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Ma S, Bhar S, Guffey D, Kim RB, Jamil M, Amos CI, Lee SJ, Hingorani SR, Sartain SE, Li A. Prospective Clinical and Biomarker Validation of the American Society for Transplantation and Cellular Therapy Consensus Definition for Transplantation-Associated Thrombotic Microangiopathy. Transplant Cell Ther 2023; 29:685.e1-685.e7. [PMID: 37597686 PMCID: PMC11037887 DOI: 10.1016/j.jtct.2023.08.015] [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: 06/14/2023] [Revised: 08/04/2023] [Accepted: 08/10/2023] [Indexed: 08/21/2023]
Abstract
Transplantation-associated thrombotic microangiography (TA-TMA) is a disorder that causes severe complications after allogeneic hematopoietic cell transplantation (allo-HCT). Diagnosing TA-TMA is challenging because of the lack of standardized criteria. In this study, we aimed to evaluate the new TA-TMA consensus definition from the American Society for Transplantation and Cellular Therapy (ASTCT) panel as part of an ongoing prospective pediatric cohort study, and also to compare the impact and outcomes of using the current definition of clinical TMA (cTMA) versus the new consensus definition. We included patients age 0 to 18 years who underwent their first allo-HCT between May 2021 and January 2023 at Texas Children's Hospital. We compared the incidence, biomarkers, and outcomes of TA-TMA applying the previous and recently proposed screening algorithms and definitions. Whereas use of the classic microangiopathic hemolytic anemia (MAHA)-based cTMA definition led to an incidence of 12.7% by day 100 post-transplantation, the ASTCT-HR definition doubled the incidence to 28.5% by day 100. In contrast to patients with a concordant diagnosis (+/+), who had significantly worse post-transplantation survival, those reclassified as TA-TMA only by the new definition (-/+) had a significantly different prognosis (100% survival at day 100) despite the lack of TMA-directed therapy. Furthermore, biomarkers of the terminal and alternative complement pathways (sC5b9 and Ba, respectively) were significantly elevated compared with non-TMA patients around day 15 in the concordant group (+/+) but not in the discordant group (-/+). The recently proposed ASTCT consensus TA-TMA diagnosis is more sensitive and allows earlier recognition of manifestation that requires closer clinical monitoring but risks overdiagnosis and overtreatment. We recommend additional prospective validation.
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Affiliation(s)
- Shengling Ma
- Section of Hematology-Oncology, Baylor College of Medicine, Houston, Texas
| | - Saleh Bhar
- Divisions of Hematology/Oncology and Critical Care Medicine and Bone Marrow Transplantation, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Danielle Guffey
- Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, Texas
| | - Rock Bum Kim
- Section of Hematology-Oncology, Baylor College of Medicine, Houston, Texas
| | - Mahrukh Jamil
- Section of Hematology-Oncology, Baylor College of Medicine, Houston, Texas
| | - Christopher I Amos
- Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, Texas; Section of Epidemiology and Population Science, Baylor College of Medicine, Houston, Texas
| | - Stephanie J Lee
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Division of Medical Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Sangeeta R Hingorani
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
| | - Sarah E Sartain
- Section of Hematology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Ang Li
- Section of Hematology-Oncology, Baylor College of Medicine, Houston, Texas.
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Wilhelm G, Mertowska P, Mertowski S, Przysucha A, Strużyna J, Grywalska E, Torres K. The Crossroads of the Coagulation System and the Immune System: Interactions and Connections. Int J Mol Sci 2023; 24:12563. [PMID: 37628744 PMCID: PMC10454528 DOI: 10.3390/ijms241612563] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 07/31/2023] [Accepted: 08/05/2023] [Indexed: 08/27/2023] Open
Abstract
The coagulation and immune systems, two vital systems in the human body, share intimate connections that fundamentally determine patient health. These systems work together through several common regulatory pathways, including the Tissue Factor (TF) Pathway. Immune cells expressing TF and producing pro-inflammatory cytokines can influence coagulation, while coagulation factors and processes reciprocally impact immune responses by activating immune cells and controlling their functions. These shared pathways contribute to maintaining health and are also involved in various pathological conditions. Dysregulated coagulation, triggered by infection, inflammation, or tissue damage, can result in conditions such as disseminated intravascular coagulation (DIC). Concurrently, immune dysregulation may lead to coagulation disorders and thrombotic complications. This review elucidates these intricate interactions, emphasizing their roles in the pathogenesis of autoimmune diseases and cancer. Understanding the complex interplay between these systems is critical for disease management and the development of effective treatments. By exploring these common regulatory mechanisms, we can uncover innovative therapeutic strategies targeting these intricate disorders. Thus, this paper presents a comprehensive overview of the mutual interaction between the coagulation and immune systems, highlighting its significance in health maintenance and disease pathology.
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Affiliation(s)
- Grzegorz Wilhelm
- Department of Plastic and Reconstructive Surgery and Microsurgery, Medical University of Lublin, 20-059 Lublin, Poland; (G.W.); (K.T.)
| | - Paulina Mertowska
- Department of Experimental Immunology, Medical University of Lublin, 20-093 Lublin, Poland; (S.M.); (E.G.)
| | - Sebastian Mertowski
- Department of Experimental Immunology, Medical University of Lublin, 20-093 Lublin, Poland; (S.M.); (E.G.)
| | - Anna Przysucha
- Chair and Department of Didactics and Medical Simulation, Medical University of Lublin, 20-093 Lublin, Poland;
| | - Jerzy Strużyna
- East Center of Burns Treatment and Reconstructive Surgery, Medical University of Lublin, 20-059 Lublin, Poland;
| | - Ewelina Grywalska
- Department of Experimental Immunology, Medical University of Lublin, 20-093 Lublin, Poland; (S.M.); (E.G.)
| | - Kamil Torres
- Department of Plastic and Reconstructive Surgery and Microsurgery, Medical University of Lublin, 20-059 Lublin, Poland; (G.W.); (K.T.)
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Vitkauskaitė M, Vinikovas A, Miglinas M, Rimševičius L, Čerkauskaitė A, Mačionienė E, Ašakienė E. Complement inhibitor eculizumab in thrombotic microangiopathy: Single‐center case series. Clin Case Rep 2022; 10:e05573. [PMID: 35317070 PMCID: PMC8922540 DOI: 10.1002/ccr3.5573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 01/16/2022] [Accepted: 02/16/2022] [Indexed: 11/07/2022] Open
Affiliation(s)
| | - Artūras Vinikovas
- Faculty of MedicineVilnius UniversityVilniusLithuania
- Clinic of Gastroenterology, Nephro‐Urology and SurgeryFaculty of MedicineInstitute of Clinical MedicineVilnius UniversityVilniusLithuania
| | - Marius Miglinas
- Faculty of MedicineVilnius UniversityVilniusLithuania
- Clinic of Gastroenterology, Nephro‐Urology and SurgeryFaculty of MedicineInstitute of Clinical MedicineVilnius UniversityVilniusLithuania
| | - Laurynas Rimševičius
- Faculty of MedicineVilnius UniversityVilniusLithuania
- Clinic of Gastroenterology, Nephro‐Urology and SurgeryFaculty of MedicineInstitute of Clinical MedicineVilnius UniversityVilniusLithuania
| | - Agnė Čerkauskaitė
- Faculty of MedicineVilnius UniversityVilniusLithuania
- Clinic of Gastroenterology, Nephro‐Urology and SurgeryFaculty of MedicineInstitute of Clinical MedicineVilnius UniversityVilniusLithuania
| | - Ernesta Mačionienė
- Faculty of MedicineVilnius UniversityVilniusLithuania
- Clinic of Gastroenterology, Nephro‐Urology and SurgeryFaculty of MedicineInstitute of Clinical MedicineVilnius UniversityVilniusLithuania
| | - Eglė Ašakienė
- Faculty of MedicineVilnius UniversityVilniusLithuania
- Clinic of Gastroenterology, Nephro‐Urology and SurgeryFaculty of MedicineInstitute of Clinical MedicineVilnius UniversityVilniusLithuania
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Al-Tamimi M, Qiao J, Gardiner EE. The utility of platelet activation biomarkers in thrombotic microangiopathies. Platelets 2022; 33:503-511. [PMID: 35287530 DOI: 10.1080/09537104.2022.2026912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Primary thrombotic microangiopathies (TMAs) are observed in thrombotic thrombocytopenic purpura (TTP) and hemolytic uremic syndrome (HUS), while secondary TMAs have a wide range of etiologies. Early diagnosis and treatment of TMA are critical for patient well-being; however, distinguishing TTP from HUS on presentation is particularly challenging. Thrombocytopenia and platelet activation are central to different types of TMAs, thus limiting the utility of standard diagnostic approaches to evaluate the platelet function and hemostatic capacity. Alternative means of quantifying and monitoring changes to platelet activation and function are urgently needed. Activated platelets have been shown to interact with proteins of the complement and coagulation cascades and form part of inflammation processes engaged in TMA. Increased levels of platelet surface receptors as well as increased plasma levels of platelet-derived soluble proteins have been reported in TMAs. Elevated levels of platelet-leukocyte aggregates and platelet microparticles are also reported in different types of TMAs. Larger prospective evaluations of platelet activation markers in TMA using standardized assays, with comparison to cohorts of patients with thrombosis, coagulopathy, and thrombocytopenia, to evaluate the clinical usefulness of platelet markers in TMA are now needed. This review will summarize the current knowledge around platelet activation markers and critically evaluate their utility in diagnosis and prognosis of TMA patients.
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Affiliation(s)
- Mohammad Al-Tamimi
- Department of Basic Medical Sciences, Faculty of Medicine, The Hashemite University, Zarqa, Jordan
| | - Jianlin Qiao
- Blood Diseases Institute, Xuzhou Medical University, Xuzhou, China
| | - Elizabeth E Gardiner
- ACRF Department of Cancer Biology and Therapeutics, John Curtin School of Medical Research, Australian National University, Canberra, Australia
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Yang F, Tian J, Peng L, Zhang L, Liu J, Tian X, Zhang W, Li M, Zhao Y, Zhang F, Zeng X, Wang L, Leng X. Thrombocytopenia Is an Independent Risk Factor for the Prognosis of Thrombotic Microangiopathy in Chinese Patients With Systemic Lupus Erythematosus. Front Med (Lausanne) 2021; 8:772607. [PMID: 34820404 PMCID: PMC8606658 DOI: 10.3389/fmed.2021.772607] [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: 09/08/2021] [Accepted: 10/05/2021] [Indexed: 11/13/2022] Open
Abstract
Objectives: This study aims to describe clinical characteristics and outcome of thrombotic microangiopathy (TMA) in Chinese patients with systemic lupus erythematosus (SLE), and investigate the risk factors. Methods: We conducted a retrospective single-center cohort and enrolled patients of TMA associated with SLE between January 2015 and December 2018. Demographic characteristics, clinical features, laboratory profiles, therapeutic strategies, and outcomes were collected. The risk factors of TMA in patients with SLE for mortality using multivariate analysis were estimated. Results: A total of 119 patients with a diagnosis of TMA were enrolled within the study period in our center, and SLE was found in 72 (60.5%) patients. The mean age was 29.2 ± 10.1 and 65 (92.3%) were women. Only 15 patients were found with definite causes, the other 57 cases remained with unclear reasons. Sixty-two patients got improved, while 10 patients died after treatment (mortality rate: 13.9%). Compared with the survival group, the deceased group had a higher prevalence of neuropsychiatric manifestations, infection with two or more sites, increased levels of C-reaction protein (CRP) and D-Dimer, and decreased platelet count. Multivariate analysis showed that the decrease of platelet count is the independent risk factor for in-hospital mortality for TMA in patients with SLE. The receiver operating characteristic (ROC) curve analysis displayed that a cutoff value of <18 × 109/L for platelet count could significantly increase the risk of death. Conclusions: Thrombotic microangiopathy often occurs in patients with active SLE with high mortality (13.9%), and thrombocytopenia, especially when the platelet count is lower than 18 × 109/L, is the risk factor for death.
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Affiliation(s)
- Fan Yang
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences and Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Junwei Tian
- Department of Rheumatology and Nephrology, The First Hospital of Changsha, Hunan, China
| | - Linyi Peng
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences and Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Li Zhang
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences and Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Jia Liu
- Department of Medical Science and Technology Evaluation, Institute of Medical Information, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xinping Tian
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences and Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Wen Zhang
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences and Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Mengtao Li
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences and Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Yan Zhao
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences and Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Fengchun Zhang
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences and Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Xiaofeng Zeng
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences and Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Li Wang
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences and Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Xiaomei Leng
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences and Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
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Netti GS, Santangelo L, Paulucci L, Piscopo G, Torres DD, Carbone V, Giordano P, Spadaccino F, Castellano G, Stallone G, Gesualdo L, Chironna M, Ranieri E, Giordano M. Low C3 Serum Levels Predict Severe Forms of STEC-HUS With Neurologic Involvement. Front Med (Lausanne) 2020; 7:357. [PMID: 32671083 PMCID: PMC7332746 DOI: 10.3389/fmed.2020.00357] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 06/15/2020] [Indexed: 12/22/2022] Open
Abstract
Background: The correlation between the severity of hemolytic uremic syndrome related to Shiga toxin–producing Escherichia coli (STEC-HUS) and involvement of the complement system has been examined in a small number of studies, with conflicting results. In the present study, we investigated whether serum C3 levels on admission are associated with neurologic involvement. Methods: To this purpose, 68 consecutive STEC-HUS patients were recruited and main clinical and laboratory variables ad hospital admission were compared between those with or without neurologic involvement. Results: STEC-HUS patients who developed neurologic involvement (NI) showed significant higher leukocyte count, C-reactive protein and hemoglobin, and lower sodium levels as compared with those without. Interestingly, baseline serum levels of C3 were significantly lower in patients with NI as compared with those without (p < 0.001). Moreover, when stratified according to need of Eculizumab rescue therapy due to severe NI, patients treated with this drug showed baseline C3 serum levels significantly lower than those who were not (p < 0.001). Low C3 was independent risk factor for NI in our patients' population when entered as covariate in a multivariate logistic regression analysis including other major variables previously proposed as possible predictors of poor prognosis in STEC-HUS (for instance, leukocyte count, c-reactive protein, sodium levels) (HR 6.401, 95%CI 1.617–25.334, p = 0.008 for C3). To underline the role of complement in the worsening of STEC-HUS patients' clinical conditions and outcomes, all patients were divided into two groups according to the baseline lower vs. normal serum levels of C3 and the main data on care needs were assessed. Interestingly more patients with lower C3 serum levels required renal replacement therapy (p = 0.024), anti-hypertensive therapy (p = 0.011), Intensive Care Unit admission (p = 0.009), and longer hospitalization (p = 0.003), thus displaying significantly more severe disease features as compared with those with normal C3 serum levels. Conclusions: Our data suggests that children with STEC-HUS with decreased C3 concentrations at admission are more likely to develop neurologic involvement and are at increased risk of having severe clinical complications.
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Affiliation(s)
- Giuseppe Stefano Netti
- Unit of Clinical Pathology and Center for Molecular Medicine, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Luisa Santangelo
- Unit of Pediatric Nephrology, University Hospital Policlinico Consorziale - Giovanni XXIII, Bari, Italy
| | - Leonardo Paulucci
- Unit of Pediatric Nephrology, University Hospital Policlinico Consorziale - Giovanni XXIII, Bari, Italy
| | - Giovanni Piscopo
- Unit of Pediatric Nephrology, University Hospital Policlinico Consorziale - Giovanni XXIII, Bari, Italy
| | - Diletta D Torres
- Unit of Pediatric Nephrology, University Hospital Policlinico Consorziale - Giovanni XXIII, Bari, Italy
| | - Vincenza Carbone
- Unit of Pediatric Nephrology, University Hospital Policlinico Consorziale - Giovanni XXIII, Bari, Italy
| | - Paolo Giordano
- Post Graduated School in Pediatrics, University of Genoa, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Federica Spadaccino
- Unit of Clinical Pathology and Center for Molecular Medicine, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Giuseppe Castellano
- Nephrology Dialysis and Transplantation Unit, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Giovanni Stallone
- Nephrology Dialysis and Transplantation Unit, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Loreto Gesualdo
- Nephrology Dialysis and Transplantation Unit, Department of Emergency and Organ Transplantation, University of Bari Aldo Moro, Bari, Italy
| | - Maria Chironna
- Department of Biomedical Sciences and Human Oncology, Hygiene Unit, University of Bari Aldo Moro, Bari, Italy
| | - Elena Ranieri
- Unit of Clinical Pathology and Center for Molecular Medicine, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Mario Giordano
- Unit of Pediatric Nephrology, University Hospital Policlinico Consorziale - Giovanni XXIII, Bari, Italy
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Giordano P, Netti GS, Santangelo L, Castellano G, Carbone V, Torres DD, Martino M, Sesta M, Di Cuonzo F, Resta MC, Gaeta A, Milella L, Chironna M, Germinario C, Scavia G, Gesualdo L, Giordano M. A pediatric neurologic assessment score may drive the eculizumab-based treatment of Escherichia coli-related hemolytic uremic syndrome with neurological involvement. Pediatr Nephrol 2019; 34:517-527. [PMID: 30362078 DOI: 10.1007/s00467-018-4112-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 10/02/2018] [Accepted: 10/04/2018] [Indexed: 01/10/2023]
Abstract
BACKGROUND Thrombotic microangiopathy (TMA) is a clinical syndrome encompassing a large group of rare but severe disorders including thrombotic thrombocytopenic purpura (TTP) and both typical and atypical forms of hemolytic uremic syndrome (HUS). The key role of the complement system is well known in TTP and atypical HUS, but recent reports describe its involvement in the pathogenesis of HUS secondary to gastrointestinal infections due to Shiga toxin-producing Escherichia coli (STEC). METHODS TMA mainly affects the kidney, but extra-renal complications are frequently described. The involvement of the central nervous system (CNS) represents often a life-threatening condition and it can result in serious long-term disability in HUS patients who overcome the acute phase of illness. In the present study, we retrospectively analyzed a pediatric cohort of a single tertiary pediatric hospital in Southern Italy, in which this complication occurred in 12/54 children (22% of cases), of whom five with severe neurological involvement had been successfully treated with eculizumab. RESULTS The great clinical variability of brain injury in our cohort has led us to retrospectively build a "neurological score" useful to assess the clinical severity of neurologic involvement. Subjects with higher neurologic score due to the most severe CNS involvement resulted in the group of patients early treated with eculizumab, obtaining a good clinical response (four out five patients). In conclusion, the early treatment with eculizumab in children with severe neurological involvement during STEC-HUS was associated with complete regression of both acute kidney injury (AKI) and neurological lesions observed at magnetic resonance imaging (MRI). CONCLUSIONS A "neurological score" may be a useful tool to drive the early treatment of CNS complications in STEC-HUS with eculizumab, although future perspective controlled studies are urgently needed to validate this therapeutic approach.
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Affiliation(s)
- Paolo Giordano
- Pediatric Nephrology and Dialysis Unit, Pediatric Hospital "Giovanni XXIII", Bari, Italy
| | - Giuseppe Stefano Netti
- Clinical Pathology Unit and Center for Molecular Medicine, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Luisa Santangelo
- Pediatric Nephrology and Dialysis Unit, Pediatric Hospital "Giovanni XXIII", Bari, Italy
| | - Giuseppe Castellano
- Nephrology, Dialysis and Transplantation Unit, Department of Emergency and Organ Transplantation, University of Bari "Aldo Moro", Bari, Italy
| | - Vincenza Carbone
- Pediatric Nephrology and Dialysis Unit, Pediatric Hospital "Giovanni XXIII", Bari, Italy
| | | | - Marida Martino
- Pediatric Nephrology and Dialysis Unit, Pediatric Hospital "Giovanni XXIII", Bari, Italy
| | - Michela Sesta
- Pediatric Neurology Unit, Pediatric Hospital "Giovanni XXIII", Bari, Italy
| | - Franca Di Cuonzo
- Department of Neuroradiology, University of Bari "Aldo Moro", Bari, Italy
| | - Maria Chiara Resta
- Department of Neuroradiology, University of Bari "Aldo Moro", Bari, Italy
| | - Alberto Gaeta
- Pediatric Radiology Unit, Pediatric Hospital "Giovanni XXIII", Bari, Italy
| | - Leonardo Milella
- Intensive Care Unit, Pediatric Hospital "Giovanni XXIII", Bari, Italy
| | - Maria Chironna
- Department of Biomedical Science and Human Oncology, University of Bari "Aldo Moro", Bari, Italy
| | - Cinzia Germinario
- Department of Biomedical Science and Human Oncology, University of Bari "Aldo Moro", Bari, Italy
| | - Gaia Scavia
- Food Safety, Nutrition and Veterinary Public Health Department, National Institute of Health, Rome, Italy
| | - Loreto Gesualdo
- Nephrology, Dialysis and Transplantation Unit, Department of Emergency and Organ Transplantation, University of Bari "Aldo Moro", Bari, Italy
| | - Mario Giordano
- Pediatric Nephrology and Dialysis Unit, Pediatric Hospital "Giovanni XXIII", Bari, Italy.
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Renal Thrombotic Microangiopathy in Proliferative Lupus Nephritis: Risk Factors and Clinical Outcomes: A Case-Control Study. J Clin Rheumatol 2017; 22:235-40. [PMID: 27464767 DOI: 10.1097/rhu.0000000000000425] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Renal thrombotic microangiopathy (TMA) may be associated with lupus nephritis. Its relationship to other disease factors and its specific effect on prognosis are not precisely known. Evidence regarding these aspects is controversial, and information focusing on kidney-limited TMA in systemic lupus erythematosus (SLE) patients is scarce. OBJECTIVES The aims of this study were to identify risk factors for renal TMA in patients with lupus nephritis and to determine its impact on clinical outcomes. METHODS A case-control study was performed. We studied 245 renal biopsies from SLE patients. We included patients with renal TMA, as well as control subjects adjusted for glomerulonephritis class, estimated glomerular filtration rate, activity and chronicity indices, and follow-up time. Serological and clinical features were measured at the time of the biopsy and during follow-up. RESULTS Twenty-three patients with renal TMA and 21 control subjects were included. There were no differences in Systemic Lupus Erythematosus Disease Activity Index score, end-stage renal disease, or mortality between groups during follow-up. After multivariate analysis, lymphopenia (odds ratio, 10.69; 95% CI, 1.35-84.74) and anti-Ro antibody positivity (odds ratio, 8.96; 95% CI, 1.49-53.57) remained significantly associated with renal TMA. CONCLUSIONS Lymphopenia and anti-Ro positivity are independent risk factors for renal TMA in SLE patients. This increased risk could be a consequence of the potential role of these factors in endothelial dysfunction and damage. Outcomes were similar for patients with the same estimated glomerular filtration rate and biopsy characteristics, regardless of the presence of TMA.
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Song D, Liu XR, Chen Z, Xiao HJ, Ding J, Sun SZ, Liu HY, Guo WY, Wang SX, Yu F, Zhao MH. The clinical and laboratory features of Chinese Han anti-factor H autoantibody-associated hemolytic uremic syndrome. Pediatr Nephrol 2017; 32:811-822. [PMID: 28035470 DOI: 10.1007/s00467-016-3562-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Revised: 11/10/2016] [Accepted: 11/11/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND Anti-complement factor H (CFH) autoantibody-associated hemolytic uremic syndrome (HUS) is a severe sub-type of HUS. METHODS We assessed the clinical and renal pathological features, circulating complement levels, and genetic background of Chinese pediatric patients with this sub-type of HUS. Thirty-three consecutive patients with acute kidney injury who tested positive for serum anti-CFH autoantibodies were enrolled in this study. RESULTS All of the eight patients who underwent renal biopsies presented with changes typical of thrombotic microangiopathy, especially changes in chronic characteristics. Compared to patients in remission and normal control subjects, patients with acute disease had significantly lower plasma CFH levels and significantly higher plasma complement 3a (C3a), C5a, and terminal complement complex (SC5b-9) levels. The CFH-anti-CFH immunoglobin G (IgG) circulating immunocomplex (CFH-CIC) titers were more closely correlated with CFH plasma levels than anti-CFH IgG levels. Of the 22 patients, four (18%) were homozygous for CFHR3-1Δ and ten were heterozygous for CFHR1 or CFHR3 deletions. Most patients responded well to a combination of plasma and immunosuppressive therapies, with a remission rate of 87%. At the end of the follow-up, nine patients reached the combined end-points, including two with end-stage renal disease and seven with relapses. CONCLUSION Plasma C3a, C5a, and SC5b-9 levels predicted disease activity in anti-CFH autoantibody-associated HUS patients enrolled in this study. These patients responded well to plasma therapy combined with immunosuppression.
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Affiliation(s)
- Di Song
- Renal Division, Department of Medicine, Peking University Institute of Nephrology, Peking University First Hospital, Beijing, People's Republic of China
- Key laboratory of Renal Disease, Ministry of Health of China, Beijing, People's Republic of China
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Ministry of Education of China, Beijing, 100034, People's Republic of China
| | - Xiao-Rong Liu
- Department of Nephrology, Beijing Children's Hospital affiliated to Capital Medical University, West District Nan Li Shi Lu 56th, Beijing, 100045, People's Republic of China.
| | - Zhi Chen
- Department of Nephrology, Beijing Children's Hospital affiliated to Capital Medical University, West District Nan Li Shi Lu 56th, Beijing, 100045, People's Republic of China
| | - Hui-Jie Xiao
- Department of Pediatrics, Peking University First Hospital, Beijing, People's Republic of China
| | - Jie Ding
- Department of Pediatrics, Peking University First Hospital, Beijing, People's Republic of China
| | - Shu-Zhen Sun
- Department of Pediatrics, Shandong Provincial Hospital affiliated with Shandong University, Jinan, People's Republic of China
| | - Hong-Yan Liu
- Department of Nephrology, Renmin Hospital of Wuhan University, Wuhan, People's Republic of China
| | - Wei-Yi Guo
- Renal Division, Department of Medicine, Peking University Institute of Nephrology, Peking University First Hospital, Beijing, People's Republic of China
- Key laboratory of Renal Disease, Ministry of Health of China, Beijing, People's Republic of China
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Ministry of Education of China, Beijing, 100034, People's Republic of China
| | - Su-Xia Wang
- Renal Division, Department of Medicine, Peking University Institute of Nephrology, Peking University First Hospital, Beijing, People's Republic of China
- Key laboratory of Renal Disease, Ministry of Health of China, Beijing, People's Republic of China
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Ministry of Education of China, Beijing, 100034, People's Republic of China
| | - Feng Yu
- Renal Division, Department of Medicine, Peking University Institute of Nephrology, Peking University First Hospital, Beijing, People's Republic of China.
- Key laboratory of Renal Disease, Ministry of Health of China, Beijing, People's Republic of China.
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Ministry of Education of China, Beijing, 100034, People's Republic of China.
- Department of Nephrology, Peking University International Hospital, Beijing, 102206, People's Republic of China.
| | - Ming-Hui Zhao
- Renal Division, Department of Medicine, Peking University Institute of Nephrology, Peking University First Hospital, Beijing, People's Republic of China
- Key laboratory of Renal Disease, Ministry of Health of China, Beijing, People's Republic of China
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Ministry of Education of China, Beijing, 100034, People's Republic of China
- Peking-Tsinghua Center for Life Sciences, Beijing, People's Republic of China
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10
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Abstract
Thrombotic thrombocytopenia purpura (TTP) and the hemolytic uremic syndrome (HUS) are rare thrombotic microangiopathies that can be rapidly fatal. Although the acquired versions of TTP and HUS are generally highest on this broad differential, multiple rarer entities can produce a clinical picture similar to TTP/HUS, including microangiopathic hemolysis, renal failure, and neurologic compromise. More recent analysis has discovered a host of genetic factors that can produce microangiopathic hemolytic syndromes. This article discusses the current understanding of thrombotic microangiopathy and outlines the pathophysiology and causative agents associated with each distinct syndrome as well as the most accepted treatments.
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Affiliation(s)
- Joseph J Shatzel
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health & Science University, 3181 Southwest Sam Jackson Park Road, Portland, OR 97239, USA
| | - Jason A Taylor
- Division of Hematology and Medical Oncology, The Hemophilia Center, Portland VA Medical Center, Knight Cancer Institute, Oregon Health & Science University, 3181 Southwest Sam Jackson Park Road, L586, Portland, OR 97239, USA.
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11
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Yesodharan J, Kuruvilla S, Parameswaran Kavitha K, Lilly M. Disseminated gastric carcinoma in disguise-presentation as microangiopathic haemolytic anemia with bone marrow necrosis. Transl Gastroenterol Hepatol 2017; 1:6. [PMID: 28138574 DOI: 10.21037/tgh.2016.03.09] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Accepted: 01/11/2016] [Indexed: 11/06/2022] Open
Abstract
Cancer related microangiopathic hemolytic anemia (MAHA) and bone marrow necrosis (BMN) are two rare and distinct clinicopathological entities reported in patients with disseminated malignancy. When they emerge as initial findings in a previously undetected case of malignancy, the diagnosis is often missed resulting in inappropriate management. We report the extremely rare association of cancer related MAHA and BMN as the first presentation of unsuspected disseminated gastric carcinoma in a 63 years old male. Early institution of chemotherapy is the only effective option for both these conditions, though with little improvement in outcome. This emphasises the need for increased awareness of such presentations in advanced malignancies.
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Affiliation(s)
| | | | | | - Madhavan Lilly
- Malabar Institute of Medical Sciences Ltd., Calicut, Kerala, India
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12
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Onclinx C, Dogne S, Jadin L, Andris F, Grandfils C, Jouret F, Mullier F, Flamion B. Deficiency in mouse hyaluronidase 2: a new mechanism of chronic thrombotic microangiopathy. Haematologica 2015; 100:1023-30. [PMID: 25934767 DOI: 10.3324/haematol.2015.123828] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Accepted: 04/27/2015] [Indexed: 11/09/2022] Open
Abstract
Hyaluronan is a major component of the extracellular matrix and glycocalyx. Its main somatic degrading enzymes are hyaluronidases 1 and 2, neither of which is active in the bloodstream. We generated hyaluronidase 2-deficient mice. These animals suffer from chronic, mild anemia and thrombocytopenia, in parallel with a 10-fold increase in plasma hyaluronan concentration. In this study we explored the mechanism of these hematologic anomalies. The decreased erythrocyte and platelet counts were attributed to peripheral consumption. The erythrocyte half-life was reduced from 25 to 8 days without signs of premature aging. Hyaluronidase 2-deficient platelets were functional. Major intrinsic defects in erythrocyte membrane or stability, as well as detrimental effects of high hyaluronan levels on erythrocytes, were ruled out in vitro. Normal erythrocytes transfused into hyaluronidase 2-deficient mice were quickly destroyed but neither splenectomy nor anti-C5 administration prevented chronic hemolysis. Schistocytes were present in blood smears from hyaluronidase 2-deficient mice at a level of 1% to 6%, while virtually absent in control mice. Hyaluronidase 2-deficient mice had increased markers of endothelial damage and microvascular fibrin deposition, without renal failure, accumulation of ultra-large multimers of von Willebrand factor, deficiency of A Disintegrin And Metalloproteinase with ThromboSpondin type 1 motifs, member 13 (ADAMTS13), or hypertension. There was no sign of structural damage in hepatic or splenic sinusoids, or in any other microvessels. We conclude that hyaluronidase 2 deficiency induces chronic thrombotic microangiopathy with hemolytic anemia in mice. The link between this uncommon condition and hyaluronidase 2 remains to be explored in humans.
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Affiliation(s)
- Cécile Onclinx
- Molecular Physiology Research Unit, NARILIS, University of Namur, Belgium
| | - Sophie Dogne
- Molecular Physiology Research Unit, NARILIS, University of Namur, Belgium
| | - Laurence Jadin
- Molecular Physiology Research Unit, NARILIS, University of Namur, Belgium
| | - Fabienne Andris
- Laboratoire d'Immunobiologie, Institut de Biologie et de Médecine Moléculaire, Université Libre de Bruxelles, Belgium
| | - Christian Grandfils
- Interfacultary Research Centre of Biomaterials (CEIB), University of Liège, Belgium
| | - François Jouret
- Groupe Interdisciplinaire de Génoprotéomique Appliquée (GIGA), Cardiovascular Sciences, University of Liège, Quartier Hôpital, Avenue Hippocrate, Belgium
| | - François Mullier
- Hematology Laboratory, Namur Thrombosis and Hemostasis Center, CHU Dinant Godinne UCL Namur, Belgium
| | - Bruno Flamion
- Molecular Physiology Research Unit, NARILIS, University of Namur, Belgium
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13
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Kitai Y, Matsubara T, Yanagita M. Onco-nephrology: current concepts and future perspectives. Jpn J Clin Oncol 2015; 45:617-28. [DOI: 10.1093/jjco/hyv035] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Accepted: 02/17/2015] [Indexed: 12/18/2022] Open
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14
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Rakhmanina N, Wong EC, Davis JC, Ray PE. Hemorrhagic Stroke in an Adolescent Female with HIV-Associated Thrombotic Thrombocytopenic Purpura. ACTA ACUST UNITED AC 2014; 5. [PMID: 25429351 PMCID: PMC4241775 DOI: 10.4172/2155-6113.1000311] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
HIV-1 infection can trigger acute episodes of Idiopathic Thrombocytoponic Purpura (ITP), and Thrombotic Thrombocytopenic Purpura (TTP), particularly in populations with advanced disease and poor adherence to antiretroviral therapy (ART). These diseases should be distinguished because they respond to different treatments. Previous studies done in adults with HIV-TTP have recommended the prompt initiation or re-initiation of ART in parallel with plasma exchange therapy to improve the clinical outcome of these patients. Here, we describe a case of HIV-TTP resulting in an acute hemorrhagic stroke in a 16 year old female with perinatally acquired HIV infection and non-adherence to ART, who presented with severe thrombocytopenia, microangiopathic hemolytic anemia, and a past medical history of HIV-ITP. Both differential diagnosis and treatments for HIV-ITP and HIV-TTP were considered simultaneously. A decrease in plasma ADAMTS13 activity (<5%) without detectable inhibitory antibodies confirmed the diagnosis of HIV-TTP. Re-initiation of ART and plasma exchange resulted in a marked decrease in the HIV-RNA viral load, recovery of the platelet count, and complete recovery was achieved with sustained virologic suppression.
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Affiliation(s)
- Natella Rakhmanina
- Divisions of Infectious Disease, The George Washington University, School of Medicine and Health Sciences, Washington, DC, USA ; Department of Pediatrics, The George Washington University, School of Medicine and Health Sciences, Washington, DC, USA
| | - Edward Cc Wong
- Laboratory Medicine, The George Washington University, School of Medicine and Health Sciences, Washington, DC, USA ; Department of Pediatrics, The George Washington University, School of Medicine and Health Sciences, Washington, DC, USA ; The George Washington University, School of Medicine and Health Sciences, Washington, DC, USA
| | - Jeremiah C Davis
- Department of Pediatrics, University of Washington and Seattle Children's Hospital, Seattle WA, USA
| | - Patricio E Ray
- Children's National Medical Center, The George Washington University, School of Medicine and Health Sciences, Washington, DC, USA ; Department of Pediatrics, The George Washington University, School of Medicine and Health Sciences, Washington, DC, USA
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15
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Abstract
This review describes the epidemiology, pathophysiology, presentation, clinical causes, treatment, and long-term prognosis of pediatric patients who present with thrombotic microangiopathy. The focus is on hemolytic uremic syndrome and thrombotic thrombocytopenic purpura, the most common phenotypes of thrombotic microangiopathy.
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Affiliation(s)
- Howard Trachtman
- Division of Nephrology, Department of Pediatrics, CTSI, NYU Langone Medical Center, 227 East 30th Street, Room #110, New York, NY 10016, USA.
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16
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Humane-Immundefizienz-Virus-assoziierte thrombotisch-thrombozytopenische Purpura. Rechtsmedizin (Berl) 2013. [DOI: 10.1007/s00194-013-0917-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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17
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18
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19
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Kaplan BS, Ruebner RL, Copelovitch L. Eculizumab treatment of atypical hemolytic uremic syndrome. Expert Opin Orphan Drugs 2012. [DOI: 10.1080/21678707.2013.750579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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20
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Radhi M, Carpenter SL. Thrombotic microangiopathies. ISRN HEMATOLOGY 2012; 2012:310596. [PMID: 22888446 PMCID: PMC3410315 DOI: 10.5402/2012/310596] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/09/2012] [Accepted: 06/10/2012] [Indexed: 01/13/2023]
Abstract
Thrombotic microangiopathy results from thrombotic occlusion of the microvasculature leading to fragmentation of red blood cells, profound thrombocytopenia, and a microangiopathic hemolytic anemia with elevation of lactate dehydrogenase and negative direct Coomb's test. This constellation of clinical and laboratory findings is not due to one disease entity; rather, it represents a variety of underlying diagnoses. Among the major disease entities are TTP/HUS, which can be congenital or acquired, bacterial infections, medications, vascular or endothelial pathology like Kasabach-Merritt phenomenon, and stem cell transplantation. In this paper, we offer a review of some of the major causes of thrombotic microangiopathy.
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Affiliation(s)
- Mohamed Radhi
- Pediatric Hematology/Oncology/Stem Cell Transplant, Children's Mercy Hospital, Kansas City, MO 64108, USA
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21
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Samson M, Audia S, Leguy V, Berthier S, Janikashvili N, Martin L, Bonnotte B, Lorcerie B. Haemolytic-uraemic syndrome during severe lupus nephritis: efficacy of plasma exchange. Intern Med J 2012; 42:95-8. [PMID: 22276560 DOI: 10.1111/j.1445-5994.2011.02591.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Systemic lupus erythematosus (SLE) has been described as a cause of thrombotic microangiopathy, especially thrombotic thrombocytopenic purpura (TTP). Haemolytic-uraemic syndrome (HUS) is less frequent in SLE. We report a case of such an association during an episode of severe lupus nephritis in a young woman, who was successfully treated with steroids, cyclophosphamide and especially plasma exchange with plasma replacement. This report highlights the importance of recognising atypical HUS in SLE patients by looking for schistocytes in case of haemolytic anemia with a negative antiglobulin test, in order to begin plasma exchange.
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Affiliation(s)
- M Samson
- Department of Internal Medicine and Clinical Immunology, Dijon University Hospital, Dijon, France.
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22
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Patschan D, Korsten P, Behlau A, Vasko R, Heeg M, Sweiss N, Müller GA, Koziolek M. Idiopathic combined, autoantibody-mediated ADAMTS-13/factor H deficiency in thrombotic thrombocytopenic purpura-hemolytic uremic syndrome in a 17-year-old woman: a case report. J Med Case Rep 2011; 5:598. [PMID: 22206706 PMCID: PMC3307521 DOI: 10.1186/1752-1947-5-598] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2011] [Accepted: 12/29/2011] [Indexed: 11/10/2022] Open
Abstract
Introduction Thrombotic thrombocytopenic purpura-hemolytic uremic syndrome is a life-threatening condition with various etiopathogeneses. Without therapy approximately 90% of all patients die from the disease. Case presentation We report the case of a 17-year-old Caucasian woman with widespread hematomas and headache. Due to hemolytic anemia, thrombocytopenia, and schistocytosis, thrombotic thrombocytopenic purpura-hemolytic uremic syndrome was suspected and plasma exchange therapy was initiated immediately. Since her thrombocyte level did not increase during the first week of therapy, plasma treatment had to be intensified to a twice-daily schedule. Further diagnostics showed markedly reduced activities of both ADAMTS-13 (a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13 - also known as von Willebrand factor-cleaving protease) and factor H. Test results for antibodies against both proteins were positive. While plasma exchange therapy was continued, rituximab was given once weekly for four consecutive weeks. After the last dose, thrombocytes and activities of ADAMTS-13 and factor H increased into the normal range. Our patient improved and was discharged from the hospital. Conclusions Since no clinical symptoms/laboratory findings indicated a malignant or specific autoimmune-mediated disorder, the diagnosis made was thrombotic thrombocytopenic purpura-hemolytic uremic syndrome due to idiopathic combined, autoantibody-mediated ADAMTS-13/factor H deficiency.
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Affiliation(s)
- Daniel Patschan
- Department of Nephrology and Rheumatology, University Medicine Göttingen, Germany.
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23
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Yamada R, Nozawa K, Yoshimine T, Takasaki Y, Ogawa H, Takamori K, Sekigawa I. A Case of Thrombotic Thrombocytopenia Purpura Associated with Systemic Lupus Erythematosus: Diagnostic Utility of ADAMTS-13 Activity. Autoimmune Dis 2011; 2011:483642. [PMID: 21776377 PMCID: PMC3138087 DOI: 10.4061/2011/483642] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2011] [Accepted: 05/16/2011] [Indexed: 11/20/2022] Open
Abstract
Thrombotic thrombocytopenia purpura (TTP) caused by a deficiency in ADAMTS-13 activity is considered to involve a subset of thrombotic microangiopathy (TMA). Although concept of TTP is included under the umbrella of TMA, discrimination of TTP from TMA is occasionally difficult in an autoimmune disorder. Herein, we report a case with TTP associated with systemic lupus erythematosus (SLE). In this case, it was difficult to discriminate TTP from TMA and the measurement of ADAMTS-13 activity was useful for obtaining an accurate diagnosis. SLE patients having thrombocytopenia in complication with anemia should be considered a monitoring of ADAMTS-13 activity even though the patients lacked symptoms of TTP related to the microvascular coagulation.
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Affiliation(s)
- Risa Yamada
- Department of Rheumatology, School of Medicine, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-8421, Japan
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24
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Keir L, Coward RJM. Advances in our understanding of the pathogenesis of glomerular thrombotic microangiopathy. Pediatr Nephrol 2011; 26:523-33. [PMID: 20949284 PMCID: PMC3043262 DOI: 10.1007/s00467-010-1637-4] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2010] [Revised: 06/21/2010] [Accepted: 07/08/2010] [Indexed: 12/27/2022]
Abstract
Glomerular thrombotic microangiopathy is a hallmark feature of haemolytic uraemic syndrome, the leading cause of acute renal failure in childhood. This paper is a review of the different mechanistic pathways that lead to this histological picture in the kidney. It will focus on atypical HUS and complement dysregulation, but will also highlight some other recent advances in our understanding of this condition, including the potential role of the molecule vascular endothelial growth factor-A (VEGF-A).
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Affiliation(s)
- Lindsay Keir
- Department of Medical Pediatrics, Royal Hospital for Sick Children, Yorkhill, Glasgow, UK
| | - Richard J. M. Coward
- Academic and Children’s Renal Unit, University of Bristol and Bristol Royal Hospital for Children, Bristol, UK
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25
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Severe transient ADAMTS13 deficiency in pneumococcal-associated hemolytic uremic syndrome. Pediatr Nephrol 2011; 26:631-5. [PMID: 21161282 DOI: 10.1007/s00467-010-1721-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2010] [Revised: 11/02/2010] [Accepted: 11/04/2010] [Indexed: 12/27/2022]
Abstract
Thrombotic microangiopathies comprise different entities, including hemolytic uremic syndrome (HUS), thrombotic thrombocytopenic purpura (TTP), and several other conditions. TTP is characterized by hemolytic anemia, thrombocytopenia, and multiorgan failure. TTP is the result of severe von Willebrand factor multimer cleaving protease (ADAMTS13) deficiency that is either inherited or the result of acquired autoantibodies. We report a critically ill 2-year-old girl with invasive pneumococcal disease associated HUS (p-HUS) whose condition was complicated by severe ADAMTS13 deficiency, without detectable inhibitor, in a context of multiple organ failure. The patient recovered with supportive treatment, and ADAMTS13 activity normalized without plasmatherapy. Severe ADAMTS13 deficiency appears to be a manifestation of transient endothelial cell injury in the context of severe sepsis, including invasive p-HUS. The choice of appropriate therapy should not be based on this finding.
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26
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Haines HL, Laskin BL, Goebel J, Davies SM, Yin HJ, Lawrence J, Mehta PA, Bleesing JJ, Filipovich AH, Marsh RA, Jodele S. Blood, and not urine, BK viral load predicts renal outcome in children with hemorrhagic cystitis following hematopoietic stem cell transplantation. Biol Blood Marrow Transplant 2011; 17:1512-9. [PMID: 21385622 DOI: 10.1016/j.bbmt.2011.02.012] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2011] [Accepted: 02/16/2011] [Indexed: 12/16/2022]
Abstract
BK virus is a significant cause of hemorrhagic cystitis after hematopoietic stem cell transplantation (HSCT). However, its role in nephropathy post-HSCT is less studied. We retrospectively evaluated clinical outcomes in pediatric HSCT patients with hemorrhagic cystitis. Although most of these patients had very high urine BK viral loads (viruria), patients with higher BK plasma loads (viremia) had significant renal dysfunction, a worse clinical course, and decreased survival. Patients with a peak plasma BK viral load of >10,000 copies/mL (high viremia) were more likely to need dialysis and aggressive treatment for hemorrhagic cystitis compared to patients with ≤ 10,000 copies/mL (low viremia). Conversely, most patients with low viremia had only transient elevations in creatinine, and less severe hemorrhagic cystitis that resolved with supportive therapy. Overall survival (OS) at 1 year post-HSCT was 89% in the low viremia group and 48% in the high viremia group. We conclude that the degree of BK viremia, and not viruria, may predict renal, urologic, and overall outcome in the post-HSCT population.
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Affiliation(s)
- Hilary L Haines
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
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27
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Abstract
Shiga toxin-producing Escherichia coli is a contaminant of food and water that in humans causes a diarrheal prodrome followed by more severe disease of the kidneys and an array of symptoms of the central nervous system. The systemic disease is a complex referred to as diarrhea-associated hemolytic uremic syndrome (D+HUS). D+HUS is characterized by thrombocytopenia, microangiopathic hemolytic anemia, and acute renal failure. This review focuses on the renal aspects of D+HUS. Current knowledge of this renal disease is derived from a combination of human samples, animal models of D+HUS, and interaction of Shiga toxin with isolated renal cell types. Shiga toxin is a multi-subunit protein complex that binds to a glycosphingolipid receptor, Gb3, on select eukaryotic cell types. Location of Gb3 in the kidney is predictive of the sites of action of Shiga toxin. However, the toxin is cytotoxic to some, but not all cell types that express Gb3. It also can cause apoptosis or generate an inflammatory response in some cells. Together, this myriad of results is responsible for D+HUS disease.
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Affiliation(s)
- Tom G Obrig
- Department of Microbiology and Immunology, School of Medicine, University of Maryland, 685 W. Baltimore St., HSF I Suite 380, Baltimore, MD 21201, USA; ; Tel.: +1-410-706-6917
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28
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Abstract
PURPOSE OF REVIEW Thrombotic microangiopathies (TMAs) manifest as a spectrum of related disorders in the form of thrombocytopenic purpura (TTP) and hemolytic uremic syndrome (HUS). New data on both diseases support more and more the relatedness of the disorders and reveal related pathomechanisms, which, however, manifest in different organs. TTP develops primarily at neurological sites, and also in the kidney, and HUS is a kidney disease. In TTP thrombi formation occurs subsequently to the release of multimers of von Willebrand factor (vWF), and in HUS endothelial cell damage is considered the reason for complement and platelet activation leading to thrombus formation. RECENT FINDINGS Genetic mutations are associated with both disorders: in TTP the ADAMTS13 gene, the vWF cleaving protease, is affected, and in HUS several complement genes are mutated. In addition autoimmune forms, with acquired, de-novo generated inhibitors in the form of autoantibodies exist for both disorders, affecting ADAMTS13 in TTP or the central complement inhibitor factor H in HUS. In HUS autoantibodies can develop in the context of a specific mostly homozygous chromosomal deletion that represents a new subform of the disease, which is termed DEAP-HUS (deficient for CFHR proteins and autoantibody positive HUS). SUMMARY As the underlying disease mechanisms of TMA are now being better understood new options for a more precise diagnosis, improved therapy and prognosis for kidney transplantation become available for the benefit of patients. Here we summarize the recent developments in this rapidly progressing field.
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29
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Satoskar AA, Pelletier R, Adams P, Nadasdy GM, Brodsky S, Pesavento T, Henry M, Nadasdy T. De novo thrombotic microangiopathy in renal allograft biopsies-role of antibody-mediated rejection. Am J Transplant 2010; 10:1804-11. [PMID: 20659088 DOI: 10.1111/j.1600-6143.2010.03178.x] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The most common cause of thrombotic microangiopathy (TMA) in renal allografts is thought to be calcineurin inhibitor toxicity. Antibody-mediated rejection (AMR) can also cause TMA, but its true impact on de novo TMA is unknown. In a retrospective review of renal allograft biopsies from January 2003 to December 2008 at our institution, we determined the prevalence of TMA in patients with C4d positive (n = 243) and C4d negative (n = 715) biopsies. Over 90% of patients received cyclosporine in both groups. De novo TMA was seen in 59 (6.1%) patients; most of them (55%) with C4d positive biopsy. Among patients with C4d positive biopsies, 13.6% had TMA, as compared to only 3.6% patients with C4d negative biopsies (p < 0.0001). Incidence of graft loss between C4d positive and C4d negative TMA groups was not significantly different, but 70% of patients with C4d positive TMA who received plasmapheresis had slightly lower graft loss rate. In biopsies with AMR-associated TMA, glomerulitis and peritubular capillaritis were significantly more prominent. AMR is the most common cause of TMA in renal allografts in our patient population. It is important to recognize AMR-related TMA because plasmapheresis treatment may be beneficial.
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Affiliation(s)
- A A Satoskar
- Department of Pathology, Ohio State University, Columbus, OH, USA.
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Yılmaz VT, Koçak H, Avcı AB, Salim O, Ersoy FF, Süleymanlar G. Thrombotic thrombocytopenic purpura associated with everolimus use in a renal transplant patient. Int Urol Nephrol 2010; 43:581-4. [PMID: 20495869 DOI: 10.1007/s11255-010-9755-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2009] [Accepted: 05/03/2010] [Indexed: 01/10/2023]
Abstract
Thrombotic microangiopathy (TMA) in renal transplantation (RTX) generally develops during treatment with calcineurin inhibitors. We present a RTX case that developed TMA under everolimus treatment. A 40-year-old woman received a kidney allograft from her 77-year-old mother. She initially received tacrolimus, mycophenolate mofetil and steroids. She was discharged with a creatinine level of 2.2 mg/dl after treatment for a cellular rejection attack within the first two weeks after transplantation. Later on, tacrolimus was replaced with everolimus. One year later, she presented with fever and increased creatinine level (4 mg/dl), anemia and thrombocytopenia. Her peripheral blood smear revealed signs of microangiopathic hemolysis. Bone marrow examination revealed an increased number of megakaryocytes. We diagnosed the case as TMA and initiated plasma exchange, I.V. pulse steroid treatment and stopped everolimus. This approach improved laboratory and clinic abnormalities. The development of TMA after treatment with everolimus and the exclusion of other possible causes suggested TMA associated with proliferating signal inhibitors (PSIs) in our case.
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Glatstein M, Miller E, Garcia-Bournissen F, Scolnik D. Timing and utility of ultrasound in diarrhea-associated hemolytic uremic syndrome: 7-year experience of a large tertiary care hospital. Clin Pediatr (Phila) 2010; 49:418-21. [PMID: 20075028 DOI: 10.1177/0009922809342582] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The authors reviewed the clinical, laboratory, and imaging data from cases of diarrhea-associated hemolytic uremic syndrome (HUS D+), diagnosed at our institution, from 2001 to 2008. The timing and utility of ultrasonographic features of HUS D+ were analyzed. The aim of the study was to determine factors that could aid in the early diagnosis of this disease. A total of 13 children with HUS D+ were identified out of 23 patients with HUS diagnosed during this time period. Evidence of Escherichia coli 0157:H7 was found in 9 cases (70%). Ultrasound studies were ordered in 10 patients (71%), all of which showed renal sonographic findings compatible with HUS. Ultrasound was performed at a mean of 13 days after onset of the diarrhea. Of note, 2 patients whose ultrasounds were performed at the beginning of their diarrheal illness manifested ultrasonographic features suggestive of HUS when there was only a mild increase in serum creatinine and no decrease in hemoglobin or platelets, suggesting that ultrasonography can identify renal involvement early in the course of the disease before other systemic signs appear. Early renal ultrasound may be a useful adjunct in the initial evaluation in children with bloody diarrhea. Evidence of increased renal echogenicity in a patient with bloody diarrhea could aid in early recognition of HUS when other diagnoses such as intussusceptions are being entertained, potentially allowing early intervention.
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Affiliation(s)
- Miguel Glatstein
- Department of Pediatric Emergency Medicine, the Hospital for Sick Children, Toronto, Ontario, Canada.
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Schifferli A, von Vigier RO, Fontana M, Spartà G, Schmid H, Bianchetti MG, Rudin C. Hemolytic-uremic syndrome in Switzerland: a nationwide surveillance 1997-2003. Eur J Pediatr 2010; 169:591-8. [PMID: 19830454 DOI: 10.1007/s00431-009-1079-9] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2009] [Revised: 09/14/2009] [Accepted: 09/22/2009] [Indexed: 12/21/2022]
Abstract
Hemolytic-uremic syndrome (HUS) is a leading cause of acute renal failure in childhood. In its typical presentation, it is preceded by an episode of diarrhea mostly due to Shiga-toxin-producing Escherichia coli. There is important geographical variation of many aspects of this syndrome. Nationwide data on childhood HUS in Switzerland have not been available so far. In a prospective national study through the Swiss Pediatric Surveillance Unit 114 cases (median age 21 months, 50% boys) were reported between April 1997 and March 2003 by 38 pediatric units (annual incidence 1.42 per 10(5) children < or =16 years). Shiga-toxin-producing E. coli were isolated in 32 (60%) of tested stool samples, serotype O157:H7 in eight. Sixteen children presented with only minimal renal involvement, including three with underlying urinary tract infection. Six patients presented with atypical hemolytic-uremic syndrome, and six with HUS due to invasive Streptococcus pneumoniae infection. Mortality was 5.3%, including two out of six children with S. pneumoniae infection. The severity of thrombocytopenia and the presence of central nervous system involvement significantly correlated with mortality. In conclusion, childhood HUS is not rare in Switzerland. Contrasting other countries, E. coli O157:H7 play only a minor role in the etiology. Incomplete manifestation is not uncommon.
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Skerka C, Licht C, Mengel M, Uzonyi B, Strobel S, Zipfel PF, Józsi M. Autoimmune forms of thrombotic micorangiopathy and membranoproliferative glomerulonephritis: Indications for a disease spectrum and common pathogenic principles. Mol Immunol 2009; 46:2801-7. [DOI: 10.1016/j.molimm.2009.05.018] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2009] [Accepted: 05/14/2009] [Indexed: 10/20/2022]
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Manea M, Karpman D. Molecular basis of ADAMTS13 dysfunction in thrombotic thrombocytopenic purpura. Pediatr Nephrol 2009; 24:447-58. [PMID: 18807073 DOI: 10.1007/s00467-008-0986-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2008] [Revised: 07/14/2008] [Accepted: 07/18/2008] [Indexed: 10/21/2022]
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a thrombotic microangiopathic disorder characterized by thrombocytopenia, hemolytic anemia, neurological and renal manifestations, and fever. It is associated with dysfunctional von Willebrand factor (VWF) proteolysis and the occurrence of VWF- and platelet-rich thrombi in the microcirculation of multiple organs, including the kidneys. Von Willebrand factor is a large glycoprotein that circulates in plasma as a series of multimers, and it plays a major role in primary hemostasis by inducing the formation of platelet plugs at sites of vascular injury and high-shear stress. Its activity is dependent on the sizes of the multimers, with ultra-large (UL) VWF multimers being biologically very potent. The ULVWF multimers are rapidly degraded upon their secretion from endothelial cells in normal individuals but not in the circulation of TTP patients, causing the formation of disseminated thrombi in the latter. The defective breakdown of VWF is attributed to a severely deficient activity of the VWF-cleaving protease ADAMTS13, a plasma metalloprotease synthesized in the liver, kidneys, and endothelium. This protease rapidly degrades VWF-platelet strings under flow by proteolytic cleavage of the VWF subunit, thereby regulating the size of the platelet thrombus. Congenital TTP occurs due to ADAMTS13 mutations, with the usual debut occurring during the first years of life, while acquired TTP is associated with auto-antibodies against ADAMTS13.
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Affiliation(s)
- Minola Manea
- Department of Pediatrics, Clinical Sciences Lund, Lund University, 22185, Lund, Sweden
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Introduction: education teaching article series on hemolytic uremic syndrome. Pediatr Nephrol 2008; 23:1423-4. [PMID: 18535846 DOI: 10.1007/s00467-008-0822-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2008] [Accepted: 03/06/2008] [Indexed: 12/25/2022]
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