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Thonon H, Van Nieuwenhove M, Thachil J, Lippi G, Hardy M, Mullier F. Hemostasis Testing in the Emergency Department: A Narrative Review. Semin Thromb Hemost 2024. [PMID: 38897223 DOI: 10.1055/s-0044-1787661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2024]
Abstract
Routine laboratory screening is typically performed at initial evaluation of the vast majority of presentations to the emergency department (ED). These laboratory results are crucial to the diagnostic process, as they may influence up to 70% of clinical decisions. However, despite the usefulness of biological assessments, many tests performed are inappropriate or of doubtful clinical relevance. This overutilization rate of laboratory testing in hospitals, which represents a significant medical-economic burden, ranges from 20 to 67%, with coagulation tests at the top of the list. While reviews frequently focus on nonintensive care units, there are few published assessments of emergency-specific interventions or guidelines/guidance to date. The aim of this review is to highlight current recommendations for hemostasis evaluation in the emergency setting with a specific analysis of common situations leading to ED admissions, such as suspected venous thrombosis or severe bleeding. We revisit the evidence related to the assessment of patient's hemostatic capacity based on comprehensive history taking and physical examination as well as best practice recommendations for blood sample collection to ensure the reliability of results. This review also includes an examination of various currently available point of care tests and a comprehensive discussion on indications, limitations, and interpretation of these tests.
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Affiliation(s)
- Henri Thonon
- Emergency Department, Université catholique de Louvain, CHU UCL Namur, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), Yvoir, Belgium
| | | | - Jecko Thachil
- Department of Haematology, Manchester University Hospitals, Manchester, United Kingdom
| | - Giuseppe Lippi
- Section of Clinical Biochemistry, University of Verona, Verona, Italy
| | - Michael Hardy
- Department of Anesthesiology, Université catholique de Louvain, CHU UCL Namur, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), Yvoir, Belgium
| | - François Mullier
- Université catholique de Louvain, CHU UCL Namur, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), Hematology Laboratory, Yvoir, Belgium
- Institut de Recherche Expérimentale et Clinique (IREC), Pôle Mont, Université catholique de Louvain (UCLouvain), Yvoir, Belgium
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2
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Allen C, Ito S, Butt A, Purcell A, Richmond R, Tormey CA, Krumholz HM, Cuker A, Goshua G. Cost-effectiveness of rapid vs in-house vs send-out ADAMTS13 testing for immune thrombotic thrombocytopenic purpura. Blood Adv 2024; 8:2279-2289. [PMID: 38502197 PMCID: PMC11116991 DOI: 10.1182/bloodadvances.2024012608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 02/27/2024] [Accepted: 03/11/2024] [Indexed: 03/21/2024] Open
Abstract
ABSTRACT While awaiting confirmatory results, empiric therapy for patients suspected to have immune thrombotic thrombocytopenic purpura (iTTP) provides benefits and also accrues risks and costs. Rapid assays for ADAMTS13 may be able to avoid the cost and risk exposure associated with empiric treatment. We conducted, to our knowledge, the first cost-effectiveness evaluation of testing strategies with rapid vs traditional ADAMTS13 assays in patients with intermediate- to high-risk PLASMIC scores, with and without caplacizumab use. We built a Markov cohort simulation with 4 clinical base-case analyses: (1) intermediate-risk PLASMIC score with caplacizumab; (2) intermediate-risk PLASMIC score without caplacizumab; (3) high-risk PLASMIC score with caplacizumab; and (4) high-risk PLASMIC score without caplacizumab. Each of these evaluated 3 testing strategies: (1) rapid assay (<1-hour turnaround); (2) in-house fluorescence resonance energy transfer (FRET)-based assay (24-hour turnaround); and (3) send-out FRET-based assay (72-hour turnaround). The primary outcome was the incremental net monetary benefit reported over a 3-day time horizon and across accepted willingness-to-pay thresholds in US dollars per quality-adjusted life-year (QALY). While accruing the same amount of QALYs, the rapid assay strategy saved up to $46 820 (95% CI, $41 961-$52 486) per patient tested. No parameter variation changed the outcome. In probabilistic sensitivity analyses, the rapid assay strategy was favored in 100% (3 base cases and scenario analyses) and 99% (1 base-case and scenario analysis) across 100 000 Monte Carlo iterations within each. Rapid ADAMTS13 testing for patients with intermediate- or high-risk PLASMIC scores yields significant per patient cost savings, achieved by reducing the costs associated with unnecessary therapeutic plasma exchange and caplacizumab therapy in patients without iTTP.
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Affiliation(s)
- Cecily Allen
- Division of Hematology, Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - Satoko Ito
- Section of Hematology, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
| | - Ayesha Butt
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
| | | | | | - Christopher A. Tormey
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT
| | - Harlan M. Krumholz
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, CT
| | - Adam Cuker
- Department of Medicine and Department of Pathology & Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - George Goshua
- Section of Hematology, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, CT
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3
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Patır P, Önkibar N, Subari S, Eşkazan AE. Plasma cell-directed therapy strategies in immune-mediated thrombotic thrombocytopenic purpura (iTTP). Transfusion 2024; 64:536-545. [PMID: 38235916 DOI: 10.1111/trf.17716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Revised: 12/14/2023] [Accepted: 12/17/2023] [Indexed: 01/19/2024]
Affiliation(s)
- Püsem Patır
- Department of Hematology, Antalya Training and Research Hospital, Antalya, Turkey
| | - Nurtaç Önkibar
- Faculty of Medicine, Karadeniz Technical University, Trabzon, Turkey
| | - Sedef Subari
- Cerrahpaşa Faculty of Medicine, Istanbul University-Cerrahpaşa, Istanbul, Turkey
| | - Ahmet Emre Eşkazan
- Division of Hematology, Department of Internal Medicine, Cerrahpaşa Faculty of Medicine, Istanbul University-Cerrahpaşa, Istanbul, Turkey
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4
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De Waele L, Sakai K, Mancini I, Sinkovits G, Falter T, Inoue T, Agosti P, Rossmann H, Von Auer C, Tersteeg C, De Meyer SF, Joly BS, Veyradier A, Coppo P, Fijnheer R, Peyvandi F, Prohászka Z, Lämmle B, Vanhoorelbeke K. Open ADAMTS-13 conformation index predicts earlier relapse in immune-mediated thrombotic thrombocytopenic purpura. J Thromb Haemost 2024; 22:493-502. [PMID: 37866519 DOI: 10.1016/j.jtha.2023.10.014] [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: 06/13/2023] [Revised: 09/27/2023] [Accepted: 10/11/2023] [Indexed: 10/24/2023]
Abstract
BACKGROUND ADAMTS-13 adopts an open conformation in patients with immune-mediated thrombotic thrombocytopenic purpura (iTTP) in acute phase while being closed in healthy donors. We reported that a substantial number of patients with iTTP in remission with restored ADAMTS-13 activity (>50%) still had an open ADAMTS-13 conformation, although a closed conformation is expected given the extent of remission. OBJECTIVES To investigate whether open ADAMTS-13, represented by a conformation index >0.5, is associated with a risk of earlier ADAMTS-13 and/or clinical relapse. METHODS We collected follow-up data (ADAMTS-13 parameters, ADAMTS-13 and clinical relapse, and treatment) from 81 patients with iTTP in remission with ADAMTS-13 activity >50%. RESULTS During follow-up, 19 ADAMTS-13 and 10 clinical relapses were reported (median follow-up period, 20 months). First, open or closed ADAMTS-13 conformation was dichotomized based on the 0.5 conformation index cutoff. Open ADAMTS-13 (conformation index, >0.5) was not identified as a risk factor for ADAMTS-13 and clinical relapse (log-rank test and Cox regression model). In contrast, by identifying the optimal conformation index cutoff for relapse prediction, using classification and regression tree analysis, a conformation index >0.645 and >0.835 was shown to be a risk factor for ADAMTS-13 relapse (hazard ratio, 3.3; 95% CI, 1.3-8.3; P = .01) and clinical relapse (hazard ratio, 4.4; 95% CI, 1.3-15.3; P = .02), respectively. CONCLUSION Patients with open ADAMTS-13 with a conformation index >0.645 and >0.835 have a >3- and >4-fold higher risk of earlier ADAMTS-13 and clinical relapse, respectively. Hence, ADAMTS-13 conformation index could be used to complement ADAMTS-13 activity monitoring to timely notice ADAMTS-13 relapse and prevent clinical relapse.
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Affiliation(s)
- Laure De Waele
- Laboratory for Thrombosis Research, Interdisciplinary Research Facility Life Sciences, Katholieke Universiteit Leuven Campus Kulak Kortrijk, Kortrijk, Belgium
| | - Kazuya Sakai
- Laboratory for Thrombosis Research, Interdisciplinary Research Facility Life Sciences, Katholieke Universiteit Leuven Campus Kulak Kortrijk, Kortrijk, Belgium; Department of Blood Transfusion Medicine, Nara Medical University, Kashihara, Japan
| | - Ilaria Mancini
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Università degli Studi di Milano, Department of Pathophysiology and Transplantation, and Fondazione Luigi Villa, Milan, Italy
| | - György Sinkovits
- Department of Internal Medicine and Hematology, Semmelweis University and Research Group for Immunology and Haematology, Semmelweis University - Eötvös Loránd Research Network (Office for Supported Research Groups), Budapest, Hungary
| | - Tanja Falter
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center of the Johannes Gutenberg University, Mainz, Germany; Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Takashi Inoue
- Department of Evidence-Based Medicine, Nara Medical University, Kashihara, Japan
| | - Pasquale Agosti
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Università degli Studi di Milano, Department of Pathophysiology and Transplantation, and Fondazione Luigi Villa, Milan, Italy
| | - Heidi Rossmann
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center of the Johannes Gutenberg University, Mainz, Germany; Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Charis Von Auer
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany; Department of Hematology, Oncology and Pneumology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Claudia Tersteeg
- Laboratory for Thrombosis Research, Interdisciplinary Research Facility Life Sciences, Katholieke Universiteit Leuven Campus Kulak Kortrijk, Kortrijk, Belgium
| | - Simon F De Meyer
- Laboratory for Thrombosis Research, Interdisciplinary Research Facility Life Sciences, Katholieke Universiteit Leuven Campus Kulak Kortrijk, Kortrijk, Belgium
| | - Bérangère S Joly
- Service d'Hématologie Biologique, Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris and EA3518, Institut de Recherche Saint Louis, Université de Paris, Paris, France
| | - Agnès Veyradier
- Service d'Hématologie Biologique, Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris and EA3518, Institut de Recherche Saint Louis, Université de Paris, Paris, France
| | - Paul Coppo
- Centre de Référence des Microangiopathies Thrombotiques, Service d'hématologie, Hôpital Saint Antoine, Assistance Publique-Hôpitaux de Paris and Sorbonne Université, Paris, France
| | - Rob Fijnheer
- Department for Clinical Chemistry and Haematology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Flora Peyvandi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Università degli Studi di Milano, Department of Pathophysiology and Transplantation, and Fondazione Luigi Villa, Milan, Italy
| | - Zoltán Prohászka
- Department of Internal Medicine and Hematology, Semmelweis University and Research Group for Immunology and Haematology, Semmelweis University - Eötvös Loránd Research Network (Office for Supported Research Groups), Budapest, Hungary
| | - Bernhard Lämmle
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany; Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Haemostasis Research Unit, University College London, London, United Kingdom
| | - Karen Vanhoorelbeke
- Laboratory for Thrombosis Research, Interdisciplinary Research Facility Life Sciences, Katholieke Universiteit Leuven Campus Kulak Kortrijk, Kortrijk, Belgium.
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5
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Ruf W. Immune damage in Long Covid. Science 2024; 383:262-263. [PMID: 38236985 DOI: 10.1126/science.adn1077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
Abstract
Links between the complement and coagulation systems could lead to Long Covid therapies.
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Affiliation(s)
- Wolfram Ruf
- Center for Thrombosis and Hemostasis, Johannes-Gutenberg- University Medical Center Mainz, Mainz, Germany
- Scripps Research, La Jolla, CA, USA
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6
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Bonnez Q, Sakai K, Vanhoorelbeke K. ADAMTS13 and Non-ADAMTS13 Biomarkers in Immune-Mediated Thrombotic Thrombocytopenic Purpura. J Clin Med 2023; 12:6169. [PMID: 37834813 PMCID: PMC10573396 DOI: 10.3390/jcm12196169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 09/20/2023] [Accepted: 09/21/2023] [Indexed: 10/15/2023] Open
Abstract
Immune-mediated thrombotic thrombocytopenic purpura (iTTP) is a rare medical emergency for which a correct and early diagnosis is essential. As a severe deficiency in A Disintegrin And Metalloproteinase with ThromboSpondin type 1 repeats, member 13 (ADAMTS13) is the underlying pathophysiology, diagnostic strategies require timely monitoring of ADAMTS13 parameters to differentiate TTP from alternative thrombotic microangiopathies (TMAs) and to guide initial patient management. Assays for conventional ADAMTS13 testing focus on the enzyme activity and presence of (inhibitory) anti-ADAMTS13 antibodies to discriminate immune-mediated TTP (iTTP) from congenital TTP and guide patient management. However, diagnosis of iTTP remains challenging when patients present borderline ADAMTS13 activity. Therefore, additional biomarkers would be helpful to support correct clinical judgment. Over the last few years, the evaluation of ADAMTS13 conformation has proven to be a valuable tool to confirm the diagnosis of acute iTTP when ADAMST13 activity is between 10 and 20%. Screening of ADAMTS13 conformation during long-term patient follow-up suggests it is a surrogate marker for undetectable antibodies. Moreover, some non-ADAMTS13 parameters gained notable interest in predicting disease outcome, proposing meticulous follow-up of iTTP patients. This review summarizes non-ADAMTS13 biomarkers for which inclusion in routine clinical testing could largely benefit differential diagnosis and follow-up of iTTP patients.
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Affiliation(s)
- Quintijn Bonnez
- Department of Chemistry, KU Leuven Campus Kulak Kortrijk, 8500 Kortrijk, Belgium
| | - Kazuya Sakai
- Department of Chemistry, KU Leuven Campus Kulak Kortrijk, 8500 Kortrijk, Belgium
- Department of Blood Transfusion Medicine, Nara Medical University, Kashihara 634-8522, Japan
| | - Karen Vanhoorelbeke
- Department of Chemistry, KU Leuven Campus Kulak Kortrijk, 8500 Kortrijk, Belgium
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7
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Falter T, Rossmann H, de Waele L, Dekimpe C, von Auer C, Müller-Calleja N, Häuser F, Degreif A, Marandiuc D, Messmer X, Sprinzl M, Lackner KJ, Jurk K, Vanhoorelbeke K, Lämmle B. A novel von Willebrand factor multimer ratio as marker of disease activity in thrombotic thrombocytopenic purpura. Blood Adv 2023; 7:5091-5102. [PMID: 37399489 PMCID: PMC10471935 DOI: 10.1182/bloodadvances.2023010028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 06/02/2023] [Accepted: 06/02/2023] [Indexed: 07/05/2023] Open
Abstract
Immune-mediated thrombotic thrombocytopenic purpura (iTTP), an autoantibody-mediated severe ADAMTS13 deficiency, is caused by insufficient proteolytic processing of von Willebrand factor (VWF) multimers (MMs) and microvascular thrombi. Recurrence of acute iTTP is associated with persistence or reappearance of ADAMTS13 deficiency. Some patients remain in remission despite recurring or persisting severe ADAMTS13 deficiency. In a prospective 2-year observational study, we investigated VWF MM patterns and ADAMTS13 in patients with iTTP in remission and at acute episodes. Of the 83 patients with iTTP, 16 suffered 22 acute episodes whereas 67 remained in clinical remission during follow-up, including 13 with ADAMTS13 <10% and 54 with ADAMTS13 ≥10%. High -molecular weight to low-molecular weight VWF MM ratio based on sodium dodecyl sulfate-agarose gel electrophoresis was compared with ADAMTS13 activity. VWF MM ratio was significantly higher in patients in remission with <10% compared with ≥10% ADAMTS13 activity. Fourteen samples obtained from 13 to 50 days (interquartile range; median, 39) before acute iTTP onset (ADAMTS13 <10% in 9 patients and 10%-26% in 5) showed VWF MM ratios significantly higher than those from 13 patients remaining in remission with ADAMTS13 <10%. At acute iTTP onset, VWF MM ratio decreased significantly and was low in all patients despite <10% ADAMTS13. The VWF MM ratio does not depend exclusively on ADAMTS13 activity. The disappearance of high molecular weight VWF MMs resulting in low VWF MM ratio at iTTP onset may be explained by consumption of larger VWF MMs in the microcirculation. The very high VWF MM ratio preceding acute iTTP recurrence suggests that VWF processing is hampered more than in patients remaining in remission.
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Affiliation(s)
- Tanja Falter
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Heidi Rossmann
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Laure de Waele
- Laboratory for Thrombosis Research, Interdisciplinary Research Facility, KU Leuven Campus Kortrijk, Kortrijk, Belgium
| | - Charlotte Dekimpe
- Laboratory for Thrombosis Research, Interdisciplinary Research Facility, KU Leuven Campus Kortrijk, Kortrijk, Belgium
| | - Charis von Auer
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
- Department of Hematology, Oncology and Pneumology, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Nadine Müller-Calleja
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Friederike Häuser
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Adriana Degreif
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Dana Marandiuc
- Transfusion Center, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Xavier Messmer
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Martin Sprinzl
- Medical Department I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Karl J. Lackner
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Kerstin Jurk
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Karen Vanhoorelbeke
- Laboratory for Thrombosis Research, Interdisciplinary Research Facility, KU Leuven Campus Kortrijk, Kortrijk, Belgium
| | - Bernhard Lämmle
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
- University Clinic of Hematology & Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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8
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Soto-Mora JA, Gómez-Espitia LM, Lasalvia P, Castellanos Moreno CA, Casallas Vanegas CA, Londoño Gutiérrez SA. Effectiveness and safety of caplacizumab in acquired thrombotic thrombocytopenic purpura: health technology assessment and classification according to the methodology established in Colombia. Int J Technol Assess Health Care 2023; 39:e48. [PMID: 37476982 DOI: 10.1017/s0266462323000442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/22/2023]
Abstract
OBJECTIVES Acquired thrombotic thrombocytopenic purpura (aTTP) is a rare hematological disease whose clinical management includes caplacizumab along with plasma exchange and immunosuppression, according to international guidelines. Caplacizumab has been available in Colombia since 2022. This study seeks to determine the therapeutic classification of caplacizumab according to the methodology of the Instituto de Evaluación Tecnológica en Salud. METHODS The classification was carried out through a deliberative process following the modified Delphi technique, with a panel of experts, made up of four hemato-oncologists, a pharmaceutical chemist, and a patient. The results of effectiveness and safety obtained through a systematic review, therapeutic thresholds (clinical significance), and degree of acceptability (willingness to use the technology) were used for the classification. RESULTS Fourteen effectiveness and safety outcomes were submitted for the classification process. Caplacizumab showed clinical significance for some effectiveness outcomes, was not considered inferior in terms of safety, and displayed acceptability of use. Through consensus, the panel determined that caplacizumab plus the standard regimen is superior to the standard regimen in terms of treatment response and composite outcome, and no different for the other effectiveness and safety outcomes. Likewise, in overall terms, the panel determined that caplacizumab together with the standard regimen is superior to the standard regimen. CONCLUSION Treatment with caplacizumab together with the standard regimen was considered superior to the standard regimen for the treatment of patients with aTTP, as it showed clinically significant benefits in critical outcomes for decision making, and a safety profile no different to its comparator.
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Affiliation(s)
- Jahir A Soto-Mora
- Department of Evidence-Based Medicine, NeuroEconomix, Bogotá, Colombia
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9
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Frontiers in pathophysiology and management of thrombotic thrombocytopenic purpura. Int J Hematol 2023; 117:331-340. [PMID: 36757521 DOI: 10.1007/s12185-023-03552-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 01/25/2023] [Accepted: 01/25/2023] [Indexed: 02/10/2023]
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a fatal disease in which platelet-rich microthrombi cause end-organ ischemia and damage. TTP is caused by markedly reduced ADAMTS13 (a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13) activity. Hereditary or congenital TTP (cTTP) is caused by ADAMTS13 gene mutations. In acquired or immune TTP (iTTP), ADAMTS13 activity is reduced by anti-ADAMTS13 autoantibodies. TTP is characterized by thrombocytopenia, hemolytic anemia, fever, renal dysfunction, and neuropsychiatric symptoms. Therapeutic plasma exchange (TPE) and immunosuppressive therapy are the mainstays of treatment. As untreated TTP has a high mortality rate, immediate initiation of TPE is recommended when TTP is suspected. Conventionally, corticosteroids have been used for immunosuppressive therapy. Current drug therapies include rituximab, an anti-CD20 antibody that is effective in newly diagnosed cases and refractory cases, as well as for relapse prevention, and caplacizumab, an anti- von Willebrand factor (VWF) nanobody that inhibits the binding of platelets to VWF and prevents microthrombi formation. Recombinant human ADAMTS13 is a promising treatment for cTTP. Although these therapeutic advances have improved the outcomes of TTP, early diagnosis and prompt initiation of appropriate therapy are necessary to achieve these outcomes.
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10
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Tau J, Fernando LP, Munoz MC, Poh C, Krishnan VV, Dwyre DM. Evaluation of thrombotic thrombocytopenic purpura and other thrombotic microangiopathies: Lessons learned from a 14-year retrospective study. Ther Apher Dial 2023; 27:136-145. [PMID: 35501999 DOI: 10.1111/1744-9987.13864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 04/20/2022] [Accepted: 04/25/2022] [Indexed: 01/05/2023]
Abstract
INTRODUCTION Thrombotic thrombocytopenic purpura (TTP) is a clinical thrombotic microangiopathy (TMA) syndrome defined by the pentad of symptoms. Therapeutic plasma exchange with plasma replacement is an ASFA Category I modality that can reduce morbidity and mortality if initiated early. We describe a 14-year review of patients referred for plasma exchange with a suspected diagnosis of TTP. METHODS For 70 patients referred for urgent plasma exchange, clinical, therapeutic, and laboratory data were retrospectively analyzed, and the diagnosis was determined. RESULTS Fifteen of the patients were diagnosed with TTP based upon ADAMTS-13 activity with the other 51 patients having other non-TTP TMA diagnoses. The mortality rate was significant for both TTP and non-TTP TMAs. PLASMIC scores were also calculated retrospectively and were noted to have limited value. TMA is a diagnostic challenge and encompasses different syndromes with similar presentations. CONCLUSION Determining an accurate diagnosis, including prompt ADAMTS-13 testing, makes it possible to initiate appropriate therapy for the multiple different TMAs that can be seen in clinical practice.
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Affiliation(s)
- Jason Tau
- Department of Neurobiology, Physiology, and Behavior, University of California, Davis, California, USA
| | - Leonor P Fernando
- Department of Pathology and Laboratory Medicine, University of California Davis Medical Center, Sacramento, California, USA
| | - Meilen C Munoz
- Department of Internal Medicine, University of California Davis Medical Center, Sacramento, California, USA
| | - Christina Poh
- Division of Hematology-Oncology, University of California Davis Medical Center, Sacramento, California, USA
| | - Viswanathan V Krishnan
- Department of Pathology and Laboratory Medicine, University of California Davis Medical Center, Sacramento, California, USA.,Department of Chemistry and Biochemistry, California State University, Fresno, California, USA
| | - Denis M Dwyre
- Department of Pathology and Laboratory Medicine, University of California Davis Medical Center, Sacramento, California, USA
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11
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Xie XT, Xiao YY, Zhang Y, Luo ZM, Luo Y. Combination regimens containing daratumumab for initial diagnosed acquired thrombotic thrombocytopenic purpura. J Thromb Thrombolysis 2023; 55:399-405. [PMID: 36637776 DOI: 10.1007/s11239-023-02768-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/29/2022] [Indexed: 01/14/2023]
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a rare and life-threatening thrombotic microangiopathy characterized by microangiopathic hemolytic anemia, severe thrombocytopenia, and organ ischemia associated with disseminated microvascular platelet-rich thrombus. Before the introduction of plasma therapy, acute TTP was almost universally fatal, which improved survival from < 10 to 80-90%. However, patients who survived an acute attack were at high risk for recurrence and long-term morbidity. It was reported that daratumumab can eradicate persistent ADAMTS13-inhibiting autoantibodies and restore ADAMTS13 activity in two patients with relapsed immune-mediated TTP without associated adverse drug reactions. Here we report a case series of patients with initial diagnosed acquired TTP treated with combination regimens containing daratumumab. All the patients achieved clinical response after the initial treatment. Three patients achieved clinical remission, one patient relapsed and one patient suffered an exacerbation during follow-up. The two patients were retreated with glucocorticoids, plasma exchange combined with daratumumab, and clinical remission was achieved again. Combination of daratumumab in the treatment of initial diagnosed acquired thrombotic thrombocytopenic purpura can rapidly restore ADAMST13 activity and turn negative for ADAMST13 inhibitors, resulting in long-term remission in patients.
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Affiliation(s)
- Xiang-Ting Xie
- Department of Hematology, The Second Affiliated Hospital of Chongqing Medical University, No.288, Tian-Wen Road, Chongqing, 40010, China
| | - Ying-Ying Xiao
- Department of Hematology, The Second Affiliated Hospital of Chongqing Medical University, No.288, Tian-Wen Road, Chongqing, 40010, China
| | - Ying Zhang
- Department of Hematology, The Second Affiliated Hospital of Chongqing Medical University, No.288, Tian-Wen Road, Chongqing, 40010, China
| | - Zhi-Ming Luo
- Department of Hematology, The Second Affiliated Hospital of Chongqing Medical University, No.288, Tian-Wen Road, Chongqing, 40010, China
| | - Yun Luo
- Department of Hematology, The Second Affiliated Hospital of Chongqing Medical University, No.288, Tian-Wen Road, Chongqing, 40010, China.
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Agyapong KO, Folson A, Wonkyi R, Amenyedor K, Boateng JJ, Fiador K. Recurrent stroke in an African female with idiopathic thrombotic thrombocytopenic purpura: A case report. Clin Case Rep 2023; 11:e6860. [PMID: 36694637 PMCID: PMC9842876 DOI: 10.1002/ccr3.6860] [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: 10/04/2022] [Revised: 01/01/2023] [Accepted: 01/04/2023] [Indexed: 01/18/2023] Open
Abstract
We report on a young Ghanaian female who was diagnosed with thrombotic thrombocytopenic purpura (TTP) but had an ischemic stroke as the initial presentation. She was successfully treated with therapeutic plasma exchange. This case illustrates how TTP can masquerade as ischemic stroke and the application of PLASMIC score without ADAMTS-13 assay in risk prediction.
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Affiliation(s)
| | - Aba Folson
- School of MedicineUniversity of Health and Allied SciencesHoGhana
| | - Roland Wonkyi
- Department of Internal MedicineGreater Accra Regional HospitalRidge – AccraGhana
| | - Kelvin Amenyedor
- Department of Internal MedicineGreater Accra Regional HospitalRidge – AccraGhana
| | | | - Kate Fiador
- Department of HaematologyGreater Accra Regional HospitalRidge – AccraGhana
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13
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Osyodlo HV, Husieva SA, Boychak MP, Antonyuk O. THROMBOTIC MICROANGIOPATHY: DIAGNOSTIC CHALLENGES IN THE PRIMARY MULTIPLE NEOPLASM INVOLVEMENT WITH PREVALENT METASTASIS WITH GRANULOMATOSIS INFLAMMATORY FOCUSES. WIADOMOSCI LEKARSKIE (WARSAW, POLAND : 1960) 2023; 76:2121-2126. [PMID: 37898953 DOI: 10.36740/wlek202309131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/31/2023]
Abstract
Patient, who died during the hospital stay, had hemoblastosis and syphilis in the reported medical history. While the patient was examined doctors suspected the presence of malignancy with unknown primary localization with multiple metastatic injuries with clinical and laboratory TTP signs (hemorrhagic syndrome, thrombocytopenia, shystocytosis, and non-immune hemolytic anemia). Despite treatment, the general patient's condition progressively worsens with increasing multiple organ decompensation signs. In the final stage of the disease course, after heart arrest and the appearance of clinical death signs CPR measures were performed according to complete guidance, but CRP had no positive effect. Biological death was constated. Considering the criteria of the diagnostic clinical and laboratory dyad (thrombocytopenia and microangiopathic hemolytic anemia), the data of the patholog¬ical examination (multiple metastatic lesions, inflammatory process, tumor intoxication, thrombosis), the combination of manifestations of chronic myeloid leukemia, prostate cancer with multiple metastases, tertiary syphilis served as a condition for the initiation of TTP, which was of decisive importance in the development of the patient's death.
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Affiliation(s)
| | | | | | - Olena Antonyuk
- NATIONAL MILITARY MEDICAL CLINICAL CENTRE "MAIN MILITARY CLINICAL HOSPITAL", KYIV, UKRAINE; BOGOMOLETS NATIONAL MEDICAL UNIVERSITY, KYIV, UKRAINE
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14
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Halkidis K, Zheng XL. ADAMTS13 conformations and mechanism of inhibition in immune thrombotic thrombocytopenic purpura. J Thromb Haemost 2022; 20:2197-2203. [PMID: 35842925 PMCID: PMC9587499 DOI: 10.1111/jth.15822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 06/29/2022] [Accepted: 07/15/2022] [Indexed: 08/31/2023]
Abstract
ADAMTS13, a plasma metalloprotease that cleaves von Willebrand factor, is crucial for normal hemostasis. Acquired autoantibody-mediated deficiency of plasma ADAMTS13 results in a potentially fatal blood disorder, immune thrombotic thrombocytopenic purpura (iTTP). Plasma ADAMTS13 protease appears to exist in multiple conformations. Under physiological conditions, plasma ADAMTS13 exists predominantly in its "closed" conformation (or latent form), which may be activated by lowering pH, ligand binding, and binding of an antibody against the distal domains of ADAMTS13. In patients with iTTP, polyclonal antibodies target at various domains of ADAMTS13. However, nearly all inhibitory antibodies bind the spacer domain, whereas antibodies that bind the distal C-terminal domains may activate ADAMTS13 through removing its allosteric inhibition. Additionally, the anti-C-terminal antibodies may alter the potency of inhibitory antibodies towards ADAMTS13 activity. This review summarizes some of the most recent knowledge about the ADAMTS13 conformation and its mechanism of inhibition by its autoantibodies.
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Affiliation(s)
- Konstantine Halkidis
- Division of Hematologic Malignancies and Cellular Therapeutics, Department of Internal Medicine, The University of Kansas Medical Center, Kansas City, Kansas, USA
| | - X. Long Zheng
- Department of Pathology and Laboratory Medicine, The University of Kansas Medical Center, Kansas City, Kansas, USA
- Institute of Reproductive and Developmental Sciences, The University of Kansas Medical Center, Kansas City, Kansas, USA
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15
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Ramanan S, Singh H, Menon P, Patel PM, Parmar V, Malik D. Thrombotic Thrombocytopenic Purpura After Ad6.COV2.S Vaccination. Cureus 2022; 14:e28592. [PMID: 36185943 PMCID: PMC9521621 DOI: 10.7759/cureus.28592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2022] [Indexed: 12/04/2022] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) is caused by the deficiency of ADAMTS13, a von Willebrand factor cleaving protease, which results in thrombotic microangiopathy. It is characterized by microangiopathic hemolytic anemia, thrombocytopenia, and microvascular thrombosis leading to organ damage. It has an extremely high mortality rate if left untreated, making early diagnosis and treatment of the utmost importance. We report a case of TTP that developed after vaccination with Ad26.COV2.S COVID vaccine. We present a case of a 50-year-old African American female who presented with dyspnea one week after receiving the first dose of Ad26.COV2.S vaccine. Initial labs showed anemia, thrombocytopenia, and markers of intravascular hemolysis. The suspicion for thrombotic thrombocytopenic syndromes (TTS), vaccine-induced thrombotic thrombocytopenia (VITT), TTP, and Immune thrombocytopenic purpura (ITP) was high based on the history and laboratory results. Computed tomography (CT) of the chest and ultrasound of bilateral lower extremities did not show any evidence of thrombosis. The absence of thrombosis in the presence of a high PLASMIC score increased the suspicion of TTP over the other differentials. Diagnosis of TTP was confirmed when the ADAMTS13 level was low with an elevated autoantibody inhibitor level. The patient underwent treatment with corticosteroids, plasmapheresis, and rituximab with improvement in symptoms and platelet count. TTP and VITT are the possible differential diagnosis for a patient presenting with anemia, thrombocytopenia, and signs of hemolysis after vaccination with Ad26.COV2.S. It is necessary to differentiate these two clinical entities as the management varies based on the diagnosis.
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16
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Adeyemi A, Razakariasa F, Chiorean A, de Passos Sousa R. Epidemiology, treatment patterns, clinical outcomes, and disease burden among patients with immune-mediated thrombotic thrombocytopenic purpura in the United States. Res Pract Thromb Haemost 2022; 6:e12802. [PMID: 36176310 PMCID: PMC9481884 DOI: 10.1002/rth2.12802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 07/19/2022] [Accepted: 08/17/2022] [Indexed: 11/11/2022] Open
Abstract
Background Immune-mediated thrombotic thrombocytopenic purpura (iTTP) is a life-threatening thrombotic microangiopathy. Due to its rarity, epidemiology and real-world outcomes data are scarce. Objectives The aim was to assess epidemiology, treatment patterns, clinical outcomes, and disease burden in patients with iTTP in the United States. Methods This longitudinal, retrospective observational study of the Optum-Humedica database included patients with an iTTP diagnosis (≥1 documented ADAMTS13 activity less than 10% or one or more iTTP episodes) from January 2007 to December 2019. Results Of 666 patients with an iTTP diagnosis between October 2015 and December 2019, 302 (45%) had one or more iTTP episodes. The pooled annual incidence of documented iTTP during this period was 3.43/million, and the annual incidence of one or more iTTP episodes was 1.81/million. Patients with one or more iTTP episodes received a median of six therapeutic plasma exchange (TPE) sessions per episode; 86% received corticosteroids, and 59% received rituximab. Exacerbations occurred in 17% (52/302) and relapse in 11% (34/302); 34% (103/302) had one or more thromboembolic events. Mortality rates during the study period were 25% (167/666) among all patients with iTTP diagnosis, and 14% (41/302) among patients with one or more iTTP episodes. In the assessment of disease burden (January 2007 to September 2019), patients in the iTTP cohort (n = 514) presented with a mean of 14 comorbidities, compared with 3 in a matched non-iTTP cohort (n = 2570). In a cluster analysis, duration of iTTP episode and mortality rate were greater in older versus younger patients. Conclusions Despite treatment with TPE and immunosuppressants, patients with iTTP have high risk of morbidity and mortality, demonstrating the need for more effective therapies.
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Affiliation(s)
- Ayoade Adeyemi
- Sanofi Cambridge Massachusetts USA.,Present address: Alexion Boston Massachusetts USA
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17
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Efficacy and safety of azathioprine during remission of immune-mediated thrombotic thrombocytopenic purpura. Blood Adv 2022; 6:5463-5466. [PMID: 35772164 PMCID: PMC9631697 DOI: 10.1182/bloodadvances.2022007632] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 06/22/2022] [Indexed: 11/20/2022] Open
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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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Heeb SR, Schaller M, Kremer Hovinga JA. Naturally Occurring Anti-Idiotypic Antibodies Portray a Largely Private Repertoire in Immune-Mediated Thrombotic Thrombocytopenic Purpura. JOURNAL OF IMMUNOLOGY (BALTIMORE, MD. : 1950) 2022; 208:2497-2507. [PMID: 35589126 DOI: 10.4049/jimmunol.2100868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 03/29/2022] [Indexed: 12/30/2022]
Abstract
Rare immune-mediated thrombotic thrombocytopenic purpura (iTTP) is a life-threatening disease resulting from a severe autoantibody-mediated ADAMTS13 (a disintegrin and metalloprotease with thrombospondin type 1 motifs, member 13) deficiency. Acute iTTP episodes are medical emergencies, but when treated appropriately &gt;95% of patients survive. However, at least half of survivors will eventually experience a relapse. How remission of an initial episode is achieved and factors contributing to reemergence of anti-ADAMTS13 Abs and a relapsing course are poorly understood. In acquired hemophilia and systemic lupus erythematosus, anti-idiotypic Abs counteracting and neutralizing pathogenic autoantibodies contribute to remission. We selected and amplified the splenic anti-idiotypic IgG<sub>1</sub> Fab κ/λ repertoire of two relapsing iTTP patients on previously generated monoclonal inhibitory anti-ADAMTS13 Fabs by phage display to explore whether anti-idiotypic Abs have a role in iTTP. We obtained 27 single anti-idiotypic Fab clones, half of which had unique sequences, although both patients shared four H chain V region genes (V<sub>H</sub>1-69*01, V<sub>H</sub>3-15*01, V<sub>H</sub>3-23*01, and V<sub>H</sub>3-49*03). Anti-idiotypic Fab pools of both patients fully neutralized the inhibitor capacity of the monoclonal anti-ADAMTS13 Abs used for their selection. Preincubation of plasma samples of 22 unrelated iTTP patients stratified according to functional ADAMTS13 inhibitor titers (&gt;2 Bethesda units/ml, or 1-2 Bethesda units/ml), with anti-idiotypic Fab pools neutralized functional ADAMTS13 inhibitors and restored ADAMTS13 activity in 18-45% of those cases. Taken together, we present evidence for the presence of an anti-idiotypic immune response in iTTP patients. The interindividual generalizability of this response is limited despite relatively uniform pathogenic anti-ADAMTS13 Abs recognizing a dominant epitope in the ADAMTS13 spacer domain.
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Affiliation(s)
- Silvan R Heeb
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; and Department for BioMedical Research, University of Bern, Bern, Switzerland
| | - Monica Schaller
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; and Department for BioMedical Research, University of Bern, Bern, Switzerland
| | - Johanna A Kremer Hovinga
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; and Department for BioMedical Research, University of Bern, Bern, Switzerland
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20
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Joseph A, Eloit M, Azoulay E, Kaplanski G, Provot F, Presne C, Wynckel A, Grangé S, Rondeau É, Pène F, Delmas Y, Lautrette A, Barbet C, Mousson C, Coindre J, Perez P, Jamme M, Augusto J, Poullin P, Jacobs F, El Karoui K, Vigneau C, Ulrich M, Kanouni T, Le Quintrec M, Hamidou M, Ville S, Charvet‐Rumpler A, Ojeda‐Uribe M, Godmer P, Fremeaux‐Bacchi V, Veyradier A, Halimi J, Coppo P. Immune‐mediated thrombotic thrombocytopenic purpura prognosis is affected by blood pressure. Res Pract Thromb Haemost 2022; 6:e12702. [PMID: 35599703 PMCID: PMC9115975 DOI: 10.1002/rth2.12702] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 03/04/2022] [Accepted: 03/13/2022] [Indexed: 12/28/2022] Open
Abstract
Background The prevalence, prognostic role, and diagnostic value of blood pressure in immune-mediated thrombotic thrombocytopenic purpura (iTTP) and other thrombotic microangiopathies (TMAs) remain unclear. Methods Using a national cohort of iTTP (n = 368), Shigatoxin-induced hemolytic uremic syndrome (n = 86), atypical hemolytic uremic syndrome (n = 84), and hypertension-related thrombotic microangiopathy (n = 25), we sought to compare the cohort's blood pressure profile to assess its impact on prognosis and diagnostic performances. Results Patients with iTTP had lower blood pressure than patients with other TMAs, systolic (130 [interquartile range (IQR) 118-143] vs 161 [IQR 142-180] mmHg) and diastolic (76 [IQR 69-83] vs 92 [IQR 79-105] mmHg, both p < 0.001). The best threshold for iTTP diagnosis corresponded to a systolic blood pressure <150 mmHg. iTTP patients presenting with hypertension had a significantly poorer survival (hazard ratio 1.80, 95% confidence interval 1.07-3.04), and this effect remained significant after multivariable adjustment (hazard ratio = 1.14, 95% confidence interval 1.00-1.30). Addition of a blood pressure criterion modestly improved the French clinical score to predict a severe A disintegrin and metalloprotease with thrombospondin type 1 deficiency in patients with an intermediate score (i.e., either platelet count <30 × 109/L or serum creatinine <200 µM). Conclusions Elevated blood pressure at admission affects the prognosis of iTTP patients and may help discriminate them from other TMA patients. Particular attention should be paid to blood pressure and its management in these patients.
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Affiliation(s)
- Adrien Joseph
- INSERM, U1138, INSERM, Équipe 11 labellisée Ligue Nationale Contre le Cancer, Centre de Recherche des Cordeliers Paris France
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Médecine intensive réanimation Hôpital Saint Louis AP‐HP Paris France
| | - Martin Eloit
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service d’Hématologie et Thérapie Cellulaire CHRU de Tours Tours France
| | - Elie Azoulay
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Médecine intensive réanimation Hôpital Saint Louis AP‐HP Paris France
| | - Gilles Kaplanski
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service de Médecine Interne Hôpital la Conception Marseille France
| | - François Provot
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service de Néphrologie Hôpital Albert‐Calmette Lille France
| | - Claire Presne
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service de Néphrologie Hôpital Nord Amiens France
| | - Alain Wynckel
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service de Néphrologie Hôpital Maison Blanche Reims France
| | - Steven Grangé
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service de Réanimation Médicale CHU Charles Nicolle Rouen France
| | - Éric Rondeau
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Urgences Néphrologiques et Transplantation Rénale Hôpital Tenon Paris France
| | - Frédéric Pène
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service de Médecine Intensive–Réanimation Hôpital Cochin APHP Centre & Université de Paris Paris France
| | - Yahsou Delmas
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service de Néphrologie CHU de Bordeaux Bordeaux France
| | - Alexandre Lautrette
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service de Réanimation Médicale Hôpital Gabriel Montpied Clermont‐Ferrand France
| | - Christelle Barbet
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service de Néphrologie‐hypertension, Dialyses, Transplantation Rénale Hôpitaux Bretonneau et Clocheville Tours France
| | - Christiane Mousson
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service de Néphrologie CHU de Dijon Dijon France
| | - Jean‐Philippe Coindre
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service de Néphrologie CH Le Mans Le Mans France
| | - Pierre Perez
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service de Réanimation Polyvalente CHU de Nancy Nancy France
| | - Matthieu Jamme
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service de Réanimation Centre Hospitalier Intercommunal Poissy Saint‐Germain Poissy France
| | - Jean‐François Augusto
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service de Néphrologie Dialyse et Transplantation CHU Larrey Angers France
| | - Pascale Poullin
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service d’hémaphérèse et d’autotransfusion Hôpital la Conception Marseille France
| | - Frédéric Jacobs
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service de Réanimation Médicale Hôpital Antoine Béclère Clamart France
| | - Khalil El Karoui
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service de Néphrologie et Transplantation rénale Groupe Hospitalier Henri‐Mondor Créteil France
| | - Cécile Vigneau
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Université de Rennes, CHU Rennes, Inserm, EHESP, Irset (Institut de Recherche en Santé, Environnement et Travail)–UMR_S 1085 Rennes France
| | - Marc Ulrich
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service de Néphrologie Hôpital Jean Bernard Valenciennes France
| | - Tarik Kanouni
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Unité d’Hémaphérèse Service d’Hématologie CHU de Montpellier Montpellier France
| | - Moglie Le Quintrec
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service de Néphrologie CHU de Montpellier Montpellier France
| | - Mohamed Hamidou
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service de Médecine Interne CHU de Nantes Nantes France
| | - Simon Ville
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service de Néphrologie CHU de Nantes Nantes France
| | - Anne Charvet‐Rumpler
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service d’Hématologie Centre Hospitalier Régional Universitaire Hôpital Jean Minjoz Besançon France
| | - Mario Ojeda‐Uribe
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service d’Hématologie et de Thérapie Cellulaire Groupe Hospitalier Region Mulhouse‐Sud‐Alsace (GHRMSA) Mulhouse France
| | - Pascal Godmer
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service de Médecine Interne Centre Hospitalier Bretagne Atlantique de Vannes Vannes France
| | - Véronique Fremeaux‐Bacchi
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service d’Immunologie Biologique Hôpital Européen Georges Pompidou, AP‐HP Paris France
| | - Agnès Veyradier
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service d’Hématologie Biologique Hôpital Lariboisière, AP‐HP Paris France
| | - Jean‐Michel Halimi
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service de Néphrologie‐hypertension, Dialyses, Transplantation Rénale Hôpitaux Bretonneau et Clocheville Tours France
| | - Paul Coppo
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service d’Hématologie Hôpital Saint‐Antoine AP‐HP Paris France
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21
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Bowyer A, Brown P, Hopkins B, Scully M, Shepherd F, Lowe A, Mensah P, Maclean R, Kitchen S, van Veen JJ. Von Willebrand factor assays in patients with acquired immune thrombotic thrombocytopenia purpura treated with caplacizumab. Br J Haematol 2022; 197:349-358. [PMID: 35262910 DOI: 10.1111/bjh.18080] [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: 11/09/2021] [Revised: 01/25/2022] [Accepted: 01/26/2022] [Indexed: 11/28/2022]
Abstract
Acquired immune thrombotic thrombocytopenic purpura (iTTP) is a rare disease with a poor prognosis if undiagnosed. It is caused by autoantibody production to the von Willebrand factor (VWF) cleaving protease, A disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13 (ADAMTS13). Caplacizumab, an immunoglobulin directed to the platelet glycoprotein Ibα receptor of VWF, has been reported to induce quicker resolution of iTTP compared to placebo. The laboratory measurement of VWF activity was significantly reduced in clinical trials of caplacizumab. Several VWF assays are available in the UK and this study investigated whether differences in VWF parameters were present in 11 patients diagnosed with iTTP and treated with daily caplacizumab. Chromogenic factor VIII activity, VWF antigen, collagen binding activity, VWF multimers and six VWF activity assays were measured prior to caplacizumab therapy and on several occasions during treatment. VWF antigen and collagen binding activity levels were normal or borderline normal in all patients. Ultra-large molecular weight multimers were present in all patients following treatment. VWF activity assays were normal or reduced during treatment, but this was reagent and patient dependant. In the unusual scenario of a caplacizumab-treated patient requiring measurement of VWF activity, it is important that laboratories understand how their local reagents perform as results cannot be predicted.
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Affiliation(s)
- Annette Bowyer
- Department of Coagulation, Sheffield Laboratory Medicine, Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Sheffield, UK
| | - Paula Brown
- Department of Coagulation, Sheffield Laboratory Medicine, Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Sheffield, UK
| | - Barbara Hopkins
- Coagulation, University Hospitals of Leicester, Leicester, UK
| | - Marie Scully
- Department of Haematology, University College London Hospitals, Cardiometabolic Program, National Institute for Health Research UCLH-UCL Biomedical Research Centre, London, UK
| | - Fiona Shepherd
- Department of Coagulation, Sheffield Laboratory Medicine, Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Sheffield, UK
| | - Anna Lowe
- UK NEQAS for Blood Coagulation, Sheffield, UK
| | - Patrick Mensah
- Coagulation, University Hospitals of Leicester, Leicester, UK
| | - Rhona Maclean
- Department of Coagulation, Sheffield Laboratory Medicine, Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Sheffield, UK
| | - Steve Kitchen
- Department of Coagulation, Sheffield Laboratory Medicine, Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Sheffield, UK
| | - Joost J van Veen
- Department of Coagulation, Sheffield Laboratory Medicine, Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Sheffield, UK
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22
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Jousselme E, Sobas F, Guerre P, Simon M, Nougier C. Cost-effectiveness of thrombotic thrombocytopenic purpura diagnosis: a retrospective analysis in the University Hospital Center of Lyon (France). Blood Coagul Fibrinolysis 2022; 33:119-123. [PMID: 34393175 DOI: 10.1097/mbc.0000000000001071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The aim of the present study was to perform an economic evaluation of two alternative assays of ADAMTS13 activity (A Disintegrin And Metalloprotease with ThromboSpondin type 1 repeats, member 13) for diagnosing thrombotic thrombocytopenic purpura (TTP) in the Hospital of Lyon (France). The study approach was more economic than clinical. We retrospectively calculated the prescription costs of ADAMST13 activity from January to December 2019 for patients depending on the assay: manual ELISA (Technozym) or automated assay (AcuStar Werfen, Instrumentation Laboratory). Then, we compared the cost of therapeutic plasma exchange (TPE) consumption awaiting ADAMTS13 activity assay results. From an economic point of view, the automated assay was more cost-effective. From a clinical one, we supposed that the faster results given by AcuStar could improve patient care by reducing the number of TPEs. Automated assay could improve patient care without increasing costs in our institution.
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Affiliation(s)
- Emilie Jousselme
- Service d'Hématologie Biologique - Laboratoire d'Hémostase Hospices Civils de Lyon - Centre de Biologie et Pathologie Est -Groupement Hospitalier Est - Bat A3 - 59, Boulevard Pinel, Bron Cedex
| | - Frédéric Sobas
- Service d'Hématologie Biologique - Laboratoire d'Hémostase Hospices Civils de Lyon - Centre de Biologie et Pathologie Est -Groupement Hospitalier Est - Bat A3 - 59, Boulevard Pinel, Bron Cedex
| | - Pascale Guerre
- Service d'Evaluation Economique en Santé - Cellule Innovation, Hospices Civils de Lyon - 162 Avenue Lacassagne
| | - Marie Simon
- Service de Médecine Intensive-Réanimation -Hôpital Edouard Herriot - Place d'Arsonval, Lyon Cedex 03, France
| | - Christophe Nougier
- Service d'Hématologie Biologique - Laboratoire d'Hémostase Hospices Civils de Lyon - Centre de Biologie et Pathologie Est -Groupement Hospitalier Est - Bat A3 - 59, Boulevard Pinel, Bron Cedex
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23
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Urine Protein/Creatinine Ratio in Thrombotic Microangiopathies: A Simple Test to Facilitate Thrombotic Thrombocytopenic Purpura and Hemolytic and Uremic Syndrome Diagnosis. J Clin Med 2022; 11:jcm11030648. [PMID: 35160098 PMCID: PMC8836555 DOI: 10.3390/jcm11030648] [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: 12/06/2021] [Revised: 01/14/2022] [Accepted: 01/24/2022] [Indexed: 12/13/2022] Open
Abstract
Background: Early diagnosis of thrombotic thrombocytopenic purpura (TTP) versus hemolytic and uremic syndrome (HUS) is critical for the prompt initiation of specific therapies. Objective: To evaluate the diagnostic performance of the proteinuria/creatininuria ratio (PU/CU) for TTP versus HUS. Patients/Methods: In a retrospective study, in association with the “French Score” (FS) (platelets < 30 G/L and serum creatinine level < 200 µmol/L), we assessed PU/CU for the diagnosis of TTP in patients above the age of 15 with thrombotic microangiopathy (TMA). Patients with a history of kidney disease or with on-going cancer, allograft or pregnancy were excluded from the analysis. Results: Between February 2011 and April 2019, we identified 124 TMA. Fifty-six TMA patients for whom PU/CU were available, including 35 TTP and 21 HUS cases, were considered. Using receiver–operating characteristic curves (ROC), those with a threshold of 1.5 g/g for the PU/CU had a 77% sensitivity (95% CI (63, 94)) and a 90% specificity (95% CI (71, 100)) for TTP diagnosis compared with those having an 80% sensitivity (95% CI (66, 92)) and a 90% specificity (95% CI (76, 100) with a FS of 2. In comparison, a composite score, defined as a FS of 2 or a PU/CU ≤ 1.5 g/g, improved sensitivity to 99.6% (95% CI (93, 100)) for TTP diagnosis and enabled us to reclassify seven false-negative TTP patients. Conclusions: The addition of urinary PU/CU upon admission of patients with TMA is a fast and readily available test that can aid in the differential diagnosis of TTP versus HUS alongside traditional scoring.
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24
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Deucher W, Sukumar S, Cataland SR. Clinical relapse of immune-mediated thrombotic thrombocytopenic purpura following COVID-19 vaccination. Res Pract Thromb Haemost 2022; 6:e12658. [PMID: 35155977 PMCID: PMC8822264 DOI: 10.1002/rth2.12658] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Revised: 11/17/2021] [Accepted: 12/08/2021] [Indexed: 12/13/2022] Open
Abstract
De novo and relapsed immune-mediated thrombotic thrombocytopenic purpura (iTTP) have been documented to have occurred following severe acute respiratory syndrome coronavirus 2 (COVID-19) vaccination. Here, we present a case of a 28-year-old woman who received the tozinameran (BNT162b2, Pfizer-BioNtech) vaccine for COVID-19 and experienced an iTTP relapse during longitudinal follow-up. She received the vaccine 30 months after her initial diagnosis, while she was in clinical remission. She was not in complete ADAMTS-13 remission, as she had undetectable ADAMTS-13 activity during follow-up except for one isolated measurement of 48%. Shortly after vaccination, she developed complaints of bruising, petechiae, ataxia, and an episode of slurred speech. Laboratory testing demonstrated thrombocytopenia, schistocytes, and eventually undetectable ADAMTS-13 activity. She was successfully treated with caplacizumab, rituximab, and corticosteroids without plasma exchange. She achieved complete clinical and ADAMTS-13 remission after treatment. We recommend caution in the administration of COVID-19 vaccines for survivors of iTTP in remission with severely deficient ADAMTS-13 activity.
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25
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AlHejazi A, AlBeihany A, AlHashmi H, Alzahrani H, Motabi I, El-Hemaidi I, Alsaleh K, El Tayeb K, Rabea M, Khallaf M, Qari M. Approaches to acquired thrombotic thrombocytopenic purpura management in Saudi Arabia. JOURNAL OF APPLIED HEMATOLOGY 2022. [DOI: 10.4103/joah.joah_46_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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26
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Ho M, Zanwar S, Gertz MA. 44-Year-Old Man With Anemia, Thrombocytopenia, and Acute Kidney Injury. Mayo Clin Proc 2022; 97:176-181. [PMID: 34862074 DOI: 10.1016/j.mayocp.2021.05.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 04/22/2021] [Accepted: 05/04/2021] [Indexed: 11/16/2022]
Affiliation(s)
- Matthew Ho
- Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Rochester, MN
| | - Sauraubh Zanwar
- Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Rochester, MN
| | - Morie A Gertz
- Advisor to residents and Consultant in Hematology, Mayo Clinic, Rochester, MN.
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27
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Eller K, Knoebl P, Bakkaloglu SA, Menne JJ, Brinkkoetter PT, Grandt L, Thiem U, Coppo P, Scully M, Haller MC. OUP accepted manuscript. Nephrol Dial Transplant 2022; 37:1229-1234. [PMID: 35195251 PMCID: PMC9217651 DOI: 10.1093/ndt/gfac034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Indexed: 11/13/2022] Open
Affiliation(s)
| | - Paul Knoebl
- Division of Haematology and Haemostasis, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Sevcan A Bakkaloglu
- Department of Paediatric Nephrology, Gazi University, Faculty of Medicine, Ankara, Turkey
| | - Jan J Menne
- KRH Klinikum Mitte – Location Siloah, Hannover, Germany
| | - Paul T Brinkkoetter
- Department II of Internal Medicine and Centre for Molecular Medicine Cologne (CMMC), Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Leonie Grandt
- Department of Medicine III - Nephrology, Ordensklinikum Linz Elisabethinen, Linz, Austria
| | - Ursula Thiem
- Department of Medicine III - Nephrology, Ordensklinikum Linz Elisabethinen, Linz, Austria
| | - Paul Coppo
- Department of Haematology, Reference Centre for Thrombotic Microangiopathies, Saint-Antoine University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Marie Scully
- Department of Haematology, University College London Hospitals, London, UK
| | - Maria C Haller
- Department of Medicine III - Nephrology, Ordensklinikum Linz Elisabethinen, Linz, Austria
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28
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Botero JP, Reese JA, George JN, McIntosh JJ. Severe thrombocytopenia and microangiopathic hemolytic anemia in pregnancy: A guide for the consulting hematologist. Am J Hematol 2021; 96:1655-1665. [PMID: 34424560 PMCID: PMC8616841 DOI: 10.1002/ajh.26328] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Revised: 08/11/2021] [Accepted: 08/17/2021] [Indexed: 12/13/2022]
Abstract
A hematologist receives a call from a maternal-fetal medicine (MFM) physician about a previously healthy patient who became ill at 25 weeks' gestation. Her mental status is deteriorating. There are signs of fetal distress. Platelet count and hemoglobin are falling. The MFM physician is considering the hemolysis, elevated liver enzymes and low platelet count (HELLP) syndrome. For the hematologist, everything seems unfamiliar. Our goal is to provide hematologists with the fundamental knowledge required for understanding and managing these patients who become suddenly and seriously ill during pregnancy and in whom thrombocytopenia and microangiopathic hemolytic anemia are part of their presentation.
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Affiliation(s)
- Juliana Perez Botero
- Division of Hematology and Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
- Versiti (Blood Center of Wisconsin), Milwaukee, Wisconsin, USA
| | - Jessica A. Reese
- Department of Biostatistics & Epidemiology, Hudson College of Public Health, University of Oklahoma, Oklahoma City, Oklahoma, USA
| | - James N. George
- Department of Biostatistics & Epidemiology, Hudson College of Public Health, University of Oklahoma, Oklahoma City, Oklahoma, USA
- Hematology-Oncology Section, Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Jennifer J. McIntosh
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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29
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Fage N, Orvain C, Henry N, Mellaza C, Beloncle F, Tuffigo M, Geneviève F, Coppo P, Augusto JF, Brilland B. Proteinuria Increases the PLASMIC and French Scores Performance to Predict Thrombotic Thrombocytopenic Purpura in Patients With Thrombotic Microangiopathy Syndrome. Kidney Int Rep 2021; 7:221-231. [PMID: 35155861 PMCID: PMC8820983 DOI: 10.1016/j.ekir.2021.11.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Revised: 10/31/2021] [Accepted: 11/08/2021] [Indexed: 11/04/2022] Open
Abstract
Introduction PLASMIC and French scores have been developed to help clinicians in the early identification of patients with thrombotic thrombocytopenic purpura (TTP). Nevertheless, the validity of these scores in thrombotic microangiopathy (TMA) cohorts with low TTP prevalence remains uncertain. We aimed to evaluate their diagnostic value in routine clinical practice using an unselected cohort of patients with TMA. We also analyzed the value of adding proteinuria level to the scores. Methods We retrospectively included all patients presenting with a biological TMA syndrome between January 1, 2008, and December 31, 2019, in a tertiary hospital. TMA etiology was ascertained, and scores were evaluated. Modified scores, built by adding 1 point for low proteinuria (<1.2 g/g), were compared with original scores for TTP prediction. Results Among 273 patients presenting with a full biological TMA syndrome, 238 were classified with a TMA diagnosis. Complete scores and proteinuria level were available in 134 patients with a TTP prevalence of 7.5%. Area under the receiver operating characteristic curve (AUC) of PLASMIC and French scores for TTP diagnosis was 0.65 (0.46–0.84) and 0.72 (0.51–0.93), respectively. AUC of modified PLASMIC and French scores was 0.76 (0.59–0.92) (P = 0.003 vs. standard score) and 0.81 (0.67–0.95) (P = 0.069 vs. standard score), respectively. Specificity, positive predictive value (PPV), and positive likelihood ratio of high-risk scores were significantly improved by adding proteinuria level. Conclusion PLASMIC and French scores have low predictive values when applied to an unselected TMA cohort. Including proteinuria level in the original scores improves their performance for TTP prediction.
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30
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Bergstrand M, Hansson E, Delaey B, Callewaert F, De Passos Sousa R, Sargentini-Maier ML. Caplacizumab Model-Based Dosing Recommendations in Pediatric Patients With Acquired Thrombotic Thrombocytopenic Purpura. J Clin Pharmacol 2021; 62:409-421. [PMID: 34699078 PMCID: PMC9255589 DOI: 10.1002/jcph.1991] [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: 07/07/2021] [Accepted: 10/21/2021] [Indexed: 12/15/2022]
Abstract
Acquired thrombotic thrombocytopenic purpura (aTTP) is a rare and life‐threatening autoimmune thrombotic microangiopathy. Caplacizumab, evaluated in phase II and III studies in adults, shortens the time to platelet count response and reduces aTTP exacerbations, has a favorable safety profile, and can potentially reduce refractoriness and mortality associated with aTTP. Since no children with aTTP were enrolled in these clinical trials, caplacizumab has been initially approved for use only in adult patients with aTTP (10 mg). Pediatric dosing recommendations were developed using model‐based simulations. A semimechanistic pharmacokinetic/pharmacodynamic population model has been developed describing the interaction between caplacizumab and von Willebrand factor antigen (vWF:Ag) following intravenous and subcutaneous administration of caplacizumab in different adult populations, at various dose levels, using nonlinear mixed‐effects modeling. Based on the allometrically scaled pharmacokinetic/pharmacodynamic model, different dosing regimens were simulated in 8000 children (aged 2‐18 years). Simulated caplacizumab exposures and vWF:Ag levels across different age categories were compared to an adult reference group. A simulated daily dose of 5 mg in children weighing <40 kg and of 10 mg in children weighing ≥40 kg resulted in similar exposures and vWF:Ag suppression across age and weight groups. Despite the lack of pediatric clinical data, the results of this modeling and simulation analysis constituted the basis for the European extension of indication for caplacizumab (10 mg) to adolescents aged >12 years and with a body weight ≥40 kg. This represents a rare case in which regulatory authorities have deemed a modeling and simulation study robust enough to approve a variation of indication.
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32
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[Treatment of immune-mediated thrombotic thrombocytopenic purpura: A decisive turning point]. Transfus Clin Biol 2021; 28:380-385. [PMID: 34464709 DOI: 10.1016/j.tracli.2021.08.347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 08/25/2021] [Indexed: 11/23/2022]
Abstract
Immune-mediated thrombotic thrombocytopenic purpura (iTTP) is a rare and life-threatening thrombotic microangiopathy characterized by severe deficiency of ADAMTS13, the enzyme that cleaves von Willebrand factor multimers. Recent insights into iTTP pathophysiology have led to the development of new therapies targeting ADAMTS13 replacement, anti-ADAMTS13 antibodies, and von Willebrand factor-platelet interactions. New maximalist therapeutic strategies are emerging based on triple therapy. While plasma exchange remains the cornerstone therapy of the acute phase, the introduction of front-line immunosuppressive treatments, corticosteroids and rituximab, has led to a reduction in exacerbations and relapses but without any significant improvement in survival. Caplacizumab, a bivalent humanized anti-von Willebrand factor nanobody, is poised to revolutionize the treatment of the acute phase. By inhibiting the interaction between von Willebrand factor multimers and platelets, caplacizumab prevents platelets adhesion, prevents the formation of new microthrombi and protects organs from ischemia. Its early combination with plasma exchange and immunosuppressive therapy prevents unfavorable outcomes and reduces the burden of care. Supported by repeated ADAMTS13 assays, rituximab prevents relapse in patients with persistent or recurrent ADAMTS13 deficiency in clinical remission. This review examines how advances in diagnostics and targeted therapies are changing the current treatment paradigm in both the acute and remission phases and are contributing to dramatically improve the iTTP prognosis.
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33
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How I treat microangiopathic hemolytic anemia in patients with cancer. Blood 2021; 137:1310-1317. [PMID: 33512445 PMCID: PMC8555418 DOI: 10.1182/blood.2019003810] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 10/19/2020] [Indexed: 12/16/2022] Open
Abstract
Microangiopathic hemolytic anemia (MAHA) with thrombocytopenia, suggests a thrombotic microangiopathy (TMA), linked with thrombus formation affecting small or larger vessels. In cancer patients, it may be directly related to the underlying malignancy (initial presentation or progressive disease), to its treatment, or a separate incidental diagnosis. It is vital to differentiate incidental thrombotic thrombocytopenia purpura or atypical hemolytic uremic syndrome in cancer patients presenting with a TMA, as they have different treatment strategies, and prompt initiation of treatment impacts outcome. In the oncology patient, widespread microvascular metastases or extensive bone marrow involvement can cause MAHA and thrombocytopenia. A disseminated intravascular coagulation (DIC) picture may be precipitated by sepsis or driven by the cancer itself. Cancer therapies may cause a TMA, either dose-dependent toxicity, or an idiosyncratic immune-mediated reaction due to drug-dependent antibodies. Many causes of TMA seen in the oncology patient do not respond to plasma exchange and, where feasible, treatment of the underlying malignancy is important in controlling both cancer-TMA or DIC driven disease. Drug-induced TMA should be considered and any putative causal agent stopped. We will discuss the differential diagnosis and treatment of MAHA in patients with cancer using clinical cases to highlight management principles.
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A regimen with caplacizumab, immunosuppression, and plasma exchange prevents unfavorable outcomes in immune-mediated TTP. Blood 2021; 137:733-742. [PMID: 33150928 DOI: 10.1182/blood.2020008021] [Citation(s) in RCA: 87] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 10/12/2020] [Indexed: 12/21/2022] Open
Abstract
The anti-von Willebrand factor nanobody caplacizumab was licensed for adults with immune-mediated thrombotic thrombocytopenic purpura (iTTP) based on prospective controlled trials. However, few data are available on postmarketing surveillance. We treated 90 iTTP patients with a compassionate frontline triplet regimen associating therapeutic plasma exchange (TPE), immunosuppression with corticosteroids and rituximab, and caplacizumab. Outcomes were compared with 180 historical patients treated with the standard frontline treatment (TPE and corticosteroids, with rituximab as salvage therapy). The primary outcome was a composite of refractoriness and death within 30 days since diagnosis. Key secondary outcomes were exacerbations, time to platelet count recovery, the number of TPE, and the volume of plasma required to achieve durable remission. The percentage of patients in the triplet regimen with the composite primary outcome was 2.2% vs 12.2% in historical patients (P = .01). One elderly patient in the triplet regimen died of pulmonary embolism. Patients from this cohort experienced less exacerbations (3.4% vs 44%, P < .01); they recovered durable platelet count 1.8 times faster than historical patients (95% confidence interval, 1.41-2.36; P < .01), with fewer TPE sessions and lower plasma volumes (P < .01 both). The number of days in hospital was 41% lower in the triplet regimen than in the historical cohort (13 vs 22 days; P < .01). Caplacizumab-related adverse events occurred in 46 patients (51%), including 13 major or clinically relevant nonmajor hemorrhagic events. Associating caplacizumab to TPE and immunosuppression, by addressing the 3 processes of iTTP pathophysiology, prevents unfavorable outcomes and alleviates the burden of care.
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35
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Elevated plasma levels of syndecan-1 and soluble thrombomodulin predict adverse outcomes in thrombotic thrombocytopenic purpura. Blood Adv 2021; 4:5378-5388. [PMID: 33141886 DOI: 10.1182/bloodadvances.2020003065] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 10/08/2020] [Indexed: 02/07/2023] Open
Abstract
Immune-mediated thrombotic thrombocytopenic purpura (iTTP) is a potentially fatal blood disorder resulting from acquired deficiency of plasma ADAMTS13 activity. Despite recent advances in early diagnosis and novel therapeutics, the mortality rate of acute iTTP remains as high as 10% to 20%. Moreover, a reliable clinical and laboratory parameter that predicts disease severity and outcomes is lacking. We show in the present study that plasma levels of syndecan-1 (Sdc-1) and soluble thrombomodulin (sTM) on admission were dramatically increased in patients with acute iTTP and remained substantially elevated in a subset of patients compared with healthy controls. The elevated admission plasma levels of Sdc-1 and sTM were associated with abnormal Glasgow coma scale scores, low estimated glomerular filtration rates, the need for intensive care, and in-hospital mortality rates. Moreover, a further simultaneous increase in plasma Sdc-1 and sTM levels at the time of clinical response/remission (eg, when normalization of platelet counts and substantial reduction of serum lactate dehydrogenase activity were achieved) was highly predictive of iTTP recurrence. These results demonstrate that endothelial injury, resulting from disseminated microvascular thromboses, is severe and persistent in patients with acute iTTP. Plasma levels of Sdc-1 and sTM on admission and in remission are predictive of in-hospital mortality and recurrence of acute iTTP, respectively. Thus, an incorporation of such novel plasma biomarkers into the risk assessment in acute iTTP may help implement a more vigorous and intensive therapeutic strategy for these patients.
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36
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曾 敏, 贺 湘, 田 鑫, 黄 玉. [Recurrent thrombocytopenia with hemolytic anemia in a boy aged 3 years]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2021; 23:524-529. [PMID: 34020745 PMCID: PMC8140340 DOI: 10.7499/j.issn.1008-8830.2101085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Accepted: 02/22/2021] [Indexed: 06/12/2023]
Abstract
A boy, aged 3 years and 8 months, had recurrent thrombocytopenia with hemolytic anemia for more than 3 years. The physical examination showed no enlargement of the liver, spleen, and lymph nodes or finger deformities. Laboratory results showed a negative result of the direct antiglobulin test, normal coagulation function, and increases in bilirubin, lactate dehydrogenase and reticulocytes. The results of von Willebrand factor-cleaving protease ADAMTS13 activity assay showed extreme deficiency, and antibody assay showed negative ADAMTS13 inhibitory autoantibodies. Next-generation sequence showed compound heterozygous mutation in the ADAMTS13 gene. The boy was diagnosed with congenital thrombotic thrombocytopenic purpura. This disease may be easily misdiagnosed as Evans syndrome and is difficult to diagnose in clinical practice. The child had developed the disease since birth, but it took 3 years to make a confirmed diagnosis. Therefore, congenital thrombotic thrombocytopenic purpura should be considered for children with jaundice at birth, recurrent thrombocytopenia with hemolytic anemia, and negative results of the direct antiglobulin test. The detection of ADAMTS13 activity and ADAMTS13 inhibitory autoantibodies should be performed as soon as possible for a definite diagnosis, and gene detection should be performed to make a confirmed diagnosis when necessary.
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Affiliation(s)
- 敏慧 曾
- 湖南省人民医院/湖南师范大学附属第一医院儿童医学中心血液肿瘤科, 湖南长沙 410005Department of Pediatric Hematologic Oncology, Hunan Provincial People's Hospital/Children's Medical Center of First Affiliated Hospital of Hunan Normal University, Changsha 410005, China
| | - 湘玲 贺
- 湖南省人民医院/湖南师范大学附属第一医院儿童医学中心血液肿瘤科, 湖南长沙 410005Department of Pediatric Hematologic Oncology, Hunan Provincial People's Hospital/Children's Medical Center of First Affiliated Hospital of Hunan Normal University, Changsha 410005, China
| | - 鑫 田
- 湖南省人民医院/湖南师范大学附属第一医院儿童医学中心血液肿瘤科, 湖南长沙 410005Department of Pediatric Hematologic Oncology, Hunan Provincial People's Hospital/Children's Medical Center of First Affiliated Hospital of Hunan Normal University, Changsha 410005, China
| | - 玉辉 黄
- 益阳市资阳妇幼保健院儿科, 湖南益阳 413001
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37
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Dos Santos C, Paiva J, Romero ML, Agazzoni M, Kempfer AC, Rotondo S, Casinelli MM, Alberto MF, Sánchez‐Luceros A. Thrombotic microangiopathies: First report of 294 cases from a single institution experience in Argentina. EJHAEM 2021; 2:149-156. [PMID: 35845285 PMCID: PMC9175742 DOI: 10.1002/jha2.154] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 11/27/2020] [Accepted: 12/01/2020] [Indexed: 11/11/2022]
Abstract
Introduction Introduction: Thrombotic microangiopathies (TMAs) are rare disorders associated with fatal outcomes if left uncared for. However, healthcare problems in developing countries tend to limit medical assistance to patients. Methods Methods: We prospectively studied an Argentine cohort of 294 consecutive patients from 2013 to 2016. Patients’ subcategory classification relied on clinical symptoms and presence or absence of trigger events associated with TMA. Results Main suspected disorders were the primary TMAs known as thrombotic thrombocytopenic purpura (TTP) (n = 72/294, 24%) and atypical haemolytic uraemic syndrome (aHUS) (n = 94/294, 32%). In acute phase, demographic parameters for acquired TTP (aTTP) (n = 28) and aHUS (n = 47) showed that both groups were characterised by a young median age (37 and 25 years, respectively) and female predominance (60% and 86%). Median of a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13 activity was significantly lower in aTTP than in aHUS group (1.4% vs 83%) and was associated with a more severe thrombocytopenia (15 × 109 vs 53 × 109/L). Creatinine (Cr) and urea (Ur) were significantly increased in aHUS compared to aTTP subjects (Cr: 3.7 vs 0.7 mg/dL, Ur: 118 vs 33 mg/dL). Gastrointestinal and neurological symptoms were more frequent in aHUS and aTTP, respectively. Conclusion The first description of a TMA cohort in Argentina revealed similar clinical presentations to those of other countries.
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Affiliation(s)
- Célia Dos Santos
- Laboratory of Haemostasis and Thrombosis CONICET National Academy of Medicine Institute of Experimental Medicine Buenos Aires Argentina
| | - Juvenal Paiva
- Department of Haemostasis and Thrombosis National Academy of Medicine Haematologic Research Institute “Mariano R. Castex” Buenos Aires Argentina
| | - María Lucila Romero
- Department of Haemostasis and Thrombosis National Academy of Medicine Haematologic Research Institute “Mariano R. Castex” Buenos Aires Argentina
| | - Mara Agazzoni
- Department of Haemostasis and Thrombosis National Academy of Medicine Haematologic Research Institute “Mariano R. Castex” Buenos Aires Argentina
| | - Ana Catalina Kempfer
- Laboratory of Haemostasis and Thrombosis CONICET National Academy of Medicine Institute of Experimental Medicine Buenos Aires Argentina
| | - Sabrina Rotondo
- Department of Haemostasis and Thrombosis National Academy of Medicine Haematologic Research Institute “Mariano R. Castex” Buenos Aires Argentina
| | - María Marta Casinelli
- Department of Haemostasis and Thrombosis National Academy of Medicine Haematologic Research Institute “Mariano R. Castex” Buenos Aires Argentina
| | - María Fabiana Alberto
- Department of Haemostasis and Thrombosis National Academy of Medicine Haematologic Research Institute “Mariano R. Castex” Buenos Aires Argentina
| | - Analía Sánchez‐Luceros
- Laboratory of Haemostasis and Thrombosis CONICET National Academy of Medicine Institute of Experimental Medicine Buenos Aires Argentina
- Department of Haemostasis and Thrombosis National Academy of Medicine Haematologic Research Institute “Mariano R. Castex” Buenos Aires Argentina
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38
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Siddiqui A, Journeycake JM, Borogovac A, George JN. Recognizing and managing hereditary and acquired thrombotic thrombocytopenic purpura in infants and children. Pediatr Blood Cancer 2021; 68:e28949. [PMID: 33660913 DOI: 10.1002/pbc.28949] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Revised: 11/29/2020] [Accepted: 12/20/2020] [Indexed: 11/11/2022]
Abstract
We describe how infants and children with hereditary and acquired autoimmune thrombotic thrombocytopenic purpura (TTP) initially present and how they can be promptly diagnosed and effectively managed. These are uncommon disorders that are commonly misdiagnosed and can be rapidly fatal. TTP is caused by a severe deficiency of the plasma protease, A disintegrin and Metalloprotease with a ThromboSpondin type 1 motif, member 13 (ADAMTS13). Measurement of ADAMTS13 activity is becoming easily accessible. A common presentation of hereditary TTP is neonatal severe hemolysis and hyperbilirubinemia. However, the median age of diagnosis is not until 5.5 years. Plasma is effective treatment for exacerbations and for prophylaxis. Plasma may be replaced by recombinant ADAMTS13 when it becomes available. Acquired TTP is more frequent in older children, in whom it is more common in girls and is commonly associated with systemic lupus erythematosus. For acquired TTP, plasma exchange and immunosuppression are the current treatment for acute episodes; caplacizumab is now commonly used in adults and may replace plasma exchange.
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Affiliation(s)
- Anam Siddiqui
- Department of Pediatrics, College of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA.,Department of Medicine, College of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Janna M Journeycake
- Department of Pediatrics, College of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Azra Borogovac
- Department of Medicine, College of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - James N George
- Department of Medicine, College of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA.,Department of Biostatistics & Epidemiology, Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
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39
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Redefining outcomes in immune TTP: an international working group consensus report. Blood 2021; 137:1855-1861. [PMID: 33529333 DOI: 10.1182/blood.2020009150] [Citation(s) in RCA: 88] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 01/19/2021] [Indexed: 12/17/2022] Open
Abstract
Immune-mediated thrombotic thrombocytopenic purpura (iTTP) is a potentially fatal thrombotic microangiopathy caused by autoantibody-mediated severe deficiency of ADAMTS13. Standardized definitions of response, exacerbation, remission, and relapse were initially proposed in 2003 and modified by the International Working Group for TTP in 2017. These definitions, which have been widely used in clinical practice and research, are based primarily on the platelet count and are benchmarked against the timing of discontinuation of therapeutic plasma exchange (TPE). They do not incorporate ADAMTS13 activity or the temporizing effects on the platelet count of caplacizumab, a novel anti-von Willebrand factor (VWF) nanobody. In light of these limitations, the IWG aimed to develop revised consensus outcome definitions that incorporate ADAMTS13 activity and the effects of anti-VWF therapy, by using an estimate-talk-estimate approach. The updated definitions distinguish clinical remission and clinical relapse (defined primarily by platelet count) from ADAMTS13 remission and ADAMTS13 relapse (defined by ADAMTS13 activity). The revised definitions of exacerbation and remission are benchmarked against not only the timing of discontinuation of TPE but also that of anti-VWF therapy. Retrospective validation of the revised definitions is described, although they have yet to be prospectively validated. Clinical implications of the updated outcome definitions are also discussed and an example of their application to clinical practice is provided to highlight their clinical relevance.
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40
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Real-world experience with caplacizumab in the management of acute TTP. Blood 2021; 137:1731-1740. [PMID: 33150355 DOI: 10.1182/blood.2020007599] [Citation(s) in RCA: 78] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 10/12/2020] [Indexed: 12/13/2022] Open
Abstract
The cornerstone of life-saving therapy in immune-mediated thrombotic thrombocytopenic purpura (iTTP) has been plasma exchange (PEX) combined with immunomodulatory strategies. Caplacizumab, a novel anti-von Willebrand factor nanobody trialed in 2 multicenter randomized controlled trials (RCTs) leading to European Union and US Food and Drug Administration approval, has been available in the United Kingdom (UK) through a patient access scheme. Data were collected retrospectively from 2018 to 2020 for 85 patients (4 children) receiving caplacizumab from 22 UK hospitals. Patient characteristics and outcomes in the real-world clinical setting were compared with caplacizumab trial end points and historical outcomes in the precaplacizumab era. Eighty-four of 85 patients received steroid and rituximab alongside PEX; 26% required intubation. Median time to platelet count normalization (3 days), duration of PEX (7 days), and hospital stay (12 days) were comparable with RCT data. Median duration of PEX and time from PEX initiation to platelet count normalization were favorable compared with historical outcomes (P < .05). Thrombotic thrombocytopenic purpura (TTP) recurred in 5 of 85 patients; all had persistent ADAMTS13 activity < 5 IU/dL. Of 31 adverse events in 26 patients, 17 of 31 (55%) were bleeding episodes, and 5 of 31 (16%) were thrombotic events (2 unrelated to caplacizumab); mortality was 6% (5/85), with no deaths attributed to caplacizumab. In 4 of 5 deaths, caplacizumab was introduced >48 hours after PEX initiation (3-21 days). This real-world evidence represents the first and largest series of TTP patients, including pediatric patients, receiving caplacizumab outside of clinical trials. Representative of true clinical practice, the findings provide valuable information for clinicians treating TTP globally.
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41
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How I treat thrombotic thrombocytopenic purpura in pregnancy. Blood 2021; 136:2125-2132. [PMID: 32797178 DOI: 10.1182/blood.2019000962] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 05/20/2020] [Indexed: 12/22/2022] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) is an acute, life-threatening thrombotic microangiopathy (TMA) caused by acquired or congenital severe deficiency of ADAMTS13. Pregnancy is a recognized risk factor for precipitating acute (first or recurrent) episodes of TTP. Differential diagnosis with other TMAs is particularly difficult when the first TTP event occurs during pregnancy; a high index of suspicion and prompt recognition of TTP are essential for achieving a good maternal and fetal outcome. An accurate distinction between congenital and acquired cases of pregnancy-related TTP is mandatory for safe subsequent pregnancy planning. In this article, we summarize the current knowledge on pregnancy-associated TTP and describe how we manage TTP during pregnancy in our clinical practice.
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42
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Immune-mediated thrombotic thrombocytopenic purpura in childhood treated by caplacizumab, about 3 cases. J Nephrol 2021; 35:653-656. [PMID: 33616856 DOI: 10.1007/s40620-021-00992-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Accepted: 02/03/2021] [Indexed: 12/16/2022]
Abstract
Immune-mediated thrombotic thrombocytopenic purpura (iTTP) is a rare disease in adults and exceptional in childhood. Caplacizumab has proven its effectiveness in the treatment of iTTP in adulthood in association with standard of care. Unfortunately, this treatment is restricted to adults. We report our experience in three children who were treated successfully with caplacizumab.
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43
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Bécel G, Faict S, Picod A, Bouzid R, Veyradier A, Coppo P. Thrombotic Thrombocytopenic Purpura: When Basic Science Meets Clinical Research. Hamostaseologie 2021; 41:283-293. [PMID: 33607665 DOI: 10.1055/a-1332-3066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
The therapeutic landscape of thrombotic thrombocytopenic purpura (TTP) is rapidly changing with the recent availability of new targeted therapies. This progressive shift from empiricism to pathophysiology-based treatments reflects an intensive interaction between the continuous findings in the field of basic science and an efficient collaborative clinical research and represents a convincing example of the strength of translational medicine. Despite the rarity of TTP, national and international efforts could circumvent this limitation and shed light on the epidemiology, clinical presentation, prognosis, and long-term outcome of this disease. Importantly, they also provided high-quality results and practice changing studies for the benefit of patients. We report here the most recent therapeutic findings that allowed progressively improving the prognostic of TTP, both at the acute phase and through long-term outcome.
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Affiliation(s)
- Gaëlle Bécel
- Centre de Référence des MicroAngiopathies Thrombotiques, Paris, France.,Service d'hématologie, Hôpital Saint-Antoine, AP-HP - Sorbonne Université, Paris, France
| | - Sylvia Faict
- Centre de Référence des MicroAngiopathies Thrombotiques, Paris, France.,Service d'hématologie, Hôpital Saint-Antoine, AP-HP - Sorbonne Université, Paris, France
| | - Adrien Picod
- Centre de Référence des MicroAngiopathies Thrombotiques, Paris, France.,Service d'hématologie, Hôpital Saint-Antoine, AP-HP - Sorbonne Université, Paris, France
| | - Raïda Bouzid
- Centre de Référence des MicroAngiopathies Thrombotiques, Paris, France
| | - Agnès Veyradier
- Centre de Référence des MicroAngiopathies Thrombotiques, Paris, France.,Service d'Hématologie Biologique, Groupe Hospitalier Saint-Louis-Lariboisière, AP-HP, Paris, France.,Université Paris-Diderot, Paris, France
| | - Paul Coppo
- Centre de Référence des MicroAngiopathies Thrombotiques, Paris, France.,Service d'hématologie, Hôpital Saint-Antoine, AP-HP - Sorbonne Université, Paris, France.,Centre de Recherche des Cordeliers, INSERM, Sorbonne Université, USPC, Université Paris Descartes, Paris, France
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44
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Browning S, Bahar B, Lee AI, Gorshein E. Spontaneous recovery in a patient with acquired thrombotic thrombocytopenic purpura (TTP): observation of a 'subclinical' TTP state. ACTA ACUST UNITED AC 2021; 25:473-477. [PMID: 33269995 DOI: 10.1080/16078454.2020.1848973] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVES Thrombotic thrombocytopenic purpura (TTP) is a thrombotic microangiopathy that can have high mortality rates without prompt treatment. Standard treatment is urgent plasma exchange (PLEX), which leads to disease remission in the vast majority of patients. Deficiency of ADAMTS13 (a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13) alone is not sufficient to cause the clinical manifestations characteristic of TTP. We present a case of acquired TTP, where spontaneous recovery was observed prior to initiation of any TTP-specific therapy. CLINICAL PRESENTATION A 73-year-old asymptomatic female presented with new-onset mild haemolytic anaemia and thrombocytopenia. Further testing revealed a significantly reduced ADAMTS13 activity level and an ADAMTS13 inhibitor, concerning for acquired TTP. On reassessment, the patient's haematologic parameters had been corrected prior to initiation of therapy. During subsequent follow-up three months later, she developed acute worsening thrombocytopenia indicative of relapsed, acute TTP. The patient was then successfully managed with PLEX and rituximab and achieved a sustained remission. DISCUSSION AND CONCLUSION TTP is a haematologic emergency that requires urgent therapy to reduce morbidity and mortality. However, it is well documented that individuals with hereditary TTP and a proportion with acquired TTP in clinical remission can have low or nearly absent ADAMTS13 activity levels without evidence of microangiopathic haemolytic anaemia (MAHA) or thrombotic manifestations. Our patient represents a unique case of confirmed ADAMTS13 deficiency due to a documented inhibitor, leading to mild haemolytic anaemia and thrombocytopenia both of which recovered spontaneously. We propose that this scenario could represent a 'subclinical' TTP state that precedes the development of clinically significant disease.
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Affiliation(s)
- Sabrina Browning
- Section of Hematology, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Burak Bahar
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT, USA.,Department of Pathology and Laboratory Medicine, George Washington University, Children's National Hospital, Washington DC, USA
| | - Alfred Ian Lee
- Section of Hematology, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Elan Gorshein
- Section of Hematology, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
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45
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Ning J, Guan X, Li X. Case of acquired thrombotic thrombocytopenic purpura associated with influenza A (H1N1) virus and literature review. J Paediatr Child Health 2021; 57:282-285. [PMID: 32216073 DOI: 10.1111/jpc.14846] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 02/11/2020] [Accepted: 02/24/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Junjie Ning
- Pediatric Intensive Care Unit, First People's Hospital, Zigong, China
| | - Xiaoyan Guan
- Pediatric Intensive Care Unit, First People's Hospital, Zigong, China
| | - Xuemei Li
- Pediatric Intensive Care Unit, First People's Hospital, Zigong, China
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46
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Picod A, Veyradier A, Coppo P. Should all patients with immune-mediated thrombotic thrombocytopenic purpura receive caplacizumab? J Thromb Haemost 2021; 19:58-67. [PMID: 33236389 DOI: 10.1111/jth.15194] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 11/18/2020] [Accepted: 11/19/2020] [Indexed: 12/13/2022]
Abstract
Immune-mediated thrombotic thrombocytopenic purpura (iTTP) is a rare, life-threatening disease that causes systemic platelet-rich microthrombi with multiorgan damage. The historical treatment is based on therapeutic plasma exchange (TPE) and immunosuppression. Despite survival rates exceeding 85%, unfavorable outcomes including refractoriness, death, and exacerbations of the disease during treatment still calls for a better management strategy. Caplacizumab (Cablivi) appeared recently as a new treatment in iTTP. By inhibiting binding of von Willebrand factor to platelets, caplacizumab prevents platelets aggregation and the formation of microthrombi. Two pivotal randomized controlled trials have provided positive results where the use of caplacizumab is associated with faster platelet count recovery and less unfavorable outcomes. The other strength of this agent is an impressive alleviation in the burden of care, consisting in less TPE sessions and lower volumes of plasma to achieve remission, as well as substantial shortening in the length of hospitalization. However, since the recent approval of caplacizumab for the treatment of iTTP on the basis of these studies, debates remain regarding its systematic use in this indication. Should all patients be benefited from caplacizumab? Should we reserve caplacizumab only to the more severe patients? Should caplacizumab be initiated frontline or as a salvage therapy? If applicable, how should we select patients for caplacizumab? Last, is caplacizumab treatment cost-effective? This review aims at addressing these specific questions at a time when iTTP is entering the area of targeted therapies.
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Affiliation(s)
- Adrien Picod
- Centre National de Référence des MicroAngiopathies Thrombotiques, Paris, France
| | - Agnès Veyradier
- Centre National de Référence des MicroAngiopathies Thrombotiques, Paris, France
- Service d'hématologie biologique, Hôpital Lariboisière, Assistance Publique - Hôpitaux de Paris, Paris, France
- EA-3518, Institut de recherche Saint Louis, Université de Paris, France
| | - Paul Coppo
- Centre National de Référence des MicroAngiopathies Thrombotiques, Paris, France
- Service d'hématologie, Hôpital Saint-Antoine, Assistance publique - Hôpitaux de Paris, Sorbonne-Université (AP-HP.6), Paris, France
- INSERM UMRS 1138, Centre de Recherche des Cordeliers, Paris, France
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47
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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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48
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Veyradier A. A new drug for an old concept: aptamer to von Willebrand factor for prevention of arterial and microvascular thrombosis. Haematologica 2020; 105:2512-2515. [PMID: 33131243 PMCID: PMC7604565 DOI: 10.3324/haematol.2020.261081] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Affiliation(s)
- Agnès Veyradier
- Hematology department, French National Reference Centre for Thrombotic Microangiopathies and von Willebrand disease, Hospital Lariboisière, AP-HP.Nord; EA3518 Saint-Louis Research Institute, Paris University, Paris, France.
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Ahmadpoor P, Aglae C, Garo F, Cariou S, Renaud S, Reboul P, Moranne O. Humanized anti CD-20 as an alternative in chronic management of relapsing thrombotic thrombocytopenic microangiopathy resistant to rituximab due to anti chimeric antibody. Int J Hematol 2020; 113:456-460. [PMID: 33067738 DOI: 10.1007/s12185-020-03020-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 09/07/2020] [Accepted: 10/01/2020] [Indexed: 10/23/2022]
Abstract
Acquired Immune thrombotic thrombocytopenic purpura (iTTP) is considered among clinical situations that needs not only urgent treatment in acute setting but also long term management to prevent relapses. Important progresses have been made in management of these patients that are definitely associated with reduced mortality and relapse rate. However, there are still noticeable percentage of patients that may relapse despite application of modern treatment strategies including preemptive rituximab infusions. Hereby, we share our experience concerning a frequently relapsing iTTP due to development of anti-rituximab antibody. In our case administration of obinutuzumab, a humanized type II anti CD-20 antibody was associated with complete peripheral blood B cell depletion and increasing plasma ADAMTS-13 activity.
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Affiliation(s)
- Pedram Ahmadpoor
- Department of Nephrology, Dialysis and Apheresis, University Hospital Caremeau, Nimes, France
| | - Cedric Aglae
- Department of Nephrology, Dialysis and Apheresis, University Hospital Caremeau, Nimes, France
| | - Florian Garo
- Department of Nephrology, Dialysis and Apheresis, University Hospital Caremeau, Nimes, France
| | - Sylvain Cariou
- Department of Nephrology, Dialysis and Apheresis, University Hospital Caremeau, Nimes, France
| | - Sophie Renaud
- Department of Nephrology, Dialysis and Apheresis, University Hospital Caremeau, Nimes, France
| | - Pascal Reboul
- Department of Nephrology, Dialysis and Apheresis, University Hospital Caremeau, Nimes, France
| | - Olivier Moranne
- Department of Nephrology, Dialysis and Apheresis, University Hospital Caremeau, Nimes, France. .,Service de Néphrologie, Dialyse, Apherese, Hopital Universitaire Caremeau, 4 place Pr Robert-Debré, Nimes, 3029, France.
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50
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Zheng XL, Vesely SK, Cataland SR, Coppo P, Geldziler B, Iorio A, Matsumoto M, Mustafa RA, Pai M, Rock G, Russell L, Tarawneh R, Valdes J, Peyvandi F. ISTH guidelines for the diagnosis of thrombotic thrombocytopenic purpura. J Thromb Haemost 2020; 18:2486-2495. [PMID: 32914582 PMCID: PMC8146131 DOI: 10.1111/jth.15006] [Citation(s) in RCA: 126] [Impact Index Per Article: 31.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 07/07/2020] [Accepted: 07/10/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Despite an increase in our understandings of pathogenesis of thrombotic thrombocytopenic purpura (TTP), the approaches for initial diagnosis and management of TTP vary significantly. OBJECTIVE The evidence-based guidelines of the International Society on Thrombosis and Haemostasis (ISTH) are intended to support patients, clinicians, and other health care professionals in their decisions about the initial diagnosis and management of acute TTP. METHODS In June 2018, ISTH formed a multidisciplinary panel that included hematologists, an intensive care physician, nephrologist, clinical pathologist, biostatistician, and patient representatives, as well as a methodology team from McMaster University. The panel composition was designed to minimize the potential conflicts of interests. The panel used the Grading of Recommendations Assessment, Development, and Evaluation approach and the Population, Intervention, Comparison, Outcome framework to develop and grade their recommendations. Public comments were sought and incorporated in the final document. RESULTS The panel agreed on three recommendations covering the initial diagnosis with emphasis on the importance of ADAMTS13 testing (eg, activity, anti-ADAMTS13 IgG or inhibitor) and assessment of the pretest probability of TTP by clinical assessment and/or the risk assessment models like the PLASMIC or French score. The panel noted how availability and turnaround time of ADAMTS13 test results might affect early diagnosis and management, in particular the use of caplacizumab. CONCLUSIONS There is a lack of high-quality evidence to support strong recommendations for the initial diagnosis and management of a suspected TTP. The panel emphasized the importance of obtaining ADAMTS13 testing in a proper clinical context. Future research should focus on how to monitor and act on ADAMTS13 levels during remission.
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Affiliation(s)
- X. Long Zheng
- Department of Pathology and Laboratory Medicine, The University of Kansas Medical Center, Kansas City, KS, USA
| | - Sara K. Vesely
- Hudson College of Public Health, The University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Spero R. Cataland
- Department of Medicine, The Ohio State University, Columbus, OH, USA
| | - Paul Coppo
- Centre de Référence des Microangiopathies Thrombotiques, Service d’Hématologie, Hôpital Saint-Antoine, Assistance Publique, Hôpitaux de Paris, Sorbonne Université, Paris, France
| | | | - Alfonso Iorio
- Department of Health Research Methods, Research, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Masanori Matsumoto
- Department of Blood Transfusion Medicine, Nara Medical University, Kashihara, Japan
| | - Reem A. Mustafa
- Department of Medicine, The University of Kansas Mediccal Center, Kansas City, KS, USA
| | - Menaka Pai
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Gail Rock
- University of Ottawa, Ottawa, CA, USA
| | - Lene Russell
- Department of Intensive Care, Copenhagen University Hospital, Copenhagen, Denmark
| | - Rawan Tarawneh
- Department of Neurology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | | | - Flora Peyvandi
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
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