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Zhang B, Chu R, Huang C, Song X, Wang J, Li L, Xu Y, Ma Y. Progress in the Management of Pregnancy with Paroxysmal Nocturnal Hemoglobinuria: A Review. J Womens Health (Larchmt) 2024; 33:98-104. [PMID: 37917919 DOI: 10.1089/jwh.2023.0164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2023] Open
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) is a rare acquired complement-mediated hemolytic disease characterized by intravascular hemolysis, thrombosis, smooth muscle dystonia, and so on. Thrombosis is the principal cause of death in PNH patients. During the perinatal period, pregnant PNH patients have increased morbidity and mortality with a heightened risk of complications, including significant preterm birth. The management of pregnancy complicated by PNH is difficult. Therefore, early diagnosis, standardized treatment protocols, and improving perinatal outcomes are crucial. However, there is a lack of consensus on treating patients with PNH during pregnancy. This article reviews 32 studies of pregnancy affected by PNH, focusing on the clinical presentation, diagnosis, and treatment strategies of PNH, to provide guidance for obstetricians on how to handle pregnant patients with PNH, and to offer academic support for the management of PNH patients. We found that Eculizumab has become the primary choice for treating PNH, effectively controlling intravascular hemolysis and reducing the frequency of blood transfusions necessary to stabilize the condition, with no severe threat to the safety of the mother and fetus.
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Affiliation(s)
- Bei Zhang
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, Jinan, P.R. China
| | - Ran Chu
- Department of Obstetrics and Gynecology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, P.R. China
| | - Changzhen Huang
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, Jinan, P.R. China
| | - Xiao Song
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University Dezhou Hospital, Dezhou, P.R. China
| | - Jianye Wang
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, Jinan, P.R. China
| | - Liang Li
- Department of Anesthesiology, Qilu Hospital of Shandong University, Jinan, Shandong, P.R. China
| | - Yintao Xu
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, Jinan, P.R. China
| | - Yuyan Ma
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, Jinan, P.R. China
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Panse J. Paroxysmal nocturnal hemoglobinuria: Where we stand. Am J Hematol 2023; 98 Suppl 4:S20-S32. [PMID: 36594182 DOI: 10.1002/ajh.26832] [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: 10/19/2022] [Revised: 12/26/2022] [Accepted: 12/27/2022] [Indexed: 01/04/2023]
Abstract
For the last 20 years, therapy of paroxysmal nocturnal hemoglobinuria (PNH) relied-up until recently-on antibody based terminal complement inhibitionon. PNH pathophysiology-a mutational defect leading to partial or complete absence of complement-regulatory proteins on blood cells-leads to intravascular hemolysis and consequences such as thrombosis and other sequelae. A plethora of new drugs interfering with the proximal and terminal complement cascade are under recent development and the first "proof-of-pinciple" proximal complement inhibitor targeting C3 has been approved in 2021. "PNH: where we stand" will try to give a brief account on where we came from and where we stand focusing on approved therapeutic options. The associated improvements as well as potential consequences of actual and future treatments as well as their impact on the disease will continue to necessitate academic and scientific focus on improving treatment options as well as on side effects and outcomes relevant to individual patient lives and circumstances in order to develop effective, safe, and available treatment for all hemolytic PNH patients globally.
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Affiliation(s)
- Jens Panse
- Department of Oncology, Hematology, Hemostaseology and Stem Cell Transplantation, University Hospital RWTH Aachen, Aachen, Germany
- Center for Integrated Oncology (CIO), Aachen Bonn Cologne Düsseldorf (ABCD), Aachen, Germany
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Alashkar F, Weber SN, Vance C, Herich-Terhürne D, Dührsen U, Lammert F, Röth A. Persisting hyperbilirubinemia in patients with paroxysmal nocturnal hemoglobinuria (PNH) chronically treated with eculizumab: The role of hepatocanalicular transporter variants. Eur J Haematol 2017; 99:350-356. [PMID: 28692147 DOI: 10.1111/ejh.12927] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/05/2017] [Indexed: 12/30/2022]
Abstract
BACKGROUND Eculizumab-treated paroxysmal nocturnal hemoglobinuria (PNH) patients (pts) show a dramatic decrease in serum lactate dehydrogenase (LDH) activities and bilirubin concentrations. However, some pts remain hyperbilirubinemic, possibly indicating an inadequate response due to extravascular hemolysis. METHODS Mutation analyses of hepatocanalicular transporter/nuclear receptor variants (ABCB4, ABCB11, ATP8B1, NR1H4) were performed in eight (five of eight males; mean age 38 years [range 26-68 years]) out of the 174 pts with PNH/-clone at our department due to a persistent increase in total bilirubin concentrations (median 3.4 mg/dL; range 2.1-8.1 mg/dL) during chronic eculizumab treatment and normal/or slightly increased serum aminotransferase activities. Median observation time was 70.1 months (range 10.6-135.2 months). All pts were treated according to German PNH guidelines. RESULTS Homozygous and heterozygous procholestatic variants in the ABCB4, ABCB11, and ATP8B1 genes were identified in all eight pts. All carried the common ABCB4 c.787A>T polymorphism. The A(TA)7 TAA variant in the UGT1A1 promoter causing Gilbert syndrome was detected in three pts (5/8). CONCLUSIONS Hyperbilirubinemia in PNH pts treated with eculizumab might not only be due to an insufficient response but rather a combination of mutations in hepatocanalicular transporter variants, Gilbert syndrome, and extravascular hemolysis. Our findings warrant further studies concerning transporter and enzyme variants in PNH to determine their clinical significance.
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Affiliation(s)
- Ferras Alashkar
- Department of Hematology, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Susanne N Weber
- Department of Medicine II, Saarland University Medical Center, Saarland University, Homburg, Germany
| | - Colin Vance
- Rheinisch-Westfälisches Institut für Wirtschaftsforschung, Essen, Germany
| | - Dörte Herich-Terhürne
- Department of Hematology, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Ulrich Dührsen
- Department of Hematology, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Frank Lammert
- Department of Medicine II, Saarland University Medical Center, Saarland University, Homburg, Germany
| | - Alexander Röth
- Department of Hematology, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
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Morita Y, Nishimura JI, Shimada T, Tanaka H, Serizawa K, Taniguchi Y, Tsuritani M, Kanakura Y, Matsumura I. Successful anticoagulant therapy for two pregnant PNH patients, and prospects for the eculizumab era. Int J Hematol 2013; 97:491-7. [DOI: 10.1007/s12185-013-1302-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2012] [Revised: 02/18/2013] [Accepted: 02/19/2013] [Indexed: 10/27/2022]
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Weitz IC, Razavi P, Rochanda L, Zwicker J, Furie B, Manly D, Mackman N, Green R, Liebman HA. Eculizumab therapy results in rapid and sustained decreases in markers of thrombin generation and inflammation in patients with PNH independent of its effects on hemolysis and microparticle formation. Thromb Res 2012; 130:361-8. [PMID: 22542362 DOI: 10.1016/j.thromres.2012.04.001] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2011] [Revised: 03/28/2012] [Accepted: 04/03/2012] [Indexed: 12/28/2022]
Abstract
Paroxysmal Nocturnal Hemoglobinuria (PNH) is a clonal bone marrow disorder which results in the loss of glycosylphosphatidyl inositol (GPI) anchors from cell membranes. As a consequence, membrane inhibitors of complement are lost rendering the cells more susceptible to complement mediated destruction. This results in hemolysis, leukopenia, thrombocytopenia and thrombophilia. Eculizumab, a monoclonal antibody to complement protein 5, has been approved for the treatment of PNH and is associated with a significant reduction in hemolysis, thromboembolic events and fatigue. We prospectively studied the effect of Eculizumab therapy on plasma markers of thrombin generation (D-Dimers, TAT), inflammation (IL-6), soluble P-selectin (sP-selectin), antigenic (TFMP) and functional (fTFMP) tissue factor bearing microparticles and total plasma microparticle ex vivo factor Xa generation (MPFXa) in eleven Eculizumab naive PNH patients. Blood sampling occurred day 1, prior to Eculizumab treatment, then on days 8,15,22,29, 43, 90. Our results demonstrate a statistically significant reduction in D-Dimer, TAT, IL-6, sP-selectin, and TFMP during the induction phase of treatment (day 1-29) which was sustained during the maintenance treatment (day 29-90). Although the serum LDH levels decreased rapidly, there was no correlation between the change in LDH and the markers of thrombin generation and inflammation. Although there was a statistically significant decrease in TFMP, this decrease did not correlate with changes in markers of thrombin generation or inflammation. Ex vivo MPFXa generation did not decrease with Eculizumab treatment suggesting continued microparticle formation despite inhibition of hemolysis. Ex vivo total microparticle FXa generation was found to have an inverse correlation with markers of thrombin generation, suggesting that in PNH patients in vivo thrombin generation occurs by a pathway independent of hemolysis and microparticle generation.
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Affiliation(s)
- Ilene C Weitz
- Department of Medicine, University of Southern California-Keck School of Medicine, Los Angeles 90033, CA, USA.
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Danilov AV, Brodsky RA, Craigo S, Smith H, Miller KB. Managing a pregnant patient with paroxysmal nocturnal hemoglobinuria in the era of eculizumab. Leuk Res 2010; 34:566-71. [PMID: 19954846 DOI: 10.1016/j.leukres.2009.10.025] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2009] [Revised: 10/27/2009] [Accepted: 10/28/2009] [Indexed: 11/16/2022]
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) is a rare clonal stem cell disorder, which affects women of child-bearing age. PNH is associated with thrombotic complications, which are the main causes of morbidity and mortality. Management of a pregnant woman with PNH remains a challenge due to high incidence of thrombotic complications and the difficulty of differentiating a PNH crisis from the complications of pregnancy. PNH is associated with an increased rate of premature labor and fetal loss. Eculizumab, a humanized monoclonal antibody directed against the terminal complement protein C5, has revolutionized treatment of PNH. However, the role of eculizumab in pregnancy is unclear. We review the current strategies for the management of pregnant women with PNH, underline the controversies and present our recommendations.
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Affiliation(s)
- Alexey V Danilov
- Department of Hematology and Oncology, Tufts Medical Center, 800 Washington St, Boston, MA 02111, USA
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Kirkizlar O, Kendir M, Karaali Z, Ure U, Ozbay G, Selcuk D, Kazancioglu R. Acute renal failure in a patient with severe hemolysis. Int Urol Nephrol 2007; 39:651-4. [PMID: 17235485 DOI: 10.1007/s11255-006-9096-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2006] [Accepted: 07/26/2006] [Indexed: 10/23/2022]
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) is a clonal disorder of bone marrow. It is characterized by blood cells lacking membrane proteins that are normally attached by the glycosylphosphatidylinositol (GPI) anchor. The cellular defect arises in a hematopoetic stem cell and is due to somatic mutation of the Phosphatidylinositol-glycan protein-A gene (PIG-A gene), encoding a protein needed for the biosynthesis of the anchor GPI. Paroxysmal nocturnal hemoglobinuria is presented by intravascular hemolysis, cytopenias, frequent infections, bone marrow hypoplasia, and a high incidence of life threatening venous thrombosis. Kidney involvement is usually benign and secondary to chronic tubular deposition of hemosiderin. Acute renal failure may occur in association with a hemolytic crisis. Here we report a case of 40-year-old woman with hematuria, pancytopenia, and acute renal failure due to PNH.
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Affiliation(s)
- Onur Kirkizlar
- Internal Medicine Clinic, Haseki Education and Research Hospital, Adivar street, Aksaray/Fatih, Istanbul, Turkey.
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Omine M, Kinoshita T, Nakakuma H, Maciejewski JP, Parker CJ, Socié G. Paroxysmal Nocturnal Hemoglobinuria. Int J Hematol 2005; 82:417-21. [PMID: 16533745 DOI: 10.1532/ijh97.05140] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Mitsuhiro Omine
- Division of Hematology, Internal Medicine, Showa University Fujigaoka Hospital, 1-30 Fujigaoka, Aoba-ku, Yokohama City 227-8501, Japan.
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Dolezel Z, Dostalkova D, Blatny J, Starha J, Gerykova H. Paroxysmal nocturnal hemoglobinuria in a girl with hemolysis and "hematuria". Pediatr Nephrol 2004; 19:1177-9. [PMID: 15278422 DOI: 10.1007/s00467-004-1563-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2004] [Revised: 05/18/2004] [Accepted: 05/18/2004] [Indexed: 02/08/2023]
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) is a rare disorder of unknown frequency. In its classic form, PNH is characterized by hemolysis accompanied by nocturnal hemoglobinuria. The clinical course is unpredictable and may vary from severe hemolysis and recurrent venous thrombosis to latent periods with milder symptoms. We report a 15-year-old girl with hemolytic episodes, abdominal pain, and passage of dark urine. Hemoglobinuria was demonstrated by a "blood"-positive dipstick test in the absence of red blood cells in the urinary sediment. The diagnosis of PNH was confirmed by flow cytometry.
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Affiliation(s)
- Zdenek Dolezel
- Department of Pediatrics, University Hospital Brno, Cernopolni 9, 625 00 Brno, Czech Republic.
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Paech MJ, Pavy TJG. Management of a parturient with paroxysmal nocturnal haemoglobinuria. Int J Obstet Anesth 2004; 13:188-91. [PMID: 15321400 DOI: 10.1016/j.ijoa.2004.02.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/01/2004] [Indexed: 11/30/2022]
Abstract
We present the case of a 30-year-old parturient diagnosed in the first trimester of her first pregnancy as having paroxysmal nocturnal haemoglobinuria. Pancytopenia necessitated regular transfusion of blood products. The risks of infection, haemorrhage and thrombosis, in the presence of severe thrombocytopenia, mild neutropenia and prophylactic anticoagulation, posed management challenges. We discuss the pathophysiology of paroxysmal nocturnal haemoglobinuria and the impact of pregnancy on the disorder, particularly on maternal morbidities such as thrombosis. The issues relevant to antenatal and peripartum obstetric, haematological and anaesthetic care for vaginal delivery are considered. Severe thrombocytopenia proved a contraindication to regional techniques and she required general anaesthesia for evacuation of a retained placenta. The post-partum period was complicated by fever and a requirement for blood products. Management of these problems, of prophylactic anticoagulation and subsequent therapy, are discussed.
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Affiliation(s)
- M J Paech
- Department of Anaesthesia and Pain Medicine, King Edward Memorial Hospital for Women, Perth, Western Australia, Australia.
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