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Ruzdija D, Bertolo A, Pandya SK, Amaraneni A. A Case Report of Refractory Diffuse Alveolar Hemorrhage as a Complication of Antiphospholipid Syndrome and Review of Its Management. Cureus 2023; 15:e47267. [PMID: 38022217 PMCID: PMC10655834 DOI: 10.7759/cureus.47267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/18/2023] [Indexed: 12/01/2023] Open
Abstract
Diffuse alveolar hemorrhage is a rare complication of antiphospholipid syndrome with high mortality rates. Early diagnosis and treatment with steroids and immunosuppressive agents, along with the achievement of hemostasis and hemodynamic stability, is critical to improving outcomes. This case demonstrates the complexity of managing refractory diffuse alveolar hemorrhage in a 48-year-old woman with antiphospholipid syndrome requiring treatment with high-dose corticosteroids, rituximab, and cyclophosphamide.
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Affiliation(s)
- Denis Ruzdija
- Internal Medicine, University of Arizona, Tucson, USA
| | - Aaron Bertolo
- Internal Medicine, University of Arizona, Tucson, USA
| | | | - Akshay Amaraneni
- Hematology and Oncology, University of Arizona Cancer Center, Tucson, USA
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2
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De Simone E, Sciascia S, Fenoglio R, Oddone V, Barreca A, Roccatello D. Antiphospholipid Syndrome and Kidney Involvement. Kidney Blood Press Res 2023; 48:666-677. [PMID: 37734329 DOI: 10.1159/000529229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 01/07/2023] [Indexed: 09/23/2023] Open
Abstract
BACKGROUND Antiphospholipid syndrome (APS) is an autoimmune disease characterized by the development of autoantibodies and the impairment of the coagulation system. Knowledge about this syndrome is increasing over time, but kidney involvement, especially APS nephropathy, still represents a challenge for physicians. SUMMARY A "two hit" model has been hypothesized to explain APS pathophysiology, and the role played by some factors, such as the complement system, is becoming more and more clear. From a clinical point of view, along with thrombosis in any site and/or obstetric morbidities, that are the hallmarks of APS, a constellation of several other clinical symptoms is related to APS. These symptoms alone are not sufficient to fulfill Sydney criteria for APS and this could potentially lead to omitting some diagnoses. The mainstay of management of APS is antithrombotic therapy, but there are expectations for new drugs that regulate the immune system. APS could affect the kidneys in many ways and among them, APS nephropathy is an intriguing entity that has been overlooked in recent years. Novel studies on APS nephropathy are lacking. KEY MESSAGES In this review, we discuss what we currently know about APS and its relationship with the kidney, with an eye toward the future perspectives. Multicenter studies on APS nephropathy are necessary in order to develop targeted therapies.
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Affiliation(s)
- Emanuele De Simone
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) Including the Nephrology and Dialysis Unit, Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), Department of Clinical and Biological Sciences, San Giovanni Bosco Hub Hospital-ASL Città di Torino, University of Turin, Turin, Italy,
| | - Savino Sciascia
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) Including the Nephrology and Dialysis Unit, Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), Department of Clinical and Biological Sciences, San Giovanni Bosco Hub Hospital-ASL Città di Torino, University of Turin, Turin, Italy
| | - Roberta Fenoglio
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) Including the Nephrology and Dialysis Unit, Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), Department of Clinical and Biological Sciences, San Giovanni Bosco Hub Hospital-ASL Città di Torino, University of Turin, Turin, Italy
| | - Valentina Oddone
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) Including the Nephrology and Dialysis Unit, Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), Department of Clinical and Biological Sciences, San Giovanni Bosco Hub Hospital-ASL Città di Torino, University of Turin, Turin, Italy
| | - Antonella Barreca
- Division of Pathology, Città Della Salute e Della Scienza Hospital and University of Turin, Turin, Italy
| | - Dario Roccatello
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) Including the Nephrology and Dialysis Unit, Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), Department of Clinical and Biological Sciences, San Giovanni Bosco Hub Hospital-ASL Città di Torino, University of Turin, Turin, Italy
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3
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Nusrat S, Tewari S, Khan O. Successful treatment of lupus anticoagulant hypoprothrombinemia syndrome with rituximab. Thromb J 2023; 21:77. [PMID: 37461027 DOI: 10.1186/s12959-023-00517-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 06/24/2023] [Indexed: 07/20/2023] Open
Abstract
Lupus anticoagulant-hypoprothrombinemia syndrome (LAHPS) is a rare acquired bleeding disorder secondary to development of antibodies against prothrombin protein, in the presence of antiphospholipid antibodies. We describe the case of a 13-year-old girl who presented with severe menorrhagia and symptomatic anemia. Labs indicated anemia, thrombocytopenia, elevated PT and aPTT, high-titer inhibitor on mixing studies, positive ANA and anti-dsDNA antibodies, along with a triple-positive antiphospholipid antibody panel. Given additional systemic manifestations, systemic lupus erythematosus was diagnosed. High dose steroids and hydroxychloroquine subsequently started. Her clinical course was complicated by femoral deep venous thrombosis and post renal biopsy retroperitoneal hematoma. Further workup revealed low prothrombin level and the diagnosis of lupus anticoagulant hypoprothrombinemia syndrome. In view of suboptimal response to initial immunosuppressive therapy, rituximab was added to her regimen, leading to an improvement in clinical symptoms and resolution of hypoprothrombinemia. She remains recurrence free 5 years from the event.
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Affiliation(s)
- Sanober Nusrat
- Hematology-Oncology Section, Department of Medicine, University of Oklahoma Health Sciences Center, 800 NE 10th Street, Oklahoma City, OK, 73104, USA.
| | | | - Osman Khan
- Pediatric Hematology-Oncology Section, Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
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4
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Youkhana K, Heiling H, Deal A, Moll S. The Effect of Rituximab on Antiphospholipid Titers in Patients with Antiphospholipid Syndrome. TH OPEN 2023; 7:e191-e194. [PMID: 37415617 PMCID: PMC10322224 DOI: 10.1055/s-0043-1770784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 04/21/2023] [Indexed: 07/08/2023] Open
Affiliation(s)
- Kimberley Youkhana
- Division of Hematology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, United States
| | - Hilary Heiling
- Department of Biostatistics, Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina, United States
| | - Allison Deal
- Department of Biostatistics, Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina, United States
| | - Stephan Moll
- Division of Hematology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, United States
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5
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Du X, Ma X, Tan Y, Shao F, Li C, Zhao Y, Miao Y, Han L, Dang G, Song Y, Yang D, Deng Z, Wang Y, Jiang C, Kong W, Feng J, Wang X. B cell-derived anti-beta 2 glycoprotein I antibody mediates hyperhomocysteinemia-aggravated hypertensive glomerular lesions by triggering ferroptosis. Signal Transduct Target Ther 2023; 8:103. [PMID: 36907919 PMCID: PMC10008839 DOI: 10.1038/s41392-023-01313-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 10/14/2022] [Accepted: 01/09/2023] [Indexed: 03/14/2023] Open
Abstract
Hyperhomocysteinemia (HHcy) is a risk factor for chronic kidney diseases (CKDs) that affects about 85% CKD patients. HHcy stimulates B cells to secrete pathological antibodies, although it is unknown whether this pathway mediates kidney injury. In HHcy-treated 2-kidney, 1-clip (2K1C) hypertensive murine model, HHcy-activated B cells secreted anti-beta 2 glycoprotein I (β2GPI) antibodies that deposited in glomerular endothelial cells (GECs), exacerbating glomerulosclerosis and reducing renal function. Mechanistically, HHcy 2K1C mice increased phosphatidylethanolamine (PE) (18:0/20:4, 18:0/22:6, 16:0/20:4) in kidney tissue, as determined by lipidomics. GECs oxidative lipidomics validated the increase of oxidized phospholipids upon Hcy-activated B cells culture medium (Hcy-B CM) treatment, including PE (18:0/20:4 + 3[O], PE (18:0a/22:4 + 1[O], PE (18:0/22:4 + 2[O] and PE (18:0/22:4 + 3[O]). PE synthases ethanolamine kinase 2 (etnk2) and ethanolamine-phosphate cytidylyltransferase 2 (pcyt2) were increased in the kidney GECs of HHcy 2K1C mice and facilitated polyunsaturated PE synthesis to act as lipid peroxidation substrates. In HHcy 2K1C mice and Hcy-B CM-treated GECs, the oxidative environment induced by iron accumulation and the insufficient clearance of lipid peroxides caused by transferrin receptor (TFR) elevation and down-regulation of SLC7A11/glutathione peroxidase 4 (GPX4) contributed to GECs ferroptosis of the kidneys. In vivo, pharmacological depletion of B cells or inhibition of ferroptosis mitigated the HHcy-aggravated hypertensive renal injury. Consequently, our findings uncovered a novel mechanism by which B cell-derived pathogenic anti-β2GPI IgG generated by HHcy exacerbated hypertensive kidney damage by inducing GECs ferroptosis. Targeting B cells or ferroptosis may be viable therapeutic strategies for ameliorating lipid peroxidative renal injury in HHcy patients with hypertensive nephropathy.
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Affiliation(s)
- Xing Du
- Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Key Laboratory of Molecular Cardiovascular Science, Ministry of Education, Peking University, 100191, Beijing, P. R. China
| | - Xiaolong Ma
- Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Key Laboratory of Molecular Cardiovascular Science, Ministry of Education, Peking University, 100191, Beijing, P. R. China
| | - Ying Tan
- Department of Nephrology, Peking University First Hospital, 100034, Beijing, P. R. China
| | - Fangyu Shao
- Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Key Laboratory of Molecular Cardiovascular Science, Ministry of Education, Peking University, 100191, Beijing, P. R. China
| | - Chun Li
- Department of Rheumatology and Immunology, Peking University People's Hospital, Beijing, China
| | - Yang Zhao
- Department of Laboratory Medicine, Peking University Third Hospital, 100083, Beijing, P. R. China
| | - Yutong Miao
- Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Key Laboratory of Molecular Cardiovascular Science, Ministry of Education, Peking University, 100191, Beijing, P. R. China
| | - Lulu Han
- Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Key Laboratory of Molecular Cardiovascular Science, Ministry of Education, Peking University, 100191, Beijing, P. R. China
| | - Guohui Dang
- Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Key Laboratory of Molecular Cardiovascular Science, Ministry of Education, Peking University, 100191, Beijing, P. R. China
| | - Yuwei Song
- Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Key Laboratory of Molecular Cardiovascular Science, Ministry of Education, Peking University, 100191, Beijing, P. R. China
| | - Dongmin Yang
- Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Key Laboratory of Molecular Cardiovascular Science, Ministry of Education, Peking University, 100191, Beijing, P. R. China
| | - Zhenling Deng
- Department of Nephrology, Peking University Third Hospital, 100083, Beijing, P. R. China
| | - Yue Wang
- Department of Nephrology, Peking University Third Hospital, 100083, Beijing, P. R. China
| | - Changtao Jiang
- Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Key Laboratory of Molecular Cardiovascular Science, Ministry of Education, Peking University, 100191, Beijing, P. R. China
| | - Wei Kong
- Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Key Laboratory of Molecular Cardiovascular Science, Ministry of Education, Peking University, 100191, Beijing, P. R. China
| | - Juan Feng
- Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Key Laboratory of Molecular Cardiovascular Science, Ministry of Education, Peking University, 100191, Beijing, P. R. China.
| | - Xian Wang
- Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Key Laboratory of Molecular Cardiovascular Science, Ministry of Education, Peking University, 100191, Beijing, P. R. China.
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6
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Abstract
Antiphospholipid syndrome (APS) is a thrombo-inflammatory disease propelled by circulating autoantibodies that recognize cell surface phospholipids and phospholipid binding proteins. The result is an increased risk of thrombotic events, pregnancy morbidity, and various other autoimmune and inflammatory complications. Although antiphospholipid syndrome was first recognized in patients with lupus, the stand alone presentation of antiphospholipid syndrome is at least equally common. Overall, the diagnosis appears to affect at least one in 2000 people. Studies of antiphospholipid syndrome pathogenesis have long focused on logical candidates such as coagulation factors, endothelial cells, and platelets. Recent work has shed light on additional potential therapeutic targets within the innate immune system, including the complement system and neutrophil extracellular traps. Vitamin K antagonists remain the mainstay of treatment for most patients with thrombotic antiphospholipid syndrome and, based on current data, appear superior to the more targeted direct oral anticoagulants. The potential role of immunomodulatory treatments in antiphospholipid syndrome management is receiving increased attention. As for many systemic autoimmune diseases, the most important future direction is to more precisely identify mechanistic drivers of disease heterogeneity in pursuit of unlocking personalized and proactive treatments for patients.
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Affiliation(s)
- Jason S Knight
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - D Ware Branch
- James R. and Jo Scott Research Chair, Department of Obstetrics and Gynecology, University of Utah Health and Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Thomas L Ortel
- Division of Hematology, Departments of Medicine and Pathology, Duke University, Durham, North Carolina, USA
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7
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Boggio F, Ciavarella A, Arcudi S, Gualtierotti R, Rossio R, Tafuri F, Artoni A, Peyvandi F. Plasma Exchange in a Patient with Immune Thrombocytopenia Associated with Antiphospholipid Syndrome Hospitalized for COVID-19. Rheumatol Ther 2022; 9:1213-1219. [PMID: 35704176 PMCID: PMC9199312 DOI: 10.1007/s40744-022-00469-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 05/27/2022] [Indexed: 11/23/2022] Open
Abstract
Thrombocytopenia is a common feature of antiphospholipid syndrome (APS) and rarely requires treatment. Here we present the case of a 71-year-old man hospitalized for severe immune thrombocytopenia (ITP) secondary to APS and concomitant SARS-CoV-2 infection. The patient was successfully treated with systemic corticosteroids, intravenous immunoglobulins, and plasma exchange (PEX). Few data are published on the use of plasma exchange in the treatment of thrombocytopenia in non-catastrophic APS. In the setting of acute infection when immunosuppressive therapies might be contraindicated, plasma exchange may be considered an effective therapeutic option. SARS-CoV-2 infection may be a trigger for a relapse of immune thrombocytopenia.
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Affiliation(s)
| | - Alessandro Ciavarella
- Department of Biomedical Sciences for Health, Università degli Studi di Milano, Milan, Italy.,Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Sara Arcudi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Roberta Gualtierotti
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Raffaella Rossio
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Francesco Tafuri
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Andrea Artoni
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Flora Peyvandi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
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8
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Abstract
Antiphospholipid syndrome (APS) is a thromboinflammatory disease with a variety of clinical phenotypes. Primary thrombosis prophylaxis should take an individualized risk stratification approach. Moderate-intensity vitamin K antagonist such as warfarin remains the primary strategy for secondary thrombosis prophylaxis among APS patients, especially for patients with predominantly venous disease. For now, direct oral anti-coagulants should be avoided in most APS patients, especially those with history of arterial manifestations. Obstetric APS management should be tailored based on an individual patient's antiphospholipid antibody profile, and obstetric and thrombotic history. Pharmacological agents beyond anticoagulants may be considered for the management of microthrombotic and nonthrombotic manifestations of APS, although more data are needed. A relatively recent discovery in the area of APS pathogenesis is the implication of neutrophil extracellular traps in thrombin generation and initiation of inflammatory cascades. APS is a complex thromboinflammatory disease with a broad clinical spectrum. Personalized therapy according to an individual's unique thrombosis and obstetric risk should be advocated.
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9
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Rituximab and immune thrombocytopenia in adults: The state of knowledge 20 years later. Rev Med Interne 2020; 42:32-37. [PMID: 32680716 DOI: 10.1016/j.revmed.2020.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 05/23/2020] [Indexed: 01/19/2023]
Abstract
Rituximab has been used for immune thrombocytopenia (ITP) for almost 20 years and is now considered a valid off-label second-line treatment. About 60% to 70% of patients with ITP show initial response to rituximab, but in half of these patients, the disease will eventually relapse. Therefore, in 30% of patients with persistent or chronic ITP, one course of rituximab at 375 mg/m2/week for 4 weeks or 2 fixed 1000-mg rituximab infusions allows for a sustained response rate at 5 years. Unfortunately, to date, no robust predictor of long-term sustained response has been found to assist the physician in deciding to treat with rituximab on an individual basis, and the choice of rituximab or another second-line treatment must be individualized and shared with the patient. Retreatment with rituximab has been found efficient, with a similar or higher magnitude and duration of response in most patients. Rituximab is usually well tolerated, with mainly mild and easily manageable infusion-related adverse events. Severe infections are uncommon, including in the long-term, and occur in patients with at least another contributing factor in more than two thirds. Several issues remain to be resolved. Indeed, head-to-head comparisons with other and new treatments in ITP and robust predictors of long-term response are urgently needed to better determine the position of rituximab in the therapeutic armamentarium for adult ITP. Additionally, the place of combination therapies, maintenance therapy with rituximab and rituximab in newly-diagnosed ITP deserve additional studies.
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Abstract
Purpose of review Although antiphospholipid syndrome (APS) is best known for conveying increased risk of thrombotic events and pregnancy morbidity, thrombocytopenia is also recognized as a common association. In this review, we will explore the relationship between thrombocytopenia and APS, highlighting our evolving understanding – and persistent knowledge gaps – through clinically oriented questions and answers. Recent findings A history of thrombocytopenia likely portends a more severe APS phenotype (including increased risk of thrombosis). Although the pathophysiology underlying thrombocytopenia in APS has yet to be definitively revealed, mechanisms that play a role (at least in subsets of patients) include: immune thrombocytopenic purpura/ITP-like autoantibodies against platelet glycoproteins; antiphospholipid antibody (aPL)-mediated platelet activation and consumption; and potentially life threatening thrombotic microangiopathy. Although thrombocytopenia is often ‘mild’ in APS (and therefore, may not require specific therapy), there are causes of acute-onset thrombocytopenia that mandate emergent work-up and treatment. When APS-related thrombocytopenia does require therapy, the approach must be individualized (requiring an understanding of pathophysiology in the particular APS patient). For patients with ITP-like disease, rituximab is emerging as a popular approach to treatment; in contrast, there are hints that thrombopoietin mimetics may be associated with elevated thrombotic risk. Summary Thrombocytopenia is common in APS, and is likely associated with more severe disease. Improved understanding of thrombocytopenia in APS has the potential to improve risk stratification, reveal novel aspects of APS pathophysiology, and lead to treatments that are more individualized and holistic.
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11
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Svenungsson E, Antovic A. The antiphospholipid syndrome - often overlooked cause of vascular occlusions? J Intern Med 2020; 287:349-372. [PMID: 31957081 DOI: 10.1111/joim.13022] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 01/09/2020] [Indexed: 01/25/2023]
Abstract
The antiphospholipid syndrome (APS) was fully recognized as a clinical entity in the early 1980s. Still, more than 30 years later, the epidemiology of APS is not well described, and furthermore, APS remains a challenge in terms of both diagnostic issues and clinical praxis involving a wide range of specialties. To date, there are no diagnostic criteria for APS. The present classification criteria rely on a combination of clinical manifestations and persistently positive tests for antiphospholipid antibodies (aPL). Clinical symptoms comprise vascular thrombosis, which can affect any vascular bed, including venous, microvascular and arterial vessels, and a set of pregnancy morbidities including early and late miscarriages, foetal death and preeclampsia. APS is more frequent among patients with other autoimmune diseases, and it is especially common in systemic lupus erythematosus (SLE). Importantly, APS symptoms can present in almost any medical specialty, but general knowledge and most previous clinical studies have essentially been confined to haematology, rheumatology and obstetrics/gynaecology. However, recent data demonstrate a relatively high prevalence of aPL also in patients from the general population who suffer from vascular occlusions or pregnancy complications. It is important that these patients are recognized by the general health care since APS is a treatable condition. This review aims to summarize the present knowledge on the history, pathogenesis, clinical manifestations and treatment of APS in order to urge a wide range of clinicians to consider comprehensive assessment of all patients where the diagnosis APS may be conceivable.
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Affiliation(s)
- E Svenungsson
- From the, Department of Medicine Solna, Division of Rheumatology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - A Antovic
- From the, Department of Medicine Solna, Division of Rheumatology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
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12
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Fujimoto M, Asai J, Asano Y, Ishii T, Iwata Y, Kawakami T, Kodera M, Abe M, Amano M, Ikegami R, Isei T, Isogai Z, Ito T, Inoue Y, Irisawa R, Ohtsuka M, Omoto Y, Kato H, Kadono T, Kaneko S, Kanoh H, Kawaguchi M, Kukino R, Kono T, Koga M, Sakai K, Sakurai E, Sarayama Y, Shintani Y, Tanioka M, Tanizaki H, Tsujita J, Doi N, Nakanishi T, Hashimoto A, Hasegawa M, Hayashi M, Hirosaki K, Fujita H, Fujiwara H, Maekawa T, Matsuo K, Madokoro N, Motegi SI, Yatsushiro H, Yamasaki O, Yoshino Y, Pavoux AJLE, Tachibana T, Ihn H. Wound, pressure ulcer and burn guidelines - 4: Guidelines for the management of connective tissue disease/vasculitis-associated skin ulcers. J Dermatol 2020; 47:1071-1109. [PMID: 31960490 DOI: 10.1111/1346-8138.15186] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 11/17/2019] [Indexed: 11/30/2022]
Abstract
The Japanese Dermatological Association prepared guidelines focused on the treatment of skin ulcers associated with connective tissue disease/vasculitis practical in clinical settings of dermatological care. Skin ulcers associated with connective tissue diseases or vasculitis occur on the background of a wide variety of diseases including, typically, systemic sclerosis but also systemic lupus erythematosus (SLE), dermatomyositis, rheumatoid arthritis (RA), various vasculitides and antiphospholipid antibody syndrome (APS). Therefore, in preparing the present guidelines, we considered diagnostic/therapeutic approaches appropriate for each of these disorders to be necessary and developed algorithms and clinical questions for systemic sclerosis, SLE, dermatomyositis, RA, vasculitis and APS.
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Affiliation(s)
- Manabu Fujimoto
- Department of Dermatology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Jun Asai
- Department of Dermatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yoshihide Asano
- Department of Dermatology, University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Takayuki Ishii
- Department of Dermatology, Toyama Prefectural Central Hospital, Toyama, Japan
| | - Yohei Iwata
- Department of Dermatology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Tamihiro Kawakami
- Department of Dermatology, St Marianna University School of Medicine, Kawasaki, Japan
| | - Masanari Kodera
- Department of Dermatology, JCHO Chukyo Hospital, Nagoya, Japan
| | | | - Masahiro Amano
- Department of Dermatology, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Ryuta Ikegami
- Department of Dermatology, JCHO Osaka Hospital, Osaka, Japan
| | - Taiki Isei
- Department of Dermatology, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Zenzo Isogai
- Division of Dermatology and Connective Tissue Medicine, Department of Advanced Medicine, National Center for Geriatrics and Gerontology, Obu, Japan
| | - Takaaki Ito
- Department of Dermatology, Hyogo College of Medicine, Nishinomiya, Japan
| | - Yuji Inoue
- Suizenji Dermatology Clinic, Kumamoto, Japan
| | - Ryokichi Irisawa
- Department of Dermatology, Tokyo Medical University, Tokyo, Japan
| | - Masaki Ohtsuka
- Department of Dermatology, Shizuoka Cancer Center, Shizuoka, Japan
| | - Yoichi Omoto
- Department of Dermatology, Yokkaichi Municipal Hospital, Yokkaichi, Japan
| | - Hiroshi Kato
- Department of Geriatric and Environmental Dermatology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Takafumi Kadono
- Department of Dermatology, St Marianna University School of Medicine, Kawasaki, Japan
| | - Sakae Kaneko
- Department of Dermatology, Faculty of Medicine, Shimane University, Izumo, Japan
| | - Hiroyuki Kanoh
- Department of Dermatology, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Masakazu Kawaguchi
- Department of Dermatology, Yamagata University, Faculty of Medicine, Yamagata, Japan
| | | | - Takeshi Kono
- Department of Dermatology, Nippon Medical School Chiba Hokusoh Hospital, Inzei, Japan
| | - Monji Koga
- Department of Dermatology, School of Medicine, Fukuoka University, Fukuoka, Japan
| | - Keisuke Sakai
- Department of Dermatology, Minamata City General Hospital & Medical Center, Minamata, Japan
| | | | | | | | | | - Hideaki Tanizaki
- Department of Dermatology, Osaka Medical College, Takatsuki, Japan
| | - Jun Tsujita
- Department of Dermatology, Social Insurance Inatsuki Hospital, Fukuoka Prefecture Social Insurance Hospital Association, Fukuoka, Japan
| | - Naotaka Doi
- Department of Dermatology, Wakayama Medical University, Wakayama, Japan
| | - Takeshi Nakanishi
- Department of Dermatology, Shiga University of Medical Science, Otsu, Japan
| | - Akira Hashimoto
- Department of Dermatology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Minoru Hasegawa
- Department of Dermatology, Faculty of Medical Sciences, University of Fukui, Yoshida-gun, Japan
| | - Masahiro Hayashi
- Department of Dermatology, Yamagata University, Faculty of Medicine, Yamagata, Japan
| | | | - Hideki Fujita
- Division of Dermatological Science, Department of Dermatology, Nihon University School of Medicine, Tokyo, Japan
| | - Hiroshi Fujiwara
- Department of Dermatology, Niigata University Graduate, School of Medical and Dental Sciences, Niigata, Japan.,Department of Dermatology, Uonuma Kikan Hospital, Minamiuonuma, Japan
| | - Takeo Maekawa
- Department of Dermatology, Jichi Medical University, Shimotsuke, Japan
| | | | - Naoki Madokoro
- Department of Dermatology, MAZDA Hospital, Aki-gun, Japan
| | - Sei-Ichiro Motegi
- Department of Dermatology, Gunma University Graduate School of Medicine, Maebashi, Japan
| | | | - Osamu Yamasaki
- Department of Dermatology, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan
| | - Yuichiro Yoshino
- Department of Dermatology, Japanese Red Cross Kumamoto Hospital, Kumamoto, Japan
| | | | - Takao Tachibana
- Department of Dermatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Hironobu Ihn
- Department of Dermatology and Plastic Surgery, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
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Nasonov EL, Beketova TV, Ananyeva LP, Vasilyev VI, Solovyev SK, Avdeeva AS. PROSPECTS FOR ANTI-B-CELL THERAPY IN IMMUNO-INFLAMMATORY RHEUMATIC DISEASES. RHEUMATOLOGY SCIENCE AND PRACTICE 2019. [DOI: 10.14412/1995-4484-2019-3-40] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- E L. Nasonov
- V.A. Nasonova Research Institute of Rheumatology; I.M. Sechenov First Moscow State Medical University (Sechenov University), Ministry of Health of Russia
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14
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Sciascia S, Radin M, Cecchi I, Rubini E, Bazzan M, Roccatello D. Long-term effect of B-cells depletion alone as rescue therapy for severe thrombocytopenia in primary antiphospholipid syndrome. Semin Arthritis Rheum 2019; 48:741-744. [DOI: 10.1016/j.semarthrit.2018.04.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 03/29/2018] [Accepted: 04/06/2018] [Indexed: 10/17/2022]
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15
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Frison L, Lombardi A, Caputo I, Semenzato G, Fabris F, Vianello F. Relevance of antiphospholipid antibody profile in the clinical outcome of ITP: a single-centre study. ACTA ACUST UNITED AC 2018; 24:134-138. [PMID: 30355275 DOI: 10.1080/10245332.2018.1532649] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES The relevance of detecting antibodies against anticardiolipin, β2-glycoprotein I (β2gpI) or lupus anticoagulant (LA), collectively called antiphospholipid autoantibodies (APA), in subjects with immune thrombocytopenia (ITP) is still a debated issue. In particular, whether APA profile may affect the clinical course of ITP is unknown. METHODS In this study, we report our experience in a cohort of ITP patients with APA with specific interest to the relevance of different antiphospholipid antibody profiles in clinical outcome and response to treatment. RESULTS Thirty-seven out of 159 patients (23.2%) fulfilling ITP criteria had a platelet count ≤50 × 109/L and tested positive at APA at ITP onset. Twenty-three (62.1%) patients received at least one line of treatment for ITP. Fourteen subjects (37.8%) showing triple positivity for APA showed a significantly lower median platelet count compared to other APA patients (p = .006). Among these ITP subjects with triple positivity, 85.7% needed a treatment because of low platelet count compared to 47.8% ITP patients with non-triple-positive APA (p = .0094). ITP/APA subjects who received immunosuppressors had a higher rate of thrombosis (p = .024) as well as thrombosis developed in subjects who were on steroid therapy at a significantly higher dosage than subjects who did not develop thrombotic episodes (p < .001). When considering treatment, CR and SR rate were significantly higher in ITP/triple-positive patients compared to non-triple-positive subjects (p = .021 and p = .005). CONCLUSIONS The profile of APA may affect the outcome of patients with ITP.
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Affiliation(s)
- Luca Frison
- a Department of Medicine , Padova University School of Medicine , Padova , Italy
| | - Annamaria Lombardi
- a Department of Medicine , Padova University School of Medicine , Padova , Italy
| | - Ilaria Caputo
- a Department of Medicine , Padova University School of Medicine , Padova , Italy
| | - Gianpietro Semenzato
- a Department of Medicine , Padova University School of Medicine , Padova , Italy
| | - Fabrizio Fabris
- a Department of Medicine , Padova University School of Medicine , Padova , Italy
| | - Fabrizio Vianello
- a Department of Medicine , Padova University School of Medicine , Padova , Italy
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16
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Abstract
Abstract. Antiphospholipid syndrome (APS) is an autoantibody-mediated acquired thrombophilia. It is characterized by the presence of antiphospholipid antibodies (APL) that are directed against phospholipid-binding plasma proteins, such as beta-2-glycoprotein I (b2GPI). Its main manifestations are recurrent vascular thromboses (so-called “thrombotic APS”) and pregnancy complications (“obstetric APS”). According to the current consensus criteria, a persistently positive functional lupus anticoagulant (LA) assay and/or the presence of anti-b2GPI and/or anti-cardiolipin antibodies, together with clinical symptoms, is mandatory for the diagnosis of APS. Other clinical features, such as thrombocytopenia, Coombs-positive haemolytic anaemia, heart valve disease, renal microangiopathy and neurologic disorders are also common in APL-positive patients. APS can be associated with other autoimmune disorders, such as systemic lupus erythematosus. In rare cases, catastrophic APS (CAPS) occurs, with the development of excessive thrombosis at multiple sites, usually affecting small vessels and leading to multi-organ dysfunction and organ failure. Treatment usually comprises antithrombotic therapy using antiplatelet and anticoagulant agents. However, there is no consensus concerning the intensity or duration of therapy. Despite apparently adequate anticoagulation, the risk of recurrent thrombosis remains high. For patients with CAPS, a combined therapeutic approach that includes anticoagulation, glucocorticoids, plasma exchange and/or intravenous immunoglobulin seems to be the best treatment option. Keywords: Antiphospholipid syndrome, lupus anticoagulants, anti-cardiolipin, anti-beta-2-glycoprotein I, vascular thrombosis, pregnancy complication
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Affiliation(s)
- Birgit Linnemann
- Division of Angiology, East Bavarian Center of Vascular Medicine, University Hospital Regensburg, Regensburg, Germany
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17
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Campbell EJ, Clarke AE, Ramsey-Goldman R. Systemic lupus erythematosus: a case-based presentation of renal, neurologic, and hematologic emergencies. Expert Rev Clin Immunol 2018; 14:803-816. [PMID: 30173578 DOI: 10.1080/1744666x.2018.1518132] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Systemic lupus erythematosus (SLE) is a chronic autoimmune disorder with systemic manifestations and multiorgan involvement. Although primarily diagnosed, and managed in the outpatient setting, it can occasionally present with life-threatening complications that require rapid assessment and urgent aggressive therapy. Areas covered: In our review, we explore three organ systems that are often affected in SLE, but have the potential to present as medical emergencies; these are the kidney, the central nervous system, and the hematologic system. We take a case-based approach to each clinical scenario, with information given sequentially in order to reflect "real-life" situations where management decisions need to be made with limited information. We review the acute management, pathophysiology, diagnostic approach, and treatment along with a review of the literature, for lupus nephritis presenting as rapidly progressive glomerulonephritis, acute lupus transverse myelitis, and refractory antiphospholipid syndrome. Expert commentary: At the conclusion of each section, we provide an expert commentary regarding each issue, relating to diagnosis, early management, and current evidence behind treatment recommendations.
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Affiliation(s)
- Eric J Campbell
- a Internal Medicine Resident, Department of Medicine, Cumming School of Medicine , University of Calgary , Calgary , Alberta , Canada
| | - Ann E Clarke
- b Professor of Medicine, Division of Rheumatology, The Arthritis Society Chair in Rheumatic Diseases, Cumming School of Medicine , University of Calgary , Calgary , Alberta , Canada
| | - Rosalind Ramsey-Goldman
- c Solovy Arthritis Research Society Professor of Medicine, Department of Medicine/Rheumatology , Northwestern University Feinberg School of Medicine , Chicago , IL , USA
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18
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Unlu O, Erkan D. Catastrophic Antiphospholipid Syndrome: Candidate Therapies for a Potentially Lethal Disease. Annu Rev Med 2018; 68:287-296. [PMID: 28099080 DOI: 10.1146/annurev-med-042915-102529] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Catastrophic antiphospholipid syndrome (CAPS) is a potentially lethal disease that presents with rapidly progressive multiple organ thromboses. Anticoagulation, corticosteroids, intravenous immunoglobulin, and plasma exchange are the most commonly used treatments for CAPS patients. However, the high mortality despite these medications necessitates new treatment strategies. Following a brief review of current diagnostic and management strategies, we discuss the candidate therapies, i.e., hydroxychloroquine, rituximab, eculizumab, sirolimus, and defibrotide, that can be considered in CAPS patients refractory to traditional treatment.
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Affiliation(s)
- Ozan Unlu
- Hospital for Special Surgery, New York, NY 10021;
| | - Doruk Erkan
- Barbara Volcker Center for Women and Rheumatic Diseases, Hospital for Special Surgery, Weill Cornell Medicine, New York, NY 10021
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19
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Chaturvedi S, McCrae KR. Diagnosis and management of the antiphospholipid syndrome. Blood Rev 2017; 31:406-417. [PMID: 28784423 DOI: 10.1016/j.blre.2017.07.006] [Citation(s) in RCA: 95] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Revised: 06/22/2017] [Accepted: 07/28/2017] [Indexed: 12/14/2022]
Abstract
Antiphospholipid syndrome (APS) is characterized by thrombosis and/or pregnancy complications in the presence of persistent antiphospholipid antibodies (APLA). Laboratory diagnosis of APLA depends upon the detection of a lupus anticoagulant, which prolongs phospholipid-dependent anticoagulation tests, and/or anticardiolipin (aCL) and anti-β2-glycoprotein-1 (β2GPI) antibodies. APLA are primarily directed toward phospholipid binding proteins. Pathophysiologic mechanisms underlying thrombosis and pregnancy loss in APS include APLA induced cellular activation, inhibition of natural anticoagulant and fibrinolytic systems, and complement activation, among others. There is a high rate of recurrent thrombosis in APS, especially in triple positive patients (patients with lupus anticoagulant, aCL and anti-β2GPI antibodies), and indefinite anticoagulation with a vitamin K antagonist is the standard of care for thrombotic APS. There is currently insufficient evidence to recommend the routine use of direct oral anticoagulants (DOAC) in thrombotic APS. Aspirin with low molecular weight or unfractionated heparin may reduce the incidence of pregnancy loss in obstetric APS. Recent insights into the pathogenesis of APS have led to the identification of new potential therapeutic interventions, including anti-inflammatory and immunomodulatory therapies. Additional research is needed to better understand the effects of APLA on activation of signaling pathways in vascular cells, to identify more predictive biomarkers that define patients at greatest risk for a first or recurrent APLA-related clinical event, and to determine the safety and efficacy of DOACs and novel anti-inflammatory and immune-modulatory therapies for refractory APS.
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Affiliation(s)
- Shruti Chaturvedi
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Keith R McCrae
- Department of Hematology and Solid Tumor Oncology, Cleveland Clinic, Cleveland, OH 44195, USA.
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20
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Arachchillage DRJ, Laffan M. Pathogenesis and management of antiphospholipid syndrome. Br J Haematol 2017; 178:181-195. [PMID: 28339096 DOI: 10.1111/bjh.14632] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Antiphospholipid antibodies are a heterogeneous group of autoantibodies that have clear associations with thrombosis and pregnancy morbidity, and which together constitute the 'antiphospholipid syndrome' (APS). However, the pathophysiology of these complications is not well understood and their heterogeneity suggests that more than one pathogenic process may be involved. Diagnosis remains a combination of laboratory analysis and clinical observation but there have been significant advances in identifying specific pathogenic features, such as domain I-specific anti-β2-glycoprotein-I antibodies. This in turn has pointed to endothelial and complement activation as important factors in the pathogenesis of APS. Consequently, although anticoagulation remains the standard treatment for thrombotic APS and during pregnancy, the realisation that these additional pathways are involved in the pathogenesis of APS has significant implications for treatment: agents acting outside the coagulation system, such as hydroxychloroquine for pregnancy complications and sirolimus as an inhibitor of the mammalian target of rapamycin (mTOR) pathway, are now under evaluation and represent a radical change in thinking for haematologists. Conventional anticoagulation is also under challenge from new, direct acting anticoagulants. This review will provide a comprehensive overview of the evolving understanding of APS pathogenesis and how this and novel therapeutics will alter diagnosis and management.
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Affiliation(s)
- Deepa R J Arachchillage
- Department of Haematology, Imperial College Healthcare NHS Trust and Imperial College London, Hammersmith Hospital, London, UK
| | - Mike Laffan
- Department of Haematology, Imperial College Healthcare NHS Trust and Imperial College London, Hammersmith Hospital, London, UK
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21
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Velo-García A, Castro SG, Isenberg DA. The diagnosis and management of the haematologic manifestations of lupus. J Autoimmun 2016; 74:139-160. [DOI: 10.1016/j.jaut.2016.07.001] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Accepted: 07/01/2016] [Indexed: 12/21/2022]
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22
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Fujimoto M, Asano Y, Ishii T, Ogawa F, Kawakami T, Kodera M, Abe M, Isei T, Ito T, Inoue Y, Imafuku S, Irisawa R, Ohtsuka M, Ohtsuka M, Kadono T, Kawaguchi M, Kukino R, Kono T, Sakai K, Takahara M, Tanioka M, Nakanishi T, Nakamura Y, Hashimoto A, Hasegawa M, Hayashi M, Fujiwara H, Maekawa T, Matsuo K, Madokoro N, Yamasaki O, Yoshino Y, Le Pavoux A, Tachibana T, Ihn H. The wound/burn guidelines - 4: Guidelines for the management of skin ulcers associated with connective tissue disease/vasculitis. J Dermatol 2016; 43:729-57. [PMID: 26972733 DOI: 10.1111/1346-8138.13275] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Accepted: 11/21/2015] [Indexed: 11/27/2022]
Abstract
The Japanese Dermatological Association prepared guidelines focused on the treatment of skin ulcers associated with connective tissue disease/vasculitis practical in clinical settings of dermatological care. Skin ulcers associated with connective tissue diseases or vasculitis occur on the background of a wide variety of diseases including, typically, systemic sclerosis but also systemic lupus erythematosus (SLE), dermatomyositis, rheumatoid arthritis (RA), various vasculitides and antiphospholipid antibody syndrome (APS). Therefore, in preparing the present guidelines, we considered diagnostic/therapeutic approaches appropriate for each of these disorders to be necessary and developed algorithms and clinical questions for systemic sclerosis, SLE, dermatomyositis, RA, vasculitis and APS.
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Affiliation(s)
- Manabu Fujimoto
- Department of Dermatology, Faculty of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Ishikawa, Japan
| | - Yoshihide Asano
- Department of Dermatology, Faculty of Medicine, University of Tokyo, Tokyo, Japan
| | - Takayuki Ishii
- Department of Dermatology, Faculty of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Ishikawa, Japan
| | - Fumihide Ogawa
- Department of Dermatology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Tamihiro Kawakami
- Department of Dermatology, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Masanari Kodera
- Department of Dermatology, Japan Community Health Care Organization Chukyo Hospital, Aichi, Japan
| | - Masatoshi Abe
- Department of Dermatology, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Taiki Isei
- Department of Dermatology, Kansai Medical University, Osaka, Japan
| | - Takaaki Ito
- Department of Dermatology, Hyogo College of Medicine, Hyogo, Japan
| | - Yuji Inoue
- Department of Dermatology and Plastic Surgery, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Shinichi Imafuku
- Department of Dermatology, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Ryokichi Irisawa
- Department of Dermatology, Tokyo Medical University, Tokyo, Japan
| | - Masaki Ohtsuka
- Department of Dermatology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Mikio Ohtsuka
- Department of Dermatology, Fukushima Medical University, Fukushima, Japan
| | - Takafumi Kadono
- Department of Dermatology, Faculty of Medicine, University of Tokyo, Tokyo, Japan
| | - Masakazu Kawaguchi
- Department of Dermatology, Yamagata University Faculty of Medicine, Yamagata, Japan
| | - Ryuichi Kukino
- Department of Dermatology, NTT Medical Center Tokyo, Tokyo, Japan
| | - Takeshi Kono
- Department of Dermatology, Nippon Medical School, Tokyo, Japan
| | - Keisuke Sakai
- Intensive Care Unit, Kumamoto University Hospital, Kumamoto, Japan
| | - Masakazu Takahara
- Department of Dermatology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Miki Tanioka
- Department of Dermatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Takeshi Nakanishi
- Department of Dermatology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | | | - Akira Hashimoto
- Department of Dermatology, Tohoku University Graduate School of Medicine, Miyagi, Japan
| | - Minoru Hasegawa
- Department of Dermatology, Faculty of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Ishikawa, Japan
| | - Masahiro Hayashi
- Department of Dermatology, Yamagata University Faculty of Medicine, Yamagata, Japan
| | - Hiroshi Fujiwara
- Department of Dermatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Takeo Maekawa
- Department of Dermatology, Jichi Medical University, Tochigi, Japan
| | - Koma Matsuo
- Department of Dermatology, The Jikei University School of Medicine, Tokyo, Japan
| | - Naoki Madokoro
- Department of Dermatology, Mazda Hospital, Hiroshima, Japan
| | - Osamu Yamasaki
- Department of Dermatology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Yuichiro Yoshino
- Department of Dermatology, Japanese Red Cross Kumamoto Hospital, Kumamoto, Japan
| | | | - Takao Tachibana
- Department of Dermatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Hironobu Ihn
- Department of Dermatology and Plastic Surgery, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
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23
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Abstract
The association between antiphospholipid antibodies (aPL) and clinical problems goes beyond what is stated in the antiphospholipid syndrome (APS) classification criteria, namely thrombosis and pregnancy morbidity, and thrombocytopenia is the most common non-criteria hematologic manifestation of aPL with a frequency ranging from 20 to 50 %. Thrombocytopenia is rarely severe, and hemorrhage is far less common than thrombosis. However, when anticoagulation is considered, it may constitute a clinical problem with increased bleeding risk. Furthermore, thrombocytopenia represents a risk factor for thrombosis in aPL-positive patients. Therefore, it is important to understand the pathogenesis and the clinical associations of thrombocytopenia to build the right medical approach in aPL-positive patients. In this paper, we review the literature on aPL/APS-associated thrombocytopenia and briefly discuss the other conditions that can result in thrombocytopenia as they have commonalities with APS and their recognition is important to establish the most appropriate treatment strategy.
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24
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Lopez-Pedrera C, Aguirre MA, Ruiz-Limon P, Pérez-Sánchez C, Jimenez-Gomez Y, Barbarroja N, Cuadrado MJ. Immunotherapy in antiphospholipid syndrome. Int Immunopharmacol 2015; 27:200-8. [PMID: 26086363 DOI: 10.1016/j.intimp.2015.06.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Revised: 04/20/2015] [Accepted: 06/03/2015] [Indexed: 10/23/2022]
Abstract
Antiphospholipid syndrome (APS) is a disorder characterized by the association of arterial or venous thrombosis and/or pregnancy morbidity with the presence of antiphospholipid antibodies (anticardiolipin antibodies, lupus anticoagulant antibodies, and/or anti-β2-glycoprotein I antibodies). Thrombosis is the major manifestation in patients with aPLs, but the spectrum of symptoms and signs associated with aPLs has broadened considerably, and other manifestations, such as thrombocytopenia, non-thrombotic neurological syndromes, psychiatric manifestations, livedo reticularis, skin ulcers, hemolytic anemia, pulmonary hypertension, cardiac valve abnormality, and atherosclerosis, have also been related to the presence of those antibodies. Several studies have contributed to uncovering the basis of antiphospholipid antibody pathogenicity, including the targeted cellular components, affected systems, involved receptors, intracellular pathways used, and the effector molecules that are altered in the process. Therapy for thrombosis traditionally has been based on long-term oral anticoagulation; however, bleeding complications and recurrence despite high-intensity anticoagulation can occur. The currently accepted first-line treatment for obstetric APS (OAPS) is low-dose aspirin plus prophylactic unfractionated or low-molecular-weight heparin (LMWH). However, in approximately 20% of OAPS cases, the final endpoint, i.e. a live birth, cannot be achieved. Based on all the data obtained in different research studies, new potential therapeutic approaches have been proposed, including the use of new oral anticoagulants, statins, hydroxychloroquine, coenzyme Q10, B-cell depletion, platelet and TF inhibitors, peptide therapy or complement inhibition among others. Current best practice in use of these treatments is discussed.
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Affiliation(s)
- Ch Lopez-Pedrera
- Maimonides Institute for Research in Biomedicine of Cordoba (IMIBIC), Reina Sofia University Hospital, University of Cordoba, Córdoba, Spain.
| | - M A Aguirre
- Maimonides Institute for Research in Biomedicine of Cordoba (IMIBIC), Reina Sofia University Hospital, University of Cordoba, Córdoba, Spain
| | - P Ruiz-Limon
- Maimonides Institute for Research in Biomedicine of Cordoba (IMIBIC), Reina Sofia University Hospital, University of Cordoba, Córdoba, Spain
| | - C Pérez-Sánchez
- Maimonides Institute for Research in Biomedicine of Cordoba (IMIBIC), Reina Sofia University Hospital, University of Cordoba, Córdoba, Spain
| | - Y Jimenez-Gomez
- Maimonides Institute for Research in Biomedicine of Cordoba (IMIBIC), Reina Sofia University Hospital, University of Cordoba, Córdoba, Spain
| | - N Barbarroja
- Maimonides Institute for Research in Biomedicine of Cordoba (IMIBIC), Reina Sofia University Hospital, University of Cordoba, Córdoba, Spain
| | - M J Cuadrado
- Lupus Research Unit, St. Thomas Hospital, London, UK
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25
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Abstract
Systemic lupus erythematosus is a remarkable and challenging disorder. Its diversity of clinical features is matched by the complexity of the factors (genetic, hormonal, and environmental) that cause it, and the array of autoantibodies with which it is associated. In this Seminar we reflect on changes in its classification criteria; consider aspects of its more serious clinical expression; and provide a brief review of its aetiopathogenesis, major complications, coping strategies, and conventional treatment. Increased understanding of the cells and molecules involved in the development of the diseases has encouraged the identification of new, better targeted biological approaches to its treatment. The precise role of these newer therapies remains to be established.
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Affiliation(s)
| | - Grainne Murphy
- Centre for Rheumatology, Department of Medicine, University College London Hospital, London, UK
| | - David Isenberg
- Centre for Rheumatology, Department of Medicine, University College London Hospital, London, UK.
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26
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Serrano M, Martínez-Flores JA, Castro MJ, García F, Lora D, Pérez D, Gonzalez E, Paz-Artal E, Morales JM, Serrano A. Renal transplantation dramatically reduces IgA anti-beta-2-glycoprotein I antibodies in patients with endstage renal disease. J Immunol Res 2014; 2014:641962. [PMID: 24818167 PMCID: PMC4003762 DOI: 10.1155/2014/641962] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Revised: 03/10/2014] [Accepted: 03/10/2014] [Indexed: 02/04/2023] Open
Abstract
IgA anti-beta-2-glycoprotein I (aB2GPI) antibodies have been related to vascular pathology in the general population and mainly in hemodialyzed patients (prevalence 33%) in whom an elevated incidence of thrombosis and mortality is found. In this paper we have studied the presence of IgA aB2GPI antibodies at pretransplant and their evolution after transplantation with a cross-sectional-based follow-up study of a cohort of 288 endstage renal disease (ESRD) patients treated with kidney transplantation. Pretransplant IgA aB2GPI levels were elevated 31.7 ± 4.2 U/mL without differences in age or type of dialysis. Patients with different etiologies of ESRD showed higher levels of IgA aB2GPI than blood donors, except the groups of non-IgA glomerular disease and systemic erythematosus lupus, whose nonsignificant differences were observed. IgA aB2GPI antibodies dropped immediately after transplantation (10.7 ± 1.0 U/mL, P < 0.0001), coinciding with a high degree of immunosuppression, and remained significantly lower than that observed in pretransplant status. Prevalence of patients with elevated antibodies was also less in transplanted patients (8.9% versus 30.4%, P < 0.0001). Among, positivity for IgA aB2GPI was higher than in patients who had received their first transplant that those were retransplanted. This finding could have important clinical implications and can suggest new therapeutic strategies in patients with IgA aB2GPI antibodies.
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Affiliation(s)
- Manuel Serrano
- Servicio de Nefrología, Instituto de Investigacion Hospital Universitario 12 de Octubre, Avenida Córdoba s/n, 28041 Madrid, Spain
| | - Jose Angel Martínez-Flores
- Servicio de Inmunología, Instituto de Investigacion Hospital Universitario 12 de Octubre, Avenida Córdoba s/n, 28041 Madrid, Spain
| | - Maria José Castro
- Servicio de Inmunología, Instituto de Investigacion Hospital Universitario 12 de Octubre, Avenida Córdoba s/n, 28041 Madrid, Spain
| | - Florencio García
- Servicio de Nefrología, Instituto de Investigacion Hospital Universitario 12 de Octubre, Avenida Córdoba s/n, 28041 Madrid, Spain
| | - David Lora
- Servicio de Epidemiología, Instituto de Investigacion Hospital Universitario 12 de Octubre, Avenida Córdoba s/n, 28041 Madrid, Spain
| | - Dolores Pérez
- Servicio de Inmunología, Instituto de Investigacion Hospital Universitario 12 de Octubre, Avenida Córdoba s/n, 28041 Madrid, Spain
| | - Esther Gonzalez
- Servicio de Nefrología, Instituto de Investigacion Hospital Universitario 12 de Octubre, Avenida Córdoba s/n, 28041 Madrid, Spain
| | - Estela Paz-Artal
- Servicio de Inmunología, Instituto de Investigacion Hospital Universitario 12 de Octubre, Avenida Córdoba s/n, 28041 Madrid, Spain
- Sección de Inmunología, Universidad San Pablo-CEU, Campus de Monteprincipe, 28668 Madrid, Spain
- Facultad de Medicina, Universidad Complutense, 28040 Madrid, Spain
| | - Jose M. Morales
- Servicio de Nefrología, Instituto de Investigacion Hospital Universitario 12 de Octubre, Avenida Córdoba s/n, 28041 Madrid, Spain
- Facultad de Medicina, Universidad Complutense, 28040 Madrid, Spain
| | - Antonio Serrano
- Servicio de Inmunología, Instituto de Investigacion Hospital Universitario 12 de Octubre, Avenida Córdoba s/n, 28041 Madrid, Spain
- Sección de Inmunología, Universidad San Pablo-CEU, Campus de Monteprincipe, 28668 Madrid, Spain
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Cervera R, Rodríguez-Pintó I, Colafrancesco S, Conti F, Valesini G, Rosário C, Agmon-Levin N, Shoenfeld Y, Ferrão C, Faria R, Vasconcelos C, Signorelli F, Espinosa G. 14th International Congress on Antiphospholipid Antibodies Task Force Report on Catastrophic Antiphospholipid Syndrome. Autoimmun Rev 2014; 13:699-707. [PMID: 24657970 DOI: 10.1016/j.autrev.2014.03.002] [Citation(s) in RCA: 133] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2014] [Accepted: 02/28/2014] [Indexed: 12/24/2022]
Abstract
The 'Task Force on Catastrophic Antiphospholipid Syndrome (CAPS)' was developed on the occasion of the 14th International Congress on Antiphospholipid Antibodies. The objectives of this Task Force were to assess the current knowledge on pathogenesis, clinical and laboratory features, diagnosis and classification, precipitating factors and treatment of this condition in order to address recommendations for future research. This article summarizes the studies analyzed by the Task Force, its recommendations and the future research agenda.
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Affiliation(s)
- Ricard Cervera
- Department of Autoimmune Diseases, Hospital Clínic, Barcelona, Catalonia, Spain.
| | | | - Serena Colafrancesco
- Dipartimento di Medicina Interna e Specialità Mediche, Sapienza Università di Roma, Rome, Italy
| | - Fabrizio Conti
- Dipartimento di Medicina Interna e Specialità Mediche, Sapienza Università di Roma, Rome, Italy
| | - Guido Valesini
- Dipartimento di Medicina Interna e Specialità Mediche, Sapienza Università di Roma, Rome, Italy
| | - Cristina Rosário
- Internal Medicine Department, Hospital de Pedro Hispano, Matosinhos, Portugal
| | - Nancy Agmon-Levin
- The Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Israel
| | - Yehuda Shoenfeld
- The Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Israel; Incumbent of the Laura Schwarz-Kipp Chair for Research of Autoimmune Diseases, Tel-Aviv University, Israel
| | - Claudia Ferrão
- Unidade de Imunologia Clínica, Hospital Santo António, Centro Hospitalar do Porto, ICBAS, Instituto Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal
| | - Raquel Faria
- Unidade de Imunologia Clínica, Hospital Santo António, Centro Hospitalar do Porto, ICBAS, Instituto Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal
| | - Carlos Vasconcelos
- Unidade de Imunologia Clínica, Hospital Santo António, Centro Hospitalar do Porto, ICBAS, Instituto Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal
| | - Flavio Signorelli
- Hospital Universitário Pedro Ernesto, Universidade do Estado do Rio de Janeiro, Brazil
| | - Gerard Espinosa
- Department of Autoimmune Diseases, Hospital Clínic, Barcelona, Catalonia, Spain
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28
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Erkan D, Aguiar CL, Andrade D, Cohen H, Cuadrado MJ, Danowski A, Levy RA, Ortel TL, Rahman A, Salmon JE, Tektonidou MG, Willis R, Lockshin MD. 14th International Congress on Antiphospholipid Antibodies: task force report on antiphospholipid syndrome treatment trends. Autoimmun Rev 2014; 13:685-96. [PMID: 24468415 DOI: 10.1016/j.autrev.2014.01.053] [Citation(s) in RCA: 220] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2014] [Accepted: 01/09/2014] [Indexed: 12/30/2022]
Abstract
Antiphospholipid Syndrome (APS) is characterized by vascular thrombosis and/or pregnancy morbidity occurring in patients with persistent antiphospholipid antibodies (aPL). The primary objective of the APS Treatment Trends Task Force, created as part of the 14th International Congress on aPL, was to systematically review the potential future treatment strategies for aPL-positive patients. The task force chose as future clinical research directions: a) determining the necessity for controlled clinical trials in venous thromboembolism with the new oral direct thrombin or anti-factor Xa inhibitors pending the results of the ongoing rivaroxaban in APS (RAPS) trial, and designing controlled clinical trials in other forms of thrombotic APS; b) systematically analyzing the literature as well as aPL/APS registries, and creating specific registries for non-warfarin/heparin anticoagulants; c) increasing recruitment for an ongoing primary thrombosis prevention trial, and designing secondary thrombosis and pregnancy morbidity prevention trials with hydroxychloroquine; d) determining surrogate markers to select patients for statin trials; e) designing controlled studies with rituximab and other anti-B-cell agents; f) designing mechanistic and clinical studies with eculizumab and other complement inhibitors; and g) chemically modifying peptide therapy to improve the half-life and minimize immunogenicity. The report also includes recommendations for clinicians who consider using these agents in difficult-to-manage aPL-positive patients.
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Affiliation(s)
- Doruk Erkan
- Hospital For Special Surgery, Weill Cornell Medical College, New York, NY, USA.
| | - Cassyanne L Aguiar
- Hospital For Special Surgery, Weill Cornell Medical College, New York, NY, USA
| | - Danieli Andrade
- Department of Rheumatology, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Hannah Cohen
- Department of Hematology, University College London Hospitals NHS Foundation Trust and University College London, London UK
| | | | - Adriana Danowski
- Department of Rheumatology, Hospital Federal dos Servidores do Estado, Rio de Janeiro, Brazil
| | - Roger A Levy
- Department of Rheumatology, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Thomas L Ortel
- Hemostasis and Thrombosis Center, Duke University Medical Center, Durham, NC, USA
| | - Anisur Rahman
- Department of Hematology, University College London Hospitals NHS Foundation Trust and University College London, London UK
| | - Jane E Salmon
- Hospital For Special Surgery, Weill Cornell Medical College, New York, NY, USA
| | - Maria G Tektonidou
- First Department of Medicine, University of Athens School of Medicine, Athens, Greece
| | - Rohan Willis
- Division of Rheumatology,University of Texas Medical Branch, Galveston, TX, USA
| | - Michael D Lockshin
- Hospital For Special Surgery, Weill Cornell Medical College, New York, NY, USA
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29
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Nyo MTL, Kalla AA. Thrombocytopenia and thrombosis: a double-edged sword. Clin Rheumatol 2013; 33:587-90. [PMID: 24196990 DOI: 10.1007/s10067-013-2416-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2013] [Accepted: 10/18/2013] [Indexed: 01/08/2023]
Abstract
Severe thrombocytopenia with bleeding associated with a life-threatening thrombotic manifestation in the setting of antiphospholipid syndrome is a major diagnostic and therapeutic challenge for the clinician. Hemorrhage is a less common complication than thrombosis in patients with APS, although severe thrombocytopenia can sometimes result in bleeding. There are no evidence-based guidelines regarding the management of a patient with severe thrombocytopenia associated with a major thrombotic manifestation. In this case report, we review the literature reporting the difficulties in management of such patient.
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Affiliation(s)
- Myat Tun Lin Nyo
- Department of Medicine, Division of Rheumatology, Medical University of Southern Africa, MEDUNSA 0204, P O Box 625, Pretoria, South Africa,
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30
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Bashal F. Hematological disorders in patients with systemic lupus erythematosus. Open Rheumatol J 2013; 7:87-95. [PMID: 24198852 PMCID: PMC3816272 DOI: 10.2174/1874312901307010087] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2013] [Revised: 08/26/2013] [Accepted: 08/26/2013] [Indexed: 11/22/2022] Open
Abstract
UNLABELLED This article is a review of different management strategies for the hematological manifestations of systemic lupus erythematosus (SLE), the strategies include immunosuppressive drugs, some noval therapies and B-cell depletion for refractory thrombocytopenia in patients with SLE and in antiphospholipid antibody syndrome associated with SLE. The researcher questions the validity of the current classic treatment modes and the article explores the relationships between SLE hematological manifestations and the level of morbidity and mortality burden and focuses on the pathophysiology, diagnostic approaches and management strategies of these manifestations. The researcher focuses on hematological abnormalities because they are the commonest among most manifestations in SLE seen in Anemia, leucopenias and thrombocytopenia. They commonly result from an immune mediated bone marrow failure, excessive peripheral cells destruction or certain drugs and infections. There is also an association between anti-phospholipid antibody syndrome (APS) and SLE referred to as secondary APS or SLE-APS. Furthermore, it was recently found that mycophenolatemofetil acts as corticosteroids and as cyclophosphamide sparing agent. Although there is no specific therapy for cytopenias in SLE, corticosteroids remain the mainstay in the treatment of these patients along with less used other conventional treatment options such as azathioprine, cyclophosphamide and human normal immunoglobulin. There are other novel therapies such as thrombopoietin receptor agonists in thrombocytopenia and the use of autologous hematopoitic stem cells transplantation in refractory SLE-APS that are under review. Some of these therapies include thrombopoietin receptor agonists in thrombocytopenia and the use of autologous hematopoitic stem cells transplantation in refractory SLE-APS. The study concludes that treatment of hematological abnormalities is challenging because the treatment itself can cause undue complications sometimes such as granulocytosis due to infection or the use of high doses of steroids and may occur during acute exacerbations of SLE. It is important to take these factors into consideration for disease therapy and management. PUBLICATION ABSTRACT This article is a review of different management strategies for the hematological manifestations of systemic lupus erythematosus (SLE). The strategies include immunosuppressive drugs, some novel therapies and B-cell depletion for refractory thrombocytopenia in patients with SLE and in anti-phospholipid antibody syndrome associated with SLE. The researcher questions the validity of the current classic treatment modes and the article explores the relationships between SLE hematological manifestations and the level of morbidity and mortality burden while it focuses on the pathophysiology, diagnostic approaches and management strategies. The study concludes that hematological abnormalities are the commonest among most manifestations in SLE, and that their treatment is challenging because the treatment itself can cause undue complications sometimes such as granulocytosis due to infection or the use of high doses of steroids and may occur during acute exacerbations of SLE. It is important to take these factors into consideration for disease therapy and management.
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Affiliation(s)
- Fozya Bashal
- Faculty of Medicine, Department of Internal Medicine, Umm AlQura University, Saudia Arabia
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31
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Furtado J, Isenberg DA. Reprint of: B cell elimination in systemic lupus erythematosus. Clin Immunol 2013; 148:344-58. [DOI: 10.1016/j.clim.2013.04.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2012] [Accepted: 11/15/2012] [Indexed: 11/28/2022]
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Punnialingam S, Khamashta MA. Duration of anticoagulation treatment for thrombosis in APS: is it ever safe to stop? Curr Rheumatol Rep 2013; 15:318. [PMID: 23494857 DOI: 10.1007/s11926-013-0318-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Antiphospholipid syndrome (APS) is an auto-immune thrombophilia for which anti-thrombotic medication is necessary for long-term management to reduce thrombotic risk or pregnancy morbidity. Choosing the type of pharmacological treatment, i.e. the intensity and duration of anticoagulation, depends on the severity of an individual's APS and the risk of bleeding. This article reviews the current literature on anticoagulation therapy, provides recommendations on when to initiate therapy, and suggests possible alternatives for optimisation of management.
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Affiliation(s)
- Sinthiya Punnialingam
- Department of General Medicine, Guy's and St Thomas' Hospital, Westminster Bridge Rd, London, UK.
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33
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Jovancevic B, Lindholm C, Pullerits R. Anti B-cell therapy against refractory thrombocytopenia in SLE and MCTD patients: long-term follow-up and review of the literature. Lupus 2013; 22:664-74. [PMID: 23612795 DOI: 10.1177/0961203313485489] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The objective of this study was to retrospectively evaluate the clinical and immunological effects of anti-B cell treatment in patients with systemic lupus erythematosus (SLE) and mixed connective-tissue disease (MCTD) with autoimmune thrombocytopenia (AITP) refractory to conventional immunosuppressive treatment. METHODS Rituximab (RTX) was added to the ongoing treatment of 16 patients (median age 36 years, range 17-84, all female) with treatment-resistant AITP. Thirteen patients had SLE and three had MCTD. RTX was given intravenously on four occasions during four consecutive weeks at a dose of 375 mg/m(2). Clinical and laboratory disease activity variables recorded at every follow-up visit were analyzed. RESULTS The median disease duration before RTX treatment was nine years (range 0.2-27) and the median post-treatment follow-up time was 28 months (range 3 to 92). Ten patients (63%) were treated repeatedly with RTX during the follow-up period. Complete depletion of B cells was achieved in 94% of cases one month after RTX treatment. A significant increase (p = 0.0001) of platelet counts was seen already after one month (median 58 × 10(9)/ml vs 110 × 10(9)/ml) whereas within three months platelet counts normalized in 10 patients (median 223 × 10(9)/ml). Three patients did not respond to RTX treatment (median platelet count 69 × 10(9)/ml). High titers of anti-platelet antibodies were detected in seven patients before RTX treatment, and the autoantibody titers decreased significantly (p < 0.03) after RTX treatment in six of these patients who also achieved complete remission. A review of the literature revealed 24 articles including 18 case reports, one retrospective cohort study and five prospective studies documenting the outcomes of 65 RTX-treated patients with SLE- or MCTD-related thrombocytopenia with an overall treatment response rate of 80%. In conclusion, these findings indicate that RTX is an additional potent therapeutic treatment option for SLE patients with AITP refractory to conventional immunosuppressive treatment whereas best response may be expected in patients with high titers of anti-platelet antibodies at baseline.
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Affiliation(s)
- B Jovancevic
- Department of Rheumatology, Sahlgrenska University Hospital, Gothenburg, Sweden.
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34
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Erkan D, Vega J, Ramón G, Kozora E, Lockshin MD. A pilot open-label phase II trial of rituximab for non-criteria manifestations of antiphospholipid syndrome. ACTA ACUST UNITED AC 2013; 65:464-71. [DOI: 10.1002/art.37759] [Citation(s) in RCA: 197] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2012] [Accepted: 10/11/2012] [Indexed: 11/06/2022]
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35
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Furtado J, Isenberg DA. B cell elimination in systemic lupus erythematosus. Clin Immunol 2012; 146:90-103. [PMID: 23280492 DOI: 10.1016/j.clim.2012.11.006] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2012] [Revised: 11/12/2012] [Accepted: 11/15/2012] [Indexed: 10/27/2022]
Abstract
Systemic lupus erythematosus (SLE) is an autoimmune disorder with a worldwide distribution, potentially life-threatening with considerable morbidity. The elimination of pathogenic B cells has emerged as a rational therapeutic option. Many open label studies have reported encouraging results in which clinical and serological remission have invariably been described, often enabling the reduction of steroid and immunosuppressive treatment. However, the results from randomized controlled studies have been disappointing and several questions remain to be answered. In this review we will focus on results of B cell direct depletion in the treatment of patients with systemic lupus erythematosus.
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Affiliation(s)
- João Furtado
- Department of Internal Medicine, Egas Moniz Hospital, Lisbon, Portugal.
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36
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Abstract
Ischemic stroke is one of the most common complications of the antiphospholipid syndrome (APS). Because of the relative lack of definitive prospective studies, there is still some debate as to whether the persistent presence of antiphospholipid antibodies (aPLs) increases the risk of recurrent stroke. There is more evidence for aPLs as a risk factor for first stroke. The mechanisms of ischemic stroke are considered to be thrombotic and embolic. APS patients with thrombotic stroke frequently have other, often conventional vascular risk factors. Transesophageal echocardiogram is strongly recommended in APS patients with ischemic stroke because of the high yield of valvular abnormalities. The appropriate management of thrombosis in patients with APS is still controversial because of limited randomized clinical trial data. This review discusses the current evidence for antithrombotic therapy in patients who are aPL positive but do not fulfill criteria for APS, and in APS patients. Alternative and emerging therapies including low molecular weight heparin, new oral anticoagulants (including direct thrombin inhibitors), hydroxychloroquine, statins, and rituximab, are also addressed.
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Affiliation(s)
- Kessarin Panichpisal
- Department of Neurology, SUNY Downstate Medical Center, Brooklyn, NY 11203-2098, USA.
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37
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Much more than thrombosis and pregnancy loss: The antiphospholipid syndrome as a ‘systemic disease’. Best Pract Res Clin Rheumatol 2012; 26:79-90. [DOI: 10.1016/j.berh.2012.01.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2011] [Accepted: 01/04/2012] [Indexed: 11/19/2022]
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38
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Hadaya K, Ferrari-Lacraz S, Fumeaux D, Boehlen F, Toso C, Moll S, Martin PY, Villard J. Eculizumab in acute recurrence of thrombotic microangiopathy after renal transplantation. Am J Transplant 2011; 11:2523-7. [PMID: 21831149 DOI: 10.1111/j.1600-6143.2011.03696.x] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Renal thrombotic microangiopathy (TMA) is a severe complication of systemic lupus erythematosus (SLE), which is associated with the presence of antiphospholipid (aPL) antibodies. In its most fulminant form, TMA leads to a rapid and irreversible end-stage renal failure. Eculizumab, an anti-C5 monoclonal antibody, is a novel therapy of choice for patients with paroxysmal nocturnal hemoglobinuria (PNH) and atypical hemolytic uremic syndrome. Here, we report the case of a 27-year-old woman, known for SLE and end-stage renal disease due to fulminant TMA. Both aPL antibodies and antinucleosome antibodies were positive. The patient underwent a living-related kidney transplantation with immediate production of urine. Although serum creatinine was remaining high, a graft biopsy, performed on day 6, demonstrated a TMA recurrence. Despite a treatment with plasma exchange, the situation got worse and dialysis was started. Eculizumab treatment was subsequently administered and renal function improved rapidly. Three months after transplantation, serum creatinine was at 100 μmol/L, without proteinuria. This case illustrates the benefit of eculizumab therapy in a fulminant recurrence of TMA after kidney transplantation, resistant to classical therapy.
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Affiliation(s)
- K Hadaya
- Division of Nephrology, University Hospital and Medical School, Geneva, Switzerland
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39
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Tripodi A, de Groot PG, Pengo V. Antiphospholipid syndrome: laboratory detection, mechanisms of action and treatment. J Intern Med 2011; 270:110-22. [PMID: 21323768 DOI: 10.1111/j.1365-2796.2011.02362.x] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The antiphospholipid syndrome (APS) identifies a condition at increased risk of vascular occlusion and/or pregnancy complications. Patients are defined as having APS if they have at least one clinical (vascular occlusion and/or pregnancy complications) and one laboratory criterion at the same time. The laboratory criteria that define APS are repeated positivity (confirmed 12 weeks apart) for lupus anticoagulants and/or antibodies targeted against cardiolipin or β(2) -glycoprotein I immobilized on solid surfaces. Over the years, APS has attracted the interest of many medical specialties. The aim of this review is to provide an update on (i) the laboratory criteria that determine the presence of APS, (ii) how the antibodies increase the risk of vascular occlusion and foetal loss and (iii) the treatment of the related clinical events.
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Affiliation(s)
- A Tripodi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Department of Internal Medicine, IRCCS Cà Granda Ospedale Maggiore Policlinico Foundation and Università degli Studi di Milano, Milan, Italy.
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40
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Pengo V. APS--controversies in diagnosis and management, critical overview of current guidelines. Thromb Res 2011; 127 Suppl 3:S51-2. [PMID: 21262441 DOI: 10.1016/s0049-3848(11)70014-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Because the diagnosis of antiphospholipid syndrome is based on laboratory data, performance and interpretation of such tests is essential. Positivity in a single test among Lupus Anticoagulant (LA), anti cardiolipin (aCL) and anti β2-glycoprotein I (aβ2GPI) antibodies calls APS diagnosis into question. Conversely, triple positivity is strongly associated to thrombosis and pregnancy morbidity. A new era in studying APS should take into account different antiphospholipid antibodies profiles. Clinical studies on groups of patients that are homogeneous in terms of laboratory tests will provide information on the real risk of patients and on the real effect of therapeutic interventions.
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Affiliation(s)
- Vittorio Pengo
- Clinical Cardiology, Thrombosis Center, University of Padova School of Medicine, Padova, Italy.
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