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Mingot Castellano ME, Pascual Izquierdo C, González A, Viejo Llorente A, Valcarcel Ferreiras D, Sebastián E, García Candel F, Sarmiento Palao H, Gómez Seguí I, de la Rubia J, Cid J, Martínez Nieto J, Hernández Mateo L, Goterris Viciedo R, Fidalgo T, Salinas R, Del Rio-Garma J. Recommendations for the diagnosis and treatment of patients with thrombotic thrombocytopenic purpura. Med Clin (Barc) 2022; 158:630.e1-630.e14. [PMID: 34266669 DOI: 10.1016/j.medcli.2021.03.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Revised: 03/10/2021] [Accepted: 03/16/2021] [Indexed: 11/09/2022]
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a thrombotic microangiopathy (TMA) characterized by the development of microangiopathic haemolytic anaemia, thrombocytopenia, and ischaemic organ dysfunction associated with ADAMTS13 levels lower than 10% in most cases. Recently there have been numerous advances in the field of PTT, new, rapid and accessible techniques capable of quantifying ADAMTS13 activity and inhibitors. The massive sequencing systems facilitate the identification of polymorphisms in the ADAMTS13 gene. In addition, new drugs such as caplacizumab have appeared and relapse prevention strategies are being proposed with the use of rituximab. The existence of TTP patient registries allow a deeper understanding of this disease but the great variability in the diagnosis and treatment makes it necessary to elaborate guidelines that homogenize terminology and clinical practice. The recommendations set out in this document were prepared following the AGREE methodology. The research questions were formulated according to the PICO format. A search of the literature published during the last 10 years was carried out. The recommendations were established by consensus among the entire group, specifying the existing strengths and limitations according to the level of evidence obtained. In conclusion, this document contains recommendations on the management, diagnosis, and treatment of TTP with the ultimate objective of developing guidelines based on the evidence published to date that allow healthcare professionals to optimize TTP treatment.
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Affiliation(s)
| | | | - Ataulfo González
- Servicio de Hematología y Hemoterapia, Hospital Universitario de San Carlos, Madrid, España
| | - Aurora Viejo Llorente
- Servicio de Hematología, Área de Hemoterapia, Hospital Universitario La Paz, Madrid, España
| | - David Valcarcel Ferreiras
- Unidad de Hematología Intensiva y Terapia Celular, Departamento de Hematología, Instituto de Oncología Vall d'Hebron (VHIO), Hospital Universitario Vall d'Hebron, Barcelona, España
| | - Elena Sebastián
- Servicio de Hematología y Hemoterapia, Hospital Infantil Universitario Niño Jesús, Madrid, España
| | - Faustino García Candel
- Sección de Hemostasia y Trombosis, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, España
| | | | - Inés Gómez Seguí
- Servicio de Hematología, Hospital Universitario y Politécnico La Fe, Valencia, España
| | - Javier de la Rubia
- Servicio de Hematología, Hospital Universitario y Politécnico La Fe, Valencia, España
| | - Joan Cid
- Unidad de Aféresis y Terapia Celular, Servicio de Hemoterapia y Hemostasia, Institut Clínic de Malalties Hematològiques i Oncològiques (ICMHO). Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universidad de Barcelona, Hospital Clínic i Provincial de Barcelona, Barcelona, España
| | - Jorge Martínez Nieto
- Servicio de Hematología y Hemostasia, Hospital Universitario Clínico San Carlos. Instituto de Investigación Sanitaria San Carlos (IdissC), Madrid, España
| | - Luis Hernández Mateo
- Servicio de Hematología y Hemoterapia, Hospital General de Alicante, Valencia, España
| | - Rosa Goterris Viciedo
- Servicio de Hematología y Hemoterapia, Hospital Clínico Valencia. INCLIVA, Valencia, España
| | - Teresa Fidalgo
- Departamento de Hematología Clínica, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Ramon Salinas
- Banc de Sang i Teixits de Catalunya, Barcelona, España
| | - Julio Del Rio-Garma
- Servicio de Transfusión. Servicio de Hematología. Complexo Hospitalario Universitario de Ourense, Galicia, España.
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Gómez-Seguí I, Pascual Izquierdo C, de la Rubia Comos J. Best practices and recommendations for drug regimens and plasma exchange for immune thrombotic thrombocytopenic purpura. Expert Rev Hematol 2021; 14:707-719. [PMID: 34275393 DOI: 10.1080/17474086.2021.1956898] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
INTRODUCTION Thrombotic thrombocytopenic purpura (TTP) is a life-threatening thrombotic microangiopathy characterized by microangiopathic hemolytic anemia, thrombocytopenia, and organ injury. TTP pathophysiology is based on a severe ADAMTS13 deficiency, and is a medical emergency with fatal outcome if appropriate treatment is not initiated promptly. AREAS COVERED Authors will review the best options currently available to minimize mortality, prevent relapses, and obtain the best clinical response in patients with immune TTP (iTTP). Available bibliography about iTTP treatment has been searched in Library's MEDLINE/PubMed database from January 1990 until April 2021. EXPERT OPINION The generalized use of plasma exchange marked a paradigm in the management of iTTP. In recent years, strenuous efforts have been done for a better understanding of the pathophysiology of this disease, improve diagnosis, optimize treatment, reduce mortality, and prevent recurrences. The administration of front-line rituximab and, more recently, the availability of caplacizumab, the first targeted therapy for iTTP, have been steps toward a further reduction in early mortality and for the prevention of relapses.
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Affiliation(s)
- Inés Gómez-Seguí
- Servicio De Hematología Y Hemoterapia, Hospital Universitari I Politècnic La Fe, Valencia, Spain
| | - Cristina Pascual Izquierdo
- Servicio De Hematología Y Hemoterapia, Hospital General , Universitario Gregorio Marañón. Gregorio Marañón Health Research Institute, Madrid, Spain
| | - Javier de la Rubia Comos
- Servicio De Hematología Y Hemoterapia, Hospital Universitari I Politècnic La Fe, Valencia, Spain.,School of Medicine and Dentistry, Catholic University of Valencia, Valencia, Spain
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Yang JJ, Ryu KS, Kim JS, Chung Y, Kim H, Hwang SH, Oh HB, Ko DH. Evaluation of safety of using incompatible plasma for therapeutic plasma exchange during shortage of AB plasma. J Clin Apher 2021; 36:628-633. [PMID: 33950554 DOI: 10.1002/jca.21904] [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: 11/23/2020] [Revised: 02/17/2021] [Accepted: 04/26/2021] [Indexed: 01/28/2023]
Abstract
BACKGROUND Criteria for selection of FFP blood type has not been clearly established and use of group AB plasma is preferred by numerous transplantation protocols. AIMS This study assesses the safety and efficacy of alternative group A or B plasma in ABO incompatible solid organ transplantation. MATERIALS & METHODS Alternative use of group A or B plasma (incompatible plasma) was inevitable during the shortage of group AB plasma. Experience from select number of patients during the period of extreme group AB plasma shortage is described. RESULTS The result of alternative use of group A or B plasma was within expectation, showing effective reduction of isoagglutinin titers for pre-operative desensitization and efficacy for treatment of post-operative patients. No immediate hemolytic transfusion reaction was reported. DISCUSSION While validation in a larger cohort of patients is necessary, our limited experience have shown satisfactory clinical outcomes without adverse events. CONCLUSIONS Use of incompatible group A or B plasma is a viable option when group AB plasma is limited.
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Affiliation(s)
- John Jeongseok Yang
- Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Kyong-Suk Ryu
- Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jin Seok Kim
- Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yousun Chung
- Department of Laboratory Medicine, Kangdong Sacred Heart Hospital, Seoul, Republic of Korea
| | - Hyungsuk Kim
- Department of Laboratory Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Sang-Hyun Hwang
- Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Heung-Bum Oh
- Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Dae-Hyun Ko
- Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Piedrafita A, Ribes D, Cointault O, Chauveau D, Faguer S, Huart A. Plasma exchange and thrombotic microangiopathies: From pathophysiology to clinical practice. Transfus Apher Sci 2020; 59:102990. [PMID: 33272850 DOI: 10.1016/j.transci.2020.102990] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Thrombotic microangiopathy (TMA) brings together many diseases that have a commonality in the apparition of mechanical hemolysis with consuming thrombopenia. In all cases, these diseases can be life threatening, thereby justifying the implementation of treatment as an emergency. First-line treatment represents plasma exchange. This treatment has proven efficiency in improving the vital patient's and functional prognosis. However, the administration methods of plasma exchange can be redefined in light of the understanding of the pathophysiology of TMA. The aim of this review is to try to define, from pathophysiology, the place of plasma exchanges in the modern therapeutic arsenal of TMA.
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Affiliation(s)
- Alexis Piedrafita
- Département de Néphrologie et Transplantation d'Organes, Centre Hospitalier Universitaire de Toulouse, Toulouse, France; Institut National de la Santé et de la Recherche Médicale, UMR1048, Institut des Maladies Métaboliques et Cardiovasculaires, Toulouse, France; Université Paul Sabatier - Toulouse 3, Toulouse, France
| | - David Ribes
- Département de Néphrologie et Transplantation d'Organes, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Olivier Cointault
- Département de Néphrologie et Transplantation d'Organes, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Dominique Chauveau
- Département de Néphrologie et Transplantation d'Organes, Centre Hospitalier Universitaire de Toulouse, Toulouse, France; Institut National de la Santé et de la Recherche Médicale, UMR1048, Institut des Maladies Métaboliques et Cardiovasculaires, Toulouse, France; Université Paul Sabatier - Toulouse 3, Toulouse, France
| | - Stanislas Faguer
- Département de Néphrologie et Transplantation d'Organes, Centre Hospitalier Universitaire de Toulouse, Toulouse, France; Institut National de la Santé et de la Recherche Médicale, UMR1048, Institut des Maladies Métaboliques et Cardiovasculaires, Toulouse, France; Université Paul Sabatier - Toulouse 3, Toulouse, France
| | - Antoine Huart
- Département de Néphrologie et Transplantation d'Organes, Centre Hospitalier Universitaire de Toulouse, Toulouse, France.
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Successful management of three patients with autoimmune thrombotic thrombocytopenic purpura with paradigm-changing therapy: Caplacizumab, steroids, plasma exchange, rituximab, and intravenous immunoglobulins (CASPERI). Transfus Apher Sci 2020; 60:103011. [PMID: 33221124 DOI: 10.1016/j.transci.2020.103011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 11/04/2020] [Indexed: 12/17/2022]
Abstract
Autoimmune thrombotic thrombocytopenic purpura (aTTP) is a severe disease caused by the production of autoantibodies against von Willebrand factor (vWF)-cleaving ADAMTS13 (a disintegrin and metalloproteinase with thrombospondin-1 motifs; 13th member of the family). In 2018, caplacizumab was approved for the treatment of patients with acute aTTP in conjunction with plasma exchange (PE) and immunosuppressive therapy. Immunosuppressive standard of care includes mainly steroids whereas rituximab is usually reserved for refractory cases. We report three patients with a first acute episode of aTTP who were successfully treated with a paradigm-changing scheme including standard of care (caplacizumab, steroids and PE) plus upfront therapy with rituximab and intravenous immunoglobulins (CASPERI). Rituximab was added 1-4 days after diagnosis, when ADAMTS13 autoantibodies were detected and intravenous immunoglobulins were administered after performing PE using albumin as replacement solution. Successful outcome was observed in all three patients: platelet recovery (>150 × 109/L) was observed after 3, 4, and 5 days from diagnosis; ADAMTS13 activity >5% and ADAMTS13 autoantibodies were negative after 14, 15, and 21 days from diagnosis. In conclusion, caplacizumab, steroids, PE (using fresh frozen plasma or albumin as replacement solution and adding intravenous immunoglobulins) plus upfront rituximab therapy was a safe and efficient combination to induce remission in case of acute aTTP.
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Hou R, Tian W, Qiao R, Zhang J. Efficacy of albumin and compounded plasma for plasma exchange in acquired thrombotic thrombocytopenic purpura. J Clin Apher 2020; 35:154-162. [PMID: 32110837 DOI: 10.1002/jca.21771] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 02/10/2020] [Accepted: 02/11/2020] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Thrombotic thrombocytopenic purpura (TTP) is a rare life-threatening thrombotic microangiopathy. Therapeutic plasma exchange (TPE) is the first-line treatment for TTP. In our institution, albumin plus plasma (fresh frozen plasma [FFP] and/or cryoprecipitate-reduced plasma [CRP]) has been used as replacement fluid since 2014. We aimed to evaluate the efficacy of albumin combined with plasma as TPE for TTP. MATERIAL AND METHODS We retrospectively evaluated 20 patients admitted to our institution due to an acute episode of TTP between January 1, 2014 and February 1, 2019. They were divided into two groups according to the replacement fluid protocols: (a) albumin plus FFP (1:1) and (b) albumin plus mixed plasma [ie, albumin and FFP with CRP (2:1:1)] groups. Data on patient characteristics, replacement parameters, outcome, and hemorrhage risk were collected and analyzed. RESULTS There were no significant differences in treatment outcomes between the two groups (P > .05). However, the albumin plus mixed plasma group tended to require fewer plasma exchanges (median, 4) and shorter time to response (median, 15 days) compared to albumin plus FFP group (median, 6; 31 days). Although the cumulative survival of the albumin plus mixed plasma group was higher than the other group starting from day 23 after treatment, we did not observe significant difference (P = .50). No significant increase in the risk for hemorrhage was observed in either group. CONCLUSIONS The therapeutic efficacy of albumin and mixed plasma (2:1:1) is not inferior to that of albumin and FFP (1:1), and it can be used in treating TTP.
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Affiliation(s)
- Ruiqin Hou
- Laboratory Medicine Department, Peking University Third Hospital, Beijing, People's Republic of China
| | - Wenqin Tian
- Department of Blood Transfusion, Peking University People's Hospital, Beijing, People's Republic of China
| | - Rui Qiao
- Laboratory Medicine Department, Peking University Third Hospital, Beijing, People's Republic of China
| | - Jie Zhang
- Laboratory Medicine Department, Peking University Third Hospital, Beijing, People's Republic of China
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Picod A, Provôt F, Coppo P. Therapeutic plasma exchange in thrombotic thrombocytopenic purpura. Presse Med 2019; 48:319-327. [PMID: 31759790 DOI: 10.1016/j.lpm.2019.08.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 08/02/2019] [Indexed: 12/31/2022] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a life-threatening disease related to the formation of microvascular thrombosis and subsequent organ failure. The disease is accompanied with microangiopathic haemolytic anaemia, consumptive thrombocytopenia and lies on a severe deficiency in ADAMTS13, the von Willebrand factor-cleaving protease. In the acquired, immune-mediated form, this deficiency is due to the production of autoantibodies directed against the enzyme. Therapeutic plasma exchange has been used empirically for decades and still represents the cornerstone of TTP treatment. However, a better understanding of pathophysiological mechanisms underlying the disease has led these last years to the development of highly effective targeted therapies that might in the future restraint the use of therapeutic plasma exchange.
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Affiliation(s)
- Adrien Picod
- Centre national de référence des microangiopathies thrombotiques, 75000 Paris, France
| | - François Provôt
- Centre national de référence des microangiopathies thrombotiques, 75000 Paris, France; Hôpital Albert-Calmette, service de néphrologie, 59000 Lille, France
| | - Paul Coppo
- Centre national de référence des microangiopathies thrombotiques, 75000 Paris, France; Assistance publique-Hôpitaux de Paris, hôpital Saint-Antoine, service d'hématologie, 75012 Paris, France; Sorbonne-Université, 75006 Paris, France.
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Padmanabhan A, Connelly-Smith L, Aqui N, Balogun RA, Klingel R, Meyer E, Pham HP, Schneiderman J, Witt V, Wu Y, Zantek ND, Dunbar NM, Schwartz GEJ. Guidelines on the Use of Therapeutic Apheresis in Clinical Practice - Evidence-Based Approach from the Writing Committee of the American Society for Apheresis: The Eighth Special Issue. J Clin Apher 2019; 34:171-354. [PMID: 31180581 DOI: 10.1002/jca.21705] [Citation(s) in RCA: 766] [Impact Index Per Article: 153.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The American Society for Apheresis (ASFA) Journal of Clinical Apheresis (JCA) Special Issue Writing Committee is charged with reviewing, updating and categorizing indications for the evidence-based use of therapeutic apheresis (TA) in human disease. Since the 2007 JCA Special Issue (Fourth Edition), the committee has incorporated systematic review and evidence-based approaches in the grading and categorization of apheresis indications. This Eighth Edition of the JCA Special Issue continues to maintain this methodology and rigor in order to make recommendations on the use of apheresis in a wide variety of diseases/conditions. The JCA Eighth Edition, like its predecessor, continues to apply the category and grading system definitions in fact sheets. The general layout and concept of a fact sheet that was introduced in the Fourth Edition, has largely been maintained in this edition. Each fact sheet succinctly summarizes the evidence for the use of TA in a specific disease entity or medical condition. The Eighth Edition comprises 84 fact sheets for relevant diseases and medical conditions, with 157 graded and categorized indications and/or TA modalities. The Eighth Edition of the JCA Special Issue seeks to continue to serve as a key resource that guides the utilization of TA in the treatment of human disease.
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Affiliation(s)
- Anand Padmanabhan
- Medical Sciences Institute & Blood Research Institute, Versiti & Department of Pathology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Laura Connelly-Smith
- Department of Medicine, Seattle Cancer Care Alliance & University of Washington, Seattle, Washington
| | - Nicole Aqui
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rasheed A Balogun
- Department of Medicine, University of Virginia, Charlottesville, Virginia
| | - Reinhard Klingel
- Apheresis Research Institute, Cologne, Germany & First Department of Internal Medicine, University of Mainz, Mainz, Germany
| | - Erin Meyer
- Department of Hematology/Oncology/BMT/Pathology, Nationwide Children's Hospital, Columbus, Ohio
| | - Huy P Pham
- Department of Pathology, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Jennifer Schneiderman
- Department of Pediatric Hematology/Oncology/Neuro-oncology/Stem Cell Transplant, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University, Chicago, Illinois
| | - Volker Witt
- Department for Pediatrics, St. Anna Kinderspital, Medical University of Vienna, Vienna, Austria
| | - Yanyun Wu
- Bloodworks NW & Department of Laboratory Medicine, University of Washington, Seattle, Washington, Yale University School of Medicine, New Haven, Connecticut
| | - Nicole D Zantek
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota
| | - Nancy M Dunbar
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
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Abstract
Thrombotic thrombocytopenic purpura is a rare and severe disease that manifests as a thrombotic microangiopathy with severe thrombocytopenia and variable multiorgan failure. The disease relies on a severe deficiency in a disintegrin and metalloprotease with thrombospondin type-1 repeats, 13th member (ADAMTS13), the von Willebrand factor (vWF) cleaving protease which can be either inherited (congenital TTP) or immune-mediated (iTTP). In iTTP, the therapeutic strategy has long relied on therapeutic plasma exchange alone which still represents the only way to deliver large amounts of ADAMTS13 without risking fluid overload. Yet, several therapeutic strategies have been developed in recent years and are about to transform the standard of care of iTTP. The immunosuppressive regimen now increasingly encompasses the administration of frontline rituximab to all patients. Moreover, the impressive results of the anti-vWF nanobody caplacizumab in phase 2 and 3 studies have recently prompted its approval by health authorities for the initial treatment of the disease. The increasing use of these highly effective targeted therapies should translate in a reduced need for therapeutic plasma exchange and an improvement in the prognosis of the disease. Nevertheless, and until the development of a recombinant ADAMTS13, this cornerstone therapy remains irreplaceable.
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Combination of Fresh Frozen Plasma and Cryosupernatant Plasma for Therapeutic Plasma Exchange in Thrombotic Thrombocytopenic Purpura: A Single Institution Experience. BIOMED RESEARCH INTERNATIONAL 2019; 2019:1756109. [PMID: 30834255 PMCID: PMC6374794 DOI: 10.1155/2019/1756109] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 01/05/2019] [Accepted: 01/13/2019] [Indexed: 11/18/2022]
Abstract
Purpose To evaluate the impact of a combination of fresh frozen plasma (FFP) and cryosupernatant plasma (CP) as a replacement fluid in therapeutic plasma exchange (TPE) on early therapeutic response and long-term survival of patients with thrombotic thrombocytopenic purpura (TTP). Materials and Methods A total of 44 patients with suspected TTP were screened by Bentley and PLASMIC scores. Twenty-seven patients treated with TPE using the FFP and CP combination as the replacement fluid were enrolled and divided into two groups: 11 patients who received TPE with CP-dominant replacement fluid (FFP/CP<1) and 16 patients who received TPE with FFP-dominant replacement fluid (FFP/CP>1). Results There were no significant differences in the demographic and clinicopathological characteristics between the two groups except for the international normalized ratio (INR). The number of TPE procedures was lower, and time to achieve complete response was shorter in the CP-dominant group than in the FFP-dominant group. There were no significant differences in overall survival between the two groups. Conclusion The CP-dominant replacement fluid was superior to the FFP-dominant replacement fluid in early response to TPE in patients with TTP, but did not impact the patients' overall survival.
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Kaplan A, Sevcik J, Kiss JE. Low titer A plasma in three AB patients for therapeutic plasma exchange. J Clin Apher 2018; 34:7-12. [DOI: 10.1002/jca.21656] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 08/02/2018] [Accepted: 08/03/2018] [Indexed: 01/06/2023]
Affiliation(s)
- Alesia Kaplan
- Department of Pathology; University of Pittsburgh Medical Center; Pittsburgh Pennsylvania
- Institute for Transfusion Medicine; Pittsburgh Pennsylvania
| | - Joan Sevcik
- Institute for Transfusion Medicine; Pittsburgh Pennsylvania
| | - Joseph E. Kiss
- Institute for Transfusion Medicine; Pittsburgh Pennsylvania
- Department of Medicine, Division of Hematology/Oncology; University of Pittsburgh Medical Center; Pittsburgh Pennsylvania
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Abstract
PURPOSE OF REVIEW Acquired thrombotic thrombocytopenic purpura is an immune-mediated thrombotic microangiopathy caused by antibodies to ADAMTS13 (A Disintegrin And Metalloproteinase with a ThromboSpondin type 1 motif, member 13). Standard treatment with therapeutic plasma exchange and immunosuppression with steroids results in high remission and low mortality rates. However, a number of patients remain refractory to frontline therapy and/or experience multiple relapses. This study reviews emerging therapies for thrombotic thrombocytopenic purpura. RECENT FINDINGS Studies indicate that reducing anti-ADAMTS13 antibody levels through B-cell depletion or proteasome inhibition is effective for the management of refractory disease. Preliminary reports examining anti-CD20 therapy for the treatment of initial disease or as maintenance therapy for seropositive patients suggest the addition of immunosuppression in other disease phases may delay relapse. Exciting developments in targeted therapies to von Willebrand Factor and recombinant ADAMTS13 hold promise for transforming disease management. SUMMARY Approximately half of patients diagnosed with acquired thrombotic thrombocytopenic purpura experience refractory and/or relapsing disease. For these patients, a hematologic remission may be an insufficient therapeutic goal. With recent developments, it is now possible to envision a multifaceted approach targeting disease mechanisms that may dramatically improve outcomes for this otherwise debilitating disease.
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13
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Li A, Khalighi PR, Wu Q, Garcia DA. External validation of the PLASMIC score: a clinical prediction tool for thrombotic thrombocytopenic purpura diagnosis and treatment. J Thromb Haemost 2018; 16:164-169. [PMID: 29064619 PMCID: PMC5760324 DOI: 10.1111/jth.13882] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Indexed: 11/25/2022]
Abstract
Essentials Severe ADAMTS-13 deficiency is key to thrombotic thrombocytopenic purpura (TTP) diagnosis. PLASMIC score predicts ADAMTS-13 deficiency in suspected TTP with high discrimination. PLASMIC score is more generalizable with fewer missing data than alternative clinical scores. PLASMIC score identifies a subgroup of patients lacking significant response to plasma exchange. SUMMARY Background The PLASMIC score was recently published to distinguish patients with severe ADAMTS-13 deficiency from those without for early identification of thrombotic thrombocytopenia purpura (TTP). Objective We performed an independent external validation of the PLASMIC score for clinical prediction of severe ADAMTS-13 deficiency. Patients/Methods We studied an independent cohort of 112 consecutive hospitalized patients with suspected thrombotic microangiopathy and appropriate ADAMTS-13 testing (including 21 patients with TTP diagnosis). Results The PLASMIC score model predicted severe ADAMTS-13 deficiency with a c statistic of 0.94 (0.88-0.98). When dichotomized at high (score 6-7) vs. low-intermediate risk (score 0-5), the model predicted severe ADAMTS-13 deficiency with positive predictive value of 72%, negative predictive value of 98%, sensitivity of 90% and specificity of 92%. In the low-intermediate risk group (score 0-5) there was no significant improvement in overall survival associated with plasma exchange. Conclusions The PLASMIC score model had excellent applicability, discrimination and calibration for predicting severe ADAMTS-13 deficiency. The clinical algorithm allowed identification of a subgroup of patients who lacked a significant response to empiric treatment.
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Affiliation(s)
- Ang Li
- Division of Hematology, University of Washington School of Medicine, Seattle, WA
| | | | - Qian Wu
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - David A. Garcia
- Division of Hematology, University of Washington School of Medicine, Seattle, WA
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Schwartz J, Padmanabhan A, Aqui N, Balogun RA, Connelly-Smith L, Delaney M, Dunbar NM, Witt V, Wu Y, Shaz BH. Guidelines on the Use of Therapeutic Apheresis in Clinical Practice-Evidence-Based Approach from the Writing Committee of the American Society for Apheresis: The Seventh Special Issue. J Clin Apher 2017; 31:149-62. [PMID: 27322218 DOI: 10.1002/jca.21470] [Citation(s) in RCA: 276] [Impact Index Per Article: 39.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The American Society for Apheresis (ASFA) Journal of Clinical Apheresis (JCA) Special Issue Writing Committee is charged with reviewing, updating, and categorizing indications for the evidence-based use of therapeutic apheresis in human disease. Since the 2007 JCA Special Issue (Fourth Edition), the Committee has incorporated systematic review and evidence-based approaches in the grading and categorization of apheresis indications. This Seventh Edition of the JCA Special Issue continues to maintain this methodology and rigor to make recommendations on the use of apheresis in a wide variety of diseases/conditions. The JCA Seventh Edition, like its predecessor, has consistently applied the category and grading system definitions in the fact sheets. The general layout and concept of a fact sheet that was used since the fourth edition has largely been maintained in this edition. Each fact sheet succinctly summarizes the evidence for the use of therapeutic apheresis in a specific disease entity. The Seventh Edition discusses 87 fact sheets (14 new fact sheets since the Sixth Edition) for therapeutic apheresis diseases and medical conditions, with 179 indications, which are separately graded and categorized within the listed fact sheets. Several diseases that are Category IV which have been described in detail in previous editions and do not have significant new evidence since the last publication are summarized in a separate table. The Seventh Edition of the JCA Special Issue serves as a key resource that guides the utilization of therapeutic apheresis in the treatment of human disease. J. Clin. Apheresis 31:149-162, 2016. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Joseph Schwartz
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York
| | - Anand Padmanabhan
- Blood Center of Wisconsin, Department of Pathology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Nicole Aqui
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rasheed A Balogun
- Division of Nephrology, University of Virginia, Charlottesville, Virginia
| | - Laura Connelly-Smith
- Department of Medicine, Seattle Cancer Care Alliance and University of Washington, Seattle, Washington
| | - Meghan Delaney
- Bloodworks Northwest, Department of Laboratory Medicine, University of Washington, Seattle, Washington
| | - Nancy M Dunbar
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Volker Witt
- Department for Pediatrics, St. Anna Kinderspital, Medical University of Vienna, Vienna, Austria
| | - Yanyun Wu
- Bloodworks Northwest, Department of Laboratory Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Beth H Shaz
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York.,New York Blood Center, Department of Pathology.,Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia
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Crabbe A, McNeil JS, Deshpande SP, Kon Z, Pham SM, Tanaka KA. Therapeutic plasma exchange in heart transplantation: role of coagulation assessment with thromboelastometry. JA Clin Rep 2016; 2:31. [PMID: 29492426 PMCID: PMC5814793 DOI: 10.1186/s40981-016-0058-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 10/11/2016] [Indexed: 11/12/2022] Open
Abstract
Therapeutic plasma exchange (TPE) is a potentially life-saving procedure which effectively removes donor-specific human leukocyte antigen (HLA) antibodies from the bloodstream, allowing critically ill heart transplant recipients to receive a donor organ with less wait time, and reducing the risk of acute organ rejection. The bulk of coagulation factors is initially removed from the blood during TPE using albumin and is later replaced with allogeneic plasma. Coagulopathy may develop during TPE and then can persist due to intraoperative blood loss and hemodilution during surgery and cardiopulmonary bypass. We hereby describe the utility of rotational thromboelastometry to assess rapid coagulation changes during TPE and subsequent heart transplant (HT) surgery.
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Affiliation(s)
- Andrew Crabbe
- Department of Anesthesiology, University of Maryland, 22 South Greene Street, Suite S8D12, Baltimore, MD 21201 USA
| | - John S McNeil
- Department of Anesthesiology, University of Virginia, Charlottesville, VA USA
| | - Seema P Deshpande
- Department of Anesthesiology, University of Maryland, 22 South Greene Street, Suite S8D12, Baltimore, MD 21201 USA
| | - Zachary Kon
- Department of Surgery, Division of Cardiothoracic Surgery, University of Maryland, Baltimore, MD USA
| | - Si M Pham
- Department of Surgery, Division of Cardiothoracic Surgery, University of Maryland, Baltimore, MD USA
| | - Kenichi A Tanaka
- Department of Anesthesiology, University of Maryland, 22 South Greene Street, Suite S8D12, Baltimore, MD 21201 USA
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16
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Acute Disseminated Encephalomyelitis. J Clin Apher 2016; 31:163-202. [PMID: 27322219 DOI: 10.1002/jca.21474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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17
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Sidhu D, Snyder EL, Tormey CA. Two approaches to the clinical dilemma of treating TTP with therapeutic plasma exchange in patients with a history of anaphylactic reactions to plasma. J Clin Apher 2016; 32:158-162. [DOI: 10.1002/jca.21475] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Revised: 05/03/2016] [Accepted: 05/08/2016] [Indexed: 12/21/2022]
Affiliation(s)
- Davinder Sidhu
- Department of Laboratory Medicine; Yale University School of Medicine; New Haven Connecticut 06510
- Department of Pathology and Laboratory Medicine; University of Calgary; Calgary Alberta , T2N 1N4 Canada
| | - Edward L. Snyder
- Department of Laboratory Medicine; Yale University School of Medicine; New Haven Connecticut 06510
| | - Christopher A. Tormey
- Department of Laboratory Medicine; Yale University School of Medicine; New Haven Connecticut 06510
- Pathology & Laboratory Medicine Service; VA Connecticut Healthcare System; West Haven Connecticut 06516
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18
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Honoré PM, Jacobs R, De Waele E, Van Gorp V, Spapen HD. Immunoadsorption versus therapeutic plasma exchange. Will fibrinogen make the difference? Blood Purif 2014; 38:158-159. [PMID: 25501843 DOI: 10.1159/000369378] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/20/2023]
Affiliation(s)
- Patrick M Honoré
- ICU Department, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
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19
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[Diagnostic and therapeutic guidelines of thrombotic microangiopathies of the Spanish Apheresis Group]. Med Clin (Barc) 2014; 144:331.e1-331.e13. [PMID: 25433791 DOI: 10.1016/j.medcli.2014.09.013] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2014] [Accepted: 09/18/2014] [Indexed: 12/18/2022]
Abstract
Thrombotic microangiopathies (TMA) are disorders defined by the presence of a microangiopathic hemolytic anemia (with the characteristic hallmark of schistocytes in the peripheral blood smear), thrombocytopenia and organ malfunction of variable intensity. Thrombotic thrombocytopenic purpura and hemolytic uremic syndrome are the most important forms of TMA and, without the adequate treatment, they are associated with high morbimortality. In recent years, significant advances in the knowledge of the pathophysiology of TMA have occurred. Those advances have allowed us to move from a syndromic diagnosis with a similar treatment to all entities to the search of etiologic diagnosis which would lead to a specific treatment, finally leading to a better outcome of the patient. This document pretends to summarize the current status of knowledge of the pathophysiology of TMA and the therapeutic options available, and to offer a diagnostic and therapeutic practical tool to the professionals caring for the patients.
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20
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Raval JS, Mazepa MA, Brecher ME, Park YA. How we approach an acquired thrombotic thrombocytopenic purpura patient. Transfusion 2014; 54:2375-82. [DOI: 10.1111/trf.12794] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Revised: 05/15/2014] [Accepted: 06/02/2014] [Indexed: 12/16/2022]
Affiliation(s)
- Jay S. Raval
- Department of Pathology and Laboratory Medicine; University of North Carolina; Chapel Hill North Carolina
| | - Marshall A. Mazepa
- Department of Pathology and Laboratory Medicine; University of North Carolina; Chapel Hill North Carolina
| | - Mark E. Brecher
- Department of Pathology and Laboratory Medicine; University of North Carolina; Chapel Hill North Carolina
- Laboratory Corporation of America; Burlington North Carolina
| | - Yara A. Park
- Department of Pathology and Laboratory Medicine; University of North Carolina; Chapel Hill North Carolina
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21
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Chai W, Chaudhry A, Rabinowitz AP. Successful management of thrombotic thrombocytopenic purpura in a Jehovah's Witness without plasma exchange. J Clin Apher 2014; 30:46-9. [DOI: 10.1002/jca.21325] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2013] [Revised: 02/22/2014] [Accepted: 03/21/2014] [Indexed: 12/16/2022]
Affiliation(s)
- Wanxing Chai
- Department of Internal Medicine; Lahey Hospital and Medical Center; Burlington Massachusetts
| | - Abrar Chaudhry
- Department of Internal Medicine; Lahey Hospital and Medical Center; Burlington Massachusetts
| | - Arthur P. Rabinowitz
- Department of Hematology and Oncology; Lahey Hospital and Medical Center; Burlington Massachusetts
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