA is typically a primary lymphoproliferative disorder with marrow B-cell clones producing pathogenic IgM. More rarely, secondary cold AIHA (cAIHA) can develop from malignancy, infection, or other autoimmune disorders. However, in children cAIHA is typically post infection, mild, and self-limited. Symptoms include a sequelae of anemia, fatigue, and acrocyanosis. The severity of disease is variable and highly dependent on the thermal binding range of the autoantibody. In adults, treatment has most commonly focused on reducing antibody production with rituximab-based regimens. The addition of cytotoxic agents to rituximab improves response rates, but at the expense of tolerability. Recent insights into the cause of cold agglutinin disease as a clonal disorder driven by complement form the basis of newer therapeutic options. While rituximab-based regimens are still the mainstay of therapy, options have now expanded to include complement-directed treatments and other B-cell-directed or plasma-cell-directed therapies.
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8
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Kuter DJ. Warm autoimmune hemolytic anemia and the best treatment strategies. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2022; 2022:105-113. [PMID: 36485114 PMCID: PMC9821065 DOI: 10.1182/hematology.2022000405] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Warm autoimmune hemolytic anemia (wAIHA) is characterized by evidence of red blood cell (RBC) hemolysis and a direct antiglobulin test positive for IgG and sometimes complement. While varying with the extent of the compensatory increase in RBC production, symptoms of anemia predominate, as does jaundice, the latter often exacerbated by concurrent Gilbert's syndrome. Initial treatment with corticosteroids is highly effective, with over 85% of patients responding but with less than one-third maintaining that response upon weaning. Subsequent rituximab administration in those failing corticosteroids provides complete remission in over 75% of patients and may be long-lasting. Over 50% of patients failing rituximab respond to erythropoiesis-stimulating agents or immunosuppressive agents. Splenectomy is best deferred if possible but does offer long-term remission in over two-thirds of patients. A number of new treatments for wAIHA (fostamatinib, rilzabrutinib, and FcRn inhibitors) show promise. A treatment algorithm for wAIHA is proposed to avoid the excessive use of corticosteroids.
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Affiliation(s)
- David J. Kuter
- Correspondence David J. Kuter, Hematology Division, Massachusetts General Hospital, Ste 118, Rm 110, Zero Emerson Pl, Boston, MA 02114; e-mail:
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9
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Sair M, Moulis G, Boutboul D, Costedoat-Chalumeau N, Pouchelon C, comont T, Benyamine A, Delphine G, Grumet P, Bert A, Pierre-Yves J, Lobbes H, Pestre V, Roumieu V, Sire S, Dossier A, Riviere E, Ebbo M, Michel M. Utilisation des immunoglobulines polyvalentes intraveineuses au cours des anémies hémolytiques auto-immunes de l’adulte : série rétrospective multicentrique de 34 cas. Rev Med Interne 2022. [DOI: 10.1016/j.revmed.2022.10.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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10
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Ehrlich S, Wichmann C, Spiekermann K. [Autoimmune haemolytic anemias]. Dtsch Med Wochenschr 2022; 147:1243-1250. [PMID: 36126922 DOI: 10.1055/a-1767-8281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Autoimmune haemolytic anemia (AIHA) is defined as the immune-mediated destruction of red blood cells. In most cases, antibodies that target surface antigens on erythrocytes lead to their premature degradation in the spleen or, less commonly, in the liver. The term includes a heterogenous group of diseases, which differ largely in pathophysiology and treatment. The two most common entities are warm AIHA and cold AIHA. Diagnostic testing involves the analysis of haemolytic markers like lactate dehydrogenase, haptoglobin and unconjugated bilirubin as well as a hemoglobin and reticulocytes. In case of a haemolytic anemia, further testing like a blood smear and a direct antiglobulin test should follow. As diagnostic testing and treatment of AIHA are complex, affected patients should always be referred to a hematologist.In warm AIHA, mainly IgG autoantibodies bind to their antigen on the erythrocyte surface at body temperature, leading to their premature destruction in the spleen. First line treatment options include the administration of steroids which mitigate the destruction of red blood cells by macrophages in the spleen. In contrast, IgM autoantibodies in cold AIHA lead to intravasal agglutination of erythrocytes and complement activation. The IgM antibodies have their highest affinity below body temperature which is why patients experience symptoms mainly in cold-exposed body areas. Although the IgM antibodies dissolve at body temperature, the complement-loaded erythrocytes are destroyed in the liver. Therapeutic options include protection from cold and immunosuppressive agents or complement inhibition.
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Jiang Y, Zhao HJ, Luo H, Li BJ, Zhang ZM, Zhao LD, Zuo XX. Efficacy of Whole-Blood Exchange Transfusion in Refractory Severe Autoimmune Haemolytic Anaemia Secondary to Systemic Lupus Erythematosus: A Real-World Observational Retrospective Study. Front Immunol 2022; 13:861719. [PMID: 35757744 PMCID: PMC9226305 DOI: 10.3389/fimmu.2022.861719] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 05/12/2022] [Indexed: 11/13/2022] Open
Abstract
Background Severe autoimmune haemolytic anaemia (AIHA) in systemic lupus erythematosus (SLE) patients could be life-threatening and formidable, especially in those nonresponsive to glucocorticoids (GCs) and immunosuppressants (ISAs). Whole-blood exchange transfusion (WBE), with plasma exchange and pathogenic cell removal as well as healthy red blood cell transfusion, could be beneficial. The objective of this study was to investigate the efficacy and safety of WBE in combination with GCs/ISAs. Methods In this retrospective study, the clinical data of 22 refractory severe SLE-AIHA inpatients between February 2016 and February 2021 were collected and analysed, among whom 14 patients had received WBE and were compared with those treated with typical second-line therapy of intravenous immunoglobulin and/or rituximab (IVIG/RTX). Results Among the 22 severe refractory SLE-AIHA patients, eight patients received IVIG and/or RTX without WBE (group 1, IVIG/RTX, n = 8), seven patients were given WBE without IVIG/RTX (group 2, WBE alone, n = 7), and seven patients who failed initial IVIG/RTX therapy were given sequential WBE therapy (group 3 IVIG/RTX→WBE, n = 7). Fourteen patients had accepted WBE treatment regardless of prior IVIG/RTX usage (group 2 + 3, WBE ± IVIG/RTX, n = 14). On days 1, 3, 5, and 7 after corresponding therapies, patients of groups 2, 3, and 2 + 3 showed significantly higher levels of haemoglobin (Hb) than patients of group 1. Compared with patients of group 1, patients of groups 2, 3, and 2 + 3 took less time to reach and maintain Hb ≥60 g/L from baseline. Groups 2 and 2 + 3 consumed a lower dose of GCs than group 1 to reach and maintain Hb ≥60 g/L from baseline. Group 1 experienced longer hospital stays than group 2, and group 3's cost of hospitalisation is more than groups 1 and 2. Hbmin <40 g/L may be a key indicative factor for initiating WBE remedy therapy as IVIG/RTX may not be effective enough in 48-72 h in those patients with refractory severe SLE-AIHA. No severe adverse effects were observed in the WBE group. Conclusions WBE could be a safe and beneficial alternative therapy for refractory severe SLE-AIHA.
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Affiliation(s)
- Ying Jiang
- Department of Rheumatology, Xiangya Hospital, Central South University, Changsha, China
| | - Hong Jun Zhao
- Department of Rheumatology, Xiangya Hospital, Central South University, Changsha, China
| | - Hui Luo
- Department of Rheumatology, Xiangya Hospital, Central South University, Changsha, China
| | - Bi Juan Li
- Department of Blood Transfusion, Xiangya Hospital, Central South University, Changsha, China
| | - Zhi Min Zhang
- Department of Blood Transfusion, Xiangya Hospital, Central South University, Changsha, China
| | - Li Dan Zhao
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiao Xia Zuo
- Department of Rheumatology, Xiangya Hospital, Central South University, Changsha, China
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12
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Calhoun B, Moore A, Dickey A, Shoemaker DM. Systemic loxoscelism induced warm autoimmune hemolytic anemia: clinical series and review. Hematology 2022; 27:543-554. [PMID: 35544675 DOI: 10.1080/16078454.2022.2065086] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Describe the development of warm autoimmune hemolytic anemia warm (AIHA) secondary to a brown recluse spider (Loxosceles reclusa) bite is known as systemic loxoscelism; and review epidemiology, clinical manifestations, diagnostic work-up, pathophysiology, and treatment options associated with warm AIHA secondary to systemic loxoscelism. METHODS Cases series of two cases of warm AIHA due to systemic loxoscelism and a review of the current literature: epidemiology, clinical manifestations, diagnostic work-up, pathophysiology, and treatment options associated with warm AIHA secondary to systemic loxoscelism. RESULTS Presented here are two cases of warm AIHA due to systemic loxoscelism. Each patient was generally healthy appearing and presented with symptomatic anemia in the setting of brown recluse spider bites. Both patients were eventually found to have warm AIHA. Upon recognition of the diagnosis, the patients were started on corticosteroids and aggressive intravenous fluid hydration. In addition, they received transfusions of packed red blood cells. Their clinical courses improved, and they recovered to eventually be discharged home. CONCLUSION Envenomation by a brown recluse spider, Loxosceles reclusa, can result in systemic loxoscelism which can cause warm AIHA. The diagnosis of warm AIHA is confirmed by the direct antiglobulin/Coomb's test. Warm AIHA can be a life-threatening disease process. Hemodynamic support with intravenous fluids and RBC transfusion is the initial step in the management of these patients. Corticosteroids are the mainstay of current management. Second line treatments include rituximab. Rarely patients require splenectomy for refractory disease. Corticosteroids should be tapered over a three-month period.
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Affiliation(s)
- Brandon Calhoun
- Division of Infectious Diseases, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, MO, USA
| | - Andrew Moore
- SEHealth Cancer Center, SEHealth, Cape Girardeau, MO, USA
| | - Andrew Dickey
- SEHealth Cancer Center, SEHealth, Cape Girardeau, MO, USA
| | - D Matthew Shoemaker
- Division of Infectious Diseases, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, MO, USA
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13
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Autoimmune Hemolytic Anemia in Children: Laboratory Investigation, Disease Associations, and Treatment Strategies. J Pediatr Hematol Oncol 2022; 44:71-78. [PMID: 35235549 DOI: 10.1097/mph.0000000000002438] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 01/25/2022] [Indexed: 01/19/2023]
Abstract
Autoimmune hemolytic anemia is a relatively uncommon pediatric clinical condition. As such, the evaluation and management of these cases can be challenging for even the most seasoned pediatrician. In this review, the 3 major forms of autoimmune hemolytic anemia in children will be discussed: warm autoimmune hemolytic anemia, cold agglutinin disease, and paroxysmal cold hemoglobinuria. After a general description of the laboratory approach to these entities, the pathophysiology of these disease processes, including important disease associations, will be described, and treatment strategies will be discussed. This will provide the reader with a rational approach to identifying and managing pediatric patients with these uncommon autoimmune conditions.
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14
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Hwang SR, Saliba AN, Wolanskyj-Spinner AP. Immunotherapy-associated Autoimmune Hemolytic Anemia. Hematol Oncol Clin North Am 2022; 36:365-380. [PMID: 35339260 DOI: 10.1016/j.hoc.2021.11.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Over the past decade, the role of immunotherapy treatment in cancer has expanded; specifically, indications for immune checkpoint inhibitors (ICI) have multiplied and are used as first-line therapy. ICIs include cytotoxic T-lymphocyte-associated protein 4 and programmed cell death protein 1 inhibitors, as monotherapies or in combination. Autoimmune hemolytic anemia (AIHA) has emerged as a rare yet serious immune-related adverse event in ICI use. This review describes diagnosis and management of immunotherapy related AIHA (ir-AIHA) including an algorithmic approach based on severity of anemia. Suggested mechanisms are discussed, guidance on ICI resumption provided and prognosis reviewed including risk of recurrence.
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Affiliation(s)
- Steven R Hwang
- Division of Hematology, Department of Medicine, Mayo Clinic, 200 First street Southwest, Rochester, Minnesota 55905, USA; Division of Medical Oncology, Department of Oncology, Mayo Clinic, 200 First Street Southwest, Rochester, Minnesota 55905, USA
| | - Antoine N Saliba
- Division of Hematology, Department of Medicine, Mayo Clinic, 200 First street Southwest, Rochester, Minnesota 55905, USA; Division of Medical Oncology, Department of Oncology, Mayo Clinic, 200 First Street Southwest, Rochester, Minnesota 55905, USA
| | - Alexandra P Wolanskyj-Spinner
- Division of Hematology, Department of Medicine, Mayo Clinic, 200 First street Southwest, Rochester, Minnesota 55905, USA; Mayo Clinic Alix School of Medicine, Mayo Clinic College of Medicine and Science, 200 First Street Southwest, Rochester, Minnesota 55905, USA.
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15
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Michel M. Adult Evans' Syndrome. Hematol Oncol Clin North Am 2022; 36:381-392. [DOI: 10.1016/j.hoc.2021.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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16
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MESH Headings
- Anemia, Hemolytic, Autoimmune/diagnosis
- Anemia, Hemolytic, Autoimmune/pathology
- Anemia, Hemolytic, Autoimmune/physiopathology
- Anemia, Hemolytic, Autoimmune/therapy
- Blood Transfusion
- Complement Inactivating Agents/therapeutic use
- Glucocorticoids/therapeutic use
- Hemoglobinuria, Paroxysmal/diagnosis
- Hemoglobinuria, Paroxysmal/pathology
- Hemoglobinuria, Paroxysmal/physiopathology
- Hemoglobinuria, Paroxysmal/therapy
- Humans
- Immunologic Factors/therapeutic use
- Rituximab/therapeutic use
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Affiliation(s)
- Sigbjørn Berentsen
- From the Department of Research and Innovation, Haugesund Hospital, Helse Fonna Hospital Trust, Haugesund, Norway (S.B.); and the Hematology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan (W.B.)
| | - Wilma Barcellini
- From the Department of Research and Innovation, Haugesund Hospital, Helse Fonna Hospital Trust, Haugesund, Norway (S.B.); and the Hematology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan (W.B.)
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17
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Ying Q, Lv D, Fu X, Shi S, Chen L, He Y, Yang J, Yang S, Mu Q. Resolution of serologic problems due to cold agglutinin mediated autoimmune hemolytic anemia and its transfusion decision. J Clin Lab Anal 2021; 35:e23894. [PMID: 34216510 PMCID: PMC8373330 DOI: 10.1002/jcla.23894] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 06/11/2021] [Accepted: 06/19/2021] [Indexed: 12/11/2022] Open
Abstract
Background Autoimmune hemolytic anemia (AIHA) is a rare disease characterized by hemolysis caused by autoantibodies against erythrocyte surface antigen. These antibodies can be classified as warm, cold, or mixed types. Methods We report two cases of cold agglutinin disease (CAD), which were eventually diagnosed owing to blood group discrepancy. Resolution was achieved after washing the red blood cells (RBCs) with warm saline and absorbing the autoantibodies at 4°C with the washed RBCs. We also assessed the patient's condition and discussed the strategy of blood transfusion. Results The first case occurred after postoperative chemotherapy for rectal cancer, and the other manifested with anemia from the outset. Direct antiglobulin tests were positive and revealed autoantibodies against C3d only. Cold agglutinin titration was performed, and the titers of both were 1:1024. Eventually, the patient's condition stabilized without blood transfusion. Conclusion The serological discrepancies observed in the blood transfusion department can successfully guide blood transfusion decisions in cases of CAD.
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Affiliation(s)
- Qiming Ying
- School of Medicine, Ningbo University, Ningbo, China.,Department of Blood Transfusion, Ningbo City First Hospital, Ningbo, China
| | - Dingfeng Lv
- School of Medicine, Ningbo University, Ningbo, China.,Department of Blood Transfusion, Ningbo City First Hospital, Ningbo, China
| | - Xiaomei Fu
- Department of Blood Transfusion, Ningbo City First Hospital, Ningbo, China
| | - Shuanglu Shi
- School of Medicine, Ningbo University, Ningbo, China.,Department of Blood Transfusion, Ningbo City First Hospital, Ningbo, China
| | - Luyan Chen
- Department of Blood Transfusion, Ningbo City First Hospital, Ningbo, China
| | - Yiwen He
- Department of Blood Transfusion, Ningbo City First Hospital, Ningbo, China
| | - Jing Yang
- Department of Blood Transfusion, Ningbo City First Hospital, Ningbo, China
| | - Shujun Yang
- The Laboratory of Stem Cell Transplantation, Department of Hematology, Ningbo City First Hospital, Ningbo, China
| | - Qitian Mu
- The Laboratory of Stem Cell Transplantation, Department of Hematology, Ningbo City First Hospital, Ningbo, China
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18
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Brahmer JR, Abu-Sbeih H, Ascierto PA, Brufsky J, Cappelli LC, Cortazar FB, Gerber DE, Hamad L, Hansen E, Johnson DB, Lacouture ME, Masters GA, Naidoo J, Nanni M, Perales MA, Puzanov I, Santomasso BD, Shanbhag SP, Sharma R, Skondra D, Sosman JA, Turner M, Ernstoff MS. Society for Immunotherapy of Cancer (SITC) clinical practice guideline on immune checkpoint inhibitor-related adverse events. J Immunother Cancer 2021; 9:e002435. [PMID: 34172516 PMCID: PMC8237720 DOI: 10.1136/jitc-2021-002435] [Citation(s) in RCA: 287] [Impact Index Per Article: 95.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/24/2021] [Indexed: 02/06/2023] Open
Abstract
Immune checkpoint inhibitors (ICIs) are the standard of care for the treatment of several cancers. While these immunotherapies have improved patient outcomes in many clinical settings, they bring accompanying risks of toxicity, specifically immune-related adverse events (irAEs). There is a need for clear, effective guidelines for the management of irAEs during ICI treatment, motivating the Society for Immunotherapy of Cancer (SITC) to convene an expert panel to develop a clinical practice guideline. The panel discussed the recognition and management of single and combination ICI irAEs and ultimately developed evidence- and consensus-based recommendations to assist medical professionals in clinical decision-making and to improve outcomes for patients.
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Affiliation(s)
- Julie R Brahmer
- Department of Oncology and the Thoracic Oncology, Johns Hopkins Sidney Kimmel Cancer Center, Baltimore, Maryland, USA
| | - Hamzah Abu-Sbeih
- Department of Internal Medicine, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Paolo Antonio Ascierto
- Unit of Melanoma Cancer Immunotherapy and Innovative Therapy, National Tumour Institute IRCCS Fondazione 'G. Pascale', Napoli, Italy
| | - Jill Brufsky
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Laura C Cappelli
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Frank B Cortazar
- Massachusetts General Hospital, Boston, Massachusetts, USA
- New York Nephrology Vasculitis and Glomerular Center, Albany, New York, USA
| | - David E Gerber
- Department of Hematology and Oncology, Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Lamya Hamad
- Department of Pharmacy, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Eric Hansen
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Douglas B Johnson
- Department of Medicine, Vanderbilt-Ingram Cancer Center, Nashville, Tennessee, USA
| | - Mario E Lacouture
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Gregory A Masters
- Department of Medicine, Helen F. Graham Cancer Center, Newark, Delaware, USA
| | - Jarushka Naidoo
- Department of Oncology and the Thoracic Oncology, Johns Hopkins Sidney Kimmel Cancer Center, Baltimore, Maryland, USA
- Department of Oncology, Beaumont Hospital Dublin, The Royal College of Surgeons of Ireland, Dublin, Ireland
| | - Michele Nanni
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Miguel-Angel Perales
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Igor Puzanov
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Bianca D Santomasso
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Satish P Shanbhag
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Cancer Specialist of North Florida, Fleming Island, Florida, USA
| | - Rajeev Sharma
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Dimitra Skondra
- Department of Ophthalmology and Visual Science, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Jeffrey A Sosman
- Robert H. Lurie Comprehensive Cancer Center, Northwestern University Medical Center, Chicago, Illinois, USA
| | - Michelle Turner
- Department of Oncology and the Thoracic Oncology, Johns Hopkins Sidney Kimmel Cancer Center, Baltimore, Maryland, USA
| | - Marc S Ernstoff
- Division of Cancer Treatment & Diagnosis, National Cancer Institute, Rockville, Maryland, USA
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19
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[Pediatric expert consensus on the application of intravenous immunoglobulin in children with hematological/neoplastic diseases]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2021; 23. [PMID: 33840401 PMCID: PMC8050546 DOI: 10.7499/j.issn.1008-8830.2101174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Intravenous immunoglobulin (IVIG) has been widely used in chemotherapy for hematological malignancies, targeted therapy, and hematopoietic stem cell transplantation; however, there are still no available guidelines or consensus statements on the application of IVIG in pediatric hematological/neoplastic diseases at present in China and overseas. This consensus is developed based on the research advances in the application of IVIG in pediatric hematological/neoplastic diseases across the world and provides detailed recommendations for the clinical application of IVIG in pediatric hematological/neoplastic diseases and the prevention and treatment of related adverse reactions.
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20
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Abstract
BACKGROUND Primary autoimmune haemolytic anaemia (AIHA) is an autoantibody mediated condition characterised by a variable disease course. A myriad of immunomodulatory agents have been employed but there is a paucity of evidence to support their use or compare their effectiveness. OBJECTIVES To determine the effects of various disease-modifying treatment modalities in people with AHIHA. SEARCH METHODS We searched MEDLINE (Ovid) (1946 to 2021), Embase (Ovid) (1974 to 2021), Latin American and Caribbean Health Sciences Literature (LILACS) (1982 to 2021), and the Cochrane Library (CENTRAL). Clinical trial registries and relevant conference proceedings were also reviewed. Records were included as of 7 March 2021. We did not impose any language restrictions. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing immunosuppressive or immunomodulatory treatments against no treatment, placebo, or another immunosuppressive or immunomodulatory treatment, for people of all age with idiopathic AIHA. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. The prioritised pre-defined outcomes included complete haematological response at 12 months, frequency of adverse events at two, six and 12 months, partial haematological response at 12 months, overall survival at six and 12 months, relapse-free survival (RFS) at six and 12 months, red blood cel (RBC) transfusion requirement after treatment at 12 months, and quality of life (QOL) as measured by validated instruments at 12 months. Based on data availability, we were only able to perform meta-analysis on frequency of complete haematological response. MAIN RESULTS Two trials were included, enrolling a total of 104 adult participants (96 randomised) with warm AIHA in the setting of tertiary referral centres, both comparing the effectiveness between rituximab (375 mg/m2 weekly for four weeks, or 1000 mg for two doses two weeks apart) plus glucocorticoid (prednisolone 1.5 or 1mg/kg/day with taper) and glucocorticoid monotherapy. The average age of participants in the two trials were 67 and 71, respectively. One of the included studies had good methodological quality with low risk of bias, whereas the other study had high risk of performance and detection bias due to lack of blinding. Compared with glucocorticoid alone, adding rituximab may result in a large increase of complete response at 12 months (n = 96, risk ratio (RR) 2.13, 95% confidence interval (CI) 1.34 to 3.40, GRADE: low-certainty evidence). Rates of adverse effects at prespecified time-points were not reported. Limited data on partial haematological response were reported. The evidence is very uncertain about the effect of adding rituximab to glucocorticoids on partial haematological response at 12 months (n = 32; study = 1; RR 3.00, 95% CI 0.13 to 68.57; GRADE very low-certainty evidence). RBC transfusion need at 12 months was reported in one study, with four participants (mean number of packed red cell units 4.0 ± 2.82) from the rituximab group and five participants from the placebo (corticosteroid only) (mean number of packed red cell units 5.6 ± 4.15) group requiring transfusion, indicating very uncertain evidence about the effect of adding rituximab to glucocorticoids (n = 32, RR 0.80, 95% CI 0.26 to 2.45, GRADE very low-certainty evidence). The other study did not report transfusion requirement at prespecified time points but reported no difference in transfusion requirement between the two groups when comparing responders from enrolment to end of response or to the end of study follow-up (34 units versus 30 units, median [range]: 0 [1 to 6] versus 0 [1 to 5], P = 0·81). Overall survival and RFS rates at prespecified time-points were not explicitly reported in either study. Data on QOL were not available. AUTHORS' CONCLUSIONS Available literature on the effectiveness of immunomodulatory therapy for primary AIHA is restricted to comparison between rituximab plus glucocorticoid and glucocorticoid alone, in patients with newly diagnosed warm AIHA, calling for need for additional studies. The current result suggests that combinatory therapy with rituximab and glucocorticoid may increase the rate of complete haematological response over glucocorticoid monotherapy.
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Affiliation(s)
- Anthony Pak-Yin Liu
- Department of Pediatrics and Adolescent Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong, China
| | - Daniel Kl Cheuk
- Department of Pediatrics and Adolescent Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong, China
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21
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Thiagarajan P, Parker CJ, Prchal JT. How Do Red Blood Cells Die? Front Physiol 2021; 12:655393. [PMID: 33790808 PMCID: PMC8006275 DOI: 10.3389/fphys.2021.655393] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 02/24/2021] [Indexed: 12/24/2022] Open
Abstract
Normal human red blood cells have an average life span of about 120 days in the circulation after which they are engulfed by macrophages. This is an extremely efficient process as macrophages phagocytose about 5 million erythrocytes every second without any significant release of hemoglobin in the circulation. Despite large number of investigations, the precise molecular mechanism by which macrophages recognize senescent red blood cells for clearance remains elusive. Red cells undergo several physicochemical changes as they age in the circulation. Several of these changes have been proposed as a recognition tag for macrophages. Most prevalent hypotheses for red cell clearance mechanism(s) are expression of neoantigens on red cell surface, exposure phosphatidylserine and decreased deformability. While there is some correlation between these changes with aging their causal role for red cell clearance has not been established. Despite plethora of investigations, we still have incomplete understanding of the molecular details of red cell clearance. In this review, we have reviewed the recent data on clearance of senescent red cells. We anticipate recent progresses in in vivo red cell labeling and the explosion of modern proteomic techniques will, in near future, facilitate our understanding of red cell senescence and their destruction.
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Affiliation(s)
- Perumal Thiagarajan
- Center for Translational Research on Inflammatory Diseases (CTRID), Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, United States.,Department of Pathology and Immunology, Baylor College of Medicine, Houston, TX, United States
| | - Charles J Parker
- University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Josef T Prchal
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, United States
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22
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How I treat warm autoimmune hemolytic anemia. Blood 2021; 137:1283-1294. [PMID: 33512406 DOI: 10.1182/blood.2019003808] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 08/28/2020] [Indexed: 12/17/2022] Open
Abstract
Warm autoimmune hemolytic anemia (wAIHA) is caused by increased erythrocyte destruction by immunoglobulin G (IgG) autoantibodies, with or without complement activation. Antibody-dependent cell-mediated cytotoxicity by macrophages/activated lymphocytes occurs in the lymphoid organs and spleen (extravascular hemolysis). The ability of the bone marrow (BM) to compensate determines clinical severity. The different pathogenic mechanisms, their complex interplay, and changes over time may explain wAIHA's great clinical heterogeneity and unpredictable course. The disease may be primary, drug induced, or associated with lymphoproliferative neoplasms, autoimmune and infectious diseases, immunodeficiencies, solid tumors, or transplants. Therapeutic interventions include steroids, splenectomy, immunosuppressants, and rituximab; the latter is increasingly used in steroid-refractory cases based on evidence from the literature and a few prospective trials. We present 5 patient case studies highlighting important issues: (1) the diagnosis and proper use of steroid therapy, (2) the concerns about the choice between rituximab and splenectomy in second-line treatment, (3) the need of periodical re-evaluation of the disease to assess the possible evolution of relapsed/refractory cases in myelodysplastic and BM failure syndromes, and (4) the difficulties in managing cases of severe/acute disease that are at high risk of relapse. Incorporating novel targeted therapies into clinical practice will be an exciting challenge in the future.
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Brand A, De Angelis V, Vuk T, Garraud O, Lozano M, Politis D. Review of indications for immunoglobulin (IG) use: Narrowing the gap between supply and demand. Transfus Clin Biol 2021; 28:96-122. [DOI: 10.1016/j.tracli.2020.12.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Autoimmune Hemolytic Anemia in the Pediatric Setting. J Clin Med 2021; 10:jcm10020216. [PMID: 33435309 PMCID: PMC7828053 DOI: 10.3390/jcm10020216] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 01/04/2021] [Accepted: 01/05/2021] [Indexed: 12/21/2022] Open
Abstract
Autoimmune hemolytic anemia (AIHA) is a rare disease in children, presenting with variable severity. Most commonly, warm-reactive IgG antibodies bind erythrocytes at 37 °C and induce opsonization and phagocytosis mainly by the splenic macrophages, causing warm AIHA (w-AIHA). Post-infectious cold-reactive antibodies can also lead to hemolysis following the patient’s exposure to cold temperatures, causing cold agglutinin syndrome (CAS) due to IgM autoantibodies, or paroxysmal cold hemoglobinuria (PCH) due to atypical IgG autoantibodies which bind their target RBC antigen and fix complement at 4 °C. Cold-reactive antibodies mainly induce intravascular hemolysis after complement activation. Direct antiglobulin test (DAT) is the gold standard for AIHA diagnosis; however, DAT negative results are seen in up to 11% of warm AIHA, highlighting the need to pursue further evaluation in cases with a phenotype compatible with immune-mediated hemolytic anemia despite negative DAT. Prompt supportive care, initiation of treatment with steroids for w-AIHA, and transfusion if necessary for symptomatic or fast-evolving anemia is crucial for a positive outcome. w-AIHA in children is often secondary to underlying immune dysregulation syndromes and thus, screening for such disorders is recommended at presentation, before initiating treatment with immunosuppressants, to determine prognosis and optimize long-term management potentially with novel targeted medications.
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25
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Evans' Syndrome: From Diagnosis to Treatment. J Clin Med 2020; 9:jcm9123851. [PMID: 33260979 PMCID: PMC7759819 DOI: 10.3390/jcm9123851] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Revised: 11/21/2020] [Accepted: 11/25/2020] [Indexed: 12/13/2022] Open
Abstract
Evans' syndrome (ES) is defined as the concomitant or sequential association of warm auto-immune haemolytic anaemia (AIHA) with immune thrombocytopenia (ITP), and less frequently autoimmune neutropenia. ES is a rare situation that represents up to 7% of AIHA and around 2% of ITP. When AIHA and ITP occurred concomitantly, the diagnosis procedure must rule out differential diagnoses such as thrombotic microangiopathies, anaemia due to bleedings complicating ITP, vitamin deficiencies, myelodysplastic syndromes, paroxysmal nocturnal haemoglobinuria, or specific conditions like HELLP when occurring during pregnancy. As for isolated auto-immune cytopenia (AIC), the determination of the primary or secondary nature of ES is important. Indeed, the association of ES with other diseases such as haematological malignancies, systemic lupus erythematosus, infections, or primary immune deficiencies can interfere with its management or alter its prognosis. Due to the rarity of the disease, the treatment of ES is mostly extrapolated from what is recommended for isolated AIC and mostly relies on corticosteroids, rituximab, splenectomy, and supportive therapies. The place for thrombopoietin receptor agonists, erythropoietin, immunosuppressants, haematopoietic cell transplantation, and thromboprophylaxis is also discussed in this review. Despite continuous progress in the management of AIC and a gradual increase in ES survival, the mortality due to ES remains higher than the ones of isolated AIC, supporting the need for an improvement in ES management.
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Irikura T, Mitani Y, Seki M, Takita J, Hiwatari M. Cold agglutinin disease in an infant: remission after intravenous immunoglobulin. Pediatr Int 2020; 62:1214-1216. [PMID: 33034109 DOI: 10.1111/ped.14289] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 04/27/2020] [Accepted: 05/01/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Tomoya Irikura
- Department of Pediatrics, The University of Tokyo, Tokyo, Japan
| | - Yuichi Mitani
- Department of Pediatrics, The University of Tokyo, Tokyo, Japan
| | - Masafumi Seki
- Department of Pediatrics, The University of Tokyo, Tokyo, Japan
| | - Junko Takita
- Department of Pediatrics, The University of Tokyo, Tokyo, Japan
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Successful Treatment of an Adolescent Male With Severe Refractory Evans Syndrome Using Bortezomib-based Therapy. J Pediatr Hematol Oncol 2020; 42:e110-e113. [PMID: 30299351 DOI: 10.1097/mph.0000000000001325] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Evans syndrome is defined by bilineal autoimmune cytopenia, typically coombs positive hemolytic anemia and thrombocytopenia. Corticosteroids are the mainstay of treatment, with rituximab and/or mycophenolate mofetil often used in steroid-refractory cases. However, no treatment methodology has ever evaluated by a randomized clinical trial. We present a 15-year-old boy with Evans syndrome and common variable immunodeficiency who experienced a severe, refractory flare 16 months postsplenectomy. After failing to respond to multiple other agents, he achieved a durable response to a bortezomib-based regimen. Bortezomib may be a reasonable second or third line option, especially before high-morbidity therapies such as splenectomy or stem cell transplantation.
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Diagnosis and treatment of autoimmune hemolytic anemia in adults: Recommendations from the First International Consensus Meeting. Blood Rev 2019; 41:100648. [PMID: 31839434 DOI: 10.1016/j.blre.2019.100648] [Citation(s) in RCA: 240] [Impact Index Per Article: 48.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Revised: 11/21/2019] [Accepted: 11/25/2019] [Indexed: 12/15/2022]
Abstract
Autoimmune hemolytic anemias (AIHAs) are rare and heterogeneous disorders characterized by the destruction of red blood cells through warm or cold antibodies. There is currently no licensed treatment for AIHA. Due to the paucity of clinical trials, recommendations on diagnosis and therapy have often been based on expert opinions and some national guidelines. Here we report the recommendations of the First International Consensus Group, who met with the aim to review currently available data and to provide standardized diagnostic criteria and therapeutic approaches as well as an overview of novel therapies. Exact diagnostic workup is important because symptoms, course of disease, and therapeutic management relate to the type of antibody involved. Monospecific direct antiglobulin test is considered mandatory in the diagnostic workup, and any causes of secondary AIHA have to be diagnosed. Corticosteroids remain first-line therapy for warm-AIHA, while the addition of rituximab should be considered early in severe cases and if no prompt response to steroids is achieved. Rituximab with or without bendamustine should be used in the first line for patients with cold agglutinin disease requiring therapy. We identified a need to establish an international AIHA network. Future recommendations should be based on prospective clinical trials whenever possible.
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Jaime-Pérez JC, Aguilar-Calderón PE, Salazar-Cavazos L, Gómez-Almaguer D. Evans syndrome: clinical perspectives, biological insights and treatment modalities. J Blood Med 2018; 9:171-184. [PMID: 30349415 PMCID: PMC6190623 DOI: 10.2147/jbm.s176144] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Evans syndrome (ES) is a rare and chronic autoimmune disease characterized by autoimmune hemolytic anemia and immune thrombocytopenic purpura with a positive direct anti-human globulin test. It is classified as primary and secondary, with the frequency in patients with autoimmune hemolytic anemia being 37%–73%. It predominates in children, mainly due to primary immunodeficiencies or autoimmune lymphoproliferative syndrome. ES during pregnancy is associated with high fetal morbidity, including severe hemolysis and intracranial bleeding with neurological sequelae and death. The clinical presentation can include fatigue, pallor, jaundice and mucosal bleeding, with remissions and exacerbations during the person’s lifetime, and acute manifestations as catastrophic bleeding and massive hemolysis. Recent molecular theories explaining the physiopathology of ES include deficiencies of CTLA-4, LRBA, TPP2 and a decreased CD4/CD8 ratio. As in other autoimmune cytopenias, there is no established evidence-based treatment and steroids are the first-line therapy, with intravenous immunoglobulin administered as a life-saving resource in cases of severe immune thrombocytopenic purpura manifestations. Second-line treatment for refractory ES includes rituximab, mofetil mycophenolate, cyclosporine, vincristine, azathioprine, sirolimus and thrombopoietin receptor agonists. In cases unresponsive to immunosuppressive agents, hematopoietic stem cell transplantation has been successful, although it is necessary to consider its potential serious adverse effects. In conclusion, ES is a disease with a heterogeneous course that remains challenging to patients and physicians, with prospective clinical trials needed to explore potential targeted therapy to achieve an improved long-term response or even a cure.
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Affiliation(s)
- José Carlos Jaime-Pérez
- Department of Hematology, Internal Medicine Division, Dr José E González University Hospital, School of Medicine of the Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México,
| | - Patrizia Elva Aguilar-Calderón
- Department of Hematology, Internal Medicine Division, Dr José E González University Hospital, School of Medicine of the Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México,
| | - Lorena Salazar-Cavazos
- Department of Hematology, Internal Medicine Division, Dr José E González University Hospital, School of Medicine of the Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México,
| | - David Gómez-Almaguer
- Department of Hematology, Internal Medicine Division, Dr José E González University Hospital, School of Medicine of the Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México,
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Clinical features and treatment of primary autoimmune hemolytic anemia in childhood. Transfus Apher Sci 2018; 57:665-668. [DOI: 10.1016/j.transci.2018.07.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 07/26/2018] [Accepted: 07/27/2018] [Indexed: 11/17/2022]
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Parvovirus B19-triggered Acute Hemolytic Anemia and Thrombocytopenia in a Child with Evans Syndrome. Mediterr J Hematol Infect Dis 2018. [PMID: 29531655 PMCID: PMC5841940 DOI: 10.4084/mjhid.2018.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Background Human parvovirus B19 (HPV-B19) is the etiologic agent of erythema infectiosum, of transient aplastic crises in individuals with underlying chronic hemolytic disorders, and of chronic pure red cell aplasia in immunocompromised individuals. Case report We describe a 14-year-old girl with long-standing Evans syndrome, who presented with severe anemia, reticulocytopenia and thrombocytopenia. A bone marrow aspirate revealed severe erythroid hypoplasia along with the presence of giant pronormoblasts, while serological studies and real-time PCR of whole blood were positive for acute parvovirus B19 infection. The patient was initially managed with corticosteroids, but both cytopenias resolved only after administration of intravenous gamma globulin 0.8g/kg. Conclusion Acute parvovirus B19 infection should be suspected in patients with immunologic diseases, who present reticulocytopenic hemolytic anemia and thrombocytopenia. In this setting, intravenous gamma globulin is effective for both cytopenias.
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Abstract
Primary Evans syndrome (ES) is defined by the concurrent or sequential occurrence of immune thrombocytopenia and autoimmune hemolytic anemia in the absence of an underlying etiology. The syndrome is characterized by a chronic, relapsing, and potentially fatal course requiring long-term immunosuppressive therapy. Treatment of ES is hardly evidence-based. Corticosteroids are the mainstay of therapy. Rituximab has emerged as the most widely used second-line treatment, as it can safely achieve high response rates and postpone splenectomy. An increasing number of new genetic defects involving critical pathways of immune regulation identify specific disorders, which explain cases of ES previously reported as "idiopathic".
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Bruggeman CW, Dekkers G, Bentlage AEH, Treffers LW, Nagelkerke SQ, Lissenberg-Thunnissen S, Koeleman CAM, Wuhrer M, van den Berg TK, Rispens T, Vidarsson G, Kuijpers TW. Enhanced Effector Functions Due to Antibody Defucosylation Depend on the Effector Cell Fcγ Receptor Profile. THE JOURNAL OF IMMUNOLOGY 2017; 199:204-211. [PMID: 28566370 DOI: 10.4049/jimmunol.1700116] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 05/04/2017] [Indexed: 01/12/2023]
Abstract
Abs of the IgG isotype are glycosylated in their Fc domain at a conserved asparagine at position 297. Removal of the core fucose of this glycan greatly increases the affinity for FcγRIII, resulting in enhanced FcγRIII-mediated effector functions. Normal plasma IgG contains ∼94% fucosylated Abs, but alloantibodies against, for example, Rhesus D (RhD) and platelet Ags frequently have reduced fucosylation that enhances their pathogenicity. The increased FcγRIII-mediated effector functions have been put to use in various afucosylated therapeutic Abs in anticancer treatment. To test the functional consequences of Ab fucosylation, we produced V-gene-matched recombinant anti-RhD IgG Abs of the four different subclasses (IgG1-4) with and without core fucose (i.e., 20% fucose remaining). Binding to all human FcγR types and their functional isoforms was assessed with surface plasmon resonance. All hypofucosylated anti-RhD IgGs of all IgG subclasses indeed showed enhanced binding affinity for isolated FcγRIII isoforms, without affecting binding affinity to other FcγRs. In contrast, when testing hypofucosylated anti-RhD Abs with FcγRIIIa-expressing NK cells, a 12- and 7-fold increased erythrocyte lysis was observed with the IgG1 and IgG3, respectively, but no increase with IgG2 and IgG4 anti-RhD Abs. Notably, none of the hypofucosylated IgGs enhanced effector function of macrophages, which, in contrast to NK cells, express a complex set of FcγRs, including FcγRIIIa. Our data suggest that the beneficial effects of afucosylated biologicals for clinical use can be particularly anticipated when there is a substantial involvement of FcγRIIIa-expressing cells, such as NK cells.
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Affiliation(s)
- Christine W Bruggeman
- Department of Blood Cell Research, Sanquin Research and Landsteiner Laboratory, Academic Medical Center, University of Amsterdam, 1066 CX Amsterdam, the Netherlands;
| | - Gillian Dekkers
- Department of Experimental Immunohematology, Sanquin Research and Landsteiner Laboratory, Academic Medical Center, University of Amsterdam, 1066 CX Amsterdam, the Netherlands
| | - Arthur E H Bentlage
- Department of Experimental Immunohematology, Sanquin Research and Landsteiner Laboratory, Academic Medical Center, University of Amsterdam, 1066 CX Amsterdam, the Netherlands
| | - Louise W Treffers
- Department of Blood Cell Research, Sanquin Research and Landsteiner Laboratory, Academic Medical Center, University of Amsterdam, 1066 CX Amsterdam, the Netherlands
| | - Sietse Q Nagelkerke
- Department of Blood Cell Research, Sanquin Research and Landsteiner Laboratory, Academic Medical Center, University of Amsterdam, 1066 CX Amsterdam, the Netherlands
| | - Suzanne Lissenberg-Thunnissen
- Department of Experimental Immunohematology, Sanquin Research and Landsteiner Laboratory, Academic Medical Center, University of Amsterdam, 1066 CX Amsterdam, the Netherlands
| | - Carolien A M Koeleman
- Center for Proteomics and Metabolomics, Leiden University Medical Center, 2300 RC Leiden, the Netherlands
| | - Manfred Wuhrer
- Center for Proteomics and Metabolomics, Leiden University Medical Center, 2300 RC Leiden, the Netherlands
| | - Timo K van den Berg
- Department of Blood Cell Research, Sanquin Research and Landsteiner Laboratory, Academic Medical Center, University of Amsterdam, 1066 CX Amsterdam, the Netherlands
| | - Theo Rispens
- Department of Immunopathology, Sanquin Research and Landsteiner Laboratory, Academic Medical Center, University of Amsterdam, 1066 CX Amsterdam, the Netherlands; and
| | - Gestur Vidarsson
- Department of Experimental Immunohematology, Sanquin Research and Landsteiner Laboratory, Academic Medical Center, University of Amsterdam, 1066 CX Amsterdam, the Netherlands
| | - Taco W Kuijpers
- Department of Blood Cell Research, Sanquin Research and Landsteiner Laboratory, Academic Medical Center, University of Amsterdam, 1066 CX Amsterdam, the Netherlands.,Emma Children's Hospital, Academic Medical Center, University of Amsterdam, 1100 DD Amsterdam, the Netherlands
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Ladogana S, Maruzzi M, Samperi P, Perrotta S, Del Vecchio GC, Notarangelo LD, Farruggia P, Verzegnassi F, Masera N, Saracco P, Fasoli S, Miano M, Girelli G, Barcellini W, Zanella A, Russo G. Diagnosis and management of newly diagnosed childhood autoimmune haemolytic anaemia. Recommendations from the Red Cell Study Group of the Paediatric Haemato-Oncology Italian Association. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2017; 15:259-267. [PMID: 28151390 PMCID: PMC5448833 DOI: 10.2450/2016.0072-16] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Accepted: 11/09/2016] [Indexed: 01/20/2023]
Abstract
Autoimmune haemolytic anaemia is an uncommon disorder to which paediatric haematology centres take a variety of diagnostic and therapeutic approaches. The Red Cell Working Group of the Italian Association of Paediatric Onco-haematology (Associazione Italiana di Ematologia ed Oncologia Pediatrica, AIEOP) developed this document in order to collate expert opinions on the management of newly diagnosed childhood autoimmune haemolytic anaemia.The diagnostic process includes the direct and indirect antiglobulin tests; recommendations are given regarding further diagnostic tests, specifically in the cases that the direct and indirect antiglobulin tests are negative. Clear-cut definitions of clinical response are stated. Specific recommendations for treatment include: dosage of steroid therapy and tapering modality for warm autoimmune haemolytic anaemia; the choice of rituximab as first-line therapy for the rare primary transfusion-dependent cold autoimmune haemolytic anaemia; the indications for supportive therapy; the need for switching to second-line therapy. Each statement is provided with a score expressing the level of appropriateness and the agreement among participants.
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Affiliation(s)
- Saverio Ladogana
- Paediatric Onco-haematology Unit, “Casa Sollievo della Sofferenza” Hospital, IRCCS, San Giovanni Rotondo, Italy
| | - Matteo Maruzzi
- Paediatric Onco-haematology Unit, “Casa Sollievo della Sofferenza” Hospital, IRCCS, San Giovanni Rotondo, Italy
| | - Piera Samperi
- Paediatric Onco-haematology Unit, Azienda Policlinico “Vittorio Emanuele”, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Silverio Perrotta
- Department of Women, Children and General and Specialized Surgery, Second University of Naples, Naples, Italy
| | | | - Lucia D. Notarangelo
- Paediatric Onco-haematology Unit, Children’s Hospital, Spedali Civili, Brescia, Italy
| | - Piero Farruggia
- Paediatric Onco-haematology Unit, Civico Hospital, Palermo, Italy
| | | | - Nicoletta Masera
- Paediatric Department, University of Milano-Bicocca, “San Gerardo” Hospital, Monza, Italy
| | - Paola Saracco
- Paediatric and Adolescent Science Department, University of Turin, Turin, Italy
| | - Silvia Fasoli
- Paediatric Unit, “Carlo Poma” Hospital, Mantua, Italy
| | - Maurizio Miano
- Clinical and Experimental Haematology Unit, “G. Gaslini” Children’s Hospital, Genoa, Italy
| | - Gabriella Girelli
- Immunohaematology and Transfusion Medicine Unit, Policlinico Umberto I, Sapienza University, Rome, Italy
| | - Wilma Barcellini
- Onco-haematology, Physiopathology of Anaemia Unit, IRCCS Ca’ Granda Foundation, Ospedale Maggiore Policlinico, Milan, Italy
| | - Alberto Zanella
- Onco-haematology, Physiopathology of Anaemia Unit, IRCCS Ca’ Granda Foundation, Ospedale Maggiore Policlinico, Milan, Italy
| | - Giovanna Russo
- Paediatric Onco-haematology Unit, Azienda Policlinico “Vittorio Emanuele”, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
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Hill QA, Stamps R, Massey E, Grainger JD, Provan D, Hill A. Guidelines on the management of drug-induced immune and secondary autoimmune, haemolytic anaemia. Br J Haematol 2017; 177:208-220. [PMID: 28369704 DOI: 10.1111/bjh.14654] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Quentin A Hill
- Department of Haematology, Leeds Teaching Hospitals, Leeds, UK
| | | | | | - John D Grainger
- Royal Manchester Children's Hospital, University of Manchester, Manchester, UK
| | - Drew Provan
- Barts and The London School of Medicine and Dentistry, London, UK
| | - Anita Hill
- Department of Haematology, Leeds Teaching Hospitals, Leeds, UK
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36
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Affiliation(s)
- Anthony Pak-yin Liu
- The University of Hong Kong, Queen Mary Hospital; Department of Pediatrics and Adolescent Medicine; 102 Pokfulam Road Hong Kong China
| | - Daniel KL Cheuk
- The University of Hong Kong, Queen Mary Hospital; Department of Pediatrics and Adolescent Medicine; 102 Pokfulam Road Hong Kong China
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37
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Villanueva G, de Jong JLO, McNeer JL. Intravenous Immunoglobulin in the Treatment of Hematologic Disorders in Pediatrics. Pediatr Ann 2017; 46:e13-e18. [PMID: 28079913 DOI: 10.3928/19382359-20161213-01] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Intravenous immunoglobulin (IVIG) is pooled immunoglobulin G derived from human blood donors. It was introduced in the early 1980s to treat immunodeficiency disorders. Since then, its use has expanded to other fields such as neurology, rheumatology, and hematology. IVIG has been used to provide passive immunity in qualitative and quantitative immunoglobulin disorders, to neutralize antibodies in immune-mediated diseases, and as an immune modulatory agent. The difficulty of producing IVIG in high quantities, in addition to a growing list of "off-label" indications, has resulted in a worldwide shortage and increase in cost. From a pediatric hematology perspective, IVIG is considered an appropriate therapeutic option in autoimmune cytopenias, sometimes coadministrated with steroids. Its use in other hematologic disorders is questionable, and there is not sufficient evidence to recommend it. This article provides clear information to the general pediatrician about indications for IVIG therapy in children with hematologic disorders. [Pediatr Ann. 2017;46(1):e13-e18.].
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Perez EE, Orange JS, Bonilla F, Chinen J, Chinn IK, Dorsey M, El-Gamal Y, Harville TO, Hossny E, Mazer B, Nelson R, Secord E, Jordan SC, Stiehm ER, Vo AA, Ballow M. Update on the use of immunoglobulin in human disease: A review of evidence. J Allergy Clin Immunol 2016; 139:S1-S46. [PMID: 28041678 DOI: 10.1016/j.jaci.2016.09.023] [Citation(s) in RCA: 371] [Impact Index Per Article: 46.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Revised: 09/12/2016] [Accepted: 09/23/2016] [Indexed: 12/20/2022]
Abstract
Human immunoglobulin preparations for intravenous or subcutaneous administration are the cornerstone of treatment in patients with primary immunodeficiency diseases affecting the humoral immune system. Intravenous preparations have a number of important uses in the treatment of other diseases in humans as well, some for which acceptable treatment alternatives do not exist. We provide an update of the evidence-based guideline on immunoglobulin therapy, last published in 2006. Given the potential risks and inherent scarcity of human immunoglobulin, careful consideration of its indications and administration is warranted.
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Affiliation(s)
- Elena E Perez
- Allergy Associates of the Palm Beaches, North Palm Beach, Fla.
| | - Jordan S Orange
- Department of Pediatrics, Section of Immunology Allergy and Rheumatology, Center for Human Immunobiology, Texas Children's Hospital and Baylor College of Medicine, Houston, Tex
| | - Francisco Bonilla
- Department of Pediatrics, Clinical Immunology Program, Children's Hospital Boston and Harvard Medical School, Boston, Mass
| | - Javier Chinen
- Department of Pediatrics, Section of Immunology Allergy and Rheumatology, Center for Human Immunobiology, Texas Children's Hospital and Baylor College of Medicine, Houston, Tex
| | - Ivan K Chinn
- Department of Pediatrics, Section of Immunology Allergy and Rheumatology, Center for Human Immunobiology, Texas Children's Hospital and Baylor College of Medicine, Houston, Tex
| | - Morna Dorsey
- Department of Pediatrics, Allergy, Immunology and BMT Division, Benioff Children's Hospital and University of California, San Francisco, Calif
| | - Yehia El-Gamal
- Department of Pediatrics, Pediatric Allergy and Immunology Unit, Children's Hospital and Ain Shams University, Cairo, Egypt
| | - Terry O Harville
- Departments of Pathology and Laboratory Services and Pediatrics, University of Arkansas, Little Rock, Ark
| | - Elham Hossny
- Department of Pediatrics, Pediatric Allergy and Immunology Unit, Children's Hospital and Ain Shams University, Cairo, Egypt
| | - Bruce Mazer
- Department of Pediatrics, Allergy and Immunology, Montreal Children's Hospital and McGill University, Montreal, Quebec, Canada
| | - Robert Nelson
- Department of Medicine and Pediatrics, Division of Hematology and Oncology and Stem Cell Transplantation, Riley Hospital, Indiana University School of Medicine and the IU Melvin and Bren Simon Cancer Center, Indianapolis, Ind
| | - Elizabeth Secord
- Department of Pediatrics, Wayne State University, Children's Hospital of Michigan, Detroit, Mich
| | - Stanley C Jordan
- Nephrology & Transplant Immunology, Kidney Transplant Program, David Geffen School of Medicine at UCLA and Cedars-Sinai Medical Center, Los Angeles, Calif
| | - E Richard Stiehm
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, Calif
| | - Ashley A Vo
- Transplant Immunotherapy Program, Comprehensive Transplant Center, Kidney Transplant Program, Cedars-Sinai Medical Center, Los Angeles, Calif
| | - Mark Ballow
- Department of Pediatrics, Division of Allergy & Immunology, University of South Florida, Morsani College of Medicine, Johns Hopkins All Children's Hospital, St Petersburg, Fla
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Hill QA, Stamps R, Massey E, Grainger JD, Provan D, Hill A. The diagnosis and management of primary autoimmune haemolytic anaemia. Br J Haematol 2016; 176:395-411. [PMID: 28005293 DOI: 10.1111/bjh.14478] [Citation(s) in RCA: 131] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Quentin A Hill
- Department of Haematology, Leeds Teaching Hospitals, Leeds, UK
| | | | | | - John D Grainger
- Royal Manchester Children's Hospital, University of Manchester, Manchester, UK
| | - Drew Provan
- Barts and The London School of Medicine and Dentistry, London, UK
| | - Anita Hill
- Department of Haematology, Leeds Teaching Hospitals, Leeds, UK
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40
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Velo-García A, Castro SG, Isenberg DA. The diagnosis and management of the haematologic manifestations of lupus. J Autoimmun 2016; 74:139-160. [DOI: 10.1016/j.jaut.2016.07.001] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Accepted: 07/01/2016] [Indexed: 12/21/2022]
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Wang SW, Cheng TT. Systemic lupus erythematosus with refractory hemolytic anemia effectively treated with cyclosporin A: a case report. Lupus 2016; 14:483-5. [PMID: 16038113 DOI: 10.1191/0961203305lu2090cr] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
A 51 year old woman with systemic lupus erythematosus (SLE) serially developed thrombocytopenia, arthritis, lupus nephritis, pleuritis, mesenteric vasculitis and refractory hemolytic anemia during the past 19 years prior to presentation. The woman had been managed with high doses of prednisolone, splenectomy, methylprednisolone pulse therapy and cytotoxic drugs, including oral cyclophosphamide, azathioprine, mexotrexate and monthly parenteral cyclophosphamide for hemolytic anemia. After two months of therapeutic trial with Cyclosporin A (CsA) (3 mg/kg), the follow-up hemoglobin (Hb) level was increased to 12.0 gm% and the dose of prednislone was reduced to 5 mg every other day without occurring rebound during the subsequent three months. There were no obvious side effects from the medication.
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Affiliation(s)
- S W Wang
- Section of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Chang Gung Memorial Hospital, Kaohsiung, Taiwan, ROC
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Abstract
Mycophenolate mofetil (MMF) has been increasingly used in patients with systemic lupus erythematosus (SLE). While most information concentrates on lupus nephritis, its efficacy in nonrenal manifestations of SLE has not been systematically studied. We describe the successful use of MMF in a patient with SLE-related hemolytic anemia that was refractory to cyclophosphamide, pulse methylprednisolone, intravenous immunoglobulin and cyclosporine. The mechanisms of action of MMF are briefly reviewed.
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MESH Headings
- Adult
- Anemia, Hemolytic/drug therapy
- Anemia, Hemolytic/etiology
- Anemia, Hemolytic/pathology
- Anemia, Refractory/drug therapy
- Anemia, Refractory/etiology
- Anemia, Refractory/pathology
- Dose-Response Relationship, Drug
- Female
- Glucocorticoids/therapeutic use
- Humans
- Immunosuppressive Agents/therapeutic use
- Lupus Erythematosus, Systemic/complications
- Lupus Erythematosus, Systemic/drug therapy
- Lupus Erythematosus, Systemic/pathology
- Mycophenolic Acid/analogs & derivatives
- Mycophenolic Acid/therapeutic use
- Treatment Outcome
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Affiliation(s)
- A Mak
- Department of Medicine, Tuen Mun Hospital, New Territories, Hong Kong SAR, China.
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Tavakolpour S. The role of intravenous immunoglobulin in treatment of mucous membrane pemphigoid: A review of literature. JOURNAL OF RESEARCH IN MEDICAL SCIENCES : THE OFFICIAL JOURNAL OF ISFAHAN UNIVERSITY OF MEDICAL SCIENCES 2016; 21:37. [PMID: 27904583 PMCID: PMC5122191 DOI: 10.4103/1735-1995.183992] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Revised: 01/27/2016] [Accepted: 02/23/2016] [Indexed: 12/25/2022]
Abstract
BACKGROUND Mucous membrane pemphigoid (MMP) is considered an autoimmune blistering disease that predominantly affects mucous membranes. Various treatments are available for controlling the diseases, but not all of them may respond. MATERIALS AND METHODS PubMed and Google Scholar were searched for all the associated studies until 2015, using the keywords such as "cicatricial pemphigoid" or "ocular pemphigoid" or "mucous membrane pemphigoid" or "MMP" and "intravenous immunoglobulin" or "IVIg" to find all the relevant studies. The last search update was for September 2, 2015. Among the searched items, only English studies were included in the review. RESULTS After excluding nonrelevant studies, 13 studies with a total number of seventy patients with MMP who were under treatment with IVIg were analyzed. The 65 patients responded completely, one did not respond, two had partially responded, and the remaining two patients stopped IVIg therapy, which resulted in ocular cicatricial pemphigoid progression. Majority of the studies reported mild adverse effects while two of them did not report any unwanted side effect. The most common side effect was headache, followed by nausea. Most of the patients who had a cessation of IVIg therapy before achieving clinical remission experienced the disease progression. CONCLUSION Overall, it can be concluded that IVIg therapy was very helpful in treatment of MMP patients who did not respond to conventional therapy or stopped using them for various side effects. Adverse effects associated with IVIg therapy were considerably lower than conventional therapy that can lead toward treatment with this agent in patients who suffer from severe side effects.
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Affiliation(s)
- Soheil Tavakolpour
- Department of Dermatology, Faculty of Medicine, Iran University of Medical Sciences, Tehran, Iran
- Skin Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Affiliation(s)
- Maurizio Miano
- Clinical and Experimental Haematology Unit; Department of Haematology/Oncology; IRCCS Istituto Giannina Gaslini; Genoa Italy
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The role of rituximab in adults with warm antibody autoimmune hemolytic anemia. Blood 2015; 125:3223-9. [DOI: 10.1182/blood-2015-01-588392] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2014] [Accepted: 03/27/2015] [Indexed: 02/07/2023] Open
Abstract
Abstract
Warm antibody hemolytic anemia is the most common form of autoimmune hemolytic anemia. When therapy is needed, corticosteroids remain the cornerstone of initial treatment but are able to cure only a minority of patients (<20%). Splenectomy is usually proposed when a second-line therapy is needed. This classical approach is now challenged by the use of rituximab both as second-line and as first-line therapy. Second-line treatment with rituximab leads to response rates similar to splenectomy (∼70%), but rituximab-induced responses seem less sustained. However, additional courses of rituximab are most often followed by responses, at the price of reasonable toxicity. In some major European centers, rituximab is now the preferred second-line therapy of warm antibody hemolytic anemia in adults, although no prospective study convincingly supports this attitude. A recent randomized study strongly suggests that in first-line treatment, rituximab combined with steroids is superior to monotherapy with steroids. If this finding is confirmed, rituximab will emerge as a major component of the management of warm antibody hemolytic anemia not only after relapse but as soon as treatment is needed.
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Abstract
Autoimmune hemolytic anemia (AIHA) is a relatively uncommon disorder caused by autoantibodies directed against self red blood cells. It can be idiopathic or secondary, and classified as warm, cold (cold hemagglutinin disease (CAD) and paroxysmal cold hemoglobinuria) or mixed, according to the thermal range of the autoantibody. AIHA may develop gradually, or have a fulminant onset with life-threatening anemia. The treatment of AIHA is still not evidence-based. The first-line therapy for warm AIHA are corticosteroids, which are effective in 70-85% of patients and should be slowly tapered over a time period of 6-12 months. For refractory/relapsed cases, the current sequence of second-line therapy is splenectomy (effective approx. in 2 out of 3 cases but with a presumed cure rate of up to 20%), rituximab (effective in approx. 80-90% of cases), and thereafter any of the immunosuppressive drugs (azathioprine, cyclophosphamide, cyclosporin, mycophenolate mofetil). Additional therapies are intravenous immunoglobulins, danazol, plasma-exchange, and alemtuzumab and high-dose cyclophosphamide as last resort option. As the experience with rituximab evolves, it is likely that this drug will be located at an earlier point in therapy of warm AIHA, before more toxic immunosuppressants, and in place of splenectomy in some cases. In CAD, rituximab is now recommended as first-line treatment.
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Affiliation(s)
- Alberto Zanella
- U.O. Ematologia, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Wilma Barcellini
- U.O. Ematologia, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
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Inhibition of FcγR-mediated phagocytosis by IVIg is independent of IgG-Fc sialylation and FcγRIIb in human macrophages. Blood 2014; 124:3709-18. [DOI: 10.1182/blood-2014-05-576835] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Key Points
Phagocytosis of IgG-opsonized blood cells by human macrophages is inhibited by intravenous immunoglobulins. This inhibition is independent of IgG-Fc sialylation but improves with IgG preparations that bind FcγRs more avidly.
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Abstract
The use of IVIG to treat a wide variety of immune-driven diseases has grown rapidly, although the mechanism of action is not completely understood. Increasing demand for IVIG coupled with concerns regarding potential transmissible agents has led to worldwide supply shortages. National agencies have therefore produced guidelines for its use, with the latest England and Wales guideline being published in 2011. Due to the rarity of the rheumatic diseases, the evidence for IVIG use has been shown to be lacking in some areas and promising in others. Conditions in which IVIG has been shown to have benefit include ITP, Guillain-Barré syndrome and chronic inflammatory demyelinating polyneuropathy occurring in the context of rheumatic disease, as well as in SLE, idiopathic inflammatory myopathies and ANCA-associated vasculitides. This review looks at current IVIG use and is designed to be an aid for rheumatologists when considering the use of IVIG in clinical practice.
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Affiliation(s)
- Ben Mulhearn
- Christie NHS Foundation Trust, Arthritis Research UK Epidemiology Unit, Institute of Inflammation and Repair, Manchester Academic Health Sciences Centre, University of Manchester and Kellgren Centre for Rheumatology, NIHR Manchester Musculoskeletal Biomedical Research Unit, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Ian N Bruce
- Christie NHS Foundation Trust, Arthritis Research UK Epidemiology Unit, Institute of Inflammation and Repair, Manchester Academic Health Sciences Centre, University of Manchester and Kellgren Centre for Rheumatology, NIHR Manchester Musculoskeletal Biomedical Research Unit, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK Christie NHS Foundation Trust, Arthritis Research UK Epidemiology Unit, Institute of Inflammation and Repair, Manchester Academic Health Sciences Centre, University of Manchester and Kellgren Centre for Rheumatology, NIHR Manchester Musculoskeletal Biomedical Research Unit, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
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