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Matteocci A, Pierelli L. Immuno-Hematologic Complexity of ABO-Incompatible Allogeneic HSC Transplantation. Cells 2024; 13:814. [PMID: 38786038 PMCID: PMC11119197 DOI: 10.3390/cells13100814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 04/23/2024] [Accepted: 05/03/2024] [Indexed: 05/25/2024] Open
Abstract
ABO incompatibility is not considered a contraindication for hematopoietic stem cell transplantation (HSCT). Approximately 30% of transplants from related donors and up to 50% of transplants from unrelated donors are ABO incompatible. Immuno-hematologic investigations allow to estimate donor/recipient ABO mismatch and anti-A/B isohemagglutinin (IHA) titration in the pre-HSCT phase. Immediate hemolysis or delayed complications (passenger lymphocyte syndrome and pure red cell aplasia) can occur post HSCT. Some preventive measures take into consideration either decision-making algorithms based on the recipient's IHA titration or clinical protocols for the removal/reduction of IHAs through plasma exchange or immunoadsorption procedures. Product manipulation through red blood cell (RBC) and/or plasma depletion can also be taken into account. Currently, the best approach in the management of ABO-incompatible transplant is not defined in expert consensus documents or with solid evidence. In addition, the methods for IHA titration are not standardized. A transfusion strategy must consider both the donor's and recipient's blood group systems until the RBC engraftment catches on and ABO conversion (forward and reverse typing) is confirmed on two consecutive and independent samples. Therefore, ABO incompatibility in HSCT represents a demanding immuno-hematologic challenge and requires all necessary preventive measures, including the appropriate selection of ABO blood components for transfusion.
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Affiliation(s)
- Antonella Matteocci
- Transfusion Medicine and Stem Cells Unit, San Camillo Forlanini Hospital, Circonvallazione Gianicolense 87, 00152 Rome, Italy;
| | - Luca Pierelli
- Transfusion Medicine and Stem Cells Unit, San Camillo Forlanini Hospital, Circonvallazione Gianicolense 87, 00152 Rome, Italy;
- Department of Experimental Medicine, Sapienza University, 00185 Rome, Italy
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2
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Xie L, Xu J, Xu H, Zhang B, Lin W, Yang T. Multiple autoimmune disorders refractory to glucocorticoids after allogeneic hematopoietic stem cell transplantation: a case report and review of the literature. Front Immunol 2024; 15:1366101. [PMID: 38707905 PMCID: PMC11066190 DOI: 10.3389/fimmu.2024.1366101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 04/08/2024] [Indexed: 05/07/2024] Open
Abstract
We report here the case of a 50-year-old man who was first diagnosed with myelodysplastic syndrome with excess blasts-2 (MDS-EB-2) and underwent allogeneic hematopoietic stem cell transplantation (allo-HSCT) in 2019, resulting in complete remission. However, he was diagnosed in 2021 with several autoimmune disorders, including autoimmune hepatitis (AIH), Hashimoto's thyroiditis (HT), and autoimmune hemolytic anemia (AIHA). This is referred as multiple autoimmune syndrome (MAS), which is a rare occurrence after allo-HSCT, as previously noted in the literature. Despite being treated with glucocorticoids, cyclosporine A, and other medications, the patient did not fully recover. To address the glucocorticoid-refractory MAS, a four-week course of rituximab (RTX) at a weekly dose of 100mg was administered, which significantly improved the patient's condition. Thus, this case report underscores the importance of implementing alternative treatments in patients with post-transplant autoimmune diseases, who are glucocorticoid-refractory or glucocorticoid-dependent, and highlights the effectiveness of RTX as second-line therapy.
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Affiliation(s)
- Linjun Xie
- Department of Hematology, The First Hospital of Putian City, Putian, China
- The School of Clinical Medicine, Fujian Medical University, Fuzhou, China
| | - Jingjing Xu
- Department of Hematology, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Department of Hematology, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Institute of Precision Medicine, Fujian Medical University, Fuzhou, China
| | - Huiping Xu
- Department of Clinical Nutrition, The First Hospital of Putian City, Putian, China
| | - Beibei Zhang
- Department of Hematology, The First Hospital of Putian City, Putian, China
| | - Wuqiang Lin
- Department of Hematology, The First Hospital of Putian City, Putian, China
| | - Ting Yang
- Department of Hematology, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Department of Hematology, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Institute of Precision Medicine, Fujian Medical University, Fuzhou, China
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3
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Longitudinal proteomics study of serum changes after allogeneic HSCT reveals potential markers of metabolic complications related to aGvHD. Sci Rep 2022; 12:14002. [PMID: 35977993 PMCID: PMC9385631 DOI: 10.1038/s41598-022-18221-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 08/08/2022] [Indexed: 01/19/2023] Open
Abstract
Even though hematopoietic stem cell transplantation (HSCT) allows successful treatment for many malignant and non-malignant disorders, its curative potential remains limited by severe side effects, including infections and other transplant-related complications such as graft-versus-host disease (GvHD). This study examined changes in serum proteome via high-performance two-dimensional gel electrophoresis (2-DE) during HSCT to search for diagnostic biomarkers for post-HSCT complications. Longitudinal proteomic analysis revealed proteins related to metabolic complications and hemolytic anemia. Retinol-binding protein 4 (RBP4), a reliable marker of insulin resistance, was identified, and is possibly associated with the onset mechanism of acute graft-versus-host disease (aGvHD) and/or skin GvHD. Although the cause of insulin resistance is not fully understood, it is thought to be associated with adipocytes inflammation induced by RBP4, iron overload and hemolytic anemia after HSCT, as observed in this study. The present study has demonstrated that insulin resistance and metabolic complications could be immediate complications after transplantation and are associated with aGvHD. The biomarkers revealed in this study are promising tools to be used for improving the early diagnosis of HSCT-associated complications, especially aGvHD, possibly even before clinical manifestations.
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4
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Kennedy C, Jackson DE. The effect of HLA matching and donor relatedness on the risk of autoimmune haemolytic anaemia in haematopoietic stem cell transplant recipients: A systematic review and meta-analysis. EJHAEM 2022; 3:609-618. [PMID: 36051056 PMCID: PMC9421999 DOI: 10.1002/jha2.509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 05/24/2022] [Accepted: 06/01/2022] [Indexed: 06/15/2023]
Abstract
Recent studies have identified autoimmune haemolytic anaemia (AIHA) as a haematopoietic stem cell transplant (HSCT) complication that represents a significant cause of morbidity and mortality for these patients. In order to understand this autoimmune phenomenon, emerging research has focused on the prognostic factors associated with the development of the disorder. These studies have identified numerous possible associations with often contrasting and conflicting results. A systematic review and meta-analysis were performed in order to determine the effect of human leucocyte antigen (HLA) matching and donor relatedness on the risk of AIHA post-HSCT. PubMed, SCOPUS and ProQuest were searched from 1 January 1995 to 1 August 2021 using a range of keywords. Meta-analysis was performed using OpenMeta-Analyst software using a random effects model and arcsine risk difference (ARD). Eight eligible articles were identified, and meta-analysis showed an increased risk of AIHA in those who received HLA-mismatched transplants (ARD -0.082; 95% confidence interval [CI] -0.157, -0.007; p = 0.031) and those who received donations from unrelated donor sources (ARD -0.097; 95% CI -0.144, -0.051; p < 0.001). Patients who receive HSCT from HLA-matched and related donor sources have a reduced risk of developing AIHA. Healthcare practitioners should be mindful of the risk of AIHA, especially in those who receive HLA-mismatched and unrelated donor-sourced stem cells. While these findings provide further evidence for researchers investigating the pathogenesis of this HSCT complication, more studies are needed to fully understand the cause.
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Affiliation(s)
- Cassandra Kennedy
- Discipline of Laboratory MedicineSchool of Health and Biomedical SciencesSTEM CollegeRMIT UniversityBundooraVictoriaAustralia
| | - Denise E. Jackson
- Discipline of Laboratory MedicineSchool of Health and Biomedical SciencesSTEM CollegeRMIT UniversityBundooraVictoriaAustralia
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5
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Hansen DL, Möller S, Frederiksen H. Survival in autoimmune hemolytic anemia remains poor, results from a nationwide cohort with 37 years of follow-up. Eur J Haematol 2022; 109:10-20. [PMID: 35276014 PMCID: PMC9314695 DOI: 10.1111/ejh.13764] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 03/05/2022] [Accepted: 03/07/2022] [Indexed: 02/06/2023]
Abstract
Introduction Autoimmune hemolytic anemia (AIHA) is considered a chronic disease, with an overall good prognosis. However, recent reports indicate pre‐mature mortality. Causes of death have not been evaluated previously. Methods In a nationwide setting, we identified all patients with warm type AIHA or cold agglutinin disease (CAD), and age–sex‐matched comparators from Denmark, 1980–2016. We estimated overall survival and cause‐specific mortality from anemia, infection, cardiovascular causes, hematological or solid cancer, bleeding, or other causes, using cumulative incidence proportions. Results We identified 1460 patients with primary AIHA, 1078 with secondary AIHA, 112 with CAD, and 130 801 comparators. One‐year survival and median survival were, 82.7% and 9.8 years for primary AIHA, 69.1% and 3.3 years for secondary AIHA, and 85.5% and 8.8 years for CAD. Prognosis was comparable to the general population only in patients with primary AIHA below 30 years. In all other age and subgroups, the difference was considerable. Cumulated cause‐specific mortality at 1 year was increased among patients versus comparators. Discussion All groups of autoimmune hemolytic anemia are associated with increased overall and cause‐specific mortality compared to the general population. This probably reflects unmet needs in both treatment and follow‐up programs.
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Affiliation(s)
- Dennis Lund Hansen
- Department of Hematology, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Sören Möller
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark.,OPEN, Odense University Hospital, Odense, Denmark
| | - Henrik Frederiksen
- Department of Hematology, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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Towards a Better Understanding of the Atypical Features of Chronic Graft-Versus-Host Disease: A Report from the 2020 National Institutes of Health Consensus Project Task Force. Transplant Cell Ther 2022; 28:426-445. [PMID: 35662591 PMCID: PMC9557927 DOI: 10.1016/j.jtct.2022.05.038] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 05/16/2022] [Accepted: 05/24/2022] [Indexed: 12/31/2022]
Abstract
Alloreactive and autoimmune responses after allogeneic hematopoietic cell transplantation can occur in non-classical chronic graft-versus-host disease (chronic GVHD) tissues and organ systems or manifest in atypical ways in classical organs commonly affected by chronic GVHD. The National Institutes of Health (NIH) consensus projects were developed to improve understanding and classification of the clinical features and diagnostic criteria for chronic GVHD. While still speculative whether atypical manifestations are entirely due to chronic GVHD, these manifestations remain poorly captured by the current NIH consensus project criteria. Examples include chronic GVHD impacting the hematopoietic system as immune mediated cytopenias, endothelial dysfunction, or as atypical features in the musculoskeletal system, central and peripheral nervous system, kidneys, and serous membranes. These purported chronic GVHD features may contribute significantly to patient morbidity and mortality. Most of the atypical chronic GVHD features have received little study, particularly within multi-institutional and prospective studies, limiting our understanding of their frequency, pathogenesis, and relation to chronic GVHD. This NIH consensus project task force report provides an update on what is known and not known about the atypical manifestations of chronic GVHD, while outlining a research framework for future studies to be undertaken within the next three to seven years. We also provide provisional diagnostic criteria for each atypical manifestation, along with practical investigation strategies for clinicians managing patients with atypical chronic GVHD features.
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7
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Faraci M, Dell'Orso G, Giardino S, Pierri F. Autoimmune diseases after allogeneic stem cell transplantation: a clinician's guide and future outlook. Expert Rev Clin Immunol 2022; 18:1-14. [PMID: 35500169 DOI: 10.1080/1744666x.2022.2072299] [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: 03/11/2022] [Accepted: 04/27/2022] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Autoimmune disease (AD) may occur after allogeneic hematopoietic stem cell transplantation (HSCT). The autoimmune mechanism seems to be related to an imbalance of the immune regulation effect of T-regulatory lymphocytes on autoreactive T-lymphocytes. AREAS COVERED ADs include hematological ADs (HADs) and nonhematologic ADs (NHADs) involving organs such as thyroid, peripheral and central nervous system, skin, liver, connective tissue, gastrointestinal tract, and kidney. To identify the risk factors for ADs, to report their clinical characteristics, and to discuss new approaches represent the areas covered in this review. EXPERT OPINION Some risk factors for HAD and NHAD are common and include nonmalignant diseases, young age, cord blood as a stem cell source, conditioning regimens without total body irradiation, alemtuzumab, antithymocyte globulin, T-cell-depleted transplant, some viral infection, mixed chimerism, and chronic Graft versus Host Disease. In NHADs, the detection of autoantibodies is more frequent and the transfer of autoimmunity from the donor to the recipient represents the pathogenetic mechanism responsible for these complications. New therapeutic approaches such as bortezomib, daratumumab, sirolimus, eculizumab, and eltrombopag appear to be promising in terms of better efficacy and reduced toxicity compared to traditional therapies. New horizons based on personalized therapies will allow us to improve the prognosis of AD.
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Affiliation(s)
- Maura Faraci
- Hematopoietic Stem Cell Unit, Department of Hematology-Oncology, IRCSS Istituto G. Gaslini I Istituto GGaslini, Genova, Italy
| | - Gianluca Dell'Orso
- Hematopoietic Stem Cell Unit, Department of Hematology-Oncology, IRCSS Istituto G. Gaslini I Istituto GGaslini, Genova, Italy
| | - Stefano Giardino
- Hematopoietic Stem Cell Unit, Department of Hematology-Oncology, IRCSS Istituto G. Gaslini I Istituto GGaslini, Genova, Italy
| | - Filomena Pierri
- Hematopoietic Stem Cell Unit, Department of Hematology-Oncology, IRCSS Istituto G. Gaslini I Istituto GGaslini, Genova, Italy
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8
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Hillier K, Harris EM, Berbert L, Pai SY, Grace RF. Characteristics and outcomes of autoimmune hemolytic anemia after pediatric allogeneic stem cell transplant. Pediatr Blood Cancer 2022; 69:e29410. [PMID: 34709706 DOI: 10.1002/pbc.29410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 09/29/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND Autoimmune hemolytic anemia (AIHA) after allogeneic hematopoietic stem cell transplant (HSCT) is a rare but complex and serious complication. Detailed descriptions of cases and management strategies are needed due to lack of prospective trials. OBJECTIVES Describe the incidence, clinical characteristics, and management of AIHA after HSCT in a pediatric cohort. METHODS This is a retrospective cohort study of 33 pediatric patients with AIHA after HSCT at an academic tertiary care center from 2003 to 2019. RESULTS The overall incidence of AIHA after allogeneic HSCT was 3.8% (33/868). AIHA was significantly more common after transplant for nonmalignant versus malignant diagnoses (7.0% [26/370] vs. 1.4% [7/498], p < .0001). AIHA developed at a median of 4.7 months (range 1.0-29.7) after transplant. Sixteen of 33 patients (48.5%) required new AIHA-directed pharmacologic therapy; 17 (51.5%) were managed on their current immunosuppression and supportive care. Patients managed without additional therapy were significantly older, more likely to have a malignant diagnosis, and tended to develop AIHA at an earlier time point after transplant. Patients received a median of two red blood cell transfusions within the first 2 weeks of diagnosis and a median of one AIHA-directed medication (range one to four), most commonly corticosteroids and rituximab. CONCLUSIONS AIHA after HSCT is rare but occurs more commonly in patients transplanted for nonmalignant diagnoses. While some pediatric patients who develop AIHA after transplant can be managed on current immunosuppression and supportive care, many require AIHA-directed therapy including second-line medications.
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Affiliation(s)
- Kirsty Hillier
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts, USA.,Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Emily M Harris
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Laura Berbert
- Clinical Research Center, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Sung-Yun Pai
- Immune Deficiency Cellular Therapy Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Rachael F Grace
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
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Murphy D, Orgel E, Koek W, Frei-Jones M, Denton C, Kamat D. A Meta-analysis of the Utility of Red Cell Distribution Width as a Biomarker to Predict Outcomes in Pediatric Illness (PROSPERO CRD42020208777). J Pediatr Intensive Care 2021. [DOI: 10.1055/s-0041-1735876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
AbstractRed cell distribution width (RDW) is an average of the variation in red blood cell (RBC) sizes reported on a complete blood count. An elevated RDW indicates a pathological process that is affecting erythropoiesis. Studies showed that as the severity of disease process increases, the RDW often increases as well. Particularly in resource-limited countries, RDW has been studied as an outcome predictor for conditions in a variety of disciplines and is offered as an adjunct monitoring tool that is cost effective, readily available, and indicative of pathological processes amenable to intervention. Particularly in pediatric critical care settings, RDW has been shown to be a reliable tool for surveillance of disease states such as sepsis. Despite the increased attention of RDW as a marker for disease outcome, collective evaluation on the utility of RDW as a marker for outcome in pediatric critical care settings is lacking. We offer a systematic review and meta-analysis of published studies to assess the ability of RDW to predict illness severity and mortality among pediatric critical care patients. Among eight studies of over 4,800 patients, we found over a two-fold increase in odds for mortality in critically ill children whose RDW was above 15.7%. This is the first systematic review of RDW being used to predict mortality in critically ill children and findings of this study may prompt early intervention in the pediatric critical care setting.
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Affiliation(s)
- Devin Murphy
- Department of Pediatrics, University of Texas Health Science Center at San Antonio, San Antonio, Texas, United Sates
| | - Etan Orgel
- Division of Hematology, Oncology and Blood and Marrow Transplantation, Children's Hospital Los Angeles, Los Angeles, California, United Sates
- Department of Psychiatry, Keck School of Medicine, University of Southern California, Los Angeles, California, United Sates
| | - Wouter Koek
- Department of Pediatrics, University of Texas Health Science Center at San Antonio, San Antonio, Texas, United Sates
| | - Melissa Frei-Jones
- Department of Pediatrics, University of Texas Health Science Center at San Antonio, San Antonio, Texas, United Sates
- Department of Pediatrics, Pediatric Hematology–Oncology, Long School of Medicine, University of Texas Health Science Center San Antonio, Texas, United Sates
| | - Christopher Denton
- Division of Hematology, Oncology and Blood and Marrow Transplantation, Children's Hospital Los Angeles, Los Angeles, California, United Sates
- Department of Psychiatry, Keck School of Medicine, University of Southern California, Los Angeles, California, United Sates
| | - Deepak Kamat
- Department of Pediatrics, University of Texas Health Science Center at San Antonio, San Antonio, Texas, United Sates
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10
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Gabelli M, Ademokun C, Cooper N, Amrolia PI. Pathogenesis, risk factors and therapeutic options for autoimmune haemolytic anaemia in the post-transplant setting. Br J Haematol 2021; 196:45-62. [PMID: 34195990 DOI: 10.1111/bjh.17648] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 05/26/2021] [Indexed: 11/27/2022]
Abstract
Autoimmune haemolytic anaemia (AIHA) is a rare complication of allogeneic haematopoietic stem cell transplantation (HSCT), observed with an incidence of 1-5%. Paediatric age, diagnosis of non-malignant disease, lympho-depleting agents in the conditioning regimen, use of unrelated donor, graft versus host disease and infections have been associated with a higher risk of AIHA post HSCT. Post-HSCT AIHA is associated with high mortality and morbidity, and it is often very difficult to treat. Steroids and rituximab are used with a response rate around 30-50%. These and other therapeutic strategies are mainly derived from data on primary AIHA, although response rates in post-HSCT AIHA have been generally lower. Here we review the currently available data on risk factors and therapeutic options. There is a need for prospective studies in post-HSCT AIHA to guide clinicians in managing these complex patients.
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Affiliation(s)
- Maria Gabelli
- Department of Bone Marrow Transplantation, Great Ormond Street Hospital, London, UK
| | - Christine Ademokun
- Department of Haematology, Imperial College Healthcare NHS Trust, London, UK
| | - Nichola Cooper
- Department of Immunology and Inflammation, Imperial College, London, UK
| | - Persis I Amrolia
- Department of Bone Marrow Transplantation, Great Ormond Street Hospital, London, UK
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11
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Driouk L, Schmitt R, Peters A, Heine S, Girschick HJ, Strahm B, Niemeyer CM, Speckmann C. Daratumumab therapy for post-HSCT immune-mediated cytopenia: experiences from two pediatric cases and review of literature. Mol Cell Pediatr 2021; 8:5. [PMID: 33914175 PMCID: PMC8085143 DOI: 10.1186/s40348-021-00114-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 04/06/2021] [Indexed: 12/18/2022] Open
Abstract
Background Immune-mediated cytopenias (AIC) are challenging complications following allogeneic hematopoietic stem cell transplantation (HSCT). While broad-acting immunosuppressive agents like corticosteroids are often standard of care, several novel therapies which target specific immunological pathways have recently been developed and provide hope for patients with steroid-refractory courses and may limit long-term toxicity. The successful off-label use of the plasma cell depleting anti-CD38 antibody daratumumab was published in several case reports, suggesting efficacy, i.e., in patients with antibody-mediated AIC refractory to previous B cell depletion. We want to share our experience with two children, whom we treated with daratumumab, including one fatal course with uncontrolled disease. Given the absence of substantial data from HSCT registries or prospective trials, we furthermore provide a critical review of the literature on daratumumab treatment of AIC. Case presentations Patient 1 (P1), an 11-year-old girl with lipopolysaccharide-responsive and beige-like anchor protein (LRBA) deficiency who developed immune-mediated thrombocytopenia (AIT) from day +58 after HSCT, showed a complete response to daratumumab after the fourth of six total daratumumab doses. She remains transfusion independent for over a year of follow-up. Previously, her thrombocytopenia was refractory to corticosteroids, rituximab, intravenous immunoglobulins (IVIG), eltrombopag, cyclosporine A, and sirolimus. Patient 2 (P2), a 6-year-old boy with CD40 ligand (CD40L) deficiency, developed both AIT and hemolytic anemia (AIHA) after HSCT on days +58 and +83, respectively, and was also treated with daratumumab after being previously refractory to prednisolone, rituximab, and IVIG. Yet, he did neither respond to daratumumab nor the concomitantly administered methyprednisolone pulse, plasmapheresis, and eculizumab and succumbed due to refractory disease. Conclusion Reviewing the literature on the use of daratumumab for refractory AIC post-HSCT, we consider daratumumab a promising agent for this life-threatening disorder: ten of the twelve patients reached transfusion independency in the literature. However, treatment failures are likely to be underreported. Thus, controlled trials are needed to explore the safety and efficacy of daratumumab in this rare post-HSCT complication.
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Affiliation(s)
- Lina Driouk
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Hematology and Oncology, Medical Centre, Faculty of Medicine, University of Freiburg, Mathildenstr. 1, 79106, Freiburg, Germany
| | - Robert Schmitt
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Hematology and Oncology, Medical Centre, Faculty of Medicine, University of Freiburg, Mathildenstr. 1, 79106, Freiburg, Germany
| | - Anke Peters
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Hematology and Oncology, Medical Centre, Faculty of Medicine, University of Freiburg, Mathildenstr. 1, 79106, Freiburg, Germany
| | - Sabine Heine
- Department of Pediatric Hematology and Oncology, Saarland University Homburg, Homburg, Germany
| | | | - Brigitte Strahm
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Hematology and Oncology, Medical Centre, Faculty of Medicine, University of Freiburg, Mathildenstr. 1, 79106, Freiburg, Germany
| | - Charlotte M Niemeyer
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Hematology and Oncology, Medical Centre, Faculty of Medicine, University of Freiburg, Mathildenstr. 1, 79106, Freiburg, Germany.,German Cancer Consortium (DKTK), Freiburg, Germany.,German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Carsten Speckmann
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Hematology and Oncology, Medical Centre, Faculty of Medicine, University of Freiburg, Mathildenstr. 1, 79106, Freiburg, Germany. .,Center for Chronic Immunodeficiency, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
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12
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How I treat warm autoimmune hemolytic anemia. Blood 2021; 137:1283-1294. [PMID: 33512406 DOI: 10.1182/blood.2019003808] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 08/28/2020] [Indexed: 12/17/2022] Open
Abstract
Warm autoimmune hemolytic anemia (wAIHA) is caused by increased erythrocyte destruction by immunoglobulin G (IgG) autoantibodies, with or without complement activation. Antibody-dependent cell-mediated cytotoxicity by macrophages/activated lymphocytes occurs in the lymphoid organs and spleen (extravascular hemolysis). The ability of the bone marrow (BM) to compensate determines clinical severity. The different pathogenic mechanisms, their complex interplay, and changes over time may explain wAIHA's great clinical heterogeneity and unpredictable course. The disease may be primary, drug induced, or associated with lymphoproliferative neoplasms, autoimmune and infectious diseases, immunodeficiencies, solid tumors, or transplants. Therapeutic interventions include steroids, splenectomy, immunosuppressants, and rituximab; the latter is increasingly used in steroid-refractory cases based on evidence from the literature and a few prospective trials. We present 5 patient case studies highlighting important issues: (1) the diagnosis and proper use of steroid therapy, (2) the concerns about the choice between rituximab and splenectomy in second-line treatment, (3) the need of periodical re-evaluation of the disease to assess the possible evolution of relapsed/refractory cases in myelodysplastic and BM failure syndromes, and (4) the difficulties in managing cases of severe/acute disease that are at high risk of relapse. Incorporating novel targeted therapies into clinical practice will be an exciting challenge in the future.
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13
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Immune cytopenia after allogeneic haematopoietic stem-cell transplantation: challenges, approaches, and future directions. LANCET HAEMATOLOGY 2021; 8:e229-e239. [PMID: 33636143 DOI: 10.1016/s2352-3026(20)30404-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 11/24/2020] [Accepted: 11/30/2020] [Indexed: 12/20/2022]
Abstract
Immune-mediated cytopenia after allogeneic haematopoietic stem-cell transplantation is rare. The pathophysiology of immune-mediated anaemia, thrombocytopenia, and neutropenia, which occur alone or in combination with other cytopenias, is unclear and most probably a consequence of immune dysregulation. Risk factors for this complication have been identified in retrospective studies but these should be interpreted with caution and should not be generalised to this heterogeneous patient population. Diagnosis is challenging, requires awareness of such complications, and has to be differentiated from a multitude of other, and sometimes overlapping, possible complications. The clinical course of immune-mediated cytopenia is highly variable. Treatment requires an interdisciplinary approach and ranges from observation to symptomatic measures and directed therapies. Intensive immunosuppression is associated with an increased risk of infections and relapse, and current treatments are based on approaches in patients who have not undergone transplantation. Plasma cell-directed therapies, immunomodulation, and receptor-stimulating agents can be used to treat immune-mediated cytopenia.
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14
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Stubbs J, Klompas A, Thalji L. Transfusion Therapy in Specific Clinical Situations. Transfus Med 2021. [DOI: 10.1002/9781119599586.ch11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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15
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Brand A, De Angelis V, Vuk T, Garraud O, Lozano M, Politis D. Review of indications for immunoglobulin (IG) use: Narrowing the gap between supply and demand. Transfus Clin Biol 2021; 28:96-122. [DOI: 10.1016/j.tracli.2020.12.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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16
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Rituximab Use in Warm and Cold Autoimmune Hemolytic Anemia. J Clin Med 2020; 9:jcm9124034. [PMID: 33322221 PMCID: PMC7763062 DOI: 10.3390/jcm9124034] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 12/06/2020] [Accepted: 12/09/2020] [Indexed: 01/22/2023] Open
Abstract
Autoimmune hemolytic anemia is a rare condition characterized by destruction of red blood cells with and without involvement of complement. It is associated with significant morbidity and mortality. In warm autoimmune hemolytic anemia, less than 50% of patients remain in long-term remission following initial steroid therapy and subsequent therapies are required. Cold agglutinin disease is a clonal hematologic disorder that requires therapy in the majority of patients and responds poorly to steroids and alkylators. Rituximab has a favorable toxicity profile and has demonstrated efficacy in autoimmune hemolytic anemia in first-line as well as relapsed settings. Rituximab is the preferred therapy for steroid refractory warm autoimmune hemolytic anemia (wAIHA) and as part of the first- and second-line treatment of cold agglutinin disease. This article reviews the mechanism of action of rituximab and the current literature on its role in the management of primary and secondary warm autoimmune hemolytic anemia and cold agglutinin disease.
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Steuer LV, Kondo AT, Cipolletta AN, Sakashita AM, Hamerschlak N, Kutner JM. Predictive factors for the development of anemia after hematopoietic stem cell donation. Transfusion 2020; 61:159-166. [PMID: 33052621 DOI: 10.1111/trf.16124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 08/29/2020] [Accepted: 08/31/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Although Hematopoietic Stem Cells (HSC) donation through bone marrow (BM) and peripheral blood (PB) are usually safe procedures, adverse events are expected. One of the most common events especially among BM donors (BMD) is the development of anemia. To protect the BMD and preserve the hemoglobin levels, many centers collect autologous pre-procedure blood, but the actual benefits of this procedure is controversial. METHODS AND MATERIALS This study analyzed retrospectively data to observe what factors may influence the occurrence of post-donation anemia and also evaluate the relevance of autologous red blood cell pre procedure donation (PAD). RESULTS The development of immediately post donation anemia (IP) was higher in BMD than in PB donors (64.2% BMD and 10.7% PBD, P < .001) and also in late post donation (LP) (28.4% BMD and 3.6% PBD, P = .007). The study demonstrated an association between PAD and anemia in IP (72.7% with anemia and 27.3% without anemia, P = .006) and an association between the volume of red blood cells in the donated hematopoietic product and the development of anemia in LP (356.3 mL and 297.8 mL, P = .037). CONCLUSION In conclusion, collection of HSC through BM is a risk factor for anemia and PAD is a risk factor for IP anemia.
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Affiliation(s)
- Lia V Steuer
- Hemotherapy and Cell Therapy Department, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Andrea T Kondo
- Hemotherapy and Cell Therapy Department, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Andrea N Cipolletta
- Hemotherapy and Cell Therapy Department, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Araci M Sakashita
- Hemotherapy and Cell Therapy Department, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Nelson Hamerschlak
- Hemotherapy and Cell Therapy Department, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - José M Kutner
- Hemotherapy and Cell Therapy Department, Hospital Israelita Albert Einstein, São Paulo, Brazil
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Koo J, Giller RH, Quinones R, McKinney CM, Verneris MR, Knight-Perry J. Autoimmune cytopenias following allogeneic hematopoietic stem cell transplant in pediatric patients: Response to therapy and late effects. Pediatr Blood Cancer 2020; 67:e28591. [PMID: 32658382 DOI: 10.1002/pbc.28591] [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: 04/28/2020] [Revised: 06/05/2020] [Accepted: 06/30/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Autoimmune cytopenias (AICs) are rare, but serious complications of allogeneic hematopoietic cell transplantation (allo-HSCT). PROCEDURE We performed a case-control study using 20 pediatric AIC cases and 40 controls, matched by stem cell source and primary indication comparing clinical and transplant characteristics, treatment, outcomes, and late effects. RESULTS Cases were more likely to be human leukocyte antigen mismatched (P = 0.04). There was no difference in conditioning regimen, serotherapy use, graft-versus-host disease (GVHD) prophylaxis, incidence of acute or chronic GVHD, ABO compatibility, infections, and donor engraftment. The median time to AIC onset was 219 days (range, 97-1205 days) and AIC resolution was 365 days (range, 10 days to 2737.5 days). First-line therapies for AIC patients most commonly included corticosteroids (75%) and rituximab (55%). Only 25% of patients responded to first-line treatment. At a median of 611.5 days from last rituximab dose, 82.5% patients were still receiving intravenous immune globulin for hypogammaglobulinemia compared with 2.5% of controls (P < 0.0001). Iron overload was higher in AIC patients (P = 0.0004), as was avascular necrosis (P = 0.04). There was no difference in overall survival at one year after HSCT (85% vs 82.5%). Two patients with refractory autoimmune hemolytic anemia responded to daratumumab and had resolution of B-cell aplasia. CONCLUSIONS In this study, we find poor initial responses to AIC-directed therapies and significant late effects.
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Affiliation(s)
- Jane Koo
- Children's Hospital Colorado, Division of Pediatric Hematology/Oncology/Bone Marrow Transplant, Colorado, University of Colorado Anschutz Medical Campus, Aurora
| | - Roger H Giller
- Children's Hospital Colorado, Division of Pediatric Hematology/Oncology/Bone Marrow Transplant, Colorado, University of Colorado Anschutz Medical Campus, Aurora
| | - Ralph Quinones
- Children's Hospital Colorado, Division of Pediatric Hematology/Oncology/Bone Marrow Transplant, Colorado, University of Colorado Anschutz Medical Campus, Aurora
| | - Christopher M McKinney
- Children's Hospital Colorado, Division of Pediatric Hematology/Oncology/Bone Marrow Transplant, Colorado, University of Colorado Anschutz Medical Campus, Aurora
| | - Michael R Verneris
- Children's Hospital Colorado, Division of Pediatric Hematology/Oncology/Bone Marrow Transplant, Colorado, University of Colorado Anschutz Medical Campus, Aurora
| | - Jessica Knight-Perry
- Children's Hospital Colorado, Division of Pediatric Hematology/Oncology/Bone Marrow Transplant, Colorado, University of Colorado Anschutz Medical Campus, Aurora
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Defining autoimmune hemolytic anemia: a systematic review of the terminology used for diagnosis and treatment. Blood Adv 2020; 3:1897-1906. [PMID: 31235526 DOI: 10.1182/bloodadvances.2019000036] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 05/21/2019] [Indexed: 12/11/2022] Open
Abstract
The terminology applied to autoimmune hemolytic anemia (AIHA) seems inconsistent. We aimed to evaluate the consistency of definitions used for diagnosis and treatment. In this systematic review of literature from January 2006 to December 2015, we assessed heterogeneity in the definition of AIHA and its subtypes, refractory disease, disease phase, severity, criteria for treatment response, and response durability. A Medline search for anemia, hemolytic, autoimmune was supplemented with keyword searches. Main exclusions were conference abstracts, animal and non-English studies, and studies with <10 cases. Of 1371 articles retrieved, 1209 were excluded based on titles and abstracts. Two authors independently reviewed 10% and 16% of abstracts and full papers, respectively. After full-paper review, 84 studies were included. AIHA was most frequently (32 [52%] of 61) defined as hemolytic anemia with positive direct antiglobulin test (DAT) and exclusion of alternatives, but 10 of 32 also recognized DAT-negative AIHA. A lower threshold for diagnosis of DAT-negative AIHA was observed in literature on chronic lymphocytic leukemia. Definitions of anemia, hemolysis, and exclusion criteria showed substantial variation. Definitions of primary/secondary cold agglutinin disease/syndrome were not consistent. Forty-three studies provided criteria for treatment response, and other than studies from 1 center, these were almost entirely unique. Other criteria were rarely defined. Only 7, 0, 3, 2, 2, and 3 studies offered definitions of warm AIHA, paroxysmal cold hemoglobinuria, mixed AIHA, AIHA severity, disease phase, and refractory AIHA, respectively. Marked heterogeneity in the time period sampled indicates the need to standardize AIHA terminology.
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20
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Hamamyh T, Yassin MA. Autoimmune Hemolytic Anemia in Chronic Myeloid Leukemia. Pharmacology 2020; 105:630-638. [PMID: 32485715 PMCID: PMC7845422 DOI: 10.1159/000507295] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 03/13/2020] [Indexed: 01/06/2023]
Abstract
Background Autoimmune hemolytic anemia (AIHA) might be associated with underlying hematological malignancies such as chronic lymphocytic leukemia. However, the association between AIHA and chronic myelogenous leukemia is extremely unusual. Summary We reviewed case reports and series of 54 patients with chronic myeloid leukemia (CML) who developed autoimmune hemolysis between 1952 and 2018. Almost all the patients were in the chronic phase and were classified into transplant and non-transplant groups. The onset of autoimmune hemolysis was earlier in the transplant group and required second- and third-line therapy to control it. The etiology of hemolysis is poorly understood but attributed in the transplant group to immune reconstitution, viral infections, or CML relapse. On the other hand, it is thought to be related in the non-transplant group to CML medications, especially interferon. Key Messages Although AIHA is uncommon in chronic myelogenous leukemia patients, it should be in the differential diagnosis list for those who develop a sudden drop in hemoglobin without a bleeding source.
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Affiliation(s)
- Tahseen Hamamyh
- Department of Medical Education, Hamad Medical Corporation, Doha, Qatar,
| | - Mohamed A Yassin
- Department of Medical Oncology/Hematology Section, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar
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21
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Lum SH, Selvarajah S, Deya-Martinez A, McNaughton P, Sobh A, Waugh S, Burton-Fanning S, Newton L, Gandy J, Nademi Z, Owens S, Williams E, Emonts M, Flood T, Cant A, Abinun M, Hambleton S, Gennery AR, Slatter M. Outcome of autoimmune cytopenia after hematopoietic cell transplantation in primary immunodeficiency. J Allergy Clin Immunol 2020; 146:406-416. [PMID: 32442647 DOI: 10.1016/j.jaci.2020.04.053] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Revised: 04/02/2020] [Accepted: 04/09/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Post hematopoietic cell transplantation (HCT) autoimmune cytopenia (AIC) is a potentially life-threatening complication, but studies focusing on large cohorts of patients transplanted for primary immunodeficiency are lacking. OBJECTIVES This study sought to determine the incidence, risk factors, and outcomes of post-HCT AIC and B-lymphocyte function following rituximab. METHODS We retrospectively studied 502 children with primary immunodeficiency who were transplanted at our center between 1987 and 2018. RESULTS Thirty-six patients (9%) developed post-HCT AIC, with a median onset of 6.5 months post-HCT. On univariate analysis, pre-HCT AIC, mismatched donor, alemtuzumab, anti-thymocyte antiglobulin, and acute and chronic graft versus host disease were significantly associated with post-HCT AIC. After multivariate analysis, alemtuzumab (subdistribution hazard ratio, 9.0; 95% CI, 1.50-54.0; P = .02) was independently associated with post-HCT AIC. Corticosteroid and high-dose intravenous immunoglobulin achieved remission in 50% (n = 18), additional rituximab led to remission in 25% (n = 9), and the remaining 25% were treated with a combination of various modalities including sirolimus (n = 5), bortezomib (n = 3), mycophenolate mofetil (n = 2), splenectomy (n = 2), and second HCT (n = 3). The mortality of post-HCT AIC reduced from 25% (4 of 16) prior to 2011 to 5% (1 of 20) after 2011. The median follow-up of 5.8 years (range, 0.4 to 29.1 years) showed that 26 of 30 survivors (87%) were in complete remission, and 4 were in remission with ongoing sirolimus and low-dose steroids. Of the 17 who received rituximab, 7 had B-lymphocyte recovery, 5 had persistent low B-lymphocyte count and remained on intravenous immunoglobulin replacement, 2 had second HCT, and 3 died. CONCLUSIONS The frequency of post HCT AIC in our cohort was 9%, and the most significant risk factors for its occurrence were the presence of graft versus host disease and the use of alemtuzumab.
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Affiliation(s)
- Su Han Lum
- Children's Haematopoietic Stem Cell Transplant Unit, Great North Children's Hospital, Newcastle upon Tyne Hospital National Health System Foundation Trust, Newcastle upon Tyne, United Kingdom; Department of Paediatrics, Leiden University Medical Centre, Leiden, The Netherlands.
| | - Sabeena Selvarajah
- Children's Haematopoietic Stem Cell Transplant Unit, Great North Children's Hospital, Newcastle upon Tyne Hospital National Health System Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Angela Deya-Martinez
- Children's Haematopoietic Stem Cell Transplant Unit, Great North Children's Hospital, Newcastle upon Tyne Hospital National Health System Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Peter McNaughton
- Children's Haematopoietic Stem Cell Transplant Unit, Great North Children's Hospital, Newcastle upon Tyne Hospital National Health System Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Ali Sobh
- Children's Haematopoietic Stem Cell Transplant Unit, Great North Children's Hospital, Newcastle upon Tyne Hospital National Health System Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Sheila Waugh
- Microbiology and Virology, Newcastle upon Tyne Hospital National Health System Foundation Trust, Newcastle upon Tyne, United Kingdom
| | | | - Lisa Newton
- Microbiology and Virology, Newcastle upon Tyne Hospital National Health System Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Julie Gandy
- Microbiology and Virology, Newcastle upon Tyne Hospital National Health System Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Zohreh Nademi
- Children's Haematopoietic Stem Cell Transplant Unit, Great North Children's Hospital, Newcastle upon Tyne Hospital National Health System Foundation Trust, Newcastle upon Tyne, United Kingdom; Translational and Clinical Research Institute, Newcastle upon Tyne Hospital National Health System Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Stephen Owens
- Children's Haematopoietic Stem Cell Transplant Unit, Great North Children's Hospital, Newcastle upon Tyne Hospital National Health System Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Eleri Williams
- Children's Haematopoietic Stem Cell Transplant Unit, Great North Children's Hospital, Newcastle upon Tyne Hospital National Health System Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Marieke Emonts
- Children's Haematopoietic Stem Cell Transplant Unit, Great North Children's Hospital, Newcastle upon Tyne Hospital National Health System Foundation Trust, Newcastle upon Tyne, United Kingdom; Translational and Clinical Research Institute, Newcastle upon Tyne Hospital National Health System Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Terry Flood
- Children's Haematopoietic Stem Cell Transplant Unit, Great North Children's Hospital, Newcastle upon Tyne Hospital National Health System Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Andrew Cant
- Children's Haematopoietic Stem Cell Transplant Unit, Great North Children's Hospital, Newcastle upon Tyne Hospital National Health System Foundation Trust, Newcastle upon Tyne, United Kingdom; Translational and Clinical Research Institute, Newcastle upon Tyne Hospital National Health System Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Mario Abinun
- Children's Haematopoietic Stem Cell Transplant Unit, Great North Children's Hospital, Newcastle upon Tyne Hospital National Health System Foundation Trust, Newcastle upon Tyne, United Kingdom; Microbiology and Virology, Newcastle upon Tyne Hospital National Health System Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Sophie Hambleton
- Children's Haematopoietic Stem Cell Transplant Unit, Great North Children's Hospital, Newcastle upon Tyne Hospital National Health System Foundation Trust, Newcastle upon Tyne, United Kingdom; Translational and Clinical Research Institute, Newcastle upon Tyne Hospital National Health System Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Andrew R Gennery
- Children's Haematopoietic Stem Cell Transplant Unit, Great North Children's Hospital, Newcastle upon Tyne Hospital National Health System Foundation Trust, Newcastle upon Tyne, United Kingdom; Translational and Clinical Research Institute, Newcastle upon Tyne Hospital National Health System Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Mary Slatter
- Children's Haematopoietic Stem Cell Transplant Unit, Great North Children's Hospital, Newcastle upon Tyne Hospital National Health System Foundation Trust, Newcastle upon Tyne, United Kingdom; Translational and Clinical Research Institute, Newcastle upon Tyne Hospital National Health System Foundation Trust, Newcastle upon Tyne, United Kingdom
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22
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Miller PDE, Snowden JA, De Latour RP, Iacobelli S, Eikema DJ, Knol C, Marsh JCW, Rice C, Koh M, Fagioli F, Chaganti S, Finke J, Duarte RF, Bader P, Farge D, Passweg JR, Madrigal JA, Dufour C. Autoimmune cytopenias (AIC) following allogeneic haematopoietic stem cell transplant for acquired aplastic anaemia: a joint study of the Autoimmune Diseases and Severe Aplastic Anaemia Working Parties (ADWP/SAAWP) of the European Society for Blood and Marrow Transplantation (EBMT). Bone Marrow Transplant 2020; 55:441-451. [PMID: 31554929 PMCID: PMC6995778 DOI: 10.1038/s41409-019-0680-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Revised: 07/06/2019] [Accepted: 07/20/2019] [Indexed: 12/03/2022]
Abstract
This retrospective study explored the incidence of autoimmune cytopenia (AIC) in 530 paediatric and adult patients with acquired aplastic anaemia (aAA) who underwent first allogeneic HSCT between 2002 and 2012. AIC was a rare complication with a cumulative incidence of AIC at 1, 3, 5 and 10 years post HSCT of 2.5% (1.2-3.9 95% CI), 4.4% (2.6-6.2 95% CI), 4.6% (2.8-6.5 95% CI) and 5.1% (3.1-7.2 95% CI). Overall survival at 5 years after diagnosis of AIC was 85.9% (71-100 95% CI). Twenty-five patients were diagnosed with AIC at a median of 10.6 (2.6-91.5) months post HSCT. Eight (32%) patients were diagnosed with immune thrombocytopenia (ITP), seven (28%) with autoimmune haemolytic anaemia (AIHA), seven (24%) with Evans syndrome and four (16%) with autoimmune neutropenia (AIN). Treatment strategies were heterogeneous. Complete responses were seen in 12 of 25 patients, with death in three patients. In multivariable Cox analysis of a subgroup of 475 patients, peripheral blood stem cell (PBSC) transplant was associated with higher risk of AIC compared with bone marrow (BM) when conditioning regimens contained fludarabine and/or alemtuzumab (2.81 [1.06-7.49 95% CI]; p = 0.038), or anti-thymocyte globulin (ATG) (2.86 [1.11-7.37 95% CI]; p = 0.029). Myeloablative conditioning was associated with a lower risk of AIC compared with reduced intensity conditioning (RIC) in fludarabine and/or alemtuzumab (0.34 [0.12-0.98 95% CI]; p = 0.046) and ATG containing regimens (0.34 [0.12-0.95 95% CI]; p = 0.04). These findings provide clinically useful information regarding the incidence of a rare and potentially life-threatening complication of allogeneic HSCT for aAA, and further support for BM as the preferred stem cell source for transplant of patients with aAA.
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Affiliation(s)
| | - John A Snowden
- Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | | | - Simona Iacobelli
- Department of Biology, University of Rome Tor Vergata, Rome, Italy
| | | | - Cora Knol
- EBMT Data Office, Leiden, Netherlands
| | - Judith C W Marsh
- Department of Haematological Medicine, Kings College Hospital, London, UK
| | - Carmel Rice
- Department of Haematological Medicine, Kings College Hospital, London, UK
| | - Mickey Koh
- Department of Haematology, St George's Hospital NHS Foundation Trust, London, UK
| | - Franca Fagioli
- Pediatric Onco-Hematology, Stem Cell Transplantation and Cellular Therapy Division, Regina Margherita Children's Hospital, Torino, Italy
| | - Sridhar Chaganti
- Centre for Clinical Haematology, University Hospital Birmingham, Birmingham, UK
| | - Jürgen Finke
- Department of Hematology and Oncology, University Medical Center, Freiburg, Germany
| | - Rafael F Duarte
- Department of Hematology, Hospital Universitario Puerta de Hierro, Madrid, Spain
| | - Peter Bader
- University Children's Hospital Frankfurt, Frankfurt, Germany
| | - Dominique Farge
- Department of Autoimmune Diseases and Vascular Pathology, Hopital Saint-Louis, Paris, France
| | - Jakob R Passweg
- Division of Hematology, University Hospital of Santander, Basel, Switzerland
| | | | - Carlo Dufour
- Hematology Unit, G. Gaslini Children's Hospital, Genova, Italy
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23
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Szanto CL, Langenhorst J, de Koning C, Nierkens S, Bierings M, Huitema AD, Lindemans CA, Boelens JJ. Predictors for Autoimmune Cytopenias after Allogeneic Hematopoietic Cell Transplantation in Children. Biol Blood Marrow Transplant 2020; 26:114-122. [DOI: 10.1016/j.bbmt.2019.07.022] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 07/05/2019] [Accepted: 07/16/2019] [Indexed: 12/27/2022]
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24
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Lv W, Qu H, Wu M, Fan Z, Huang F, Xu N, Xuan L, Lin R, Zhao K, Sun J, Lai Y, Xu Y, Liu Q. Autoimmune hemolytic anemia after allogeneic hematopoietic stem cell transplantation in adults: A southern China multicenter experience. Cancer Med 2019; 8:6549-6558. [PMID: 31502764 PMCID: PMC6825994 DOI: 10.1002/cam4.2539] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 08/22/2019] [Accepted: 08/22/2019] [Indexed: 01/06/2023] Open
Abstract
To investigate the incidence and risk factors as well as prognosis of autoimmune hemolytic anemia (AIHA) following allogeneic hematopoietic stem cell transplantation (allo‐HSCT), a total of 1377 adult hematological malignancies at three institutions were enrolled in this study. The 3‐year cumulative incidence of AIHA was 2.2 ± 0.4%. Multivariate analysis showed that haploidentical donors (HRDs) and chronic graft vs host disease (cGVHD) were the independent risk factors for AIHA. Patients with AIHA treated initially with corticosteroids combined with cyclosporine A (CsA) had a higher complete response rate than those with corticosteroids monotherapy (66.7% vs 11.1%; P = .013). The 3‐year cumulative incidence of malignant diseases relapse was 4.4 ± 4.3% and 28.0 ± 1.3% (P = .013), treatment‐related mortality (TRM) was 8.9 ± 6.3% and 17.4 ± 1.2% (P = .431), disease‐free survival (DFS) was 56.1 ± 1.5% and 86.7 ± 7.2% (P = .011), and overall survival (OS) was 86.3 ± 7.4% and 64.1 ± 1.5% (P = .054), respectively, in the patients with AIHA and those without AIHA. Our results indicate that HRDs and cGVHD are risk factors for AIHA and corticosteroids combined with CsA are superior to corticosteroids as initial treatment for AIHA. Autoimmune hemolytic anemia does not contribute to increase TRM and could reduce the malignant diseases relapse and increase DFS.
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Affiliation(s)
- Weiran Lv
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Hong Qu
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China.,Hematology, Guangzhou Panyu Central Hospital, Guangzhou, Guangdong, China
| | - Meiqing Wu
- Hematology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Zhiping Fan
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Fen Huang
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Na Xu
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Li Xuan
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Ren Lin
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Ke Zhao
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Jing Sun
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Yongrong Lai
- Hematology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Yajing Xu
- Hematology, Xiangya Hospital Central South University, Changsha, Hunan, China
| | - Qifa Liu
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
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25
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Immune-Mediated Cytopenias After Hematopoietic Cell Transplantation: Pathophysiology, Clinical Manifestations, Diagnosis, and Treatment Strategies. Curr Oncol Rep 2019; 21:87. [PMID: 31414187 DOI: 10.1007/s11912-019-0838-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
PURPOSE OF REVIEW Discuss the pathophysiology, clinical presentation, diagnosis, and treatment of immune-mediated cytopenias (IMC) after hematopoietic cell transplantation (HCT). RECENT FINDINGS Key risk factors for post-HCT IMC include younger age, non-malignant disease, and umbilical cord blood stem cell source. While anemia predominates, any or all three hematopoietic cell lines can be affected. In rare cases, IMC can cause graft failure or death. IMC is hypothesized to result from immune dysregulation upon reconstitution of donor hematopoietic cells (i.e., dysfunctional regulatory T cells). Aside from blood product transfusions, IMC treatment includes immune-suppressive or ablative agents. First-line therapies, including corticosteroids and intravenous immunoglobulin, are often inadequate, prompting use of additional agents aimed at antibody production/T cell dysfunction or direct antibody removal via plasmapheresis. IMC occurs in up to 20% of high-risk HCT populations. Morbidity and mortality from IMC post-HCT have been reduced by improved recognition and aggressive early interventions.
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Barcellini W, Fattizzo B, Zaninoni A. Management of refractory autoimmune hemolytic anemia after allogeneic hematopoietic stem cell transplantation: current perspectives. J Blood Med 2019; 10:265-278. [PMID: 31496855 PMCID: PMC6690850 DOI: 10.2147/jbm.s190327] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Accepted: 07/10/2019] [Indexed: 12/18/2022] Open
Abstract
Autoimmune hemolytic anemia (AIHA) is increasingly observed after allogeneic hematopoietic stem cell transplantation (allo-HSCT), with a reported incidence between 4% and 6%. The disease is generally severe and refractory to standard therapy, with high mortality, and there are neither defined therapies, nor prospective clinical trials addressing the best treatment. Most of the knowledge on the therapy of AIHAs derives from primary forms, which are highly heterogeneous as well, further complicating the management of post-allo-HSCT forms. The review addresses the risk factors associated with post-allo-AIHA, including unrelated donor, the development of chronic extensive graft-versus-host disease, CMV reactivation, nonmalignant diagnosis pre-HSCT, and alemtuzumab use in conditioning regimens. Regarding therapy, we describe standard treatments, such as corticosteroids, intravenous immunoglobulin, splenectomy, rituximab, cyclophosphamide, and plasma exchange, which have lower response rates than those reported in primary forms. New therapeutic options, including sirolimus, bortezomib, abatacept, daratumumab and complement inhibitors, are promising tools for this detrimental complication occurring after allo-HSCT.
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Affiliation(s)
- Wilma Barcellini
- UOC Ematologia, Fondazione IRCCS Ca' Grande Ospedale Maggiore Policlinico, Milano, Italy
| | - Bruno Fattizzo
- UOC Ematologia, Fondazione IRCCS Ca' Grande Ospedale Maggiore Policlinico, Milano, Italy
| | - Anna Zaninoni
- UOC Ematologia, Fondazione IRCCS Ca' Grande Ospedale Maggiore Policlinico, Milano, Italy
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27
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Neunert CE, Despotovic JM. Autoimmune hemolytic anemia and immune thrombocytopenia following hematopoietic stem cell transplant: A critical review of the literature. Pediatr Blood Cancer 2019; 66:e27569. [PMID: 30537439 DOI: 10.1002/pbc.27569] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 10/29/2018] [Accepted: 11/02/2018] [Indexed: 01/19/2023]
Abstract
Autoimmune cytopenias (AIC) post-hematopoietic stem cell transplant (HSCT) are rare but exceptionally challenging complication. We conducted a comprehensive literature review and identified a pooled incidence of post-HSCT autoimmune hemolytic anemia and/or immune thrombocytopenia of 2.66% (SE = 0.27) in pediatric patients. Nonmalignant disease, unrelated donor transplant, peripheral or cord blood stem cell source, conditioning regimen without total body irradiation, and presence of chronic graft-versus-host disease were prominent risk factors. Treatment was highly variable, and cytopenias were commonly refractory. AIC represent a significant post-HSCT complication. We report here the incidence, risk factors, and possible biology behind the development of AIC in pediatric post-HSCT patients.
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Affiliation(s)
- C E Neunert
- Department of Pediatrics, Hematology/Oncology/Bone Marrow Transplant, Columbia University School of Medicine, New York, New York
| | - J M Despotovic
- Department of Pediatrics, Hematology/Oncology Section, Baylor College of Medicine, Houston, Texas
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28
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Zhang ZM, Lai YR, Li QC, Luo L, Liu RR, Shi LL, Liu LJ. [Clinical analysis of autoimmune hemolytic anemia after allogeneic hematopoietic stem cell transplantation in thalassemia major]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2019; 39:908-911. [PMID: 30486586 PMCID: PMC7342357 DOI: 10.3760/cma.j.issn.0253-2727.2018.11.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
目的 探讨重型地中海贫血(地贫)患者异基因造血干细胞移植(allo-HSCT)后并发自身免疫性溶血性贫血(AIHA)诊断、治疗及转归,以提高地贫患者造血干细胞移植疗效。 方法 回顾性分析2007年7月至2017年12月共计291例行allo-HSCT重型地贫患者的临床资料。 结果 重型地贫allo-HSCT后AIHA发生率为1.72%(5/291);AIHA中位发生时间为移植后7(5~12)个月,5例移植后AIHA患者直接和间接Coombs试验均阳性,患者主要表现为头晕、乏力、面色苍白、皮肤巩膜黄染、酱油色尿。228例HLA相合同胞供者移植患者有1例(0.43%)移植后发生AIHA,而63例非亲缘供者移植患者有4例(6.36%)移植后发生AIHA。非亲缘供者移植患者AIHA发生率高于HLA相合同胞供者移植患者。1例患者单用泼尼松治疗死亡,4例患者采用甲泼尼龙联合利妥昔单抗治疗有效,目前生存良好,其中2例Coombs试验转阴。 结论 该组重型地贫患者allo-HSCT后AIHA发生率为1.72%,Coombs试验有助于诊断移植后AIHA,非亲缘供者移植病例移植后AIHA发生率高于HLA相合同胞供者移植组,利妥昔单抗联合糖皮质激素是治疗重型地贫allo-HSCT后AIHA的有效方法。
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Affiliation(s)
- Z M Zhang
- Department of Hematology, The First Affiliated Hospital of Guangxi Medial University, Nanning 530021, China
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29
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Scordo M, Hsu M, Jakubowski AA, Shah GL, Cho C, Maloy MA, Avecilla ST, Papadopoulos EB, Gyurkocza B, Castro-Malaspina H, Tamari R, O'Reilly RJ, Perales MA, Giralt SA, Shaffer BC. Immune Cytopenias after Ex Vivo CD34+-Selected Allogeneic Hematopoietic Cell Transplantation. Biol Blood Marrow Transplant 2019; 25:1136-1141. [PMID: 30625387 DOI: 10.1016/j.bbmt.2018.12.842] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 12/31/2018] [Indexed: 01/20/2023]
Abstract
Immune-mediated cytopenias (ICs), such as immune thrombocytopenia and immune hemolytic anemia, are among the adverse events after allogeneic hematopoietic cell transplantation (allo-HCT). Previous reports suggest that in vivo T cell depletion may increase the incidence of IC after allo-HCT. We evaluated whether a strategy that reduces functional donor T cells via ex vivo CD34+-selection associates with the development of IC in a cohort of 408 patients who underwent allo-HCT for hematologic malignancy. The cumulative incidence of IC at 6, 12, and 36 months after the 30-day landmark post-HCT was 3.4%, 4.9%, and 5.8%, respectively. Among 23 patients who developed IC, 7 died of relapse-related mortality and 4 of nonrelapse mortality. A median 2 types of treatment (range, 1 to 5) was required to resolve IC, and there was considerable heterogeneity in the therapies used. In univariable analyses, a hematologic malignancy Disease Risk Index (DRI) score of 3 was significantly associated with an increased risk of IC compared with a DRI of 1 or 2 (hazard ratio [HR], 4.12; P = .003), and IC (HR, 2.4; P = .03) was associated with increased risk of relapse. In a multivariable analysis that included DRI, IC remained significantly associated with increased risk of relapse (HR, 2.4; P = .03). Our findings show that IC events occur with relatively similar frequency in patients after ex vivo CD34+-selected allo-HCT compared with unmodified allo-HCT, suggesting that reduced donor T cell immunity is not causative of IC. Moreover, we noted a possible link between its development and/or treatment and increased risk of relapse.
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Affiliation(s)
- Michael Scordo
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York.
| | - Meier Hsu
- Department of Biostatistics and Epidemiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ann A Jakubowski
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Gunjan L Shah
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Christina Cho
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Molly A Maloy
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Scott T Avecilla
- Department of Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Esperanza B Papadopoulos
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Boglarka Gyurkocza
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Hugo Castro-Malaspina
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Roni Tamari
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Richard J O'Reilly
- Pediatric Bone Marrow Transplantation Service, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Pediatrics, Weill Cornell Medical College, New York, New York
| | - Miguel-Angel Perales
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Sergio A Giralt
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Brian C Shaffer
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
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30
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Barcellini W, Fattizzo B, Zaninoni A. Current and emerging treatment options for autoimmune hemolytic anemia. Expert Rev Clin Immunol 2018; 14:857-872. [PMID: 30204521 DOI: 10.1080/1744666x.2018.1521722] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Autoimmune hemolytic anemia (AIHA) is a heterogeneous disease mainly due to autoantibody-mediated destruction of erythrocytes but also involves complement activation, dysregulation of cellular and innate immunity, and defective bone marrow compensatory response. Several drugs targeting these mechanisms are under development in addition to standard therapies. Areas covered: The following targeted therapies are illustrated: drugs acting on CD20 (rituximab, alone or in association with bendamustine and fludarabine) and CD52 (alemtuzumab), B cell receptor and proteasome inhibitors (ibrutinib, bortezomib), complement inhibitors (eculizumab, BIVV009, APL-2), and other drugs targeting T lymphocytes (subcutaneous IL-2, belimumab, and mTOR inhibitors), IgG driven extravascular hemolysis (fostamatinib), and bone marrow activity (luspatercept). Expert opinion: Although AIHA is considered benign and often easy to treat, chronic/refractory cases represent a challenge even for experts in the field. Bone marrow biopsy is fundamental to assess one of the main mechanisms contributing to AIHA severity, i.e. inadequate compensation, along with lymphoid infiltrate, the presence of fibrosis or dyserythropoiesis. The latter may give hints for targeted therapies (either B or T cell directed) and for new immunomodulatory drugs. Future studies on the genomic landscape in AIHA will further help in designing the best choice, sequence and/or combination of targeted therapies.
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Affiliation(s)
- Wilma Barcellini
- a UOC Ematologia, Fondazione IRCCS Ca' Grande Ospedale Maggiore Policlinico , Milano , Italy
| | - Bruno Fattizzo
- a UOC Ematologia, Fondazione IRCCS Ca' Grande Ospedale Maggiore Policlinico , Milano , Italy
| | - Anna Zaninoni
- a UOC Ematologia, Fondazione IRCCS Ca' Grande Ospedale Maggiore Policlinico , Milano , Italy
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31
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Hess J, Su L, Nizzi F, Beebe K, Magee K, Salzberg D, Stahlecker J, Miller HK, Adams RH, Ngwube A. Successful treatment of severe refractory autoimmune hemolytic anemia after hematopoietic stem cell transplant with abatacept. Transfusion 2018; 58:2122-2127. [DOI: 10.1111/trf.14907] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 05/21/2018] [Accepted: 06/01/2018] [Indexed: 12/11/2022]
Affiliation(s)
- Jennifer Hess
- Center for Cancer and Blood Disorders; Phoenix Children's Hospital; Phoenix Arizona
| | - Leon Su
- Center for Cancer and Blood Disorders; Phoenix Children's Hospital; Phoenix Arizona
| | - Frank Nizzi
- Center for Cancer and Blood Disorders; Phoenix Children's Hospital; Phoenix Arizona
| | - Kristen Beebe
- Center for Cancer and Blood Disorders; Phoenix Children's Hospital; Phoenix Arizona
- Mayo Clinic; Scottsdale Arizona
| | - Kyrie Magee
- Center for Cancer and Blood Disorders; Phoenix Children's Hospital; Phoenix Arizona
- Mayo Clinic; Scottsdale Arizona
| | - Dana Salzberg
- Center for Cancer and Blood Disorders; Phoenix Children's Hospital; Phoenix Arizona
| | - Jennifer Stahlecker
- Center for Cancer and Blood Disorders; Phoenix Children's Hospital; Phoenix Arizona
| | - Holly K. Miller
- Center for Cancer and Blood Disorders; Phoenix Children's Hospital; Phoenix Arizona
| | - Roberta H. Adams
- Center for Cancer and Blood Disorders; Phoenix Children's Hospital; Phoenix Arizona
- Mayo Clinic; Scottsdale Arizona
| | - Alexander Ngwube
- Center for Cancer and Blood Disorders; Phoenix Children's Hospital; Phoenix Arizona
- Mayo Clinic; Scottsdale Arizona
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32
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Lv W, Fan Z, Huang F, Xu N, Xuan L, GuopanYu, Jiang Q, Zhou H, Lin R, Zhang X, Sun J, Liu Q. Autoimmune hematological diseases following haploidentical donor hematopoietic stem cell Transplant compared with matched sibling and unrelated donor. Oncotarget 2018; 8:26505-26514. [PMID: 28460445 PMCID: PMC5432275 DOI: 10.18632/oncotarget.15710] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Accepted: 02/10/2017] [Indexed: 01/09/2023] Open
Abstract
Autoimmune hematological diseases (AHDs) occur more frequently than other autoimmune complications after allogeneic hematopoietic stem cell transplantation (allo-HSCT) and are often refractory to treatment. This study was to analyze the incidence and risk factors of AHDs as well as their response to treatment. Four hundred and forty-five adult malignant hematopoietic disorders underwent allo-HSCT were enrolled in this retrospective study, including 124 haploidentical donor (HRD), 140 unrelated donor (MUD) and 181 HLA-matched sibling donor (MSD) transplants. Twelve patients developed AHDs, including 6 autoimmune hemolytic anemia and 6 Evans syndrome. Evans syndrome all occurred in HRD transplants. The 3-year cumulative incidence of AHDs was 4.0 ± 1.3%, and HRD had higher incidence than MUD (8.7 ± 3.0% vs 1.8 ± 1.2%, P = 0.012) and MSD (8.7 ± 3.0% vs 3.5 ± 2.6%, P = 0.004 ). The steroids combined with Cyclosporine A were acted as the first line treatment, and the response rate was 73%. No patients experienced recurrence at a median follow up of 313 days after stopping treatment. HRD transplants (vs MUD: HR, 5.87; CI, 1.24 to 27.73; p = 0.026 and vs MSD: HR, 7.70; CI, 1.63 to 36.44; P = 0.010) and concurrent chronic graft versus host disease (HR, 3.76; CI, 1.18 to 11.92; P = 0.025) were risk factors for AHDs.
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Affiliation(s)
- Weiran Lv
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou 510515 China
| | - Zhiping Fan
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou 510515 China
| | - Fen Huang
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou 510515 China
| | - Na Xu
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou 510515 China
| | - Li Xuan
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou 510515 China
| | - GuopanYu
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou 510515 China
| | - Qianli Jiang
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou 510515 China
| | - Hongsheng Zhou
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou 510515 China
| | - Ren Lin
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou 510515 China
| | - Xin Zhang
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou 510515 China
| | - Jing Sun
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou 510515 China
| | - Qifa Liu
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou 510515 China
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González-Vicent M, Sanz J, Fuster JL, Cid J, de Heredia CD, Morillo D, Fernández JM, Pascual A, Badell I, Serrano D, Fox L, de la Serna J, Benito A, Couselo JM, Molina B, Díaz MÁ, Sanz MÁ. Autoimmune hemolytic anemia (AIHA) following allogeneic hematopoietic stem cell transplantation (HSCT): A retrospective analysis and a proposal of treatment on behalf of the Grupo Español De Trasplante de Medula Osea en Niños (GETMON) and the Grupo Español de Trasplante Hematopoyetico (GETH). Transfus Med Rev 2018; 32:S0887-7963(17)30164-5. [PMID: 29573905 DOI: 10.1016/j.tmrv.2018.02.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2017] [Revised: 02/21/2018] [Accepted: 02/22/2018] [Indexed: 10/17/2022]
Abstract
Autoimmune hemolytic anemia (AIHA) is a complication of allogeneic hematopoietic stem cell transplantation (HSCT) associated with poor outcome. However, an optimal therapeutic approach is lacking. Between 2000 and 2015, 4099 allogeneic HSCT were performed in eight pediatric centers of the Grupo Español De Trasplante de Medula Osea en Niños (GETMON) and six adult centers of the Grupo Español de Trasplante Hematopoyetico (GETH). Sixty cases of AIHA were registered with a cumulative incidence of 1.5% occurring at a median of 6 months after HSCT. Patients aged less than 15 years (P=.005), and patients using cord blood (P=.005) or an HLA mismatch donor (P=.005) were more likely to develop AIHA. Most patients were lymphopenic at the time of diagnosis of AIHA, including a low number of regulatory T lymphocytes (median 3/μL). Median lines of treatment received for AIHA was 3 (range, 1-7). Almost all patients received corticosteroids (88%) and more than half received immunoglobulins or rituximab (63% and 67%, respectively). Complete resolution of AIHA was achieved in 33 of 60 cases (55%). Cumulative incidence of AIHA-related mortality was 17±6%. We found a correlation of AIHA outcome with age (better outcome in younger than 15 years, RR=1.87, P=.01) and rituximab response (higher rate of complete remission in patients responding to rituximab, RR=1.72, P=.025). We analyzed the factors involved in the response to rituximab and found a better response when there was ABO donor/receptor disparity (P=.014) and in those patients with B lymphocytes count above the median (38/μL) (P=.05).Thirty-six of 60 patients survived yielding a disease free survival of 52±8% at 40 months. In Cox analysis, age (children vs adults, HR: 8.19, CI 95%: 2.39-28.12, P=.001) and AIHA outcome (complete remission vs partial remission/non-response, HR: 4.18, CI 95%: 1.55-11.22, P=.005) were associated with a better survival. Our data suggest that patients who developed AIHA after HSCT are severely lymphopenic and have a high risk of mortality. Outcome is better in children and in patients treated with rituximab. We also propose an algorithm for treatment of AIHA after HSCT.
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Affiliation(s)
| | - Jaime Sanz
- Hematology Department, Hospital La Fe, Valencia, Spain
| | - José Luis Fuster
- Pediatric Hematology-Oncology, Hospital Virgen de la Arrixaca, Murcia, Spain
| | - Joan Cid
- Apheresis and Cellular Therapy Unit, Department of Hemotherapy and Hemostasis, ICMHO, IDIBAPS, UB, Hospital Clínic, Barcelona, Spain
| | | | - Daniel Morillo
- Hematology Department, Hospital Puerta de Hierro, Madrid, Spain
| | | | - Antonia Pascual
- Pediatric Hematology, Hospital Materno Infantil, Málaga, Spain
| | - Isabel Badell
- Pediatric Hematology-Oncology, Hospital Santa Creu i Sant Pau, Universidad Autonoma, Barcelona, Spain
| | - David Serrano
- Hematology Department, Hospital Gregorio Marañón, Madrid, Spain
| | - Laura Fox
- Hematology Department, Hospital Vall d'Hebrón, Barcelona, Spain
| | | | - Ana Benito
- Pediatric Hematology-Oncology, Hospital Universitario de Salamanca, Salamanca, Spain
| | - José Miguel Couselo
- Pediatric Hematology-Oncology, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | - Blanca Molina
- Stem Cell Transplant Unit, Hospital Niño Jesús, Madrid, Spain
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34
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Cao L, Koh LP, Linn YC. Successful treatment of refractory autoimmune hemolytic anemia after allogeneic hematopoietic stem cell transplantation with bortezomib. Leuk Lymphoma 2018; 59:2500-2502. [DOI: 10.1080/10428194.2017.1421759] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Ling Cao
- Haematology Department, Singapore General Hospital, Singapore, Singapore
| | - Liang Piu Koh
- Hematology-Oncology Department, National University Health System, Singapore, Singapore
| | - Yeh Ching Linn
- Haematology Department, Singapore General Hospital, Singapore, Singapore
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35
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Lee CF, Chen CH, Wen YC, Chang TY, Lai MW, Jaing TH. Copper-associated hepatitis in a patient with chronic myeloid leukemia following hematopoietic stem cell transplantation: A case report. Medicine (Baltimore) 2017; 96:e9041. [PMID: 29245301 PMCID: PMC5728916 DOI: 10.1097/md.0000000000009041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
RATIONALE We report a complicated case of cholestatic hepatitis with suspected autoimmune hemolytic anemia (AIHA) and copper toxicity syndrome after HSCT and donor lymphocyte infusion (DLI). PATIENT CONCERNS A 19-year-1-month-old girl presented with a history of CML. She underwent matched unrelated donor HSCT and donor lymphocyte infusion subsequently. Three months later, yellowish discoloration of the skin was found, which was accompanied by progressive itchy skin, easy fatigability, insomnia, and dark urine output. After admission, liver function disorders were observed. INTERVENTION Methylprednisolone was administered for suspected hepatic GVHD. Although abdominal sonography revealed no evidence of biliary tract obstruction and the viral hepatitis survey disclosed unremarkable findings; silymarin and ursodeoxycholic acid were administered to preserve the liver function. In addition, rituximab was prescribed for suspected AIHA. Because hyperbilirubinemia was progressive, mycophenolate and high-dose intravenous immunoglobulin were accordingly administered. As drug-induced liver injury cannot be excluded, all potential unconfirmed causes of drug-related hepatoxicity were discontinued. DIAGNOSIS In this case, the patient's history of shrimps and chocolate consumption led us to strongly suspect cholestatic hepatitis associated with copper toxicity syndrome. High 24-hour urine copper excretion and low serum zinc levels were also confirmed. Accordingly, D-penicillamine and zinc gluconate were administered. OUTCOMES She succumbed to progressive hepatic failure and eventual multisystem organ failure 14 months after HSCT. No autopsy was performed. LESSONS This report described the combined effects of hepatic GVHD, AIHA, drugs, and copper toxicity on liver damage, and demonstrated the potential diagnostic challenges and treatment dilemmas associated with this disease.
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Affiliation(s)
- Ching-Fen Lee
- Division of Clinical Pharmacy, Department of Pharmacy, Chang Gung Memorial Hospital, Taoyuan
| | - Chi-Hua Chen
- Division of Clinical Pharmacy, Department of Pharmacy, Chang Gung Memorial Hospital, Taoyuan
| | - Yu-Chuan Wen
- Department of Nursing, Chang Gung Memorial Hospital, Taoyuan
| | - Tsung-Yen Chang
- Divisions of Hematology/Oncology, Department of Pediatrics, Chang Gung Children's Hospital, Chang Gung University, Taoyuan
| | - Ming-Wei Lai
- Division of Pediatric Gastroenterology, Department of Pediatrics, Chang Gung Children's Hospital, Chang Gung University, Taoyuan
- Liver Research Center, Department of Hepato-Gastroenterology, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Tang-Her Jaing
- Divisions of Hematology/Oncology, Department of Pediatrics, Chang Gung Children's Hospital, Chang Gung University, Taoyuan
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36
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Hwang-Bo S, Kim SK, Lee JW, Jang PS, Chung NG, Jeong DC, Cho B, Kim HK. Treatment and response of autoimmune cytopenia occurring after allogeneic hematopoietic cell transplantation in children. Blood Res 2017; 52:119-124. [PMID: 28698848 PMCID: PMC5503889 DOI: 10.5045/br.2017.52.2.119] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Revised: 03/30/2017] [Accepted: 04/11/2017] [Indexed: 11/29/2022] Open
Abstract
Background Autoimmune cytopenia (AIC) is a rare complication of allogeneic hematopoietic cell transplantation (HCT). In this study, we reviewed the diagnosis, treatment and response to therapy for pediatric patients with post-HCT AIC at our institution. Methods Of the 292 allogeneic HCTs performed from January, 2011 to December, 2015 at the Department of Pediatrics, The Catholic University of Korea, seven were complicated by post-HCT AIC, resulting in an incidence of 2.4%. Results All seven patients with post-HCT AIC had received unrelated donor transplant. Six of seven patients had a major donor-recipient blood type mismatch. The subtypes of AIC were as follows: immune thrombocytopenia (ITP) 2, autoimmune hemolytic anemia (AIHA) 2, Evans syndrome 3. Median time from HCT to AIC diagnosis was 3.6 months. All but one patient responded to first line therapy of steroid±intravenous immunoglobulin (IVIG), but none achieved complete response (CR) with this treatment. After a median duration of treatment of 15.3 months, two patients with ITP achieved CR and five had partial response (PR) of AIC. Five patients were treated with rituximab, resulting in the following response: 2 CR, 2 PR, 1 no response (NR). Median time to response to rituximab was 26 days from first infusion. All patients are alive without event. Conclusion Post-HCT AIC is a rare complication that may not resolve despite prolonged therapy. Rapid initiation of second line agents including but not limited to B cell depleting treatment should be considered for those that fail to achieve CR with first line therapy.
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Affiliation(s)
- Seok Hwang-Bo
- Division of Hematology and Oncology, Department of Pediatrics, The Catholic University of Korea, Seoul, Korea
| | - Seong-Koo Kim
- Division of Hematology and Oncology, Department of Pediatrics, The Catholic University of Korea, Seoul, Korea
| | - Jae Wook Lee
- Division of Hematology and Oncology, Department of Pediatrics, The Catholic University of Korea, Seoul, Korea
| | - Pil-Sang Jang
- Division of Hematology and Oncology, Department of Pediatrics, The Catholic University of Korea, Seoul, Korea
| | - Nack-Gyun Chung
- Division of Hematology and Oncology, Department of Pediatrics, The Catholic University of Korea, Seoul, Korea
| | - Dae-Chul Jeong
- Division of Hematology and Oncology, Department of Pediatrics, The Catholic University of Korea, Seoul, Korea
| | - Bin Cho
- Division of Hematology and Oncology, Department of Pediatrics, The Catholic University of Korea, Seoul, Korea
| | - Hack-Ki Kim
- Division of Hematology and Oncology, Department of Pediatrics, The Catholic University of Korea, Seoul, Korea
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Hill QA, Stamps R, Massey E, Grainger JD, Provan D, Hill A. Guidelines on the management of drug-induced immune and secondary autoimmune, haemolytic anaemia. Br J Haematol 2017; 177:208-220. [PMID: 28369704 DOI: 10.1111/bjh.14654] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Quentin A Hill
- Department of Haematology, Leeds Teaching Hospitals, Leeds, UK
| | | | | | - John D Grainger
- Royal Manchester Children's Hospital, University of Manchester, Manchester, UK
| | - Drew Provan
- Barts and The London School of Medicine and Dentistry, London, UK
| | - Anita Hill
- Department of Haematology, Leeds Teaching Hospitals, Leeds, UK
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Chang TY, Jaing TH, Wen YC, Huang IA, Chen SH, Tsay PK. Risk factor analysis of autoimmune hemolytic anemia after allogeneic hematopoietic stem cell transplantation in children. Medicine (Baltimore) 2016; 95:e5396. [PMID: 27861376 PMCID: PMC5120933 DOI: 10.1097/md.0000000000005396] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Autoimmune hemolytic anemia (AIHA) is a clinically relevant complication after allogeneic hematopoietic stem cell transplantation (HSCT). Currently, there is no established consensus regarding the optimal therapeutic approach. Whether AIHA contributes to increased mortality is still somewhat controversial.We investigated the incidence, risk factors, and outcome of post-transplant AIHA in 265 consecutive pediatric patients undergoing allo-HSCT over a 17-year period. Onset of AIHA was calculated from the first documented detection of AIHA by either clinical symptoms or positive direct agglutinin test. Resolution of AIHA was defined as normalization of hemoglobin and biochemical markers of hemolysis with sustained transfusion independence.We identified 15 cases of AIHA after allo-HSCT (incidence rate, 6%). Ten (67%) of these patients had a positive direct antiglobulin test. Data were obtained for 9 boys and 6 girls after a median follow-up of 53 months (range 4-102). The median age was 5.1 years (range 0.5-15.4) at the time of HSCT and the median time to emergence was 149 days (range 42-273). No significant risk factor for post-transplant AIHA has emerged from our data to date. In the majority (14 of 15; 93%) of AIHA patients, multiple agents for treatment were required, with 12 of 15 (80%) patients achieving complete resolution of AIHA. No splenectomy was performed in any of our patients.For various reasons, post-transplantation AIHA poses an extraordinary challenge to transplant physicians. Despite the advancements in diagnostic tools, therapeutic challenges remain due to the myriad interacting pathways in AIHA.
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MESH Headings
- Anemia, Hemolytic, Autoimmune/diagnosis
- Anemia, Hemolytic, Autoimmune/epidemiology
- Anemia, Hemolytic, Autoimmune/etiology
- Anemia, Hemolytic, Autoimmune/therapy
- Child, Preschool
- Coombs Test/methods
- Disease Management
- Female
- Hematopoietic Stem Cell Transplantation/adverse effects
- Humans
- Incidence
- Longitudinal Studies
- Male
- Outcome and Process Assessment, Health Care
- Risk Factors
- Taiwan/epidemiology
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Affiliation(s)
| | | | - Yu-Chuan Wen
- Department of Nursing, Chang Gung Children's Hospital
| | - I-Anne Huang
- Divisions of Hematology/Oncology
- Division of Pediatric General Medicine, Department of Pediatrics
| | | | - Pei-Kwei Tsay
- Department of Public Health and Center of Biostatistics, College of Medicine, Chang Gung University, Linkou, Taoyuan, Taiwan
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Transfusion Therapy in Specific Clinical Situations. Transfus Med 2016. [DOI: 10.1002/9781119236504.ch12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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40
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Li Z, Rubinstein SM, Thota R, Savani M, Brissot E, Shaw BE, Majhail NS, Mohty M, Savani BN. Immune-Mediated Complications after Hematopoietic Stem Cell Transplantation. Biol Blood Marrow Transplant 2016; 22:1368-1375. [DOI: 10.1016/j.bbmt.2016.04.005] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Accepted: 04/06/2016] [Indexed: 11/27/2022]
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41
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Datta SS, Reddy M, Basu S, Krishnan S. Blood Group Discrepancy-First Sign of Autoimmune Hemolytic Anemia after Hematopoietic Stem Cell Transplantation in a Child. Indian J Hematol Blood Transfus 2016; 32:211-3. [PMID: 27408394 DOI: 10.1007/s12288-015-0630-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Accepted: 12/14/2015] [Indexed: 11/25/2022] Open
Abstract
A 12-year-old male child was presented in the emergency with features of anemia and mild icterus on day+67 of HSCT. The child was suffering from Fanconi anemia and undergone HSCT from ABO-matched, fully HLA matched sibling donor. The diagnosis of mixed type AIHA due to cytomegalovirus reactivation was made in the immunohematology laboratory and blood group discrepancy was the first sign of AIHA in this patient. Though the cold agglutinin titer was not significant but the clinical symptoms and laboratory evidences were suggestive of significant hemolysis due to underlying IgG autoantibody. In addition the high complement avidity of IgM autoantibody might also be a contributing factor for clinically significant hemolysis in this case. The patient was successfully treated with phenotype matched blood transfusion, rituximab and oral steroid therapy.
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Affiliation(s)
- Suvro Sankha Datta
- Department of Transfusion Medicine, The Mission Hospital, Sector-2C, Immon Kalyan Sarani, Bidhannagar, Durgapur, WB 713212 India
| | - Mahua Reddy
- Department of Transfusion Medicine, Tata Medical Center, Kolkata, India
| | - Sabita Basu
- Department of Transfusion Medicine, Tata Medical Center, Kolkata, India
| | - Shekhar Krishnan
- Department of Pediatric Oncology, Tata Medical Center, Kolkata, India
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Post-Transplantation Natural Killer Cell Count: A Predictor of Acute Graft-Versus-Host Disease and Survival Outcomes After Allogeneic Hematopoietic Stem Cell Transplantation. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2016; 16:527-535.e2. [PMID: 27375156 DOI: 10.1016/j.clml.2016.06.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Revised: 05/13/2016] [Accepted: 06/01/2016] [Indexed: 12/17/2022]
Abstract
BACKGROUND Reconstitution of the immune system after allogeneic hematopoietic stem cell transplantation (allo-HSCT) plays an important role in post-transplant outcomes. However, the clinical relevance of the lymphocyte subset (LST) counts to transplant-related complications and survival outcomes after allo-HSCT has not been fully elucidated. PATIENTS AND METHODS A total of 70 patients who had undergone allo-HSCT from 2007 to 2013, with LST results both 7 days before conditioning and 30 or 90 days after allo-HSCT were included. The LST counts in the peripheral blood were determined using 6-color flow cytometry. Clinical information, including transplant-related events during the first 100 days after allo-HSCT, was reviewed, and any association between these events and LST was analyzed. RESULTS At 30 days after allo-HSCT, the CD4+ T-cell (P = .009) and B-cell (P = .035) counts were lower and the natural killer (NK) cell count was greater (P < .001) than before conditioning. The CD8+ T-cell (P = .001) and NK cell (P < .001) counts were high 90 days after transplantation. The hazard ratios for a low NK cell count on days 30 and 90 for acute graft-versus-host disease were 6.22 and 14.67, respectively. Patients with low NK cell counts at 30 and 90 days after allo-HSCT had poorer overall survival (P = .043 and P = .028, respectively) and greater nonrelapse mortality (P = .036 and P = .033, respectively). A low NK cell count on day 30 was still prognostic for overall survival (P = .039) on multivariable analysis. CONCLUSION NK cell counts after allo-HSCT, especially on day 30, were predictive of acute graft-versus-host disease, nonrelapse mortality, and survival. Serial lymphocyte subset analysis can be used to identify and treat patients at risk during the early period after allo-HSCT.
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Park JA, Lee HH, Kwon HS, Baik CR, Song SA, Lee JN. Sirolimus for Refractory Autoimmune Hemolytic Anemia after Allogeneic Hematopoietic Stem Cell Transplantation: A Case Report and Literature Review of the Treatment of Post-Transplant Autoimmune Hemolytic Anemia. Transfus Med Rev 2016; 30:6-14. [DOI: 10.1016/j.tmrv.2015.09.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 09/18/2015] [Accepted: 09/18/2015] [Indexed: 12/18/2022]
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Barcellini W. New Insights in the Pathogenesis of Autoimmune Hemolytic Anemia. Transfus Med Hemother 2015; 42:287-93. [PMID: 26696796 PMCID: PMC4678320 DOI: 10.1159/000439002] [Citation(s) in RCA: 98] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Accepted: 07/28/2015] [Indexed: 12/18/2022] Open
Abstract
Autoimmune hemolytic anemia (AIHA) is caused by the increased destruction of red blood cells (RBCs) by anti-RBC autoantibodies with or without complement activation. RBC destruction may occur both by a direct lysis through the sequential activation of the final components of the complement cascade (membrane attack complex), or by antibody-dependent cell-mediated cytotoxicity (ADCC). The pathogenic role of autoantibodies depends on their class (the most frequent are IgG and IgM), subclass, thermal amplitude (warm and cold forms),as well as affinity and efficiency in activating complement. Several cytokines and cytotoxic mechanisms (CD8+ T and natural killer cells) are further involved in RBC destruction. Moreover, activated macrophages carrying Fc receptors may recognize and phagocyte erythrocytes opsonized by autoantibodies and complement. Direct complement-mediated lysis takes place mainly in the circulations and liver, whereas ADCC, cytotoxicity, and phagocytosis occur preferentially in the spleen and lymphoid organs. The degree of intravascular hemolysis is 10-fold greater than extravascular one. Finally, the efficacy of the erythroblastic compensatory response can greatly influence the clinical picture of AIHA. The interplay and relative burden of all these pathogenic mechanisms give reason for the great clinical heterogeneity of AIHAs, from fully compensated to rapidly evolving fatal cases.
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Affiliation(s)
- Wilma Barcellini
- U.O. Oncoematologia, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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The role of rituximab in adults with warm antibody autoimmune hemolytic anemia. Blood 2015; 125:3223-9. [DOI: 10.1182/blood-2015-01-588392] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2014] [Accepted: 03/27/2015] [Indexed: 02/07/2023] Open
Abstract
Abstract
Warm antibody hemolytic anemia is the most common form of autoimmune hemolytic anemia. When therapy is needed, corticosteroids remain the cornerstone of initial treatment but are able to cure only a minority of patients (<20%). Splenectomy is usually proposed when a second-line therapy is needed. This classical approach is now challenged by the use of rituximab both as second-line and as first-line therapy. Second-line treatment with rituximab leads to response rates similar to splenectomy (∼70%), but rituximab-induced responses seem less sustained. However, additional courses of rituximab are most often followed by responses, at the price of reasonable toxicity. In some major European centers, rituximab is now the preferred second-line therapy of warm antibody hemolytic anemia in adults, although no prospective study convincingly supports this attitude. A recent randomized study strongly suggests that in first-line treatment, rituximab combined with steroids is superior to monotherapy with steroids. If this finding is confirmed, rituximab will emerge as a major component of the management of warm antibody hemolytic anemia not only after relapse but as soon as treatment is needed.
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Holbro A, Passweg JR. Management of hemolytic anemia following allogeneic stem cell transplantation. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2015; 2015:378-384. [PMID: 26637746 DOI: 10.1182/asheducation-2015.1.378] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Hemolytic anemia (HA) is a frequent condition with variable pathophysiology. Hematopoietic stem cell transplantation (HSCT) is unique because it is performed across the ABO blood group barrier. Thereby, there is a transfer of plasma, red blood cells, and immunocompetent cells from the donor to the recipient, possibly leading to HA, due to red blood cell incompatibility. The underlying disease, drugs (particularly those used for conditioning and immunosuppressants), infections, graft-versus-host disease, and autoimmune diseases may all contribute to the clinical and laboratory picture of HA. Additionally, transplantation-associated thrombotic microangiopathy (TA-TMA) may occur and is associated with significant morbidity and mortality. This review highlights the current knowledge on HA after allogeneic HSCT, particularly due to ABO incompatibility. We follow the timeline of the transplantation process and discuss investigations, differential diagnosis, and prophylactic measures including graft processing to avoid hemolysis in case of ABO incompatibility. Finally, current therapeutic approaches for both TA-TMA and post-HSCT autoimmune HA, which are associated with high morbidity and mortality, are discussed.
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Affiliation(s)
- Andreas Holbro
- Division of Hematology, Department of Internal Medicine, University Hospital, Basel, Switzerland; and Blood Transfusion Centre, Swiss Red Cross, Basel, Switzerland
| | - Jakob R Passweg
- Division of Hematology, Department of Internal Medicine, University Hospital, Basel, Switzerland; and
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