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Hu Z, Persaud Y, Ahuja S. A systematic review and meta-analysis of the effectiveness of primary thromboprophylaxis in acute lymphoblastic leukemia during early-phase therapy including asparaginase or its prolonged form. Crit Rev Oncol Hematol 2024; 197:104347. [PMID: 38583546 DOI: 10.1016/j.critrevonc.2024.104347] [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: 11/04/2023] [Revised: 03/31/2024] [Accepted: 04/04/2024] [Indexed: 04/09/2024] Open
Abstract
Asparaginase is essential in the initial management of acute lymphoblastic leukemia (ALL) but frequently leads to venous thromboembolism (VTE). Using anticoagulants for primary VTE prevention has been studied with no consensus. We conducted a systematic literature search in PubMed, Scopus, and Web of science and performed random-effect meta-analysis using Mantel-Haenszel method in RevMan 5.4 to analyze primary pharmacological thromboprophylaxis during asparaginase treatment in early-phase (induction, consolidation, or intensification phase) therapy in patients with ALL with all ages and followed with subgroup analysis by age. Meta-analysis of 13 articles describing the effect of antithrombin supplementation in 1375 patients showed that antithrombin prophylaxis decreases the risk of VTE by 43% (RR, 0.57; 95% CI, 0.38 - 0.83; p=0.004), with mild heterogeneity (I2=35%, p=0.10) and moderate certainty by GRADE. 8 articles included for meta-analysis of low-molecular weight heparin (LMWH) treatment in 612 patients showed that it decreased the risk of VTE by nearly 40% (RR, 0.61; 95% CI, 0.45 - 0.81; p=0.00081), with minimal heterogeneity (I2=14%, p=0.31) but low certainty. Subgroup analysis showed that only prophylaxis with antithrombin supplementation significantly decreased the VTE rate in adult patients with moderate certainty. In pediatric patients, one nonrandomized prospective study showed that LMWH combined with antithrombin has a better thromboprophylaxis effect than antithrombin alone. In the PREVAPIX-ALL trial, prophylaxis with direct factor Xa inhibitor Apixaban did not benefit children younger than 18 years except for cases of obesity. We concluded that thromboprophylaxis with antithrombin is effective in ALL patients older than 18 years during the early phase of therapy, and LMWH combined with antithrombin supplementation might be effective for pediatric patients with ALL. Apixaban is effective in pediatric ALL patients with obesity and needs further study in other high-risk patients.
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Affiliation(s)
- Zhongbo Hu
- Hospitalist Medicine Program, Department of Oncology, St. Jude Children's Research Hospital, 262 Danny Thomas Place Mail Stop 278, Memphis, TN 38105, USA.
| | - Yogindra Persaud
- Department of Hematology, St. Jude Children's Research Hospital, 262 Danny Thomas Place, Memphis, TN 38105, USA
| | - Sanjay Ahuja
- Department of Pediatric Hematology & Oncology, University Hospitals Rainbow Babies and Children's Hospital, 11100 Euclid Ave, Cleveland, OH 44106, USA
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Ruiz-Llobet A, Gassiot S, Sarrate E, Zubicaray J, Dapena JL, Rives S, Sevilla J, Menárguez López Á, Panesso Romero M, Montoya C, Vagace JM, Molina Hurtado JR, García-Morín M, García Abós M, Mendoza Sánchez MC, Lendínez F, Palomo Moraleda P, Tallón M, González B, Urrutia E, Serna JV, Peláez Pleguezuelos I, Martínez Merino M, Ramos Elbal E, Orellana E, Benítez Muñoz H, Berrueco R. Venous thromboembolism in pediatric patients with acute lymphoblastic leukemia under chemotherapy treatment. Risk factors and usefulness of thromboprophylaxis. Results of LAL-SEHOP-PETHEMA-2013. J Thromb Haemost 2022; 20:1390-1399. [PMID: 35289066 DOI: 10.1111/jth.15699] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 03/09/2022] [Accepted: 03/10/2022] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Symptomatic venous thromboembolism (VTE) is diagnosed in 3%-14% of patients during pediatric acute lymphoblastic leukemia (ALL) therapy. There are well-known risk factors, but the role of others as inherited thrombophilia is still controversial. Prophylaxis with low molecular weight heparin (LMWH) has been described, but its use is not globally accepted. METHODS A retrospective multicentric study in ALL patients 1-18 years old following SEHOP-PETHEMA-2013 treatment guideline was performed to evaluate VTE rate, anticoagulant treatment, outcome, risk factors, and safety and usefulness of LMWH administration as primary thromboprophylaxis in children with inherited thrombophilia. RESULTS A total of 652 patients were included in the study. VTE incidence was 8.7%. Most of the cases occurred during induction therapy associated with central venous catheter. Univariant analysis showed that family history of thrombosis, presence of mediastinal mass, high-risk treatment group, and inherited thrombophilia were statistically significant risk factors. LMWH administration seemed to decrease VTE rate in patients with inherited thrombophilia and those with T-cell ALL phenotype. CONCLUSION Most of the VTE cases occurred in patients without inherited thrombophilia, but when it is present, the VTE risk is higher. LMWH administration was useful to decrease VTE in these patients.
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Affiliation(s)
- Anna Ruiz-Llobet
- Servicio de Hematología Pediátrica, Hospital Sant Joan de Déu Barcelona, Institut de Recerca Pediàtrica, Hospital San Joan de Déu de Barcelona (IRP-HSJD), Universitat de Barcelona, Barcelona, Spain
- Instituto Nacional de Investigación Biomédica en Enfermedades Raras (CIBER ER), Instituto de Salud Carlos III, Madrid, España
| | - Susanna Gassiot
- Laboratorio de Hematología, Hospital Sant Joan de Déu Barcelona, Institut de Recerca Pediàtrica, Hospital San Joan de Déu de Barcelona (IRP-HSJD), Universitat de Barcelona, Barcelona, Spain
| | - Edurne Sarrate
- Laboratorio de Hematología, Hospital Sant Joan de Déu Barcelona, Institut de Recerca Pediàtrica, Hospital San Joan de Déu de Barcelona (IRP-HSJD), Universitat de Barcelona, Barcelona, Spain
| | - Josune Zubicaray
- Servicio de Hematología y Hemoterapia, Hematología y Oncología Pediátricas, Hospital Infantil Universitario Niño Jesús, Fundación para la Investigación Biomédica del Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - José Luis Dapena
- Servicio de Hematología Pediátrica, Hospital Sant Joan de Déu Barcelona, Institut de Recerca Pediàtrica, Hospital San Joan de Déu de Barcelona (IRP-HSJD), Universitat de Barcelona, Barcelona, Spain
- Instituto Nacional de Investigación Biomédica en Enfermedades Raras (CIBER ER), Instituto de Salud Carlos III, Madrid, España
| | - Susana Rives
- Servicio de Hematología Pediátrica, Hospital Sant Joan de Déu Barcelona, Institut de Recerca Pediàtrica, Hospital San Joan de Déu de Barcelona (IRP-HSJD), Universitat de Barcelona, Barcelona, Spain
- Instituto Nacional de Investigación Biomédica en Enfermedades Raras (CIBER ER), Instituto de Salud Carlos III, Madrid, España
| | - Julián Sevilla
- Laboratorio de Hematología, Hospital Sant Joan de Déu Barcelona, Institut de Recerca Pediàtrica, Hospital San Joan de Déu de Barcelona (IRP-HSJD), Universitat de Barcelona, Barcelona, Spain
| | - Ángela Menárguez López
- Servicio Oncología y Hematología Pediátricas, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Melissa Panesso Romero
- Servicio Oncología y Hematología Pediátricas, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Catalina Montoya
- Departamento de Pediatría, Hospital General Universitario de Alicante, Alicante, Spain
| | - José Manuel Vagace
- Servicio de Hematología y Hemoterapia, Complejo Hospitalario Universitario de Badajoz, Departamento de Ciencias Biométicas Universidad de Extremadura, Badajoz, Spain
| | | | - Marina García-Morín
- Sección de Hematología y Oncología Pediátricas, Hospital General Universitario Gregorio Marañón, Madrid, España
- Facultad de Medicina, Universidad Complutense de Madrid, Madrid, España
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, España
| | - Miriam García Abós
- Servicio de Oncología Pediátrica, Hospital Universitario Donostia, San Sebastian, Spain
| | | | - Francisco Lendínez
- Servicio de Pediatría, Complejo Hospitalario de Torrecárdenas, Almería, Spain
| | - Pilar Palomo Moraleda
- Unidad de Hematología Pediátrica, Servicio de Hematología, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - María Tallón
- Servicio de Pediatría, Hospital Álvaro Cunquerio Vigo, Vigo, Spain
| | - Berta González
- Servicio de Hematología y Oncología Pediátricas, Hospital Universitario La Paz, Valencia, Spain
| | - Emilia Urrutia
- Servicio de Pediatría y Oncohematología Pediátricas, Hospital Materno Infantil Virgen de las Nieves, Granada, Spain
| | - José Vicente Serna
- Unidad Oncología y Hematología y TPH, Servicio de Pediatría, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | | | - Marta Martínez Merino
- Unidad de Oncohematología Pediátrica, Complejo Hospitalario de Navarra, Pamplona, Spain
| | - Eduardo Ramos Elbal
- Sección de Oncohematología Pediátrica, Hospital Clínico Virgen de la Arrixaca, Instituto Murciano de Investigación Biosanitaria (IMIB), Murcia, Spain
| | - Elena Orellana
- Servicio de Hematología y Oncología Pediátricas, Hospital 12 de Octubre, Madrid, Spain
| | - Helga Benítez Muñoz
- Servicio de Oncología Pediátrica, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - Rubén Berrueco
- Servicio de Hematología Pediátrica, Hospital Sant Joan de Déu Barcelona, Institut de Recerca Pediàtrica, Hospital San Joan de Déu de Barcelona (IRP-HSJD), Universitat de Barcelona, Barcelona, Spain
- Instituto Nacional de Investigación Biomédica en Enfermedades Raras (CIBER ER), Instituto de Salud Carlos III, Madrid, España
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Hashem H, Zeineddin M, Bater R, Amayiri N, Al-Qasem W, Hammo B, Sultan I, AlMasri R, Abdel-Razeq H. Thrombosis and Anticoagulant Therapy Among Pediatric Cancer Patients: Real-Life Data. Cureus 2021; 13:e20084. [PMID: 34987942 PMCID: PMC8719720 DOI: 10.7759/cureus.20084] [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: 11/29/2021] [Indexed: 11/17/2022] Open
Abstract
Background: Venous thromboembolism (VTE) in children is relatively rare, and more so among those with cancer. In this study, we report the characteristics and outcomes of children with cancer-associated thrombosis. Methods: We reviewed institutional databases for all children with cancer and a diagnosis of VTE at King Hussein Cancer Center in Jordan. Variables reviewed are patients’ clinical characteristics, treatment for cancer, and anticoagulation therapy. Results: Between January 2011 and December 2018, a total of 45 patients fulfilled the inclusion criteria, and the median age was 10.4 (0.8-17.9) years. The most common underlying diagnosis was acute lymphoblastic leukemia (n = 13, 29%). At the time of VTE, 29 (64.4%) patients were receiving chemotherapy, and eight (17.8%) had a central venous catheter (CVC). The majority of patients (n = 37, 82%) developed VTE within 30 days of hospitalization. Thrombosis mostly involved the extremities (n = 23, 51%) and sagittal vein (n = 12, 26.7%). All patients were treated with low-molecular-weight heparin (LMWH), complicated by bleeding in three (6.6%) patients. Conclusion: In contrast to adults, VTE in pediatric cancer patients is more associated with chemotherapy and recent hospitalization. LMWH is a safe and effective therapy for children with cancer who develop VTE.
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Pelland-Marcotte MC, Amiri N, Avila ML, Brandão LR. Low molecular weight heparin for prevention of central venous catheter-related thrombosis in children. Cochrane Database Syst Rev 2020; 6:CD005982. [PMID: 32557627 PMCID: PMC7390480 DOI: 10.1002/14651858.cd005982.pub3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND The prevalence of children diagnosed with thrombotic events has been increasing in the last decades. The most common thrombosis risk factor in neonates, infants and children is the placement of a central venous catheter (CVC). It is unknown if anticoagulation prophylaxis with low molecular weight heparin (LMWH) decreases CVC-related thrombosis in children. This is an update of the Cochrane Review published in 2014. OBJECTIVES To determine the effect of LMWH prophylaxis on the incidence of CVC-related thrombosis and major and minor bleeding complications in children. Further objectives were to determine the effect of LMWH on occlusion of CVCs, number of days of CVC patency, episodes of catheter-related bloodstream infection (CRBSI), other side effects of LMWH (allergic reactions, abnormal coagulation profile, heparin-induced thrombocytopaenia and osteoporosis) and mortality during therapy. SEARCH METHODS The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase and CINAHL databases and World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 7 May 2019. We undertook reference checking of identified trials to identify additional studies. SELECTION CRITERIA We included randomised controlled trials (RCTs) and quasi-randomised trials comparing LMWH to no prophylaxis (placebo or no treatment), or low-dose unfractionated heparin (UFH) either as continuous infusion or flushes (low-dose UFH aims to ensure the patency of the central line but has no systemic anticoagulation activity), given to prevent CVC-related thrombotic events in children. We selected studies conducted in children aged 0 to 18 years. DATA COLLECTION AND ANALYSIS Two review authors independently identified eligible studies, which were assessed for study methodology including bias, and extracted unadjusted data where available. In the data analysis step, all outcomes were analysed as binary or dichotomous outcomes. The effects of interventions were summarised with risk ratios (RR) and their respective 95% confidence intervals (CI). We assessed the certainty of evidence for each outcome using the GRADE approach. MAIN RESULTS One additional study was included for this update bringing the total to two included studies (with 1135 participants). Both studies were open-label RCTs comparing LMWH with low-dose UFH to prevent CVC-related thrombosis in children. We identified no studies comparing LMWH with placebo or no treatment. Meta-analysis found insufficient evidence of an effect of LMWH prophylaxis in reducing the incidence of CVC-related thrombosis in children with CVC, compared to low-dose UFH (RR 0.68, 95% CI 0.27 to 1.75; 2 studies; 787 participants; low-certainty evidence). One study (158 participants) reported symptomatic and asymptomatic CVC-related thrombosis separately and detected no evidence of a difference between LMWH and low-dose UFH (RR 1.03, 95% CI 0.21 to 4.93; low-certainty evidence; RR 1.17, 95% CI 0.45 to 3.08; low-certainty evidence; for symptomatic and asymptomatic participants respectively). There was insufficient evidence to determine whether LMWH impacts the risk of major bleeding (RR 0.27, 95% CI 0.05 to 1.67; 2 studies; 813 participants; low-certainty evidence); or minor bleeding. One study reported minor bleeding in 53.3% of participants in the LMWH arm and in 44.7% of participants in the low-dose UFH arm (RR 1.20, 95% CI 0.91 to 1.58; 1 study; 158 participants; very low-certainty evidence), and the other study reported no minor bleeding in either group (RR: not estimable). Mortality during the study period was reported in one study, where two deaths occurred during the study period. Both were unrelated to thrombotic events and occurred in the low-dose UFH arm. The second study did not report mortality during therapy per arm but showed similar 5-year overall survival (low-certainty evidence). No additional adverse effects were reported. Other pre-specified outcomes (including CVC occlusion, patency and CRBSI) were not reported. AUTHORS' CONCLUSIONS Pooling data from two RCTs did not provide evidence to support the use of prophylactic LWMH for preventing CVC-related thrombosis in children (low-certainty evidence). Evidence was also insufficient to confirm or exclude a difference in the incidence of major and minor bleeding complications in the LMWH prophylaxis group compared to low-dose UFH (low and very low certainty respectively). No evidence of a clear difference in overall mortality was seen. Studies did not report on the outcomes catheter occlusion, days of catheter patency, episodes of CRBSI and other side effects of LMWH (allergic reactions, abnormal coagulation profile, heparin-induced thrombocytopaenia and osteoporosis). The certainty of the evidence was downgraded due to risk of bias of the included studies, imprecision and inconsistency, preventing conclusions in regards to the efficacy of LMWH prophylaxis to prevent CVC-related thrombosis in children.
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Affiliation(s)
| | - Nour Amiri
- Division of Haematology-Oncology, The Hospital for Sick Children, Toronto, Canada
| | - Maria L Avila
- Division of Haematology-Oncology, The Hospital for Sick Children, Toronto, Canada
| | - Leonardo R Brandão
- Division of Haematology-Oncology, The Hospital for Sick Children, Toronto, Canada
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Klaassen ILM, Zuurbier CCM, Hutten BA, van den Bos C, Schouten AYN, Stokhuijzen E, van Ommen CH. Venous Thrombosis in Children with Acute Lymphoblastic Leukemia Treated on DCOG ALL-9 and ALL-10 Protocols: The Effect of Fresh Frozen Plasma. TH OPEN 2019; 3:e109-e116. [PMID: 31249990 PMCID: PMC6524923 DOI: 10.1055/s-0039-1688412] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 03/08/2019] [Indexed: 01/19/2023] Open
Abstract
Background
Venous thromboembolism (VTE) is an important complication for treatment of acute lymphoblastic leukemia (ALL) in children. Especially, ALL treatment, with therapeutics such as asparaginase and steroids, increases the thrombotic risk by reduction in procoagulant and anticoagulant proteins. Replacement of deficient natural anticoagulants by administration of fresh frozen plasma (FFP) may have a preventive effect on the occurrence of VTE.
Methods
We retrospectively analyzed all consecutive children (≤18 years) with ALL, treated on the Dutch Childhood Oncology Group (DCOG) ALL-9 and ALL-10 protocols at the Emma Children's Hospital Academic Medical Center between February 1997 and January 2012, to study the effect of FFP on VTE incidence, antithrombin and fibrinogen plasma levels, and VTE risk factors.
Results
In total, 18/205 patients developed VTE (8.8%; 95% confidence interval [CI]: 4.9–12.7%). In all patients, VTE occurred after asparaginase administration. In total, 82/205 patients (40%) received FFP. FFP supplementation did not prevent VTE or alter plasma levels of antithrombin or fibrinogen. In the multivariate analysis, VTE occurred significantly more frequently in children ≥12 years (odds ratio [OR]: 3.89; 95% CI: 1.29–11.73) and treated according to the ALL-10 protocol (OR: 3.71; 95% CI: 1.13–12.17).
Conclusion
FFP supplementation does not seem to be beneficial in the prevention of VTE in pediatric ALL patients. In addition, age ≥12 years and treatment according to the DCOG ALL-10 protocol with intensive and prolonged administration of asparaginase in combination with prednisone are risk factors. There is a need for effective preventive strategies in ALL patients at high risk for VTE.
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Affiliation(s)
- Irene L M Klaassen
- Department of Pediatric Hematology, Emma Children's Hospital, Amsterdam University Medical Centers, Amsterdam, The Netherlands.,Department of Vascular Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Charlotte C M Zuurbier
- Department of Pediatric Hematology, Emma Children's Hospital, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Barbara A Hutten
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Cor van den Bos
- Department of Pediatric Oncology, Emma Children's Hospital, Amsterdam University Medical Centers, Amsterdam, The Netherlands.,Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - A Y Netteke Schouten
- Department of Pediatric Oncology, Emma Children's Hospital, Amsterdam University Medical Centers, Amsterdam, The Netherlands.,Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Eva Stokhuijzen
- Department of Pediatric Hematology, Emma Children's Hospital, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - C Heleen van Ommen
- Department of Pediatric Hematology, Erasmus Medical Center/Sophia Children's Hospital, Rotterdam, The Netherlands
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Klaassen ILM, Lauw MN, Fiocco M, van der Sluis IM, Pieters R, Middeldorp S, van de Wetering MD, de Groot‐Kruseman HA, van Ommen CH. Venous thromboembolism in a large cohort of children with acute lymphoblastic leukemia: Risk factors and effect on prognosis. Res Pract Thromb Haemost 2019; 3:234-241. [PMID: 31011707 PMCID: PMC6462738 DOI: 10.1002/rth2.12182] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 11/15/2018] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) is relatively common in children with acute lymphoblastic leukemia (ALL). Thrombotic risk factors in ALL are asparaginase and steroids. However, within the ALL populations treated on the same regimen, it is less clear which other risk factors play a role. Furthermore, few data are available on the effect of VTE on ALL outcomes. METHODS In 778 children (1-18 years) with newly diagnosed precursor-B-lineage or T-lineage ALL, treated in the Dutch Childhood Oncology Group (DCOG) ALL-10 protocol in the Netherlands (October 2004 to April 2013), we conducted a nested case control study with 59 VTE cases and 118 controls to identify risk factors for VTE. RESULTS Fifty-nine of 778 ALL patients developed VTE (7.6%), with cerebral venous sinus thrombosis (CVST) in 26 of 59 patients (44.1%). VTE occurred during induction treatment in 59.3% (n = 35) and in 40.7% (n = 24) during medium risk intensification. Conditional multivariable logistic regression analysis showed that age and ALL subtype were significantly associated with VTE (age ≥7 years: OR 2.72, 95% CI 1.33-5.57; ALL subtype T-ALL: OR 2.95, 95% CI 1.02-8.57). A multivariable Cox model showed no association between the occurrence of VTE and event free survival. In CVST patients, permanent disability was present in 34.6%. CONCLUSION Within this large pediatric ALL cohort, we demonstrated a high morbidity in CVST patients. Age ≥7 years at diagnosis and T-ALL subtype were the main risk factors for VTE, and should be considered in preventive strategies.
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Affiliation(s)
- Irene L. M. Klaassen
- Department of Pediatric HematologyAcademic Medical CenterAmsterdamthe Netherlands
- Department of Vascular MedicineAcademic Medical CenterAmsterdamthe Netherlands
| | - Mandy N. Lauw
- Department of Vascular MedicineAcademic Medical CenterAmsterdamthe Netherlands
- Department of HematologyAcademic Medical CenterAmsterdamthe Netherlands
| | - Marta Fiocco
- Medical StatisticsDepartment of Biomedical Data SciencesLeiden University Medical CenterLeidenthe Netherlands
- Mathematical Institute Leiden UniversityLeidenthe Netherlands
- Dutch Childhood Oncology GroupThe Haguethe Netherlands
| | - Inge M. van der Sluis
- Department of Pediatric Oncology/HematologyErasmus MC‐Sophia Children's HospitalRotterdamthe Netherlands
- Princess Máxima Center for Pediatric OncologyUtrechtthe Netherlands
| | - Rob Pieters
- Princess Máxima Center for Pediatric OncologyUtrechtthe Netherlands
| | - Saskia Middeldorp
- Department of Vascular MedicineAcademic Medical CenterAmsterdamthe Netherlands
| | | | | | - C. Heleen van Ommen
- Department of Pediatric Oncology/HematologyErasmus MC‐Sophia Children's HospitalRotterdamthe Netherlands
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Klaassen IL, Sol JJ, Suijker MH, Fijnvandraat K, van de Wetering MD, Heleen van Ommen C. Are low-molecular-weight heparins safe and effective in children? A systematic review. Blood Rev 2019; 33:33-42. [DOI: 10.1016/j.blre.2018.06.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Revised: 06/16/2018] [Accepted: 06/26/2018] [Indexed: 10/28/2022]
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Greiner J, Schrappe M, Claviez A, Zimmermann M, Niemeyer C, Kolb R, Eberl W, Berthold F, Bergsträsser E, Gnekow A, Lassay E, Vorwerk P, Lauten M, Sauerbrey A, Rischewski J, Beilken A, Henze G, Korte W, Möricke A. THROMBOTECT - a randomized study comparing low molecular weight heparin, antithrombin and unfractionated heparin for thromboprophylaxis during induction therapy of acute lymphoblastic leukemia in children and adolescents. Haematologica 2018; 104:756-765. [PMID: 30262570 PMCID: PMC6442986 DOI: 10.3324/haematol.2018.194175] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 09/27/2018] [Indexed: 12/15/2022] Open
Abstract
Thromboembolism is a serious complication of induction therapy for childhood
acute lymphoblastic leukemia. We prospectively compared the efficacy and safety
of antithrombotic interventions in the consecutive leukemia trials ALL-BFM 2000
and AIEOP-BFM ALL 2009. Patients with newly diagnosed acute lymphoblastic
leukemia (n=949, age 1 to 18 years) were randomized to receive low-dose
unfractionated heparin, prophylactic low molecular weight heparin (enoxaparin)
or activity-adapted antithrombin throughout induction therapy. The primary
objective of the study was to determine whether enoxaparin or antithrombin
reduces the incidence of thromboembolism as compared to unfractionated heparin.
The principal safety outcome was hemorrhage; leukemia outcome was a secondary
endpoint. Thromboembolism occurred in 42 patients (4.4%). Patients
assigned to unfractionated heparin had a higher risk of thromboembolism
(8.0%) compared with those randomized to enoxaparin (3.5%;
P=0.011) or antithrombin (1.9%;
P<0.001). The proportion of patients who refused
antithrombotic treatment as allocated was 3% in the unfractionated
heparin or antithrombin arms, and 33% in the enoxaparin arm. Major
hemorrhage occurred in eight patients (no differences between the groups). The
5-year event-free survival was 80.9±2.2% among patients assigned
to antithrombin compared to 85.9±2.0% in the unfractionated
heparin group (P=0.06), and 86.2±2.0% in the
enoxaparin group (P=0.10). In conclusion, prophylactic use of
antithrombin or enoxaparin significantly reduced thromboembolism. Despite the
considerable number of patients rejecting the assigned treatment with
subcutaneous injections, the result remains unambiguous. Thromboprophylaxis -
for the present time primarily with enoxaparin - can be recommended for children
and adolescents with acute lymphoblastic leukemia during induction therapy.
Whether and how antithrombin may affect leukemia outcome remains to be
determined.
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Affiliation(s)
- Jeanette Greiner
- Children's Hospital of Eastern Switzerland, Hematology and Oncology Department, St. Gallen, Switzerland
| | - Martin Schrappe
- Department of Pediatrics, Christian-Albrechts-University Kiel and University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Alexander Claviez
- Department of Pediatrics, Christian-Albrechts-University Kiel and University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Martin Zimmermann
- Department of Pediatric Hematology and Oncology, Hannover Medical School, Germany
| | - Charlotte Niemeyer
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Hematology and Oncology, Medical Center - Faculty of Medicine, University of Freiburg, Germany
| | - Reinhard Kolb
- Department of Pediatrics, Zentrum für Kinder- und Jugendmedizin, Klinikum Oldenburg GmbH, Germany
| | - Wolfgang Eberl
- Institute for Clinical Transfusion Medicine and Children's Hospital, Klinikum Braunschweig GmbH, Germany
| | - Frank Berthold
- Department of Pediatric Hematology and Oncology, Children's Hospital, University of Cologne, Germany
| | - Eva Bergsträsser
- Department of Pediatric Oncology, University Children's Hospital, Zurich, Switzerland
| | - Astrid Gnekow
- Hospital for Children and Adolescents, Klinikum Augsburg, Germany
| | - Elisabeth Lassay
- Division of Pediatric Hematology, Oncology and Stem Cell Transplantation, Medical Faculty, RWTH Aachen University, Germany
| | - Peter Vorwerk
- Pediatric Oncology, Otto von Guericke University Children's Hospital, Magdeburg, Germany
| | - Melchior Lauten
- University Hospital Schleswig-Holstein, Department of Pediatrics, University of Lübeck, Germany
| | | | - Johannes Rischewski
- Department of Oncology/Hematology, Children's Hospital, Cantonal Hospital Lucerne, Switzerland
| | - Andreas Beilken
- Department of Pediatric Hematology and Oncology, Hannover Medical School, Germany
| | - Günter Henze
- Department of Pediatric Oncology/Hematology, Charité Universitätsmedizin Berlin, Germany
| | - Wolfgang Korte
- Center for Laboratory Medicine and Hemostasis and Hemophilia Center, St. Gallen, Switzerland
| | - Anja Möricke
- Department of Pediatrics, Christian-Albrechts-University Kiel and University Medical Center Schleswig-Holstein, Kiel, Germany
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9
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Prasca S, Carmona R, Ji L, Ko RH, Bhojwani D, Rawlins YA, Mittelman SD, Young G, Orgel E. Obesity and risk for venous thromboembolism from contemporary therapy for pediatric acute lymphoblastic leukemia. Thromb Res 2018; 165:44-50. [PMID: 29567586 DOI: 10.1016/j.thromres.2018.02.150] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Revised: 02/08/2018] [Accepted: 02/28/2018] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Acute lymphoblastic leukemia (ALL) therapy confers risk for venous thromboembolism (VTE) and associated acute and long-term morbidity. Obesity increases VTE risk in the general population but its impact on ALL therapy-associated VTE is unknown. METHODS In a retrospective cohort of children treated for ALL between 2008 and 2016 (n = 294), we analyzed obesity at diagnosis (body mass index [BMI] ≥95%) and subsequent development of VTE. A subset participated in two concurrent prospective ALL trials studying body composition via dual-energy X-ray absorptiometry (DXA) (n = 35) and hypercoagulability via thromboelastography (TEG) (n = 46). Secondary analyses explored whether precise measurement of body fat and/or global hemostasis ex vivo by TEG could further delineate VTE risk in the obese. RESULTS Overall, we found 27/294 (9.2%) patients developed symptomatic VTE during therapy, 19/27 (70%) occurred during Induction. Study-defined "serious" VTE developed in 4/294 (1.4%) of patients. Obesity but not overweight was strongly predictive of symptomatic VTE (obesity odds ratio = 3.8, 95% confidence interval 1.5-9.6, p = 0.008). In the DXA subset, only 2/35 patients developed symptomatic VTE. However, within those prospectively screened during Induction, 30% (14/46) developed VTE; eight (17%) of these were asymptomatic and found only via screening. CONCLUSIONS In this pediatric ALL cohort, obesity conferred more than a three-fold increased risk for symptomatic VTE. In a subgroup of patients who underwent active screening, up to a third were noted to have VTE (symptomatic and asymptomatic). TEG did not predict VTE. Additional studies are necessary to validate these findings and to further refine a risk-stratified approach to thrombo-prevention during ALL therapy.
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Affiliation(s)
- Saskia Prasca
- Children's Center for Cancer and Blood Diseases, Children's Hospital Los Angeles, 4650 Sunset Blvd, Los Angeles, 90027, CA, USA
| | - Roxana Carmona
- Children's Center for Cancer and Blood Diseases, Children's Hospital Los Angeles, 4650 Sunset Blvd, Los Angeles, 90027, CA, USA.
| | - Lingyun Ji
- Department of Preventive Medicine, USC Norris Comprehensive Cancer Center, 1441 Eastlake Ave, Los Angeles, 90033, CA, USA.
| | - Richard H Ko
- Children's Center for Cancer and Blood Diseases, Children's Hospital Los Angeles, 4650 Sunset Blvd, Los Angeles, 90027, CA, USA; Keck School of Medicine, University of Southern California, 1975 Zonal Ave, Los Angeles, 90033, CA, USA
| | - Deepa Bhojwani
- Children's Center for Cancer and Blood Diseases, Children's Hospital Los Angeles, 4650 Sunset Blvd, Los Angeles, 90027, CA, USA; Keck School of Medicine, University of Southern California, 1975 Zonal Ave, Los Angeles, 90033, CA, USA.
| | - Yasmin A Rawlins
- College of Physicians and Surgeons, Columbia University, 630 W 168th St, New York, 10032, NY, USA.
| | - Steven D Mittelman
- Center for Endocrinology, Diabetes & Metabolism, Children's Hospital Los Angeles, Los Angeles, 4650 Sunset Blvd, Los Angeles, 90027, CA, USA.
| | - Guy Young
- Children's Center for Cancer and Blood Diseases, Children's Hospital Los Angeles, 4650 Sunset Blvd, Los Angeles, 90027, CA, USA; Keck School of Medicine, University of Southern California, 1975 Zonal Ave, Los Angeles, 90033, CA, USA.
| | - Etan Orgel
- Children's Center for Cancer and Blood Diseases, Children's Hospital Los Angeles, 4650 Sunset Blvd, Los Angeles, 90027, CA, USA; Keck School of Medicine, University of Southern California, 1975 Zonal Ave, Los Angeles, 90033, CA, USA.
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10
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Sibson KR, Biss TT, Furness CL, Grainger JD, Hough RE, Macartney C, Payne JH, Chalmers EA. BSH Guideline: management of thrombotic and haemostatic issues in paediatric malignancy. Br J Haematol 2018; 180:511-525. [DOI: 10.1111/bjh.15112] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Revised: 10/28/2017] [Accepted: 11/07/2017] [Indexed: 01/19/2023]
Affiliation(s)
- Keith R. Sibson
- Department of Haematology; Great Ormond Street Hospital; London UK
| | - Tina T. Biss
- The Newcastle Upon Tyne Hospitals NHS Foundation Trust; Newcastle Upon Tyne UK
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11
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Piovesan D, Attard C, Monagle P, Ignjatovic V. Epidemiology of venous thrombosis in children with cancer. Thromb Haemost 2017; 111:1015-21. [DOI: 10.1160/th13-10-0827] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Accepted: 01/12/2014] [Indexed: 11/05/2022]
Abstract
SummaryThere has been an extensive body of research focusing on the epidemiology of thrombosis in adult cancer populations; however, there is significantly less knowledge about thrombosis in paediatric cancer populations. Thrombosis is diagnosed with increasing frequency in children being treated for cancer, and there is an urgent need to increase our understanding of the epidemiology of thrombosis in this population. Currently, there are no guidelines for identification of high-risk groups, prophylaxis or management of thrombotic complications in paediatric cancer patients. We reviewed the available literature regarding the epidemiology, mechanisms, risk factors, prophylaxis and outcomes of thrombosis in children with cancer and identified areas that require further research. The reported incidence of symptomatic venous thromboembolism (VTE) in children with cancer ranges between 2.1% and 16%, while the incidence of asymptomatic events is approximately 40%. Approximately 30% of VTE in this population is associated with central venous lines (CVL). The most common location of VTE is upper and lower extremity deep venous thrombosis (43 to 50% of events, respectively), while 50% of events in ALL patients occur in the central nervous system. Key characteristics that increase the risk of thrombosis include the type of cancer, age of the patient, the presence of a CVL, presence of pulmonary/intra thoracic disease, as well as the type of chemotherapy. Outcomes for paediatric cancer patients with VTE include post-thrombotic syndrome, pulmonary embolism, recurrent thromboembolism, destruction of upper venous system and death. Prospective studies aimed at enabling risk stratification of patients are required to facilitate development of paediatric specific recommendations related to thromboprophylaxis in this population.
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12
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van der Holt B, Middeldorp S, Meijers JCM, Cornelissen JJ, Bajetta M, Biemond BJ, Lauw MN. Venous thromboembolism in adults treated for acute lymphoblastic leukaemia: Effect of fresh frozen plasma supplementation. Thromb Haemost 2017; 109:633-42. [DOI: 10.1160/th12-11-0845] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2012] [Accepted: 01/11/2013] [Indexed: 01/19/2023]
Abstract
SummaryTreatment of acute lymphoblastic leukaemia (ALL) is frequently complicated by venous thromboembolism (VTE). The efficacy and optimal approach of VTE prevention are unclear, particularly in adult patients. We assessed the effect of thromboprophylaxis on symptomatic VTE incidence in cycle 1 of ALL treatment in adult patients. Secondly, we explored potential etiologic factors for VTE and the clinical impact of VTE on ALL outcome. We retrospectively assessed symptomatic VTE incidence and use of thromboprophylaxis in 240 adults treated for newly diagnosed ALL in the Dutch-Belgian HOVON-37 multicentre study (1999–2005). Potential etiologic factors were explored by analysis of patient and disease characteristics, impact of VTE on ALL outcome by analysis of complete remission and overall survival rates. Symptomatic VTE was observed in 24 of 240 patients (10%). Thromboprophylaxis differed by centre (prophylactic fresh frozen plasma (FFP) supplementation or no thromboprophylaxis) and was applied only during L-asparaginase in cycle 1. VTE incidence was significantly lower with FFP supplementation than without FFP (6% vs. 19%; adjusted odds ratio [OR] 0.28; 95% confidence interval [CI] 0.10–0.73). FFP did not influence antithrombin or fibrinogen plasma levels. Patients with VTE in cycle 1 had a significantly poorer complete remission rate (adjusted OR 0.18; 95% CI 0.07–0.50), particularly patients with cerebral venous thrombosis (adjusted OR 0.17; 95% CI 0.04–0.65). Our study suggests that prophylactic FFP supplementation effectively reduces symptomatic VTE incidence during ALL treatment in adults. This should be confirmed in a randomised controlled trial.
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13
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Moffett BS, Lee-Kim Y, Galati M, Mahoney D, Shah MD, Teruya J, Yee D. Population Pharmacokinetics of Enoxaparin in Pediatric Patients. Ann Pharmacother 2017; 52:140-146. [DOI: 10.1177/1060028017734234] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Brady S. Moffett
- Texas Children’s Hospital, Houston, TX, USA
- Baylor College of Medicine, Houston, TX, USA
| | | | | | | | | | - Jun Teruya
- Baylor College of Medicine, Houston, TX, USA
| | - Donald Yee
- Baylor College of Medicine, Houston, TX, USA
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14
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Klaassen ILM, Lauw MN, van de Wetering MD, Biemond BJ, Middeldorp S, Abbink FCH, Bierings M, Te Loo DMMW, Pieters R, van der Sluis IM, Tissing WJE, Michel Zwaan C, Heleen van Ommen C. TropicALL study: Thromboprophylaxis in Children treated for Acute Lymphoblastic Leukemia with Low-molecular-weight heparin: a multicenter randomized controlled trial. BMC Pediatr 2017; 17:122. [PMID: 28486976 PMCID: PMC5424373 DOI: 10.1186/s12887-017-0877-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2016] [Accepted: 04/27/2017] [Indexed: 12/13/2022] Open
Abstract
Background Venous thromboembolism (VTE) is a common and severe complication during treatment of acute lymphoblastic leukemia (ALL). An important cause is the intensive use of asparaginase. Prospective cohort studies in which prophylactic low-molecular-weight heparin (LMWH) was used to prevent VTE showed lower VTE risk than in historic control cohorts, with a negligible bleeding risk. However, the efficacy of thromboprophylaxis with LMWH during ALL treatment has never been investigated in a randomized design. Here, we present the protocol of a randomized controlled trial in which the efficacy and safety of thromboprophylaxis with high prophylactic dose LMWH versus no thromboprophylaxis will be assessed in children treated for primary ALL with asparaginase. Methods/Design Thromboprophylaxis in Children treated for Acute Lymphoblastic Leukemia with Low-molecular-weight heparin (TropicALL) is a multicenter, randomized controlled open-label trial conducted in the Netherlands. Patients between 1 and 19 years of age with primary ALL, who are treated within the Dutch Childhood Oncology Group (DCOG) ALL-11 or 12 study will be randomized to thromboprophylaxis with LMWH once daily, (dose of 85 IU/kg (intervention arm A)), or to no thromboprophylaxis (arm B, standard of care) during asparaginase courses of ALL treatment. Primary efficacy endpoint is symptomatic objectified VTE during ALL treatment; secondary efficacy endpoints are overall survival and the composite of symptomatic and asymptomatic objectified VTE. Primary safety endpoints are major bleeding, clinically relevant non-major bleeding and minor bleeding. A total of 324 patients will be included to obtain a relative risk reduction of 75% with a power of 80%, using a two-sided test with significance level α = 0.05. Discussion This trial will be the first to assess efficacy and safety of thromboprophylaxis with LMWH during asparaginase treatment for ALL in children in a randomized design. Trail registration Nederlands Trial Register NTR4707. Registered 30 July 2014.
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Affiliation(s)
- Irene L M Klaassen
- Department of Pediatric Hematology, Academic Medical Center, Amsterdam, The Netherlands.,Department of Vascular Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - Mandy N Lauw
- Department of Vascular Medicine, Academic Medical Center, Amsterdam, The Netherlands.,Department of Hematology, Academic Medical Center, Amsterdam, The Netherlands
| | | | - Bart J Biemond
- Department of Hematology, Academic Medical Center, Amsterdam, The Netherlands
| | - Saskia Middeldorp
- Department of Vascular Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - Floor C H Abbink
- Department of Hematology/Oncology, VU Medical Center, Amsterdam, The Netherlands
| | - Marc Bierings
- Department of Hematology/Oncology, Wilhelmina Children's Hospital, Utrecht, The Netherlands
| | - D Maroeska M W Te Loo
- Department of Pediatric Hematology/Oncology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Rob Pieters
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Inge M van der Sluis
- Department of Pediatric Oncology/Hematology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Wim J E Tissing
- Department of Pediatric Oncology, Beatrix Children's Hospital, University Medical Center Groningen, Groningen, the Netherlands
| | - C Michel Zwaan
- Department of Pediatric Oncology/Hematology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - C Heleen van Ommen
- Department of Pediatric Oncology/Hematology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands.
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15
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Wu YY, Tang L, Wang MH. Leukemia and Risk of Venous Thromboembolism: A Meta-analysis and Systematic Review of 144 Studies Comprising 162,126 Patients. Sci Rep 2017; 7:1167. [PMID: 28446766 PMCID: PMC5430898 DOI: 10.1038/s41598-017-01307-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Accepted: 03/27/2017] [Indexed: 11/29/2022] Open
Abstract
Venous thromboembolism (VTE) has significant clinical implications in leukemia patients. However, the actual frequency of this complication remains unknown. We performed a systematic review and meta-analysis to better estimate the frequency of this complication and to assess the risk factors that contribute to its occurrence. We searched several databases, including PubMed, Embase, and Web of Science, and assessed study quality using the Newcastle–Ottawa scale. The pooled frequency of VTE in leukemia patients was calculated. A total of 144 studies met the eligibility criteria. The incidence rate (IR) of VTE from 72 prospective studies comprising 9,061 patients was 5% (95%CI: 4–6%). The incidence rate (IR) of VTE in ALL, CLL, total-AML, and CML population was 5% (95%CI: 4–6%), 3% (95%CI: 2–5%), 6% (95%CI: 4–8%) and 13% (95%CI: 1–36%). The incidence of VTE was markedly decreased among ALL patients who received anticoagulation treatment (IR: 1%, 95%CI: 0–6%) or concentrates therapy (IR: 3%, 95%CI: 0–9%). The overall incidence of VTE in the leukemia population was high, particularly in transplant recipients, who had the highest risk (IR: 8%, 95% CI: 4–13%). Prophylactic approaches could significantly decrease the occurrence of VTE events.
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Affiliation(s)
- Ying-Ying Wu
- Department of Oncology, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Liang Tang
- Institute of Haematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Ming-Huan Wang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China.
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16
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Cooper JD, Costello AG, Shaw PH. A Comparison of Extremity Thrombosis Rates in Adolescent and Young Adult Versus Younger Pediatric Oncology Patients at a Children's Hospital. J Adolesc Young Adult Oncol 2017; 6:62-66. [DOI: 10.1089/jayao.2016.0044] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Affiliation(s)
- James D. Cooper
- Division of Hematology/Oncology, Department of Pediatrics, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Aimee G. Costello
- Division of Hematology/Oncology, Department of Pediatrics, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Peter H. Shaw
- Department of Oncology, Johns Hopkins School of Medicine, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
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17
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Ko RH, Thornburg CD. Venous Thromboembolism in Children with Cancer and Blood Disorders. Front Pediatr 2017; 5:12. [PMID: 28220143 PMCID: PMC5292750 DOI: 10.3389/fped.2017.00012] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 01/18/2017] [Indexed: 01/19/2023] Open
Abstract
Venous thromboembolism (VTE) in children is multifactorial and most often related to a combination of inherited and acquired thrombophilias. Children with cancer and blood disorders are often at risk for VTE due to disease-related factors such as inflammation and abnormal blood flow and treatment-related factors such as central venous catheters and surgery. We will review risk factors for VTE in children with leukemia, lymphoma, and solid tumors. We will also review risk factors for VTE in children with blood disorders with specific focus on sickle cell anemia and hemophilia. We will present the available evidence and clinical guidelines for prevention and treatment of VTE in these populations.
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Affiliation(s)
| | - Courtney D Thornburg
- Hemophilia and Thrombosis Treatment Center, Rady Children's Hospital San Diego , San Diego, CA , USA
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18
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Abstract
INTRODUCTION The discovery of the factor V Leiden (FVL) missense mutation (Arg506Gln) causing factor V resistance to the anticoagulant action of activated protein C was a landmark that allowed a better understanding of the basis of inherited thrombotic risk. FVL mutation is currently the most common known hereditary defect predisposing to venous thrombosis. Areas covered: Novel data-driven FVL diagnosis and therapeutic approaches in the management of FVL carriers in various clinical settings. Brief conclusions on topics of direct clinical relevance including currently available indications for primary and secondary prophylaxis, the management of female, pediatric carriers and asymptomatic relatives. Latest evidence on the association between FVL and cancer, as well as the possible use of direct oral anticoagulant therapy. Expert commentary: Although FVL diagnosis nowadays is highly accurate, many doubts remain regarding the best management and therapeutic protocols. The main role of clinicians is to tailor therapeutic strategies to carriers and their relatives. High familial penetrance, distinctive aspects of the first thrombotic event (provoked/unprovoked, age, etc.) and laboratory biomarkers can guide the optimal management of secondary antithrombotic prophylaxis, primary prophylaxis in asymptomatic individuals, and whether to screen relatives.
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Affiliation(s)
- Elena Campello
- a Hemorrhagic and Thrombotic Diseases Unit, Department of Medicine (DIMED) , University of Padua Medical School , Padua , Italy
| | - Luca Spiezia
- a Hemorrhagic and Thrombotic Diseases Unit, Department of Medicine (DIMED) , University of Padua Medical School , Padua , Italy
| | - Paolo Simioni
- a Hemorrhagic and Thrombotic Diseases Unit, Department of Medicine (DIMED) , University of Padua Medical School , Padua , Italy
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De Stefano V, Za T, Ciminello A, Betti S, Rossi E. Haemostatic alterations induced by treatment with asparaginases and clinical consequences. Thromb Haemost 2014; 113:247-61. [PMID: 25338526 DOI: 10.1160/th14-04-0372] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Accepted: 09/18/2014] [Indexed: 01/19/2023]
Abstract
The benefit of asparaginase for treating acute lymphoid leukaemia (ALL) has been well established. Native asparaginase derives from Escherichia coli (colaspase) or Erwinia chrysanthemi (crisantaspase); in a third preparation, colaspase is pegylated. Depletion of asparagine leads to decreased synthesis of procoagulant, anticoagulant, and fibrinolytic proteins, with resultant hypercoagulability and greater risk of venous thromboembolism (VTE). Colaspase and crisantaspase are not dose-equivalent, with crisantaspase displaying haemostatic toxicity only at dosages much higher and administered more frequently than those of colaspase. Cerebral venous thrombosis and pulmonary embolism are two life-endangering manifestations that occur during treatment with asparaginase particularly in children and in adults with ALL, respectively. Approximately one-third of VTEs are located in the upper extremities and are central venous line-related. Other risk factors are longer duration of asparaginase treatment and concomitant use of prednisone, anthracyclines, and oral contraceptives. The risk associated with inherited thrombophilia is uncertain but is clearly enhanced by other risk factors or by the use of prednisone. VTE prevention with fresh frozen plasma is not recommended; the efficacy of antithrombin (AT) concentrates has occasionally been reported, but these reports should be confirmed by proper studies, and AT should not be routinely employed. Therapeutic or prophylactic heparin doses are only partially effective, and direct thrombin or factor Xa inhibitors could play significant roles in the near future.
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Affiliation(s)
- Valerio De Stefano
- Valerio De Stefano, MD, Institute of Hematology, Catholic University, Largo Gemelli 8, 00168 Rome, Italy, Tel.: +39 06 30154968, Fax: +39 06 30155209, E-mail:
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20
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López-Briz E, Ruiz Garcia V, Cabello JB, Bort-Marti S, Carbonell Sanchis R, Burls A. Heparin versus 0.9% sodium chloride intermittent flushing for prevention of occlusion in central venous catheters in adults. Cochrane Database Syst Rev 2014:CD008462. [PMID: 25300172 DOI: 10.1002/14651858.cd008462.pub2] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Heparin intermittent flushing is a standard practice in the maintenance of patency in central venous catheters. However, we could find no systematic review examining its effectiveness and safety. OBJECTIVES To assess the effectiveness of intermittent flushing with heparin versus 0.9% sodium chloride (normal saline) solution in adults with central venous catheters in terms of prevention of occlusion and overall benefits versus harms. SEARCH METHODS The Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched December 2013) and the Cochrane Central Register of Controlled Trials (CENTRAL) (2013, Issue 11). Searches were also carried out in MEDLINE, EMBASE, CINAHL and clinical trials databases (December 2013). SELECTION CRITERIA Randomised controlled trials (RCTs) in adults 18 years of age and older with a central venous catheter (CVC) in which intermittent flushing with heparin (any dose with or without other drugs) was compared with 0.9% normal saline were included. No restriction on language was applied. DATA COLLECTION AND ANALYSIS Two review authors independently selected trials, assessed trial quality and extracted data. Trial authors were contacted to retrieve additional information, when necessary. MAIN RESULTS Six eligible studies with a total of 1433 participants were included. The heparin concentrations used in these studies were very different (10-5000 IU/mL), and follow-up varied from 20 days to 180 days. The overall risk of bias in the studies was low. The quality of the evidence ranged from very low to moderate for the main outcomes (occlusion of CVC, duration of catheter patency, CVC-related sepsis, mortality and haemorrhage at any site).Combined findings from three trials in which the unit of analysis was the catheter suggest that heparin was associated with reduced CVC occlusion rates (risk ratio (RR) 0.53, 95% confidence interval (CI) 0.29 to 0.94). However, no clear evidence of a similar effect was found when the results of two studies in which the unit of analysis was the participant were combined (RR 0.21, 95% CI 0.03 to 1.70), nor when findings were derived from one study, which considered total line accesses (RR 1.08, 95% CI 0.84 to 1.40). Furthermore, results for other estimated effects were found to be imprecise and compatible with benefit and harm: catheter duration in days (mean difference (MD) 0.41, 95% CI -1.29 to 2.12), CVC-related thrombosis (RR 1.22, 95% CI 0.74 to 1.99), CVC-related sepsis (RR 1.02, 95% CI 0.34 to 3.03), mortality (RR 0.77, 95% CI 0.45 to 1.32) and haemorrhage at any site (RR 1.37, 95% CI 0.49 to 3.85). AUTHORS' CONCLUSIONS We found no conclusive evidence of important differences when heparin intermittent flushing was compared with 0.9% normal saline flushing for central venous catheter maintenance in terms of efficacy or safety. As heparin is more expensive than normal saline, our findings challenge its continued use in CVC flushing outside the context of clinical trials.
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Affiliation(s)
- Eduardo López-Briz
- Department of Pharmacy & CASP Spain, Hospital Universitario y Politécnico La Fe, Bulevar Sur s/n, Valencia, Valencia, Spain, 46026
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21
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El Sissy AH, El Sissy MH, Elmoamly S. Factor V Leiden 1691G/A and prothrombin gene 20210G/A polymorphisms as prothrombotic markers in adult Egyptian acute leukemia patients. Med Oncol 2014; 31:265. [PMID: 25260809 DOI: 10.1007/s12032-014-0265-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2014] [Accepted: 09/20/2014] [Indexed: 10/24/2022]
Abstract
Factor V Leiden 1691G/A and prothrombin gene 20210G/A mutations are the most common genetic defects leading to thrombosis. This work aimed to study the FV Leiden and the prothrombin gene polymorphism in adult Egyptian patients with acute leukemia and their importance in thrombophilia screening. The study included 76 patients with acute leukemia and 100 healthy controls. Genotyping was done by real-time polymerase chain reaction technique. For factor V Leiden, the frequency of G/A mutation conferred more than 2.5-fold of increased risk of (OR 2.639 95 % CI 1.045-6.669). The frequency of factor V Leiden combined (G/A + A/A) genotypes conferred 2.83-fold of increased risk (OR 2.828, CI 1.13-7.075), The A allele conferred almost threefold increased risk (OR 2.824, 95 % CI 1.175-6.785). Despite higher frequency in patients compared to controls, there was no risk of association between prothrombin gene mutation and acute leukemia in adult Egyptians nor was there between combined genotypes of prothrombin gene mutation and factor V Leiden.
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22
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Brandão LR, Shah N, Shah PS. Low molecular weight heparin for prevention of central venous catheterization-related thrombosis in children. Cochrane Database Syst Rev 2014:CD005982. [PMID: 24615288 DOI: 10.1002/14651858.cd005982.pub2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND The prevalence of children diagnosed with deep vein thrombosis or pulmonary embolism has been increasing in the last decade. The most common thrombosis risk factor in neonates, infants and children is the placement of a central venous catheter (CVC). To date, it is unknown if the practice of anticoagulation prophylaxis with low molecular weight heparin (LMWH) decreases CVC-related thrombosis in children. OBJECTIVES The primary objective of this review was to determine the effect of LMWH prophylaxis on reducing the incidence of CVC-related thrombosis in children.Secondary objectives were to determine the effect of LMWH on occlusion of CVCs, number of days of CVC patency, episodes of catheter-related sepsis, side effects of LMWH (allergic reactions, major and minor bleeding complications, abnormal coagulation profile, osteoporosis) and mortality during therapy. SEARCH METHODS The Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched June 2013), CENTRAL (2013, Issue 5) and clinical trial databases. The authors searched MEDLINE and EMBASE (July 2013). Bibliographies of identified articles were searched. There were no language restrictions. SELECTION CRITERIA Randomised and quasi-randomised trials comparing LMWH prophylaxis to standard care given to prevent CVC-related thrombotic events in children were included. We selected studies conducted in children aged 0 to 18 years. DATA COLLECTION AND ANALYSIS Two review authors independently identified eligible studies, which were assessed for study quality including bias, and extracted unadjusted data where available. In the data analysis step, all outcomes were analysed as binary or dichotomous outcomes. The effects of interventions were summarised with risk ratios (RR) and their respective 95% confidence intervals (CI). MAIN RESULTS One of 17 studies retrieved for full-text assessment for eligibility was included in the final analysis. This study included a total of 186 participants and investigated the effect of LMWH to prevent CVC-related thrombosis compared to standard care. The risk of bias of the study was assessed to be low, except for the unclear risk of selection bias (allocation concealment not reported) and detection bias since it was an open-label study. Nonetheless, outcome adjudication was blinded. However, overall the quality of the evidence was low due to the fact that the study was underpowered. The CIs for the risk of CVC-related thrombosis (symptomatic and asymptomatic events) were compatible with benefits of either LMWH (reviparin) or the control (RR for symptomatic thrombosis 1.03, 95% CI 0.21 to 4.93; RR for asymptomatic thrombosis 1.17, 95% CI 0.45 to 3.08). Similarly, only one patient in the standard care group suffered a major bleeding event, while minor bleeding was found in 53.3% of patients in the reviparin arm and in 44.7% of patients in the standard care arm (major bleeding RR 0.34, 95% CI 0.01 to 8.26; minor bleeding RR 1.20, 95% CI 0.91 to 1.58). Lastly, there were two deaths within the study and neither were the result of a venous thrombotic event (VTE), occurring in the standard care arm. No additional adverse effects were reported. Other pre-specified outcomes for this review were not reported. AUTHORS' CONCLUSIONS A single study reported imprecise effects for the risk of CVC-related thrombosis in children on a CVC anticoagulant prophylaxis regimen. The quality of the evidence was low due to the fact that the included study was clearly underpowered, hampering any conclusions in regards to the efficacy of LMWH prophylaxis to prevent CVC-related thrombi in children. Further prospective randomised studies are highly encouraged.
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Affiliation(s)
- Leonardo R Brandão
- Division of Haematology-Oncology, The Hospital for Sick Children, 555 University Avenue, Black Wing, room 10412, Toronto, Ontario, Canada, M5G-1X8
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Dosing and monitoring of enoxaparin therapy in children: experience in a tertiary care hospital. Blood Coagul Fibrinolysis 2013; 24:194-8. [PMID: 23358201 DOI: 10.1097/mbc.0b013e32835b72b8] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Pediatric deep vein thrombosis (DVT) is an emerging problem in tertiary care hospitals, recent reviews shows a rate of 40.2/10,000 admissions. Experts affirm that enoxaparin has become in the drug of choice for DVT therapy. Despite this, there is a little information regarding the optimal dose schedule for enoxaparin therapy in children and the therapeutic guidelines for enoxaparin use in children are extrapolated from adult guidelines. Monitoring by antifactor Xa (anti-Xa) measurement and target concentrations between 0.5-1 U/ml at 4-6 h postdose are recommended. This study was designed to analyse our experience in paediatric-specific dosage requirements for enoxaparin therapy. A retrospective study was performed with patients less than 16 years old, who were treated with enoxaparin for DVT and monitored by anti-Xa concentration, between January 2005 and March 2012. Demographic and clinical characteristics and outcomes were obtained. Fourteen patients were analyzed: boy/girl ratio, 8/4; median age, 3.5 months. Cerebral venous sinus thrombosis was the most common indication for therapy. All patients presented thrombosis risks factors. Dose increases were necessary only in patients less than 6 years old. Target anti-Xa concentrations were achieved in 12 (85%) patients. Children younger than 1 year required a higher dose of enoxaparin/kg (1.5-2.7 mg/kg per 12 h). Complete resolutions of DVT were registered in all cases. The mean number of dose increases was three and a median of 11 days to achieve target anti-Xa concentration. This study indicates that an initial higher enoxaparin dose may be necessary in neonates and infants, but other factors must be considered to improve management.
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Schoot RA, Kremer LCM, van de Wetering MD, van Ommen CH. Systemic treatments for the prevention of venous thrombo-embolic events in paediatric cancer patients with tunnelled central venous catheters. Cochrane Database Syst Rev 2013:CD009160. [PMID: 24026801 DOI: 10.1002/14651858.cd009160.pub2] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Venous thrombo-embolic events (VTEs) occur in 2.2% to 14% of paediatric cancer patients and cause significant morbidity and mortality. The malignant disease itself, the cancer treatment and the presence of central venous catheters (CVCs) increase the risk of VTE. OBJECTIVES The primary objective of this review was to investigate the effects of preventive systemic treatments in paediatric cancer patients with tunnelled CVCs on (a)symptomatic VTE. Secondary objectives of this review were to investigate adverse effects of systemic treatments for the prevention of (a)symptomatic VTE in paediatric cancer patients with tunnelled CVCs; and to investigate the effects of systemic treatments in the prevention of (a)symptomatic VTE with CVC-related infection in paediatric cancer patients with tunnelled CVCs. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 8 2012), MEDLINE (1966 to August 2012) and EMBASE (1966 to August 2012). In addition, we searched reference lists from relevant articles and conference proceedings of the International Society for Paediatric Oncology (SIOP) (from 2006 to 2011), the American Society of Clinical Oncology (ASCO) (from 2006 to 2011), the American Society of Hematology (ASH) (from 2006 to 2011) and the International Society of Thrombosis and Haematology (ISTH) (from 2006 to 2011). We scanned the International Standard Randomised Controlled Trial Number (ISRCTN) Register and the National Institute of Health (NIH) Register for ongoing trials (www.controlled-trials.com) (August 2012), and we contacted the authors of eligible studies if additional information was required. SELECTION CRITERIA Randomised controlled trials (RCTs) and controlled clinical trials (CCTs) comparing systemic treatments to prevent venous thrombo-embolic events (VTEs) in paediatric cancer patients with tunnelled CVCs with a control intervention or no systemic treatment. For the description of adverse events, cohort studies were eligible for inclusion. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies, extracted data and performed risk of bias assessment of included studies. Analyses were performed according to the guidelines of the Cochrane Handbook for Systematic Reviews of Interventions. MAIN RESULTS Three RCTs and three CCTs (including 1291 children) investigated the prevention of VTE (low molecular weight heparin (LMWH) n = 134, antithrombin (AT) supplementation n = 37, low-dose warfarin n = 31, cryoprecipitate and/or fresh frozen plasma (FFP) supplementation n = 240, AT supplementation and LMWH n = 41). AT, cryoprecipitate and FFP were supplemented only in cases of AT or fibrinogen deficiency. Of the six included RCTs/CCTs, five investigated the prevention of VTE compared with no intervention (n = 737), and one CCT compared AT supplementation and LMWH with AT supplementation (n = 71). All studies had methodological limitations, and clinical heterogeneity between studies was noted.We found no significant effects of systemic treatments compared with no intervention in preventing (a)symptomatic VTE and no differences in adverse events (such as major and/or minor bleeding; none of the studies reported thrombocytopenia, heparin-induced thrombocytopenia (HIT), heparin-induced thrombocytopenia with thrombosis (HITT), death as a result of VTE, removal of CVC due to VTE, CVC-related infection, and post-thrombotic syndrome (PTS)) between experimental and control groups. Two studies with comparable participant groups and interventions were included for meta-analyses (n = 182). In the experimental group, 1/68 (1.5%) children were diagnosed with symptomatic VTE, as were 4/114 (3.5%) in the control group (best case scenario: risk ratio (RR) 0.65, 95% confidence interval (CI) 0.09 to 4.78). These studies also evaluated asymptomatic CVC-related VTE: In the experimental group, 22/68 (32.4%) were diagnosed with asymptomatic VTE, as were 35/114 (30.7%) in the control group (best case scenario: RR 1.02, 95% CI 0.40 to 2.55). Heterogeneity was substantial for this analysis: I(2) = 73%.The attribution of LMWH to AT supplementation resulted in a significant reduction in symptomatic VTE (Fisher's exact test, two-sided P = 0.028) without bleeding complications; asymptomatic VTE, thrombocytopenia, HIT, HITT, death as a result of VTE, removal of CVC due to VTE, CVC-related infection and PTS were not assessed.Four cohort studies were included for the evaluation of adverse events. Three studies provided information on bleeding episodes: One participant developed an ischaemo-haemorrhagic stroke. One study provided information on other adverse events: None occurred. AUTHORS' CONCLUSIONS We found no significant effects of systemic treatments compared with no intervention in preventing (a)symptomatic VTE in paediatric oncology patients with CVCs. However, this could be a result of the low number of included participants, which resulted in low power. In one CCT, which compared one systemic treatment with another systemic treatment, we identified a significant reduction in symptomatic VTE with the addition of LMWH to AT supplementation.All studies investigated the prevalence of major and/or minor bleeding episodes, and none found a significant difference between study groups. None of the studies reported thrombocytopenia, HIT, HITT, death as a result of VTE, removal of CVC due to VTE, CVC-related infection or PTS among participants.On the basis of currently available evidence, we are not able to give recommendations for clinical practise. Additional well-designed international RCTs are needed to further explore the effects of systemic treatments in preventing VTE. Future studies should aim for adequate power with attainable sample sizes. The incidence of symptomatic VTE is relatively low; therefore, it might be necessary to select participants with thrombotic risk factors or to investigate asymptomatic VTE instead.
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Affiliation(s)
- Reineke A Schoot
- Department of Paediatric Oncology, Emma Children's Hospital / Academic Medical Center, PO Box 22660, Amsterdam, Netherlands, 1100 DD
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De Stefano V, Rossi E. Testing for inherited thrombophilia and consequences for antithrombotic prophylaxis in patients with venous thromboembolism and their relatives. A review of the Guidelines from Scientific Societies and Working Groups. Thromb Haemost 2013; 110:697-705. [PMID: 23846575 DOI: 10.1160/th13-01-0011] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2013] [Accepted: 06/13/2013] [Indexed: 11/05/2022]
Abstract
The clinical penetrance of venous thromboembolism (VTE) susceptibility genes is variable, being lower in heterozygous carriers of factor V Leiden and prothrombin 20210A (mild thrombophilia), and higher in the rare carriers of deficiencies of antithrombin, protein C or S, and those with multiple or homozygous abnormalities (high-risk thrombophilia). The absolute risk of VTE is low, and the utility of laboratory investigation for inherited thrombophilia in patients with VTE and their asymptomatic relatives has been largely debated, leading to the production of several Guidelines from Scientific Societies and Working Groups. The risk for VTE largely depends on the family history of VTE. Therefore, indiscriminate search for carriers is of no utility, and targeted screening is potentially more fruitful. In patients with VTE inherited thrombophilia is not scored as a determinant of recurrence, playing a minor role in the decision of prolonging anticoagulation; indeed, a few guidelines consider testing worthwhile to identify carriers of high-risk thrombophilia, particularly those with a family history of VTE. The identification of the asymptomatic carrier relatives of the probands with VTE and thrombophilia could reduce cases of provoked VTE, offering them primary antithrombotic prophylaxis during risk situations. In most guidelines, this is considered justified only for relatives of probands with a deficiency of natural anticoagulants or multiple abnormalities. Counselling the asymptomatic female relatives of individuals with VTE and/or thrombophilia before pregnancy or the prescription of hormonal treatments should be administered with consideration of the risk driven by the type of thrombophilia and the family history of VTE.
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Affiliation(s)
- Valerio De Stefano
- Valerio De Stefano, MD, Institute of Hematology, Catholic University, Largo Gemelli 8, 00168 Rome, Italy, Tel.: +39 06 30154968, Fax: +39 06 30154206, E-mail:
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Abstract
Thrombosis is a common complication in patients with acute leukemia. While the presence of central venous lines, concomitant steroids, the use of Escherichia coli asparaginase and hereditary thrombophilic abnormalities are known risk factors for thrombosis in children, information on the pathogenesis, risk factors, and clinical outcome of thrombosis in adult patients with acute lymphoid leukemia (ALL) or acute myeloid leukemia (AML) is still scarce. Expert consensus and guidelines regarding leukemia-specific risk factors, thrombosis prevention, and treatment strategies, as well as optimal type of central venous catheter in acute leukemia patients are required. It is likely that each subtype of acute leukemia represents a different setting for the development of thrombosis and the risk of bleeding. This is perhaps due to a combination of different disease-specific pathogenic mechanisms of thrombosis, including the type of chemotherapy protocol chosen, the underlying patients health, associated risk factors, as well as the biology of the disease itself. The risk of thrombosis may also vary according to ethnicity and prevalence of hereditary risk factors for thrombosis; thus, it is advisable for Latin American, Asian, and African countries to report on their specific patient population.
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Affiliation(s)
- Erick Crespo-Solís
- Clínica de Leucemia Aguda, Departamento de Hematología y Oncología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico.
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Spentzouris G, Scriven RJ, Lee TK, Labropoulos N. Pediatric venous thromboembolism in relation to adults. J Vasc Surg 2012; 55:1785-93. [DOI: 10.1016/j.jvs.2011.07.047] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2011] [Revised: 06/23/2011] [Accepted: 07/06/2011] [Indexed: 12/14/2022]
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Qiao J, Qi L, Mu X, Chen Y. Monolith and coating enzymatic microreactors of l-asparaginase: kinetics study by MCE–LIF for potential application in acute lymphoblastic leukemia (ALL) treatment. Analyst 2011; 136:2077-83. [DOI: 10.1039/c1an15067g] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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