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Zhou X, Ye Y, Jin A, Pan Z, Xu Z, Ding S, Yan J, Cheng Y, Huang Y, Cao K, Xie W, Zhang J, Xu L, Zhou W, Huang L. Development and implementation of evidence-based, nurse-leading early warning model and healthcare quality improvement project for transplant-associated thrombotic microangiopathy: a mixed-methods, before-and-after study. BMC Nurs 2024; 23:535. [PMID: 39113009 PMCID: PMC11304727 DOI: 10.1186/s12912-024-02093-7] [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: 12/19/2023] [Accepted: 06/13/2024] [Indexed: 08/11/2024] Open
Abstract
OBJECTIVE The early identification and diagnosis of transplant-associated thrombotic microangiopathy (TA-TMA) are essential yet difficult in patients underwent hematopoietic stem cell transplantation (HSCT). To develop an evidence-based, nurse-leading early warning model for TA-TMA, and implement the healthcare quality review and improvement project. METHODS This study was a mixed-methods, before-and-after study. The early warning model was developed based on quality evidence from literature search. The healthcare quality review and improvement project mainly included baseline investigation of nurse, improvement action and effectiveness evaluation. The awareness and knowledge of early parameter of TA-TMA among nurses and the prognosis of patients underwent HSCT were compared before and after the improvement. RESULTS A total of 1 guideline, 1 evidence synthesis, 4 expert consensuses, 10 literature reviews, 2 diagnostic studies, and 9 case series were included in the best evidence. The early warning model including warning period, high-risk characteristics and early manifestation of TA-TMA was developed. The improvement action, including staff training and assessment, suspected TA-TMA identification and patient education, was implemented. The awareness and knowledge rate of early parameter of TA-TMA among nurses significantly improved after improvement action (100% vs. 26.7%, P < 0.001). The incidence of TA-TMA was similar among patients underwent HSCT before and after improvement action (2.8% vs. 1.2%, P = 0.643), while no fall event occurred after improvement action (0 vs. 1.2%, P < 0.001). CONCLUSION The evidence-based early warning model and healthcare quality improvement project could enhance the awareness and knowledge of TA-TMA among healthcare providers and might improve the prognosis of patients diagnosed with TA-TMA.
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Affiliation(s)
- Xiaoyu Zhou
- Department of Nursing, The First Affiliated Hospital, Zhejiang University School of Medical, Hangzhou, China
| | - Yishan Ye
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medical, Hangzhou, China
| | - Aiyun Jin
- Department of Nursing, The First Affiliated Hospital, Zhejiang University School of Medical, Hangzhou, China
| | - Zhengwen Pan
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medical, Hangzhou, China
| | - Zhe Xu
- Department of Nursing, The First Affiliated Hospital, Zhejiang University School of Medical, Hangzhou, China
| | - Shuyi Ding
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medical, Hangzhou, China
| | - Jiali Yan
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medical, Hangzhou, China
| | - Yin Cheng
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medical, Hangzhou, China
| | - Yixuan Huang
- Department of Nursing, The First Affiliated Hospital, Zhejiang University School of Medical, Hangzhou, China
| | - Kai Cao
- Department of Nursing, The First Affiliated Hospital, Zhejiang University School of Medical, Hangzhou, China
| | - Wei Xie
- Department of Nursing, The First Affiliated Hospital, Zhejiang University School of Medical, Hangzhou, China
| | - Jianli Zhang
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medical, Hangzhou, China
| | - Liwei Xu
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medical, Hangzhou, China
| | - Weiwei Zhou
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medical, Hangzhou, China
| | - Lihua Huang
- Department of Nursing, The First Affiliated Hospital, Zhejiang University School of Medical, Hangzhou, China.
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Wei X, Liu X, Yu Y, Xie W, Luo W, Tu Y, Bu S, Guo G. Application of eculizumab, a terminal complement inhibitor, in the management of atypical hemolytic uremic syndrome in a 14-month-old Chinese pediatric patient: a case report. Front Pediatr 2024; 12:1404725. [PMID: 39144472 PMCID: PMC11322081 DOI: 10.3389/fped.2024.1404725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Accepted: 07/16/2024] [Indexed: 08/16/2024] Open
Abstract
Eculizumab, a recombined humanized monoclonal antibody which possesses high affinity for the complement protein C5, is a therapeutic agent utilized in the treatment of atypical hemolytic uremic syndrome (aHUS) by inhibiting the terminal complement complex C5b-9. In a pediatric patient with aHUS of 14 months, the administration of eculizumab therapy was accompanied by the inclusion of meningococcal vaccine as part of the national immunization program. Notably, no other antibiotics were administered prior to or during the course of eculizumab treatment. Moreover, there were no occurrences of infusion reactions or meningococcal infections observed throughout the course of treatment. Due to the presence of anti-factor H antibodies and insufficient recovery, glucocorticoids and eculizumab were administered at week 0 and week 1, followed by the initiation of mycophenolate mofetil (MMF) at a dosage of 250 mg (approximately 548 mg/m2) per day starting from Day 10. Due to the recovered of complement antibody after 8 doses of eculizumab, the therapeutic interval was extended from once every 3 weeks to once a month since 9th administration. We experienced and successfully treated a rare case of aHUS with eculizumab in a 14-month-old Chinese pediatric patient.
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Affiliation(s)
- Xin Wei
- Department of Clinical Pharmacy, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Xinzhu Liu
- Department of Clinical Pharmacy, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yingying Yu
- Department of Clinical Pharmacy, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Wei Xie
- Department of Pediatric Intensive Care Unit, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wentao Luo
- Department of Clinical Pharmacy, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Ye Tu
- Department of Pharmacy, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Shuhong Bu
- Department of Clinical Pharmacy, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Guimei Guo
- Department of Pediatric Nephrology, Rheumatology and Immunology, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
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Satoh K, Wada T, Tampo A, Takahashi G, Hoshino K, Matsumoto H, Taira T, Kazuma S, Masuda T, Tagami T, Ishikura H. Practical approach to thrombocytopenia in patients with sepsis: a narrative review. Thromb J 2024; 22:67. [PMID: 39039520 PMCID: PMC11265094 DOI: 10.1186/s12959-024-00637-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 07/08/2024] [Indexed: 07/24/2024] Open
Abstract
Thrombocytopenia frequently occurs in patients with sepsis. Disseminated intravascular coagulation (DIC) may be a possible cause of thrombocytopenia owing to its high prevalence and association with poor outcomes; however, it is important to keep the presence of other diseases in mind in sepsis practice. Thrombotic microangiopathy (TMA), which is characterized by thrombotic thrombocytopenic purpura, Shiga toxin-producing Escherichia coli hemolytic uremic syndrome (HUS), and complement-mediated HUS, is characterized by thrombocytopenia, microangiopathic hemolytic anemia, and organ damage. TMA has become widely recognized in recent years because of the development of specific treatments. Previous studies have reported a remarkably lower prevalence of TMA than DIC; however, its epidemiology is not well defined, and there may be cases in which TMA is not correctly diagnosed, resulting in poor outcomes. Therefore, it is important to differentiate DIC from TMA. Nevertheless, differentiating between DIC and TMA remains a challenge as indicated by previous reports that most patients with TMA can be diagnosed as DIC using the universal coagulation scoring system. Several algorithms to differentiate sepsis-related DIC from TMA have been suggested, contributing to improving the care of septic patients with thrombocytopenia; however, it may be difficult to apply these algorithms to patients with coexisting DIC and TMA, which has recently been reported. This review describes the disease characteristics, including epidemiology, pathophysiology, and treatment, of DIC, TMA, and other diseases with thrombocytopenia and proposes a novel practical approach flow, which is characterized by the initiation of the diagnosis of TMA in parallel with the diagnosis of DIC. This practical flow also refers to the longitudinal diagnosis and treatment flow with TMA in mind and real clinical timeframes. In conclusion, we aim to widely disseminate the results of this review that emphasize the importance of incorporating consideration of TMA in the management of septic DIC. We anticipate that this practical new approach for the diagnostic and treatment flow will lead to the appropriate diagnosis and treatment of complex cases, improve patient outcomes, and generate new epidemiological evidence regarding TMA.
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Affiliation(s)
- Kasumi Satoh
- Advanced Emergency and Critical Care Center, Akita University Hospital, Akita, Japan
| | - Takeshi Wada
- Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Faculty of Medicine, Kita 15, Nishi 7, Kita-ku, Sapporo, 060-8638, Japan.
| | - Akihito Tampo
- Department of Emergency Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Gaku Takahashi
- Department of Critical Care, Disaster and General Medicine, School of Medicine, Iwate Medical University, Iwate, Japan
| | - Kota Hoshino
- Department of Emergency and Critical Care Medicine, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Hironori Matsumoto
- Department of Emergency and Critical Care Medicine, Ehime University Graduate School of Medicine, Toon, Japan
| | - Takayuki Taira
- Department of Emergency and Critical Care Medicine, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Satoshi Kazuma
- Department of Intensive Care Medicine, School of Medicine, Sapporo Medical University, Sapporo, Hokkaido, Japan
| | - Takamitsu Masuda
- Department of Emergency Medicine, Emergency and Critical Care Center, Fujieda Municipal General Hospital, Fujieda, Japan
| | - Takashi Tagami
- Department of Emergency and Critical Care Medicine, Nippon Medical School Musashikosugi Hospital, Tokyo, Japan
| | - Hiroyasu Ishikura
- Department of Emergency and Critical Care Medicine, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
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Fang W, Sun W, Fang W, Zhao S, Wang C. Clinical features, treatment, and outcomes of patients with carfilzomib induced thrombotic microangiopathy. Int Immunopharmacol 2024; 134:112178. [PMID: 38728883 DOI: 10.1016/j.intimp.2024.112178] [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: 02/15/2024] [Revised: 04/25/2024] [Accepted: 04/27/2024] [Indexed: 05/12/2024]
Abstract
BACKGROUND Thrombotic microangiopathy (TMA) is associated with carfilzomib, and knowledge of carfilzomib-induced TMA is based mainly on case reports. This study investigated the clinical characteristics of patients with carfilzomib-induced TMA and provided a reference for the rational use of carfilzomib. METHODS Reports of carfilzomib-induced TMA were collected for retrospective analysis by searching the Chinese and English databases from inception to January 31, 2024. RESULTS Sixty-six patients were included, with a median age of 63 years (range 39, 85). The median time to onset of TMA was 42 days (range 1, 1825) from initial administration, and the median number of cycles was 3 cycles (range 1, 15). Hemolytic anemia was recorded in 64 patients, with a median of 8.3 g/dL (range 4.6, 13). Sixty-three patients had thrombocytopenia with a median of 18 × 109/L (range 1, 139). The median value of increased LDH was 1192 IU/L (range 141, 5378). ADAMTS13 activity was normal in 41 (62.1 %) of the 42 patients. Mutations were found in 9 (13.6 %) of the 15 patients. Fifty-seven patients achieved a clinical response after discontinuing carfilzomib and receiving therapeutic plasma exchange (53.0 %), eculizumab (24.2 %), or hemodialysis (39.4 %). CONCLUSION Carfilzomib-induced TMA is an important adverse event that should be considered in patients receiving carfilzomib for multiple myeloma with anemia, thrombocytopenia, and acute kidney injury. Withdrawal of carfilzomib and treatment with eculizumab have proven successful in some patients.
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Affiliation(s)
- Weilun Fang
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, Hunan 410013, China; College of Pharmacy, Changsha Medical University, Changsha, Hunan 410219, China
| | - Wei Sun
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, Hunan 410013, China
| | - Weijin Fang
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, Hunan 410013, China
| | - Shaoli Zhao
- Department of Endocrinology, The Third Xiangya Hospital, Central South University, China
| | - Chunjiang Wang
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, Hunan 410013, China.
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Mannion SE, Csizmar CM, Legler SR. 51-Year-Old Woman With Bloody Diarrhea. Mayo Clin Proc 2024; 99:827-831. [PMID: 38520445 DOI: 10.1016/j.mayocp.2023.08.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 08/08/2023] [Accepted: 08/16/2023] [Indexed: 03/25/2024]
Affiliation(s)
- Samantha E Mannion
- Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Mayo Clinic, Rochester, MN, USA
| | - Clifford M Csizmar
- Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Mayo Clinic, Rochester, MN, USA
| | - Sean R Legler
- Advisor to residents and Consultant in Hospital Internal Medicine, Mayo Clinic, Rochester, MN, USA.
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Tran MH, Patel S, Desai S, Ciurea S, Lee BJ, Hanna R. Thrombotic microangiopathy - the importance of a multidisciplinary approach. Curr Opin Nephrol Hypertens 2024; 33:247-256. [PMID: 38018789 DOI: 10.1097/mnh.0000000000000954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2023]
Abstract
PURPOSE OF REVIEW The purpose of this review is to highlight the importance of a multidisciplinary thrombotic microangiopathies (TMA) Team. This goal will be accomplished through review of the complement system, discuss various causes of thrombotic microangiopathies (TMA), and aspects of their diagnosis and management. In so doing, readers will gain an appreciation for the complexity of this family of disorders and realize the benefit of a dedicated multidisciplinary TMA Team. RECENT FINDINGS TMA causes derive from multiple specialty areas, are difficult to timely recognize, pose complex challenges, and require multidisciplinary management. Hematopoietic stem cell transplant-associated TMA (TA-TMA) and TA-TMA related multiorgan dysfunction syndrome (TA-TMA MODS) are areas of burgeoning research; use of complement testing and eculizumab precision-dosing has been found to better suppress complement activity in TA-TMA than standard eculizumab dosing. Newer tests are available to risk-stratify obstetric patients at risk for severe pre-eclampsia, whose features resemble those of TA-TMA MODS. Numerous disorders may produce TMA-like findings, and a systematic approach aids in their identification. TMA Teams elevate institutional awareness of increasingly recognized TMAs, will help expedite diagnostic and therapeutic interventions, and create pathways to future TMA-related research and facilitate access to clinical trials. SUMMARY Establishment of a TMA-Team is valuable in developing the necessary institutional expertise needed to promptly recognize and appropriately manage patients with TMA.
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Affiliation(s)
- Minh-Ha Tran
- University of California-Irvine, Department of Pathology-Division of Transfusion Medicine
| | - Samir Patel
- University of California Irvine, Department of Medicine - Division of Nephrology
| | - Sheetal Desai
- University of California-Irvine, Department of Medicine- Division of Rheumatology
| | - Stefan Ciurea
- University of California Irvine, Department of Medicine- Division of Hematology-Oncology-HSCT/CT Program
| | - Benjamin J Lee
- University of California Irvine, Department of Pharmacy, Irvine, California, USA
| | - Ramy Hanna
- University of California Irvine, Department of Medicine - Division of Nephrology
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7
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Gallant TL, Zheng E, Hobbs AM, Becka AJ, Bertsch RA. Complement-Mediated Thrombotic Microangiopathy in a Patient With Antiphospholipid Syndrome and Anti-glomerular Basement Membrane Antibodies. Cureus 2023; 15:e42410. [PMID: 37637585 PMCID: PMC10448002 DOI: 10.7759/cureus.42410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/24/2023] [Indexed: 08/29/2023] Open
Abstract
Thrombotic microangiopathy (TMA) is a range of diseases characterized by thrombocytopenia, microangiopathic hemolytic anemia, and organ injury. Complement-mediated TMA is a rare, life-threatening subtype of TMA that occurs due to the uncontrolled activation of the alternative complement pathway in the absence of normal regulation, often resulting from deficiencies of various regulatory proteins. Anti-glomerular basement membrane (anti-GBM) disease, previously known as Goodpasture syndrome, is a life-threatening form of vasculitis in which immunoglobulin G autoantibodies bind to the alpha-3 chain of type IV collagen in alveolar and glomerular basement membranes. We present the case of a patient with a history of antiphospholipid syndrome who was diagnosed with complement-mediated TMA during hospital admission for elevated anti-GBM antibody titers discovered during an outpatient evaluation for elevated creatinine levels. Upon admission, treatment was started for presumed anti-GBM disease, including high-dose intravenous methylprednisolone injections and multiple plasmapheresis sessions. However, renal biopsy results showed no evidence of anti-GBM disease, but rather evidence of TMA. Subsequent laboratory studies revealed decreased complement levels, suggestive of a diagnosis of complement-mediated TMA. The patient was started on rituximab and eculizumab infusions, and she was discharged in stable condition after a 15-day hospitalization with outpatient appointments scheduled for genetic testing and further infusions. This case illustrates the importance of recognizing the key clinical and diagnostic features of complement-mediated TMA to promptly initiate appropriate therapy.
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Affiliation(s)
- Tara L Gallant
- College of Medicine, California Northstate University College of Medicine, Elk Grove, USA
| | - Emily Zheng
- College of Medicine, California Northstate University College of Medicine, Elk Grove, USA
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Catanese L, Link K, Rupprecht H. Microangiopathy in multiple myeloma: a case of carfilzomib-induced secondary thrombotic microangiopathy successfully treated with plasma exchange and complement inhibition. BMC Nephrol 2023; 24:179. [PMID: 37337151 DOI: 10.1186/s12882-023-03228-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 06/01/2023] [Indexed: 06/21/2023] Open
Abstract
BACKGROUND Thrombotic microangiopathy (TMA) is a potentially organ and life-threatening condition affecting patients with multiple myeloma (MM). Cases of proteasome inhibitor-induced TMA and specifically carfilzomib-induced TMA have been rarely reported and standards for diagnostic workup and treatment are not available. CASE PRESENTATION We describe a case of a male MM patient under salvage therapy including proteasome inhibitor carfilzomib following chemotherapy and autologous stem cell transplantation. The patient then developed acute kidney injury with clinical and laboratory signs of TMA. Hemodialysis became necessary and treatment with plasma exchange was initiated followed by therapy with C5 complement inhibitor eculizumab which led to amelioration of kidney function and hemolysis parameters. CONCLUSION We report a patient with suspected proteasome inhibitor-induced secondary thrombotic microangiopathy that has been successfully treated with plasma exchange and eculizumab, a monoclonal antibody targeting complement factor C5.
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Affiliation(s)
- Lorenzo Catanese
- Department of Medicine V (Nephrology, Hypertensiology, Angiology and Rheumatology), Klinikum Bayreuth GmbH, Medizincampus Oberfranken, Preuschwitzer Str. 101, 95445, Bayreuth, Germany
- Friedrich-Alexander-University Erlangen-Nürnberg, Schloßplatz 4, 91054, Erlangen, Germany
| | - Katharina Link
- Department of Medicine V (Nephrology, Hypertensiology, Angiology and Rheumatology), Klinikum Bayreuth GmbH, Medizincampus Oberfranken, Preuschwitzer Str. 101, 95445, Bayreuth, Germany
- Friedrich-Alexander-University Erlangen-Nürnberg, Schloßplatz 4, 91054, Erlangen, Germany
| | - Harald Rupprecht
- Department of Medicine V (Nephrology, Hypertensiology, Angiology and Rheumatology), Klinikum Bayreuth GmbH, Medizincampus Oberfranken, Preuschwitzer Str. 101, 95445, Bayreuth, Germany.
- Friedrich-Alexander-University Erlangen-Nürnberg, Schloßplatz 4, 91054, Erlangen, Germany.
- Kuratorium for Dialysis Bayreuth, Stolzingstraße 40, 95445, Bayreuth, Germany.
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Jose A, Varughese T, De S, Alam B, Sheth V. From Diagnosis to Treatment: Navigating the Clinical Challenges of Dialyzer-Associated Thrombocytopenia. Cureus 2023; 15:e38891. [PMID: 37303423 PMCID: PMC10257469 DOI: 10.7759/cureus.38891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/11/2023] [Indexed: 06/13/2023] Open
Abstract
Thrombocytopenia is a common lab finding. The two fundamental groups are lack of production versus overconsumption of platelets. When common causes of thrombocytopenia have been ruled out and less common causes, such as thrombotic microangiopathic conditions, have been considered, it is important to keep in mind that patients undergoing dialysis may develop thrombocytopenia from the dialyzer itself. This case is of a 51-year-old male who presented originally with celiac artery dissection and acute kidney injury requiring emergent dialysis. He ultimately developed thrombocytopenia during his hospitalization. It was initially presumed to be from thrombocytopenic purpura without improvement after plasmapheresis. No clear etiology was identified until it was suspected that the dialyzer was the source of thrombocytopenia. After changing the dialyzer type, the patient's thrombocytopenia resolved. Dialyzer-associated thrombocytopenia is a rare but reversible complication of hemodialysis. It is important to keep this differential in mind for patients undergoing hemodialysis.
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Affiliation(s)
- Ann Jose
- Department of Internal Medicine, Hackensack University Medical Center, Hackensack, USA
| | - Tony Varughese
- Department of Internal Medicine, Hackensack University Medical Center, Hackensack, USA
| | - Shreemayee De
- Department of Nephrology, Hackensack University Medical Center, Hackensack, USA
| | - Bisma Alam
- Department of Pulmonary and Critical Care Medicine, Hackensack University Medical Center, Hackensack, USA
| | - Vishad Sheth
- Department of Pulmonary and Critical Care Medicine, Hackensack University Medical Center, Hackensack, USA
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Zhang Z, Hong W, Wu Q, Tsavachidis S, Li JR, Amos CI, Cheng C, Sartain SE, Afshar-Kharghan V, Dong JF, Bhatraju P, Martin PJ, Makar RS, Bendapudi PK, Li A. Pathway-driven rare germline variants associated with transplant-associated thrombotic microangiopathy (TA-TMA). Thromb Res 2023; 225:39-46. [PMID: 36948020 PMCID: PMC10147584 DOI: 10.1016/j.thromres.2023.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 02/20/2023] [Accepted: 03/05/2023] [Indexed: 03/17/2023]
Abstract
The significance of rare germline mutations in transplant-associated thrombotic microangiopathy (TA-TMA) is not well studied. We performed a genetic association study in 100 adult TA-TMA patients vs. 98 post-transplant controls after matching by race, sex, and year. We focused on 5 pathways in complement, von Willebrand factor (VWF) function and related proteins, VWF clearance, ADAMTS13 function and related proteins, and endothelial activation (3641variants in 52 genes). In the primary analysis focused on 189 functional rare variants, no differential variant enrichment was observed in any of the pathways; specifically, 29 % TA-TMA and 33 % controls had at least 1 rare complement mutation. In the secondary analysis focused on 37 rare variants predicted to be pathogenic or likely pathogenic by ClinVar, Complement Database, or REVEL in-silico prediction tool, rare variants in the VWF clearance pathway were found to be significantly associated with TA-TMA (p = 0.008). On the gene level, LRP1 was the only one with significantly increased variants in TA-TMA in both analyses (p = 0.025 and 0.015). In conclusion, we did not find a significant association between rare variants in the complement pathway and TA-TMA; however, we discovered a new signal in the VWF clearance pathway driven by the gene LRP1 among likely pathogenic variants.
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Affiliation(s)
- Zhihui Zhang
- Institute for Clinical & Translational Research, Baylor College of Medicine, Houston, TX, United States of America
| | - Wei Hong
- Institute for Clinical & Translational Research, Baylor College of Medicine, Houston, TX, United States of America
| | - Qian Wu
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, United States of America
| | - Spiridon Tsavachidis
- Section of Epidemiology and Population Science, Baylor College of Medicine, Houston, TX, United States of America
| | - Jian-Rong Li
- Institute for Clinical & Translational Research, Baylor College of Medicine, Houston, TX, United States of America
| | - Christopher I Amos
- Institute for Clinical & Translational Research, Baylor College of Medicine, Houston, TX, United States of America; Section of Epidemiology and Population Science, Baylor College of Medicine, Houston, TX, United States of America
| | - Chao Cheng
- Institute for Clinical & Translational Research, Baylor College of Medicine, Houston, TX, United States of America
| | - Sarah E Sartain
- Section of Hematology-Oncology, Department of Pediatrics, Baylor College of Medicine, Houston, TX, United States of America
| | - Vahid Afshar-Kharghan
- Section of Benign Hematology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States of America
| | - Jing-Fei Dong
- BloodWorks Northwest Research Institute, Seattle, WA, United States of America
| | - Pavan Bhatraju
- Division of Pulmonary Critical Care and Sleep Medicine, Department of Medicine, University of Washington School of Medicine, Seattle, WA, United States of America
| | - Paul J Martin
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, United States of America; Division of Medical Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, WA, United States of America
| | - Robert S Makar
- Division of Hematology and Blood Transfusion Service, Massachusetts General Hospital, Boston, MA, United States of America; Division of Hemostasis and Thrombosis, Beth Israel Deaconess Medical Center, Boston, MA, United States of America
| | - Pavan K Bendapudi
- Division of Hematology and Blood Transfusion Service, Massachusetts General Hospital, Boston, MA, United States of America; Division of Hemostasis and Thrombosis, Beth Israel Deaconess Medical Center, Boston, MA, United States of America; Harvard Medical School, Boston, MA, United States of America
| | - Ang Li
- Section of Hematology-Oncology, Department of Medicine, Baylor College of Medicine, Houston, TX, United States of America.
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Mahmoudjafari Z, Alencar MC, Alexander MD, Johnson DJ, Yeh J, Evans MD. Hematopoietic stem cell transplantation-associated thrombotic microangiopathy and the role of advanced practice providers and pharmacists. Bone Marrow Transplant 2023:10.1038/s41409-023-01951-3. [PMID: 37059738 DOI: 10.1038/s41409-023-01951-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 03/01/2023] [Accepted: 03/08/2023] [Indexed: 04/16/2023]
Abstract
Hematopoietic stem cell transplantation-associated thrombotic microangiopathy (HSCT-TMA) is a severe and potentially life-threatening complication. HSCT-TMA is often underdiagnosed due to multifactorial pathophysiology and a historic lack of standard diagnostic criteria. Identification of the multi-hit hypothesis and the key role of the complement system, particularly the lectin pathway of complement, has led to development of treatments targeting the underlying pathogenesis of HSCT-TMA. Additional research is ongoing to investigate the efficacy and safety of these targeted therapies in patients with HSCT-TMA. Advanced practice providers (APPs; nurse practitioners and physician assistants) and pharmacists are critical members of the multidisciplinary HSCT team and ensure management of patients throughout the continuum of care. Additionally, pharmacists and APPs can improve patient care through medication management of complex regimens; transplant education for patients, staff, and trainees; evidence-based protocol and clinical guideline development; assessment and reporting of transplant-related outcomes; and quality improvement initiatives to improve outcomes. Understanding the presentation, prognosis, pathophysiology, and treatment options for HSCT-TMA can improve each of these efforts. Collaborative practice model for monitoring and care of HSCT-TMA. Advanced practice providers and pharmacists contribute to many aspects of patient care in transplant centers, including medication management for complex regimens; transplant education for patients, staff, and trainees; evidence-based protocol and clinical guideline development; assessment and reporting of transplant-related outcomes; and quality improvement initiatives. HSCT-TMA is a severe and potentially life-threatening complication that is often underdiagnosed. The collaboration of a multidisciplinary team of advanced practice providers, pharmacists, and physicians can optimize recognition, diagnosis, management, and monitoring of patients with HSCT-TMA, thereby improving outcomes for these patients.
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Affiliation(s)
- Zahra Mahmoudjafari
- Department of Pharmacy, University of Kansas Cancer Center, Kansas City, KS, USA.
| | - Maritza C Alencar
- Oncology Service Line, University of Miami, Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Maurice D Alexander
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Darren J Johnson
- Pediatric Hematology and Oncology, Dana Farber Cancer Institute, Boston, MA, USA
| | - Jason Yeh
- Division of Pharmacy, MD Anderson Cancer Center, Houston, TX, USA
| | - Misty D Evans
- School of Nursing, Vanderbilt University, Nashville, TN, USA
- Sarah Cannon Pediatric Hematology/Oncology & Cellular Therapy at TriStar Centennial, Nashville, TN, USA
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Azad F, Miranda CJ, Amin A, Hadwani R, Gravina M. Eculizumab in the Treatment of Gemcitabine-Induced Atypical Hemolytic Uremic Syndrome. Cureus 2023; 15:e35874. [PMID: 37033542 PMCID: PMC10078131 DOI: 10.7759/cureus.35874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/07/2023] [Indexed: 03/09/2023] Open
Abstract
Gemcitabine-induced hemolytic uremic syndrome is an often-missed condition. We present a case outlining the successful management of a patient with metastatic cholangiocarcinoma treated with gemcitabine who subsequently developed hemolytic uremic syndrome. Early recognition and stopping gemcitabine are essential in this patient population. Complement inhibitors have been used, and our patient improved on eculizumab therapy.
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Ravindran A, Pereira Palma LM, Fervenza FC, Sethi S. Overlap of C3 Glomerulopathy and Thrombotic Microangiopathy: A Case Series. Kidney Int Rep 2023; 8:619-627. [PMID: 36938079 PMCID: PMC10014380 DOI: 10.1016/j.ekir.2022.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 12/13/2022] [Accepted: 12/14/2022] [Indexed: 12/25/2022] Open
Abstract
Introduction Dysregulation of alternative complement pathway underlies the pathogenesis of both C3 glomerulopathy (C3G) and thrombotic microangiopathy (TMA). In this study, we describe both disease entities occurring in 5 patients. Methods We identified 114 patients at our institution from 2007 to 2016 with C3G in native kidney biopsies and those with concurrent TMA were included. Results The median age at diagnosis was 58 years (range: 28-69); all were male. Median serum creatinine and proteinuria at presentation were 2.3 mg/dl and 2089 mg/d, respectively. Three cases presented with TMA-predominant phenotype and 2 with C3G-predominant phenotype. Immunofluorescence (IF) showed bright C3 staining in mesangium and/or capillary walls. Electron microscopy showed marked subendothelial expansion by fluffy material in the capillary loops without associated deposits. However, capillary wall deposits were present in other loops in 4 cases. Mesangial deposits were present in all cases. Four cases showed low C3, of which 2 showed low C4. Complement evaluation in 3 cases showed pathogenic CFH mutation in 1 case, and multiple variant of unknown significance along with factor B autoantibody and C4 nephritic factor in 1 case. One patient negative for complement abnormalities had a monoclonal gammopathy. Three cases were treated with steroids and/or immunosuppressants. One case progressed to end-stage renal disease (ESRD) at 38.3 months; the remaining showed median serum creatinine and proteinuria of 2.5 mg/dl and 1169 mg/d, respectively at median follow-up of 17.5 months. Conclusion Overlap of C3G and TMA is rare and can clinically present as C3G-predominant or TMA-predominant phenotype. The significance of concurrent C3G/TMA findings on long-term renal survival remains to be explored.
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Affiliation(s)
- Aishwarya Ravindran
- Division of Anatomic Pathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
- Division of Laboratory Medicine, Department of Pathology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | | | | | - Sanjeev Sethi
- Division of Anatomic Pathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
- Correspondence: Sanjeev Sethi, Division of Anatomic Pathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA.
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Thrombotic thrombocytopenic purpura (TTP) in Human immunodeficiency virus (HIV) infected patients: New twists on an old disease. AIDS 2022; 36:1345-1354. [PMID: 35608117 DOI: 10.1097/qad.0000000000003257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Investigate the presence of inflammation, endothelial dysfunction and complement activation in patients with HIV-associated thrombotic thrombocytopenic purpura (HIV-TTP) to support the hypothesis that these processes probably contribute to the development of this thrombotic microangiopathy. DESIGN A prospective, investigational cohort study of 35 consecutive patients diagnosed with HIV-associated TTP presenting to three academic, tertiary care hospitals in Johannesburg, South Africa over 2 years. METHODS The patients with HIV-TTP received therapeutic plasma therapy and supportive treatment. Demographic data, the results of routine investigations and patient outcomes were recorded. Peripheral blood samples were collected prior to and on completion of plasma therapy and the following additional parameters were assessed at both time points: activity of the von Willebrand factor (VWF) cleaving protease, a-disintegrin-and-metalloproteinase-with-thrombospondin-motifs 13 (ADAMTS-13) and the presence of ADAMTS-13 autoantibodies, levels of pro-inflammatory cytokines, interleukin-6 and tumour necrosis factor-alpha, and two endothelial cell adhesion molecules. Complement activation was assessed by sequential measurement of C3 and C4 as well as levels of the complement inhibitor, factor H. RESULTS The inflammatory and endothelial activation markers were significantly (P < 0.001) elevated in the cohort of patients prior to plasma therapy compared with levels on discharge. Complement was activated and normalized with therapy. The ADAMTS-13 levels were reduced with significant auto-antibodies to this protease at presentation. CONCLUSION Inflammation in HIV mediates endothelial damage and complement activation. This study proposes that these processes are probably contributory to the development of HIV-TTP, which can therefore be characterized in part as a complementopathy, resembling TTP-like syndrome.
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Napolitano A, Arrigoni A, Caroli A, Cava M, Remuzzi A, Longhi LG, Barletta A, Zangari R, Lorini FL, Sessa M, Gerevini S. Cerebral Microbleeds Assessment and Quantification in COVID-19 Patients With Neurological Manifestations. Front Neurol 2022; 13:884449. [PMID: 35677326 PMCID: PMC9168977 DOI: 10.3389/fneur.2022.884449] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Accepted: 04/07/2022] [Indexed: 12/15/2022] Open
Abstract
It is increasingly acknowledged that Coronavirus Disease 2019 (COVID-19) can have neurological manifestations, and cerebral microbleeds (CMBs) have been observed in this setting. The aim of this study was to characterize CMBs patterns on susceptibility-weighted imaging (SWI) in hospitalized patients with COVID-19 with neurological manifestations. CMBs volume was quantified and correlated with clinical and laboratory parameters. The study included patients who were hospitalized due to COVID-19, exhibited neurological manifestations, and underwent a brain MRI between March and May 2020. Neurological, clinical, and biochemical variables were reported. The MRI was acquired using a 3T scanner, with a standardized protocol including SWI. Patients were divided based on radiological evidence of CMBs or their absence. The CMBs burden was also assessed with a semi-automatic SWI processing procedure specifically developed for the purpose of this study. Odds ratios (OR) for CMBs were calculated using age, sex, clinical, and laboratory data by logistic regression analysis. Of the 1,760 patients with COVID-19 admitted to the ASST Papa Giovanni XXIII Hospital between 1 March and 31 May 2020, 116 exhibited neurological symptoms requiring neuroimaging evaluation. Of these, 63 patients underwent brain MRI and were therefore included in the study. A total of 14 patients had radiological evidence of CMBs (CMBs+ group). CMBs+ patients had a higher prevalence of CSF inflammation (p = 0.020), a higher white blood cell count (p = 0.020), and lower lymphocytes (p = 0.010); the D-dimer (p = 0.026), LDH (p = 0.004), procalcitonin (p = 0.002), and CRP concentration (p < 0.001) were higher than in the CMBs- group. In multivariable logistic regression analysis, CRP (OR = 1.16, p = 0.011) indicated an association with CMBs. Estimated CMBs volume was higher in females than in males and decreased with age (Rho = −0.38; p = 0.18); it was positively associated with CRP (Rho = 0.36; p = 0.22), and negatively associated with lymphocytes (Rho = −0.52; p = 0.07). CMBs are a frequent imaging finding in hospitalized patients with COVID-19 with neurological manifestations and seem to be related to pro-inflammatory status.
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Affiliation(s)
- Angela Napolitano
- Department of Neuroradiology, ASST Papa Giovanni XXIII, Bergamo, Italy
- *Correspondence: Angela Napolitano
| | - Alberto Arrigoni
- Bioengineering Department, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Anna Caroli
- Bioengineering Department, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | | | - Andrea Remuzzi
- Department of Management, Information and Production Engineering, University of Bergamo, Bergamo, Italy
| | - Luca Giovanni Longhi
- Neurosurgical Intensive Care Unit, Department of Anesthesia and Critical Care Medicine, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Antonino Barletta
- Department of Neuroradiology, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Rosalia Zangari
- Research Foundation, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Ferdinando Luca Lorini
- Department of Emergency and Critical Care Area, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Maria Sessa
- Department of Neurology, ASST Papa Giovanni XXIII, Bergamo, Italy
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White A, Martin R, Sew K, Stucke A, Cook R. Economic impact of a rapid, on‐demand ADAMTS‐13 activity assay for the diagnosis of thrombotic thrombocytopenic purpura. Res Pract Thromb Haemost 2022; 6:e12711. [PMID: 35599707 PMCID: PMC9123086 DOI: 10.1002/rth2.12711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 02/04/2022] [Accepted: 03/02/2022] [Indexed: 11/11/2022] Open
Abstract
Background Thrombotic thrombocytopenic purpura (TTP) is a rare, life-threatening thrombotic microangiopathy (TMA), characterized by ADAMTS-13 activity <10%. ADAMTS-13 activity assays are typically performed in reference laboratories with a turnaround time of several days. First-line treatment for TTP, therapeutic plasma exchange (TPE), typically starts while results are pending. The automated, on-demand HemosIL AcuStar ADAMTS-13 Activity assay provides results in under an hour, which could reduce unnecessary TPE use and associated costs. Objectives To estimate the hospital budget impact in the United States, United Kingdom, and France of using a rapid ADAMTS-13 activity assay. Methods We compared routine use of a rapid assay in adults with TMA with a scenario in which results take 3 days. Model structure and variables were based on published literature, plus survey and interviews of five clinicians from the three countries. Costs for the ADAMTS-13 activity assays and TPE were included. Results Model results suggest that if an on-demand, rapid ADAMTS-13 activity assay is used, US, UK, and French hospitals could save $18 million, £1.2 million, and €1.6 million annually, respectively. This equates to $10 788, £3497, and €4700 saved per patient with TMA in the United States, United Kingdom, and France. The model is most sensitive to the exact split of diagnoses of TMA cases, as savings accrue from non-TTP diagnoses. Conclusions In patients with TMA, use of a rapid, on-demand ADAMTS-13 activity assay such as the HemosIL AcuStar ADAMTS-13 Activity assay has the potential to be cost saving for hospitals.
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Affiliation(s)
- Alicia White
- Economist Intelligence Unit (EIU) Health Policy and Clinical Evidence (HPCE) Practice London UK
| | - Rosie Martin
- Economist Intelligence Unit (EIU) Health Policy and Clinical Evidence (HPCE) Practice London UK
| | - Keven Sew
- EIU HPCE Practice Singapore Singapore
| | | | - Rob Cook
- Economist Intelligence Unit (EIU) Health Policy and Clinical Evidence (HPCE) Practice London UK
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Daily ZH, Rizvi SS, Baez-Bonilla R. Atypical Hemolytic Uremic Syndrome in a Patient With Metastatic Peritoneal Serous Carcinoma: A Case Report. Cureus 2022; 14:e22624. [PMID: 35371768 PMCID: PMC8958130 DOI: 10.7759/cureus.22624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/25/2022] [Indexed: 11/15/2022] Open
Abstract
Atypical hemolytic uremic syndrome (HUS) is a part of a large category of diseases known as thrombotic microangiopathies that present with hemolytic anemia, thrombocytopenia, and target organ damage mostly characterized by acute kidney injury. It is a rare and challenging diagnosis due to the complex pathophysiology underlying the disease and its overlap with other conditions. We report the case of atypical hemolytic uremic syndrome in a 61-year-old female with a history of metastatic peritoneal serous carcinoma of the ovary presenting with anemia and acute renal failure.
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Bagai S, Malik V, Khullar D, Chakravarty M, Sahu A. Thrombotic Microangiopathy Secondary to Pancreatitis: A Diagnostic Enigma. Indian J Nephrol 2022; 32:279-281. [PMID: 35814326 PMCID: PMC9267086 DOI: 10.4103/ijn.ijn_52_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 10/11/2021] [Accepted: 10/21/2021] [Indexed: 11/12/2022] Open
Abstract
The association between thrombotic microangiopathy (TMA) and pancreatitis is well known. However, TMA leading to pancreatitis is more common than the latter. TMA and renal failure are both poor prognostic markers in acute pancreatitis. TMA, if not managed timely, can lead to severe morbidity and mortality. We report a case of a young boy in whom decisive and timely diagnosis and management of TMA post pancreatitis helped in complete patient and renal recovery.
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Poole C, Strydom C, van der Berg K, Vrielink H. Taking therapeutic apheresis services to patients in South Africa: An eight year review of SANBS mobile therapeutic apheresis service, 2013-2020. Transfus Apher Sci 2021; 60:103167. [PMID: 34116933 DOI: 10.1016/j.transci.2021.103167] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION A 20 year review of health and health care presents the multiple challenges faced by South Africans. Health and poverty is highlighted with 45% of population living on approximately US$ 2 per day and 10 million living on less than US$ 1 per day. Widening disparities in health care provision between public and private sector hospital services exist. The South African population includes the largest number of people living with HIV infection/AIDS of any country in the world, with a 70% estimate of 7.5 million people living with HIV on antiretroviral therapy. The South African National Blood Service provides a mixed model therapeutic apheresis service including mobile service and fixed-site therapeutic apheresis and an apheresis collection of hematopoietic stem cell (HPC-A) service. Therapeutic apheresis modalities offered by SANBS include plasmapheresis, red cell exchange, leukocyte and platelet reduction. In addition, collection of plasma, thrombocytes, mononuclear cells including CD34+ cells (HPCs) and granulocytes by apheresis for plasma and cellular therapies, and customised apheresis products for research purposes is offered. An operational database for the period 2013 to 2020 was reviewed to characterise the SANBS's mixed therapeutic apheresis service and HPC-A service from 2013 to 2020 in terms of patient numbers, patient demographics, patient procedures, therapeutic apheresis indication or diagnosis, therapeutic apheresis modality, hospital service type, and the American Society for Apheresis (ASFA) category of diagnosis. METHODS A retrospective review of therapeutic apheresis patients referred to SANBS characterising patient numbers, patient demographics, patient procedures, therapeutic apheresis indication or diagnosis, therapeutic apheresis modality (Linz, 2017), hospital service type, and the ASFA category of diagnosis (Padmanabhan et al., 2019) for the period 01 January 2013 to 31 December 2020 was completed. Data is obtained from a SANBS operational routinely utilised to record patient procedure data. Patient procedure data is manually recorded by apheresis nurses and indexed on to the operational database, with both processes audited. The review period is a convenience sample. Storage of the database and access of the operational database is in compliance with the Protection of Personal Information Act (Government Gazette, 2013). Therapeutic apheresis modalities analysed include Plasmapheresis, Red Cell Exchange, Leukopheresis, Thrombocytapheresis, Lymphocyte collection, Granulocyte collection, Haematopoietic stem cell collection by apheresis and customised apheresis products for research purposes. Customised apheresis products for research purposes is excluded from this review. Descriptive statistics is used. RESULTS For the review period, 2,485 unique patients with 120 unique indications as recorded by referring clinicians received 13,518 procedures involving 7 therapeutic apheresis modalities at 78 hospitals (21 public sector and 57 private sector) and at 3 SANBS blood donor centres in 7 provinces of South Africa. The age range of patients serviced is 4 months to 90 years (median = 39.5 years) (figure 1), 91% by procedure count was for patients 21 years of age or older, 62% were female, with 10,783 (79.6%) procedures performed in public sector hospitals. In all patients, the most common indications was plasmapheresis for thrombotic thromobocytopaenic purpura (52.5% of cumulative procedures), HPC-A for multiple myeloma (7.86%) and Antibody-mediated kidney transplant rejection (4.90%). Plasmapheresis was the most common therapeutic apheresis modality used (82.5% of cumulative procedures) followed by HPC-A (13.7%) and leukoreduction (3.39%). A range of indications for plasmapheresis (n = 65) and HPC-A (n = 41) were observed. Red cell exchange procedures was performed for patients with severe malaria and sickle cell disease indications. For leukoreduction indications, all patients were adults managed in public sector facilities and all were symptomatic. The most common indications were Chronic Myelogenous Leukemia, Chronic Lymphocytic Leukaemia and Multiple Myeloma. A pooled, total white cell count average of 457 × 109/L (range 141-689 × 109/L) prior to first procedure. Despite complex challenges for a national mixed model service, successful patient outcomes in emergent indications such as TTP (Louw et al., 2018; Swart et al., 2019) and engraftment post HPC-A in HSCT in multiple centres (Glatt, personal communication) are reported. CONCLUSION The review confirms that apheresis medicine is increasingly used in South Africa in patients in both public and private sector, with the most common modalities being plasmapheresis, HPC-A and leukoreduction. Patients with HIV-associated TTP is the most commonly referred patient in both paediatric and adult patients and this is anticipated to continue. A growing HSCT transplant network capacity in South Africa is augmented through the mixed model mobile and fixed-site therapeutic apheresis services, including a mobile HPC-A service. The increasing number of HPC-A is a trend towards increasing numbers of patients support to HSCT for both adults and paediatric patients in private and public sector hospitals.
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Affiliation(s)
- C Poole
- South African National Blood Service, South Africa.
| | - C Strydom
- South African National Blood Service, South Africa
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Willrich MAV, Braun KMP, Moyer AM, Jeffrey DH, Frazer-Abel A. Complement testing in the clinical laboratory. Crit Rev Clin Lab Sci 2021; 58:447-478. [PMID: 33962553 DOI: 10.1080/10408363.2021.1907297] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The complement system is the human's first line of defense against microbial pathogens because of its important housekeeping and infection/inflammation roles. It is composed of a series of soluble and cell-bound proteins that are activated in a cascade effect, similar to the coagulation pathways. There are different pattern recognizing molecules that activate the complement system in response to stimuli or threats, acting through three initiation pathways: classical, lectin, and alternative. All three activation pathways converge at the C3 component and share the terminal pathway. The main outputs of the complement system action are lytic killing of microbes, the release of pro-inflammatory anaphylatoxins, and opsonization of targets. Laboratory testing is relevant in the setting of suspected complement deficiencies, as well as in the emerging number of diseases related to dysregulation (over-activation) of complement. Most common assays measure complement lytic activity and the different complement component concentrations. Specialized testing includes the evaluation of autoantibodies against complement components, activation fragments, and genetic studies. In this review, we cover laboratory testing for complement and the conditions with complement involvement, as well as current challenges in the field.
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Affiliation(s)
| | - Karin M P Braun
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Ann M Moyer
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - David H Jeffrey
- Exsera Biolabs, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Ashley Frazer-Abel
- Exsera Biolabs, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
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Abstract
Severe COVID-19 can manifest as multiorgan dysfunction with pulmonary involvement being the most common and prominent. As more reports emerge in the literature, it appears that an exaggerated immune response in the form of unfettered complement activation and a cytokine storm may be a key driver of the widespread organ injury seen in this disease. In addition, these patients are also known to be hypercoagulable with a high rate of thrombosis and a higher-than-expected failure rate of anticoagulation. While macrovascular thrombosis is common in these individuals, the frequent finding of extensive microvascular thromboses in several series and case reports, raises the possibility of thrombotic microangiopathy (TMA) as being a contributing factor in the thrombotic and multi-organ complications of the disease. If this is correct, rapidly identifying a TMA and treating the underlying pathophysiology may allow for better outcomes in these critically ill patients. To further explore this, we reviewed the published literature on COVID-19, looking for reports describing TMA-like presentations. We summarize our findings here along with a discussion about presentation, pathophysiology, and a suggested treatment algorithm.
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Furmańczyk-Zawiska A, Kubiak-Dydo A, Użarowska-Gąska E, Kotlarek-Łysakowska M, Salata K, Kolanowska M, Świerniak M, Gaj P, Leszczyńska B, Daniel M, Jażdżewski K, Durlik M, Wójcicka A. Compound Haplotype Variants in CFH and CD46 Genes Determine Clinical Outcome of Atypical Hemolytic Uremic Syndrome (aHUS)-A Series of Cases from a Single Family. J Pers Med 2021; 11:jpm11040304. [PMID: 33920896 PMCID: PMC8071215 DOI: 10.3390/jpm11040304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 04/11/2021] [Accepted: 04/12/2021] [Indexed: 11/16/2022] Open
Abstract
Atypical hemolytic uremic syndrome (aHUS) is a rare disease triggered by dysregulation of the alternative complement pathway, consisting of a characteristic triad of nonimmune hemolytic anemia, thrombocytopenia, and renal failure. The risk of aHUS onset, recurrence, and allograft loss depends on the genetic background of a patient. We show a series of cases from a single family whose five members were affected by aHUS and presented distinct clinical outcomes. Next-generation sequencing revealed combined mutations in both complement factor H and membrane cofactor protein CD46. Out of eight siblings, aHUS affected three adult brothers, and, subsequently, affected two children of an unaffected sister. The first patient died due to aHUS, and two other brothers underwent successful kidney transplantation with no aHUS recurrence. The younger, 10-month-old child presented with a severe course of the disease with cardiac involvement and persistent hemolytic anemia limited by eculizumab, while the 2-year-old recovered completely on eculizumab. The study shows a highly variable disease penetrance.
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Affiliation(s)
- Agnieszka Furmańczyk-Zawiska
- Department of Transplantation Medicine, Nephrology and Internal Diseases, Medical University of Warsaw, 02-006 Warsaw, Poland; (A.F.-Z.); (M.D.)
| | - Anna Kubiak-Dydo
- Warsaw Genomics INC, 01-682 Warsaw, Poland; (A.K.-D.); (E.U.-G.); (M.K.-Ł.); (K.S.); (M.K.); (M.Ś.); (P.G.); (K.J.)
| | - Ewelina Użarowska-Gąska
- Warsaw Genomics INC, 01-682 Warsaw, Poland; (A.K.-D.); (E.U.-G.); (M.K.-Ł.); (K.S.); (M.K.); (M.Ś.); (P.G.); (K.J.)
- Postgraduate School of Molecular Medicine, Medical University of Warsaw, 02-091 Warsaw, Poland
| | - Marta Kotlarek-Łysakowska
- Warsaw Genomics INC, 01-682 Warsaw, Poland; (A.K.-D.); (E.U.-G.); (M.K.-Ł.); (K.S.); (M.K.); (M.Ś.); (P.G.); (K.J.)
| | - Katarzyna Salata
- Warsaw Genomics INC, 01-682 Warsaw, Poland; (A.K.-D.); (E.U.-G.); (M.K.-Ł.); (K.S.); (M.K.); (M.Ś.); (P.G.); (K.J.)
| | - Monika Kolanowska
- Warsaw Genomics INC, 01-682 Warsaw, Poland; (A.K.-D.); (E.U.-G.); (M.K.-Ł.); (K.S.); (M.K.); (M.Ś.); (P.G.); (K.J.)
| | - Michał Świerniak
- Warsaw Genomics INC, 01-682 Warsaw, Poland; (A.K.-D.); (E.U.-G.); (M.K.-Ł.); (K.S.); (M.K.); (M.Ś.); (P.G.); (K.J.)
| | - Paweł Gaj
- Warsaw Genomics INC, 01-682 Warsaw, Poland; (A.K.-D.); (E.U.-G.); (M.K.-Ł.); (K.S.); (M.K.); (M.Ś.); (P.G.); (K.J.)
| | - Beata Leszczyńska
- Department of Pediatrics Nephrology, Medical University of Warsaw, 02-091 Warsaw, Poland; (B.L.); (M.D.)
| | - Maria Daniel
- Department of Pediatrics Nephrology, Medical University of Warsaw, 02-091 Warsaw, Poland; (B.L.); (M.D.)
| | - Krystian Jażdżewski
- Warsaw Genomics INC, 01-682 Warsaw, Poland; (A.K.-D.); (E.U.-G.); (M.K.-Ł.); (K.S.); (M.K.); (M.Ś.); (P.G.); (K.J.)
- Laboratory of Human Cancer Genetics, University of Warsaw, 02-089 Warsaw, Poland
| | - Magdalena Durlik
- Department of Transplantation Medicine, Nephrology and Internal Diseases, Medical University of Warsaw, 02-006 Warsaw, Poland; (A.F.-Z.); (M.D.)
| | - Anna Wójcicka
- Warsaw Genomics INC, 01-682 Warsaw, Poland; (A.K.-D.); (E.U.-G.); (M.K.-Ł.); (K.S.); (M.K.); (M.Ś.); (P.G.); (K.J.)
- Correspondence:
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The Novel Coronavirus and Haemostatic Abnormalities: Pathophysiology, Clinical Manifestations, and Treatment Recommendations. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2021; 1321:173-180. [PMID: 33656723 DOI: 10.1007/978-3-030-59261-5_15] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The COVID-19 pandemic, caused by the SARS-C0V-2 virus, was initially considered and managed in a similar manner to the previous SARS epidemic as they are both caused by coronaviruses. What has now become apparent is that a major cause of morbidity and mortality in COVID-19 is abnormal thrombosis. This thrombosis occurs on a macro- and microvascular level and is unique to this disease. The virus has been demonstrated in the endothelium of the pulmonary alveoli and as such is thought to contribute to the devastating respiratory complications encountered. D-dimer concentrations are frequently raised in COVID to levels not frequently seen previously. The optimal anticoagulation treatment in COVID remains to be determined, and the myriad of pathophysiologic effects caused by this virus in the human host have also yet to be fully elucidated.
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Chowdhury A, Griffith MP, Busse E, Pasha AK. Postoperative Atypical Hemolytic Uremic Syndrome in a 67-Year-Old Woman Associated with Hemolytic Anemia, Thrombocytopenia, and Acute Renal Failure. AMERICAN JOURNAL OF CASE REPORTS 2020; 21:e925662. [PMID: 33335086 PMCID: PMC7733150 DOI: 10.12659/ajcr.925662] [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] [Indexed: 11/23/2022]
Abstract
Patient: Female, 67-year-old Final Diagnosis: Atypical hemolytic uremic syndrome Symptoms: Anemia • renal failure • thrombocytopenia Medication: — Clinical Procedure: — Specialty: Hematology • General and Internal Medicine • Pathology
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Affiliation(s)
- Arnab Chowdhury
- Department of Hospital Medicine, Mayo Clinic Health System in Mankato, Mankato, MN, USA
| | - Megan P Griffith
- Department of Pathology, Mayo Clinic Health System in Mankato, Mankato, MN, USA
| | - Eric Busse
- Department of Orthopedic Surgery, Mayo Clinic Health System in Mankato, Mankato, MN, USA
| | - Ahmed Khurshid Pasha
- Department of Hospital Medicine, Mayo Clinic Health System in Mankato, Mankato, MN, USA
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Bray MA, Sartain SE, Gollamudi J, Rumbaut RE. Microvascular thrombosis: experimental and clinical implications. Transl Res 2020; 225:105-130. [PMID: 32454092 PMCID: PMC7245314 DOI: 10.1016/j.trsl.2020.05.006] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 05/12/2020] [Accepted: 05/17/2020] [Indexed: 02/07/2023]
Abstract
A significant amount of clinical and research interest in thrombosis is focused on large vessels (eg, stroke, myocardial infarction, deep venous thrombosis, etc.); however, thrombosis is often present in the microcirculation in a variety of significant human diseases, such as disseminated intravascular coagulation, thrombotic microangiopathy, sickle cell disease, and others. Further, microvascular thrombosis has recently been demonstrated in patients with COVID-19, and has been proposed to mediate the pathogenesis of organ injury in this disease. In many of these conditions, microvascular thrombosis is accompanied by inflammation, an association referred to as thromboinflammation. In this review, we discuss endogenous regulatory mechanisms that prevent thrombosis in the microcirculation, experimental approaches to induce microvascular thrombi, and clinical conditions associated with microvascular thrombosis. A greater understanding of the links between inflammation and thrombosis in the microcirculation is anticipated to provide optimal therapeutic targets for patients with diseases accompanied by microvascular thrombosis.
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Key Words
- adamts13, a disintegrin-like and metalloproteinase with thrombospondin type 1 motif 13
- ap, alternate pathway
- apc, activated protein c
- aps, antiphospholipid syndrome
- caps, catastrophic aps
- asfa, american society for apheresis
- atp, adenosine triphosphate
- cfh, complement factor h
- con a, concavalin a
- cox, cyclooxygenase
- damp, damage-associated molecular pattern
- dic, disseminated intravascular coagulation
- gbm, glomerular basement membrane
- hellp, hemolysis, elevated liver enzymes, low platelets
- hitt, heparin-induced thrombocytopenia and thrombosis
- hlh, hemophagocytic lymphohistiocytosis
- hus, hemolytic-uremic syndrome
- isth, international society for thrombosis and haemostasis
- ivig, intravenous immunoglobulin
- ldh, lactate nos, nitric oxide synthase
- net, neutrophil extracellular trap
- pai-1, plasminogen activator inhibitor 1
- pf4, platelet factor 4
- prr, pattern recognition receptor
- rbc, red blood cell
- scd, sickle cell disease
- sle, systemic lupus erythematosus
- tlr, toll-like receptor
- tf, tissue factor
- tfpi, tissue factor pathway inhibitor
- tma, thrombotic microangiopathy
- tnf-α, tumor necrosis factor-α
- tpe, therapeutic plasma exchange
- ulc, ultra large heparin-pf4 complexes
- ulvwf, ultra-large von willebrand factor
- vwf, von willebrand factor
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Affiliation(s)
- Monica A Bray
- Center for Translational Research on Inflammatory Diseases (CTRID), Michael E. DeBakey VA Medical Center, Houston, Texas; Baylor College of Medicine, Houston, Texas
| | - Sarah E Sartain
- Center for Translational Research on Inflammatory Diseases (CTRID), Michael E. DeBakey VA Medical Center, Houston, Texas; Baylor College of Medicine, Houston, Texas
| | - Jahnavi Gollamudi
- Center for Translational Research on Inflammatory Diseases (CTRID), Michael E. DeBakey VA Medical Center, Houston, Texas; Baylor College of Medicine, Houston, Texas
| | - Rolando E Rumbaut
- Center for Translational Research on Inflammatory Diseases (CTRID), Michael E. DeBakey VA Medical Center, Houston, Texas; Baylor College of Medicine, Houston, Texas.
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Takahashi M, Deguchi A, Nishihara H, Asou M, Asakawa T, Araki M. Quetiapine-induced thrombotic microangiopathy in a patient on maintenance dialysis. CEN Case Rep 2020; 10:159-164. [PMID: 32981026 DOI: 10.1007/s13730-020-00536-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 09/17/2020] [Indexed: 10/23/2022] Open
Abstract
Quetiapine has been reported to cause immune-mediated thrombotic microangiopathy (TMA), although few cases have been reported thus far. A 71-year-old man with autosomal dominant polycystic kidney disease on maintenance dialysis was hospitalized with a hemorrhagic basal ganglia stroke, and was treated with 25 mg quetiapine for delirium from day 4 of admission. There was no worsening of consciousness, fever, diarrhea, or elevated blood pressure during the hospitalization. Gingival bleeding appeared on day 35, and the platelet count on day 38 was 0.5 × 104/μL (13.2 × 104/μL on day 16). The presence of 1% schistocytes, high LDH level, inability to measure haptoglobin, negative direct Coombs test, and normal prothrombin time and activated partial thromboplastin time indicated TMA. We considered an exclusionary diagnosis of drug-induced TMA, because of normal ADAMTS13 activity, no evidence of complement activation and the absence of Shiga toxin or symptoms of collagen disease or cancer. Quetiapine was the most likely causative factor; however, all drugs, including heparin, were discontinued or changed. Due to persistent microbleeding, platelet transfusions were performed several times. After only quetiapine was discontinued, the platelet count recovered smoothly to 3.1 and 7.2 × 104/μL on days 45 and 72, respectively; LDH and fibrinogen levels normalized on day 47. All medications, except quetiapine, were restarted sequentially after day 47, without subsequent thrombocytopenia. Platelet activation predominantly by a drug-dependent antibody might be the etiology of quetiapine-induced TMA. Plasmapheresis may not be necessary for quetiapine, because of its unproven efficacy in drug-induced TMA.
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Affiliation(s)
- Miki Takahashi
- Department of Internal Medicine, Suwa Central Hospital, 4300 Tamagawa, Chino-shi, Nagano-ken, 391-8503, Japan
| | - Akihito Deguchi
- Department of Internal Medicine, Suwa Central Hospital, 4300 Tamagawa, Chino-shi, Nagano-ken, 391-8503, Japan
| | - Hiromu Nishihara
- Department of Internal Medicine, Suwa Central Hospital, 4300 Tamagawa, Chino-shi, Nagano-ken, 391-8503, Japan
| | - Mea Asou
- Department of Internal Medicine, Suwa Central Hospital, 4300 Tamagawa, Chino-shi, Nagano-ken, 391-8503, Japan
| | - Tomohiko Asakawa
- Department of Internal Medicine, Suwa Central Hospital, 4300 Tamagawa, Chino-shi, Nagano-ken, 391-8503, Japan
| | - Makoto Araki
- Department of Internal Medicine, Suwa Central Hospital, 4300 Tamagawa, Chino-shi, Nagano-ken, 391-8503, Japan.
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Goranta S, Deliwala SS, Haykal T, Bachuwa G. Severe primary refractory thrombotic thrombocytopenic purpura (TTP) in the post plasma exchange (PEX) and rituximab era. BMJ Case Rep 2020; 13:13/6/e234091. [PMID: 32532908 DOI: 10.1136/bcr-2019-234091] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Acute acquired thrombotic thrombocytopenic purpura (TTP) requires prompt recognition and initiation of plasma exchange (PEX) therapy and immunosuppression. When PEX fails, mortality nears 100%, making finding an effective treatment crucial. Primary refractory TTP occurs when initial therapies fail or if exacerbations occur during PEX therapy, both signifying the need for treatment intensification to achieve clinical remission. Rituximab helps treat most of the refractory TTP cases, except those that are severely refractory. A paucity of studies guiding severely refractory TTP makes management arbitrary and individualised, highlighting the value of isolated reports. We present an extremely rare case of primary refractory TTP with an insufficient platelet response to numerous types of treatments, including emerging therapies such as caplacizumab, on the background of repeated PEX and immunosuppressive therapies.
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Affiliation(s)
- Sowmya Goranta
- Department of Internal Medicine, Michigan State University at Hurley Medical Center, Flint, Michigan, USA
| | - Smit S Deliwala
- Department of Internal Medicine, Michigan State University at Hurley Medical Center, Flint, Michigan, USA
| | - Tarek Haykal
- Department of Internal Medicine, Michigan State University at Hurley Medical Center, Flint, Michigan, USA
| | - Ghassan Bachuwa
- Department of Internal Medicine, Michigan State University at Hurley Medical Center, Flint, Michigan, USA
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When to consider targeted therapies in thrombotic microangiopathies in the modern era: walking the tightrope between cost, safety, and efficacy. J Thromb Thrombolysis 2020; 49:602-605. [DOI: 10.1007/s11239-020-02094-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Abstract
Evaluating, diagnosing, and managing patients with consumptive thrombocytopenia is challenging because of the overlapping nature of many of the diseases that reduce platelet counts. Immune thrombocytopenia (and its variations), drug-induced immune thrombocytopenia, and heparin-induced thrombocytopenia result from autoimmune antibody-mediated destruction of platelets. Thrombotic thrombocytopenia (both congenital and acquired) and the hemolytic uremic syndromes (both typical and atypical) are thrombotic microangiopathies associated with platelet aggregation and consumption along with anemia and renal dysfunction. Rapid history taking, physical assessment, and laboratory evaluation are crucial to accurately managing patients with these disorders. Platelet-associated coagulopathies are infrequently encountered by most providers, and limited exposure to these types of patients, combined with the wide variety of treatment options for reversing bleeding or thrombotic sequelae, makes management difficult. This article reviews the pathophysiology, patient presentation, diagnostic testing, and specific management strategies and challenges of these thrombocytopenias.
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Affiliation(s)
- Thomas A VanDruff
- Thomas A. VanDruff is Critical Care Nurse Practitioner, PMA Health at the Virginia Hospital Center, 1625 North George Mason Drive, Arlington, VA 22205
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30
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Stratford LMI, Nahoor I, Dos Santos K, Dos Santos AA. A case of thrombotic microangiopathy of unknown aetiology, clinically presenting as an acute surgical abdomen. BMJ Case Rep 2019; 12:12/11/e230553. [PMID: 31780612 DOI: 10.1136/bcr-2019-230553] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
A 48-year-old woman presented with severe abdominal pain, bilious vomiting and bloody diarrhoea for 1 day. On examination, she was haemodynamically unstable, febrile and clinically had an acute surgical abdomen. She had markedly raised inflammatory markers, neutrophils and deranged renal function. A CT abdominal scan revealed severe colitis and thickening throughout the length of the colon. The patient was stabilised and underwent emergency laparotomy resulting in total colectomy and end ileostomy formation. Postoperatively, she required several units of human albumin solution, red blood cell transfusions and octaplex (prothrombin complex) to prevent further bleeding. An inpatient haematology review revealed a hypocomplementaemia (C3/C4), low immunoglobulin (IgG, IgM, IgA) and peripheral blood films revealed schistocytosis indicating microangiopathic haemolytic anaemia. Bowel histology supported this, demonstrating circumferential lymphocytic phlebitis with thrombi and mucosal haemorrhage, necrosis and ulceration. The patient went on to suffer multiple ischaemic strokes before undergoing plasmapheresis, subsequent rehabilitation and making a successful recovery.
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Affiliation(s)
| | | | - Kataryna Dos Santos
- General Medicine Department, Russells Hall Hospital, Dudley, West Midlands, UK
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31
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St-Pierre F, Pawar AS, Kumar R. 63-Year-Old Woman With Abdominal Pain and Thrombocytopenia. Mayo Clin Proc 2019; 94:2122-2126. [PMID: 31585585 DOI: 10.1016/j.mayocp.2019.02.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 02/20/2019] [Accepted: 02/28/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Frederique St-Pierre
- Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Rochester, MN
| | - Aditya S Pawar
- Resident in Nephrology, Mayo Clinic School of Graduate Medical Education, Rochester, MN
| | - Rajiv Kumar
- Advisor to residents and Consultant in Nephrology, Mayo Clinic, Rochester, MN.
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Sridharan M, Hook CC, Leung N, Winters JL, Go RS. Postsurgical thrombotic microangiopathy: Case series and review of the literature. Eur J Haematol 2019; 103:307-318. [PMID: 31251415 DOI: 10.1111/ejh.13284] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 06/14/2019] [Accepted: 06/17/2019] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Describe the clinical presentation, treatment, and outcomes of postsurgical thrombotic microangiopathy (TMA). METHODS In this retrospective study, records of individuals diagnosed with TMA developing within 30 days of a surgical procedure at Mayo Clinic from 2000 to 2016 were reviewed. Available literature regarding postsurgical TMA was comparatively reviewed. RESULTS Twenty patients were diagnosed with TMA developing within 30 (median 6.5, range (1-28)) days) following a procedure. Preceding procedures included orthopedic (n = 4), vascular (n = 4), abdominal (n = 8), thoracic (n = 2), and other (n = 2). Review of the literature identified 65 patients with postsurgical TMA and cardiovascular procedures were the most common preceding surgery. The majority of patients in the current cohort and literature were treated with therapeutic plasma exchange (TPE). Among the evaluable patients in the current cohort, 100% demonstrated response to TPE; however, 25% required the addition of other therapy including eculizumab to maintain a response 80% of patients in the literature demonstrated a response to TPE. CONCLUSIONS Although rare, early recognition and treatment of postsurgical TMA can lead to good outcomes. More research is necessary to determine the underlying pathophysiology and optimal treatment for postsurgical TMA.
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Affiliation(s)
| | | | - Nelson Leung
- Division of Hematology, Mayo Clinic, Rochester, MN, USA.,Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | | | - Ronald S Go
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
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Li XY, Mai YF, Huang J, Pai P. Gastrointestinal infection-related disseminated intravascular coagulation mimicking Shiga toxin-mediated hemolytic uremic syndrome - implications of classical clinical indexes in making the diagnosis: A case report and literature review. World J Clin Cases 2019; 7:1660-1670. [PMID: 31367625 PMCID: PMC6658372 DOI: 10.12998/wjcc.v7.i13.1660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 04/26/2019] [Accepted: 05/01/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Thrombocytopenia associated with acute kidney injury is a challenging disorder. Thrombotic microangiopathy (TMA) is a potentially life- or organ-threatening syndrome that can be induced by several disorders or medical interventions. There is overlap between the clinical presentation and pathophysiology of thrombotic thrombocytopenia purpura and hemolytic uremic syndrome (HUS), and to a lesser extent, disseminated intravascular coagulation (DIC). We describe a case to illustrate the potential diagnostic difficulty, especially at initial presentation.
CASE SUMMARY We reported a case of a 44-year-old woman that presented with diarrhea, thrombocytopenia, schistocytes, elevated serum lactate dehydrogenase (LDH) level and acute kidney injury. While the clinical presentation resembled that of Shiga toxin–induced HUS, the disease course was more consistent with gastrointestinal infection-related DIC. To aid in the accurate diagnosis of TMA and other associated disorders, we have undertaken a review and provided a clear interpretation of some typical biomarkers including schistocytes, LDH and platelet count, coagulation profile and more specific indexes of ADAMTS13, complement profile, and the isolation of Shiga toxin-producing Escherichia coli (commonly referred to as STEC).
CONCLUSION The use and correct interpretation of classical indexes of schistocyte, LDH, and platelet count is vital in diagnosing TMA and associated disorders. Understanding the characteristics of these biomarkers in the context of thrombocytopenia purpura, HUS and DIC will facilitate the accurate diagnosis and early initiation of appropriate treatment.
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Affiliation(s)
- Xiang-Yang Li
- Department of Nephrology, The University of Hong Kong-Shenzhen Hospital, Shenzhen 518053, Guangdong Province, China
| | - Yan-Fen Mai
- Department of Nephrology, The University of Hong Kong-Shenzhen Hospital, Shenzhen 518053, Guangdong Province, China
| | - Jing Huang
- Department of Hematology, The University of Hong Kong-Shenzhen Hospital, Shenzhen 518053, Guangdong Province, China
| | - Pearl Pai
- Department of Nephrology, The University of Hong Kong-Shenzhen Hospital, Shenzhen 518053, Guangdong Province, China
- Department of Medicine, The University of Hong Kong - Queen Mary Hospital, Hong Kong, China
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Uriol Rivera MG, Cabello Pelegrin S, Ballester Ruiz C, López Andrade B, Lumbreras J, Obrador Mulet A, Perez Montaña A, Ferreruela Serlavos M, Ayestarán Rota JI, Ferrer Balaguer J, Delgado Sanchez O, Pallares Ferreres L, Mas Bonet A, Picado Valles MJ, de Gopegui Valero RMR. Impact of a multidisciplinary team for the management of thrombotic microangiopathy. PLoS One 2018; 13:e0206558. [PMID: 30388144 PMCID: PMC6214549 DOI: 10.1371/journal.pone.0206558] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Accepted: 10/14/2018] [Indexed: 12/30/2022] Open
Abstract
Background Thrombotic microangiopathy (TMA) is an important complication associated with several diseases that are rare and life-threatening. TMA is common to thrombotic thrombocytopenic purpura (TTP) and hemolytic uremic syndrome (HUS). TTP is defined by a severe deficiency of ADAMTS13, and early treatment is associated with good prognosis. The diagnosis of HUS can be difficult due to the potential multiple etiologies, and the best treatment option in most cases is not well-established yet. The implementation of a multidisciplinary team (MDT) could decrease the time to diagnosis and treatment for HUS and may improve the outcomes of these patients. Objective To determine the impact of MDT on morbidity and mortality [death or chronic renal replacement therapy (CRRT) requirements], incidence and response time [(RT) defined as the period between hospital admission and the first day of direct therapy administration], length of stay at an intensive care unit (ICU-LOS) and total hospitalization (T-LOS) were also assessed. Methods We compared a pre-MDT implementation period (from January/2008 to May/2016) versus post-MDT period (from May/2016 to December/2016). The screening TMA diagnosis was made according the following criteria: hemolytic anemia, thrombocytopenia and acute renal damage and without ADAMTS13 deficiency. An online chat was implemented to provide instant medical information. Results Twenty-eight patients were included. The incidence changed from 2.3 cases/pre-MDT: (all cases: n = 18) to 10 cases/year post-MDT (all cases: n = 10). Two patients died in pre-MDT and post- MDT (11% versus 20%, P = 0.60). From pre-MDT, the number of patients who required CRRT by post-MDT decreased from 7 (39%) to 0, P = 0.03. Similarly, RT, ICU-LOS and T-LOS [median(p25-p75)] decreased from 10 (2–12) days to 0.5 (0–1.5) days, P = 0.04, from 16 (9–30) days to 10 (4–13) days, P = 0.01 and from 33 (22–53) days to 16 (12–32) days, P < 0.01, respectively. Conclusion MDT implementation was associated with a greater number of patients who meet TMA criteria. A decrease in the RT and T-LOS periods were observed and associated with better outcomes in these patients.
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Affiliation(s)
- Miguel G. Uriol Rivera
- Nephrology Department, Son Espases University Hospital, Palma de Mallorca, Spain
- * E-mail:
| | | | | | | | - Javier Lumbreras
- Pediatric Nephrology Unit, Son Espases University Hospital, Palma de Mallorca, Spain
| | - Aina Obrador Mulet
- Nephrology Department, Son Espases University Hospital, Palma de Mallorca, Spain
| | | | | | | | | | | | | | - Antonio Mas Bonet
- Neuroradiology Unit, Son Espases University Hospital, Palma de Mallorca, Spain
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Sridharan M, Go RS, Abraham RS, Fervenza FC, Sethi S, Bryant SC, Spears GM, Murray DL, Willrich MAV. Diagnostic Utility of Complement Serology for Atypical Hemolytic Uremic Syndrome. Mayo Clin Proc 2018; 93:1351-1362. [PMID: 30286829 DOI: 10.1016/j.mayocp.2018.07.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 06/24/2018] [Accepted: 07/17/2018] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To investigate the clinical utility of a 9-analyte complement serology panel (COMS) covering complement function (CH50 and AH50), components (C3, C4), factor B (CFB), factor H, and activation markers (C4d, Bb, and soluble membrane attack complex) for the diagnosis of atypical hemolytic uremic syndrome (aHUS). METHODS Physician orders for COMS from January 19, 2015, through November 4, 2016, were reviewed. Demographic characteristics, patient diagnosis, and laboratory parameters were recorded. RESULTS There were 177 COMS orders for 147 patients. The median patient age was 44.9 years (range, 0.9-88.0 years). Common reasons for ordering COMS included monitoring and diagnosis of C3 glomerulopathy and renal dysfunction and differentiation of aHUS from other thrombotic microangiopathies (TMAs). Forty-four patients had COMS ordered for TMAs: 8 had aHUS and all had 1 or more abnormalities within the alternative pathway of complement. Although the sensitivity of this finding for the diagnosis of aHUS is 100%, the specificity is only 28%, with a positive likelihood ratio of 1.39. Patients with aHUS had lower CH50, C3, and CFB than did those with secondary non-aHUS TMA (all P<.01). A combined CFB of 20.9 mg/dL or less and CH50 of 56% or less led to sensitivity of 75% with increased specificity of 88.9% and a diagnostic odds ratio of 24. CONCLUSION A COMS abnormality should not be interpreted in isolation. In conjunction with clinical presentation, a decrease in both CFB and CH50 may be an important clue to support the diagnosis of aHUS.
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Affiliation(s)
| | - Ronald S Go
- Division of Hematology, Mayo Clinic, Rochester, MN
| | - Roshini S Abraham
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | | | - Sanjeev Sethi
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Sandra C Bryant
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - Grant M Spears
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - David L Murray
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Maria A V Willrich
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN.
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Abstract
Thrombotic microangiopathies are heterogeneous disorders characterized by microangiopathic hemolytic anemia with thrombocytopenia and renal injury. There are a variety of causes, including metabolic disorders, infections, medications, complement disorders, pregnancy, malignancy, and autoimmune disorders. This review focuses on renal thrombotic microangiopathy in the setting of rheumatologic diseases. Systemic lupus erythematosus is the most common autoimmune disease associated with thrombotic microangiopathy. Other etiologies include scleroderma renal crisis and antiphospholipid antibody syndrome, which can be primary or secondary to autoimmune diseases including systemic lupus erythematosus. There have also been case reports of thrombotic microangiopathy in the setting of rheumatoid arthritis and dermatomyositis.
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Atypical hemolytic uremic syndrome: Review of clinical presentation, diagnosis and management. J Immunol Methods 2018; 461:15-22. [PMID: 30031798 DOI: 10.1016/j.jim.2018.07.006] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Revised: 05/30/2018] [Accepted: 07/18/2018] [Indexed: 12/12/2022]
Abstract
Thrombotic microangiopathies (TMA) are a class of disorders characterized by microangiopathic hemolytic anemia, non-immune thrombocytopenia, and organ dysfunction. One type of TMA is atypical hemolytic uremic syndrome (aHUS) a disorder caused by hyper-activation of the alternative complement pathway due to over activation of C3 convertases and loss of complement regulatory mechanisms. The pathophysiological mechanism of aHUS involves increased continuous spontaneous hydrolysis of C3 to C3b which leads to tissue deposition of C3b, the membrane attack complex formation and subsequent tissue injury. The underlying susceptibility factors to aHUS include acquired autoantibodies or germline mutations in complement proteins or their regulators. Currently there are no clear diagnostic criteria for aHUS. Diagnosis involves ruling out other causes of TMA and incorporating complement serologic and genetic data. TPE has been used to treat aHUS; however, clinical improvement in these patents is far less than in patients with thrombotic thrombocytopenic purpura. Furthermore, there is a higher rate of progression to end stage renal disease with almost half of patients progressing despite TPE. For those, another option for treatment is eculizumab, a monoclonal antibody that blocks complement C5. Eculizumab has proven effective in aHUS and dramatically changed the prognosis of this syndrome. In this review the clinical presentation, diagnosis and management of aHUS are highlighted with three clinical cases.
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Fox LC, Cohney SJ, Kausman JY, Shortt J, Hughes PD, Wood EM, Isbel NM, de Malmanche T, Durkan A, Hissaria P, Blombery P, Barbour TD. Consensus opinion on diagnosis and management of thrombotic microangiopathy in Australia and New Zealand. Intern Med J 2018; 48:624-636. [DOI: 10.1111/imj.13804] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 02/13/2018] [Accepted: 02/13/2018] [Indexed: 02/06/2023]
Affiliation(s)
- Lucy C. Fox
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Victoria Australia
| | - Solomon J. Cohney
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Victoria Australia
- Department of Medicine; University of Melbourne; Melbourne Victoria Australia
| | - Joshua Y. Kausman
- Department of Paediatrics; University of Melbourne; Melbourne Victoria Australia
- Department of Nephrology and Murdoch Children's Research Institute; Royal Children's Hospital; Melbourne Victoria Australia
| | - Jake Shortt
- Monash Haematology; Monash Health; Melbourne Victoria Australia
- School of Clinical Sciences, Monash Health; Monash University; Melbourne Victoria Australia
| | - Peter D. Hughes
- Department of Medicine; University of Melbourne; Melbourne Victoria Australia
- Department of Nephrology; Royal Melbourne Hospital; Melbourne Victoria Australia
| | - Erica M. Wood
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Victoria Australia
- Monash Haematology; Monash Health; Melbourne Victoria Australia
| | - Nicole M. Isbel
- Department of Nephrology; Princess Alexandra Hospital; Brisbane Queensland Australia
| | - Theo de Malmanche
- New South Wales Health Pathology; Newcastle New South Wales Australia
| | - Anne Durkan
- Department of Nephrology; The Children's Hospital at Westmead; Sydney New South Wales Australia
| | - Pravin Hissaria
- Department of Immunology; Royal Adelaide Hospital; Adelaide South Australia Australia
| | - Piers Blombery
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Victoria Australia
- Department of Pathology; Peter MacCallum Cancer Centre; Melbourne Victoria Australia
| | - Thomas D. Barbour
- Department of Medicine; University of Melbourne; Melbourne Victoria Australia
- Department of Nephrology; Royal Melbourne Hospital; Melbourne Victoria Australia
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Fox LC, Cohney SJ, Kausman JY, Shortt J, Hughes PD, Wood EM, Isbel NM, de Malmanche T, Durkan A, Hissaria P, Blombery P, Barbour TD. Consensus opinion on diagnosis and management of thrombotic microangiopathy in Australia and New Zealand. Nephrology (Carlton) 2018; 23:507-517. [DOI: 10.1111/nep.13234] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/02/2018] [Indexed: 02/06/2023]
Affiliation(s)
- Lucy C Fox
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Victoria Australia
| | - Solomon J Cohney
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Victoria Australia
- Department of Medicine; University of Melbourne; Melbourne Victoria Australia
| | - Joshua Y Kausman
- Department of Nephrology and Murdoch Children's Research Institute; Royal Children's Hospital; Melbourne Victoria Australia
- Department of Paediatrics; University of Melbourne; Melbourne Victoria Australia
| | - Jake Shortt
- Monash Haematology, Monash Health, Monash University; Melbourne Victoria Australia
- School of Clinical Sciences; Monash Health, Monash University; Melbourne Victoria Australia
| | - Peter D Hughes
- Department of Medicine; University of Melbourne; Melbourne Victoria Australia
- Department of Nephrology; Royal Melbourne Hospital; Melbourne Victoria Australia
| | - Erica M Wood
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Victoria Australia
- Monash Haematology, Monash Health, Monash University; Melbourne Victoria Australia
| | - Nicole M Isbel
- Department of Nephrology; Princess Alexandra Hospital; Brisbane Queensland Australia
| | - Theo de Malmanche
- New South Wales Health Pathology, Immunology; Newcastle New South Wales Australia
| | - Anne Durkan
- Department of Nephrology; The Children's Hospital at Westmead; Sydney New South Wales Australia
| | - Pravin Hissaria
- Department of Immunology; Royal Adelaide Hospital; Adelaide South Australia Australia
| | - Piers Blombery
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Victoria Australia
- Department of Pathology; Peter MacCallum Cancer Centre; Melbourne Victoria Australia
| | - Thomas D Barbour
- Department of Medicine; University of Melbourne; Melbourne Victoria Australia
- Department of Nephrology; Royal Melbourne Hospital; Melbourne Victoria Australia
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40
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Nalluru SS, Sridharan M, Go RS, Said S, Marshall AL. Shiga Toxin as a Potential Trigger of CFHR1 Deletion-Associated Thrombotic Microangiopathy. Am J Med Sci 2018; 356:492-498. [PMID: 30177262 DOI: 10.1016/j.amjms.2018.05.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Revised: 05/29/2018] [Accepted: 05/29/2018] [Indexed: 12/28/2022]
Abstract
Thrombotic microangiopathy (TMA) may result from a variety of clinical conditions, including thrombotic thrombocytopenic purpura, Shiga toxin-producing Escherichia coli-associated hemolytic uremic syndrome and complement-mediated hemolytic uremic syndrome. Thrombocytopenic purpura is diagnosed when ADAMTS13 is <10%, while a diagnosis of Shiga toxin-producing Escherichia coli-associated hemolytic uremic syndrome is made with the evidence of infection by Shiga toxin-producing Escherichia coli. Diagnosis of complement-mediated hemolytic uremic syndrome is not dependent on a specific laboratory test and is a diagnosis of exclusion. TMA is a rare disease and finding individuals that have more than 1 concurrent etiology leading to TMA is even more rare. Here we describe the presentation and management of an individual with CFHR1 deletion-associated TMA also found to have a positive stool Shiga toxin. We discuss the significance of Shiga toxin in serving as a trigger for development of TMA in an individual predisposed to development of TMA due to presence of a homozygous deletion in CFHR1.
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Affiliation(s)
| | | | - Ronald S Go
- Mayo Clinic, Division of Hematology, Rochester, Minnesota.
| | - Samar Said
- Mayo Clinic, Division of Hematology, Rochester, Minnesota.
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Abstract
PURPOSE OF REVIEW Significant and intricate immune adaptations are essential for the establishment and maintenance of normal pregnancy. Preeclampsia is a morbid, potentially life-threatening disease for both mother and neonate that occurs uniquely in pregnancy, at least in part, due to maternal immune maladaptation. We aim to review the literature that focuses on case reports, diagnostic approaches, and treatment strategies for disorders of the complement alternative pathway (CAP) as related to preeclampsia. RECENT FINDINGS There is evidence of complement dysregulation in preeclampsia and HELLP syndrome, similar to that observed in a few rare types of thrombotic microangiopathies. Complement dysregulation may be identified with functional laboratory testing as well as genetic testing. Increased utilization of a standardized diagnostic approach to establish whether persistent and/or severe cases of preeclampsia and HELLP syndrome are complement-mediated may lead to development of future treatment strategies, such as complement-targeted therapy.
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Yıldız S, Demirkan F. What is the evidence for the role of therapeutic apheresis in the management of complement-associated thrombotic microangiopathies? Transfus Apher Sci 2018; 57:31-34. [PMID: 29506907 DOI: 10.1016/j.transci.2018.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Thrombotic microangiopathies (TMAs) are disorders characterized by endothelial cell activation, microangiopathic hemolytic anemia, thrombocytopenia and organ failure of variable intensity. The pathophysiology of various types of TMAs have become an interesting field of study. Alternative complement system activation plays an important role in several pathophysiological conditions. Complement activation is also described in an increasing number of TMAs. Inherited defects in complement regulatory genes and acquired autoantibodies against complement regulatory proteins have been described. Atypical hemolytic uremic synrome (HUS) is caused by uncontrolled activation of the alternative complement system, now called complement-mediated TMAs. Recently, application of a monoclonal antibody that specifically binds to C5 became available to treat patients with complement-mediated TMAs. Eculizumab is a humanized monoclonal antibody that blocks complement C5 activation. Empiric therapeutic apheresis is also recommended in all forms of complement-mediated TMAs. The justification for therapeutic apheresis use in all forms of complement-mediated TMAs is that it can effectively remove the autoantibodies or mutated circulating complement regulators while replacing absent or defective complement regulators. Currently, therapeutic apheresis and eculizumab are the available treatment options for complement-mediated TMAs. In this paper, we review the evidence for the role of therapeutic apheresis in the management of complement-associated TMAs.
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Affiliation(s)
- Serkan Yıldız
- Dokuz Eylul University, Division of Nephrology, Department of Internal Medicine, Izmir, Turkey
| | - Fatih Demirkan
- Dokuz Eylul University, Division of Hematology, Department of Internal Medicine, 35340, Inciralti, Izmir, Turkey.
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43
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Ravi P, Leon-Ferre R, Thompson CA. 47-Year-Old Woman With Anemia and Thrombocytopenia. Mayo Clin Proc 2018; 93:108-112. [PMID: 29141773 DOI: 10.1016/j.mayocp.2017.02.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2017] [Revised: 02/21/2017] [Accepted: 02/27/2017] [Indexed: 11/21/2022]
Affiliation(s)
- Praful Ravi
- Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Rochester, MN
| | - Roberto Leon-Ferre
- Fellow in Hematology/Oncology, Mayo Clinic School of Graduate Medical Education, Rochester, MN
| | - Carrie A Thompson
- Advisor to resident and fellow and Consultant in Hematology, Mayo Clinic, Rochester, MN.
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Winters JL. Plasma exchange in thrombotic microangiopathies (TMAs) other than thrombotic thrombocytopenic purpura (TTP). HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2017; 2017:632-638. [PMID: 29222314 PMCID: PMC6142547 DOI: 10.1182/asheducation-2017.1.632] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
Thrombotic microangiopathies (TMAs) are a diverse group of disorders that are characterized by common clinical and laboratory features. The most commonly thought-of TMA is thrombotic thrombocytopenic purpura (TTP). Because of the marked improvement in patient mortality associated with the use of therapeutic plasma exchange (TPE) in TTP, this therapy has been applied to all of the TMAs. The issue, however, is that the pathophysiology varies and in many instances may represent a disorder of the endothelium and not the blood; in some cases, the pathophysiology is unknown. The use of TPE is further obscured by a lack of strong supporting literature on its use, with most consisting of case series and case reports; controlled or randomized controlled trials are lacking. Evidence supporting the use of TPE in the treatment of TMAs (other than TTP and TMA-complement mediated) is lacking, and therefore its role is uncertain. With the greater availability of genetic testing for mutations involving complement regulatory genes and complement pathway components, there seems to be a percentage of TMA cases, other than TMA-complement mediated, in which complement pathway mutations are involved in some patients. The ability of TPE to remove abnormal complement pathway components and replace them with normal components may support its use in some patients with TMAs other than TTP and TMA-complement mediated.
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Affiliation(s)
- Jeffrey L Winters
- Therapeutic Apheresis Treatment Unit, Division of Transfusion Medicine, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
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45
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Gordon CE, Chitalia VC, Sloan JM, Salant DJ, Coleman DL, Quillen K, Ravid K, Francis JM. Thrombotic Microangiopathy: A Multidisciplinary Team Approach. Am J Kidney Dis 2017; 70:715-721. [PMID: 28720207 DOI: 10.1053/j.ajkd.2017.05.017] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Accepted: 05/14/2017] [Indexed: 12/20/2022]
Abstract
Thrombotic microangiopathy (TMA) is characterized by the presence of microangiopathic hemolytic anemia and thrombocytopenia along with organ dysfunction, and pathologically, by the presence of microthrombi in multiple microvascular beds. Delays in diagnosis and initiation of therapy are common due to the low incidence, variable presentation, and poor awareness of these diseases, underscoring the need for interdisciplinary approaches to clinical care for TMA. We describe a new approach to improve clinical management via a TMA team that originally stemmed from an Affinity Research Collaborative team focused on thrombosis and hemostasis. The TMA team consists of clinical faculty from different disciplines who together are charged with the responsibility to quickly analyze clinical presentations, guide laboratory testing, and streamline prompt institution of treatment. The TMA team also includes faculty members from a broad range of disciplines collaborating to elucidate the pathogenesis of TMA. To this end, a clinical database and biorepository have been constructed. TMA leaders educate front-line providers from other departments through presentations in various forums across multiple specialties. Facilitated by an Affinity Research Collaborative mechanism, we describe an interdisciplinary team dedicated to improving both clinical care and translational research in TMA.
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Affiliation(s)
- Craig E Gordon
- Renal Section, Department of Medicine, Boston University School of Medicine, Boston, MA
| | - Vipul C Chitalia
- Renal Section, Department of Medicine, Boston University School of Medicine, Boston, MA
| | - J Mark Sloan
- Hematology-Oncology Section, Department of Medicine, Boston University School of Medicine, Boston, MA
| | - David J Salant
- Renal Section, Department of Medicine, Boston University School of Medicine, Boston, MA
| | - David L Coleman
- Department of Medicine, Boston University School of Medicine, Boston, MA
| | - Karen Quillen
- Hematology-Oncology Section, Department of Medicine, Boston University School of Medicine, Boston, MA
| | - Katya Ravid
- Department of Medicine, Boston University School of Medicine, Boston, MA; Whitaker Cardiovascular Institute, Boston University School of Medicine, Boston, MA
| | - Jean M Francis
- Renal Section, Department of Medicine, Boston University School of Medicine, Boston, MA.
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Li A, Bendapudi PK, Uhl L, Hamdan A, Kaufman RM, Makar RS. Clinical features and outcomes in patients with thrombotic microangiopathy not associated with severe ADAMTS13 deficiency. Transfusion 2017. [PMID: 28635017 DOI: 10.1111/trf.14181] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND The a disintegrin and metalloprotease with thrombospondin type 1 motifs, member 13 (ADAMTS13) activity assay has become important in distinguishing autoimmune thrombotic thrombocytopenic purpura from other forms of thrombotic microangiopathy (TMA). Although the significance of severe deficiency in ADAMTS13 (activity levels 10% or less) has been well defined, little data are available on the clinical importance of mild to moderate deficiency (activity levels 11%-70%) among patients with TMA. STUDY DESIGN AND METHODS We conducted a retrospective study using the Harvard TMA Research Collaborative Registry. Among 254 patients who met the inclusion criteria for TMA, 186 patients with ADAMTS13 activity levels greater than 10% were divided into moderate-deficiency (11%-40%), mild-deficiency (41%-70%), and no-deficiency (greater than 70%). RESULTS Compared with mild or no deficiency, moderate ADAMTS13 deficiency correlated with older age; higher bilirubin and international normalized ratio; and increased frequency of sepsis, shock, or multiorgan failure. Platelet counts, lactate dehydrogenase levels, and the presence of renal or neurologic dysfunction did not vary across the three patient cohorts. While moderate ADAMTS13 deficiency was associated with increased 90-day mortality in univariate analysis, this association was no longer significant in multivariate analysis. Variables that independetly predicted 90-day mortality in this cohort of patients included Charlson comorbidity index, alanine aminotransferase level, platelet count, creatinine, and the presence of sepsis, shock, or multiorgan failure. CONCLUSION Moderately deficient ADAMTS13 activity identifies a cohort of patients with TMA who are at increased risk for 90-day mortality. The ADAMTS13 activity level in this group is not an independent predictor of poor outcomes but instead appears to be a marker of disease acuity.
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Affiliation(s)
- Ang Li
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Pavan K Bendapudi
- Harvard Medical School, Boston, Massachusetts.,Division of Hematology, Massachusetts General Hospital, Boston, Massachusetts.,Blood Transfusion Service, Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts
| | - Lynne Uhl
- Harvard Medical School, Boston, Massachusetts.,Department of Pathology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Ayad Hamdan
- Harvard Medical School, Boston, Massachusetts.,Division of Hematology and Oncology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Richard M Kaufman
- Harvard Medical School, Boston, Massachusetts.,Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Robert S Makar
- Harvard Medical School, Boston, Massachusetts.,Blood Transfusion Service, Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts
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Singh K, Nadeem AJ, Doratotaj B. A rare case of thrombotic microangiopathy triggered by acute pancreatitis. BMJ Case Rep 2017; 2017:bcr-2016-218581. [PMID: 28512098 DOI: 10.1136/bcr-2016-218581] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Thrombotic microangiopathy (TMA) occurring after acute pancreatitis is rarely described. Without prompt intervention, TMA can be, and often is, lethal, so prompt recognition is important. Here, we present a case of a 61-year-old woman with a history of alcohol misuse who presented with epigastric pain, nausea and vomiting after binge drinking. Elevated serum lipase and imaging were suggestive of acute-on-chronic pancreatitis. Although the patient's symptoms of acute pancreatitis subsided, her anaemia, thrombocytopenia and acute kidney injury worsened. A peripheral blood smear revealed schistocytes, prompting suspicion for TMA. Therapeutic plasma exchange (TPE) was promptly initiated and she completed 10 TPE sessions that improved her anaemia and serum creatinine and resolved the thrombocytopenia. Since TPE was effective and the ADAMTS13 assay revealed 55% activity in the absence of anti-ADAMTS13 IgG prior to initiation of therapy, a confident diagnosis of TMA caused by acute pancreatitis was made. There was no evidence of relapse 2 years later.
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Affiliation(s)
- Kevin Singh
- Department of Medicine, New York University School of Medicine, Woodhull Medical and Mental Health Center, Brooklyn, New York, USA
| | - Ahmed Jamal Nadeem
- Department of Medicine, New York University School of Medicine, Woodhull Medical and Mental Health Center, Brooklyn, New York, USA
| | - Behzad Doratotaj
- Department of Haematology and Oncology, New York University School of Medicine, Woodhull Medical and Mental Health Center, Brooklyn, New York, USA
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Mutneja A, Cossey LN, Liapis H, Chen YM. A rare case of renal thrombotic microangiopathy associated with Castleman's disease. BMC Nephrol 2017; 18:57. [PMID: 28183278 PMCID: PMC5301347 DOI: 10.1186/s12882-017-0472-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2016] [Accepted: 02/01/2017] [Indexed: 12/11/2022] Open
Abstract
Background Castleman’s disease (CD) is an uncommon, heterogeneous lympho-proliferative disorder leading to high circulating levels of interleukin-6 (IL-6) and vascular endothelial growth factor (VEGF). Renal involvement has been only described in a limited number of small studies. Herein, we report a rare case of renal thrombotic microangiopathy (TMA) associated with CD and investigate the podocyte expression of VEGF in the renal biopsy prior to initiation of treatment. Case presentation An 18-year-old male presented with fever, diarrhea, diffuse lymphadenopathy, ascites and acute kidney injury. Laboratory tests for hemolytic uremic syndrome and thrombotic thrombocytopenic purpura were negative. The kidney biopsy showed TMA. An excisional lymph node biopsy was consistent with CD, plasma cell variant. Immunofluorescence staining showed suppressed podocyte VEGF expression. Chemotherapy that inhibits production of inflammatory mediators including IL-6 and VEGF led to complete recovery of renal function. Conclusions Our case illustrates a rare renal histological feature of CD. IL-6 and VEGF are postulated to suppress glomerular VEGF expression, thereby causing renal TMA. Therapy directed against these inflammatory mediators may have important therapeutic implications.
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Affiliation(s)
- Anubha Mutneja
- Division of Nephrology 8126, Department of Internal Medicine, Washington University School of Medicine, 660 S. Euclid Ave., St. Louis, MO, 63110, USA
| | | | - Helen Liapis
- Arkana Laboratories, Little Rock, AR, USA.,Department of Pathology & Immunology, Washington University School of Medicine, St. Louis, MO, USA
| | - Ying Maggie Chen
- Division of Nephrology 8126, Department of Internal Medicine, Washington University School of Medicine, 660 S. Euclid Ave., St. Louis, MO, 63110, USA.
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49
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Thrombotic microangiopathy associated with monoclonal gammopathy. Kidney Int 2016; 91:691-698. [PMID: 27998645 DOI: 10.1016/j.kint.2016.09.045] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Revised: 09/12/2016] [Accepted: 09/29/2016] [Indexed: 11/24/2022]
Abstract
Thrombotic microangiopathy (TMA) is a rare disease comprising of a diverse set of disorders linked by a common histologic finding of endothelial injury. Monoclonal immunoglobulins may act as a potential trigger in the pathogenesis of TMA. To determine the prevalence of monoclonal gammopathy and clinicopathological features of TMA associated with monoclonal immunoglobulin, we performed a retrospective study in adults (18 and older) with a clinical diagnosis of TMA. Of 146 patients with TMA, we detected monoclonal immunoglobulin in 20 patients (13.7%). Among patients 50 and older, the prevalence of monoclonal gammopathy was 21%, which is approximately five-fold higher than the 4.2% expected rate in this population. Fifteen patients had monoclonal gammopathy of undetermined significance, one had multiple myeloma, one with smoldering myeloma, two had POEMS syndrome, and one had T-cell lymphocytic leukemia. Renal biopsy was performed in 15 cases, of which six showed thrombi, 11 showed mesangiolysis, and all showed double contours along glomerular capillary walls. Acute tubular injury was present in 12 cases. Treatment options were varied and included therapeutic plasma exchange in 11 patients. Ten patients progressed to end-stage renal disease, of which two received kidney transplant. Thus, our study shows an unexpectedly high prevalence of monoclonal gammopathy in patients with TMA, suggesting a potential pathogenetic mechanism. This study underscores the importance of evaluating for a monoclonal gammopathy in patients with TMA as well as the potential for targeting the underlying hematologic disorder as an approach to treating TMA.
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