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Du P, Cristarella T, Goyer C, Moride Y. A Systematic Review of the Epidemiology and Disease Burden of Congenital and Immune-Mediated Thrombotic Thrombocytopenic Purpura. J Blood Med 2024; 15:363-386. [PMID: 39161536 PMCID: PMC11330749 DOI: 10.2147/jbm.s464365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Accepted: 07/23/2024] [Indexed: 08/21/2024] Open
Abstract
Congenital (cTTP) and immune-mediated (iTTP) thrombotic thrombocytopenic purpura are serious and rare clotting disorders resulting from a deficiency in the ADAMTS13 enzyme. A systematic review was conducted using the Ovid® MEDLINE & Embase databases to synthesize the epidemiology and burden of cTTP and iTTP worldwide (from January 1, 2010, to February 6, 2020, with an update that covered the period January 1, 2020-February 11, 2022). Outcomes of interest were incidence and prevalence of TTP, incidence of acute episodes, mortality, burden of illness (eg complications, healthcare utilization, patient-reported outcomes) and disease management. A total of 221 eligible observational studies were included. The incidence rate of acute episodes ranged from 0.19-0.35 person-years in adult patients with cTTP, and 1.81-3.93 per million persons per year for iTTP in the general population. Triggers of acute episodes were similar for cTTP and iTTP, with pregnancy and infection the most commonly observed. Exacerbation in patients with iTTP varied widely, ranging from 2.4-63.1%. All-cause mortality was observed in 0-13.4% of patients with cTTP, across studies and follow-up periods, and in 1.1% (median follow-up: 0.4 years) to 18.8% (1 year) of patients with iTTP during acute episodes. Cardiovascular, renal, and neurological disease were common complications. TTP also led to work disturbances, feelings of anxiety and depression, and general activity impairment. TTP treatment regimens used were generally reflective of current treatment guidelines. The evidence identified describes a high patient burden, highlighting the need for effective treatment regimens leading to improvements in outcomes. Considerable evidence gaps exist, particularly for disease epidemiology, patient-reported outcomes, costs of disease management, and associated healthcare resource utilization. This review may help increase disease awareness and highlights the need for additional real-world studies, particularly in geographical regions outside the United States and Western Europe.
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Affiliation(s)
- Ping Du
- Global Evidence and Outcomes, Takeda Development Center Americas, Inc., Cambridge, MA, USA
| | | | | | - Yola Moride
- YolaRX Consultants Inc., Montreal, QC, Canada
- Center for Pharmacoepidemiology and Treatment Sciences, Rutgers, The State University of New Jersey, New Brunswick, NJ, USA
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2
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Dos Santos C, Castera S, Fernandez J, Rosales JS, Crescitelli F, Boughen S, Iastrebner M, Guerrero O, Amell Menco C, Gomez M, Gonzalez J, Alberto MF, Sanchez-Luceros A. Thrombocytopenic thrombotic purpura related to COVID-19 vaccine: apropos of 4 cases. Hematol Transfus Cell Ther 2023:S2531-1379(23)02605-6. [PMID: 38233303 DOI: 10.1016/j.htct.2023.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 11/11/2023] [Accepted: 11/13/2023] [Indexed: 01/19/2024] Open
Affiliation(s)
- Célia Dos Santos
- Laboratorio de Hemostasia y Trombosis, Instituto de Medicina Experimental, CONICET, Academia Nacional de Medicina, Buenos Aires, Argentina.
| | - Santiago Castera
- Departamento de Hemostasia y Trombosis, Instituto de Investigaciones Hematológicas "Mariano R. Castex", Academia Nacional de Medicina, Buenos Aires, Argentina
| | - José Fernandez
- Fundación para la Lucha contra las Enfermedades Neurológicas de la Infancia (FLENI), Buenos Aires, Argentina
| | - Julieta Soledad Rosales
- Fundación para la Lucha contra las Enfermedades Neurológicas de la Infancia (FLENI), Buenos Aires, Argentina
| | | | | | | | | | | | - Mariela Gomez
- Hospital de Clínicas José de San Martin, Buenos Aires, Argentina
| | | | - Maria Fabiana Alberto
- Departamento de Hemostasia y Trombosis, Instituto de Investigaciones Hematológicas "Mariano R. Castex", Academia Nacional de Medicina, Buenos Aires, Argentina
| | - Analía Sanchez-Luceros
- Laboratorio de Hemostasia y Trombosis, Instituto de Medicina Experimental, CONICET, Academia Nacional de Medicina, Buenos Aires, Argentina; Departamento de Hemostasia y Trombosis, Instituto de Investigaciones Hematológicas "Mariano R. Castex", Academia Nacional de Medicina, Buenos Aires, Argentina
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Gómez-Seguí I, Francés Aracil E, Mingot-Castellano ME, Vara Pampliega M, Goterris Viciedo R, García Candel F, Pascual Izquierdo C, Del Río Garma J, Guerra Domínguez L, Vicuña Andrés I, Garcia-Arroba Peinado J, Zalba Marcos S, Vidan Estévez JM, González Arias E, Campuzano Saavedra V, García Gala JM, Ortega Sanchez S, Martínez Nieto J, Pardo Gambarte L, Solé Rodríguez M, Fernández-Docampo M, Avila Idrovo LF, Hernández L, Cid J, de la Rubia Comos J. Immune thrombotic thrombocytopenic purpura in older patients: Results from the Spanish TTP Registry (REPTT). Br J Haematol 2023; 203:860-871. [PMID: 37723363 DOI: 10.1111/bjh.19109] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 08/31/2023] [Accepted: 09/05/2023] [Indexed: 09/20/2023]
Abstract
Immune thrombotic thrombocytopenic purpura (iTTP) is an ultra-rare disease that seldom occurs in the elderly. Few reports have studied the clinical course of iTTP in older patients. In this study, we have analysed the clinical characteristics at presentation and response to therapy in a series of 44 patients with iTTP ≥60 years at diagnosis from the Spanish TTP Registry and compared them with 209 patients with <60 years at diagnosis from the same Registry. Similar symptoms and laboratory results were described in both groups, except for a higher incidence of renal dysfunction among older patients (23% vs. 43.1%; p = 0.008). Front-line treatment in patients ≥60 years was like that administered in younger patients. Also, no evidence of a difference in clinical response and overall survival was seen in both groups. Of note, 14 and 25 patients ≥60 years received treatment with caplacizumab and rituximab, respectively, showing a favourable safety and efficacy profile, like that observed in patients <60 years.
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Affiliation(s)
- I Gómez-Seguí
- H. Universitario y Politécnico La Fe, Valencia, Spain
| | | | - M E Mingot-Castellano
- Hematology Department, Instituto de Biomedicina de Sevilla, H. U. Virgen del Rocio, Sevilla, Spain
| | | | | | | | | | - J Del Río Garma
- Complejo Hospitalario Universitario de Orense, Ourense, Spain
| | | | | | | | | | | | | | | | | | - S Ortega Sanchez
- Banc de Sang i Teixits, L'Hospitalet de Llobregat, Barcelona, Spain
| | - J Martínez Nieto
- Instituto de Investigación Biomédica del Hospital Clínico San Carlos, Madrid, Spain
| | | | | | | | | | | | - J Cid
- H. Clínic, Barcelona, Spain
| | - J de la Rubia Comos
- H. Universitario y Politécnico La Fe, Valencia, Spain
- Hematology Department, Universidad Católica "San Vicente Mártir", Valencia, Spain
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Joseph A, Joly BS, Picod A, Veyradier A, Coppo P. The Specificities of Thrombotic Thrombocytopenic Purpura at Extreme Ages: A Narrative Review. J Clin Med 2023; 12:jcm12093068. [PMID: 37176509 PMCID: PMC10179719 DOI: 10.3390/jcm12093068] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 04/12/2023] [Accepted: 04/20/2023] [Indexed: 05/15/2023] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a rare and life-threatening thrombotic microangiopathy (TMA) related to a severe ADAMTS13 deficiency, the specific von Willebrand factor (VWF)-cleaving protease. This deficiency is often immune-mediated (iTTP) and related to the presence of anti-ADAMTS13 autoantibodies that enhance its clearance or inhibit its VWF processing activity. iTTP management may be challenging at extreme ages of life. International cohorts of people with TTP report delayed diagnoses and misdiagnoses in children and elderly people. Child-onset iTTP shares many features with adult-onset iTTP: a female predominance, an idiopathic presentation, and the presence of neurological disorders and therapeutic strategies. Long-term follow-ups and a transition from childhood to adulthood are crucial to preventing iTTP relapses, in order to identify the occurrence of other autoimmune disorders and psychosocial sequelae. In contrast, older iTTP patients have an atypical clinical presentation, with delirium, an atypical neurological presentation, and severe renal and cardiac damages. They also have a poorer response to treatment and prognosis. Long-term sequelae are highly prevalent in older patients. Prediction scores for iTTP diagnoses are not used for children and have a lower sensitivity and specificity in patients over 60 years old. ADAMTS13 remains the unique biological marker that is able to definitely confirm or rule out the diagnosis of iTTP and predict relapses during follow-ups.
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Affiliation(s)
- Adrien Joseph
- Medical Intensive Care Unit, Saint-Louis Hospital, Public Assistance Hospitals of Paris, 75010 Paris, France
- French Reference Center for Thrombotic Microangiopathies, 75012 Paris, France
| | - Bérangère S Joly
- French Reference Center for Thrombotic Microangiopathies, 75012 Paris, France
- Hematology Biology Department, Lariboisière Hospital, Public Assistance Hospitals of Paris, 75006 Paris, France
- EA-3518, Clinical Research in Hematology, Immunology and Transplantation, Institut de Recherche Saint-Louis, Université de Paris, 75571 Paris, France
| | - Adrien Picod
- Medical Intensive Care Unit, Saint-Louis Hospital, Public Assistance Hospitals of Paris, 75010 Paris, France
- French Reference Center for Thrombotic Microangiopathies, 75012 Paris, France
| | - Agnès Veyradier
- French Reference Center for Thrombotic Microangiopathies, 75012 Paris, France
- Hematology Biology Department, Lariboisière Hospital, Public Assistance Hospitals of Paris, 75006 Paris, France
- EA-3518, Clinical Research in Hematology, Immunology and Transplantation, Institut de Recherche Saint-Louis, Université de Paris, 75571 Paris, France
| | - Paul Coppo
- French Reference Center for Thrombotic Microangiopathies, 75012 Paris, France
- Hematology Department, Saint-Antoine hospital, Public Assistance Hospitals of Paris, 75571 Paris, France
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Issa A, Kouli M, Awwameh R, Alasadi L, Alrstom A, Arssan Alshadid O, Alsuliman T, Sulaiman A. Endocarditis-induced thrombotic thrombocytopenic purpura mimicking preeclampsia: A case report. Clin Case Rep 2021; 9:e04364. [PMID: 34257975 PMCID: PMC8259797 DOI: 10.1002/ccr3.4364] [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: 01/07/2021] [Revised: 03/22/2021] [Accepted: 05/07/2021] [Indexed: 11/26/2022] Open
Abstract
TTP, Preeclampsia have similar manifestations in pregnancy. Establishing the right diagnosis is essential as the treatment is different. Endocarditis-induced TTP should be suspected when neurological symptoms, thrombocytopenia are present.
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Affiliation(s)
- Abdulmoez Issa
- Faculty of MedicineDepartment of RadiologyDamascus UniversityDamascusSyria
| | - Moudar Kouli
- Faculty of MedicineDamascus UniversityDamascusSyria
| | - Randa Awwameh
- Department of Internal Medicine, HematologyAl‐ Mouwasat HospitalDamascus UniversityDamascusSyria
| | - Lugien Alasadi
- Faculty of MedicineDepartment of Gastroenterology and HepatologyDamascus UniversityDamascusSyria
| | - Ali Alrstom
- Department of Internal Medicine, Infectious DiseasesAl‐Mouwasat HospitalDamascus UniversityDamascusSyria
| | - Omar Arssan Alshadid
- Department of Internal Medicine, Infectious DiseasesAl‐Mouwasat HospitalDamascus UniversityDamascusSyria
| | - Tamim Alsuliman
- Service d'HématologieHôpital Saint‐AntoineAP‐HPSorbonne UniversitéParisFrance
| | - Ameen Sulaiman
- Department of Internal Medicine, HematologyAl‐ Mouwasat HospitalDamascus UniversityDamascusSyria
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Domingo-González A, Regalado-Artamendi I, Martín-Rojas RM, Pérez-Rus G, Pérez-Corral A, Díez-Martín JL, Pascual-Izquierdo C. Application of the French TMA Reference Center Score and the mortality in TTP Score in de novo and relapsed episodes of acquired thrombotic thrombocytopenic purpura at a tertiary care facility in Spain. J Clin Apher 2021; 36:420-428. [PMID: 33534947 DOI: 10.1002/jca.21880] [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] [Received: 10/27/2020] [Revised: 01/13/2021] [Accepted: 01/14/2021] [Indexed: 11/11/2022]
Abstract
Acquired thrombotic thrombocytopenic purpura (aTTP) is still associated with a 10% to 20% death rate and its clinical course is characterized by recurrent episodes in up to 50% of cases. Over the last decade, mortality predicting models like the French TMA Reference Center Score and the Mortality In TTP Score (MITS) have been developed in an attempt to personalize treatment. The objective of the present study was to compare the results in both scores of de novo and relapsed aTTP episodes. For such purpose, a total of 29 episodes of aTTP (16 de novo and 13 relapses) were analyzed. All patients were homogeneously diagnosed and treated. First episodes had a higher score in both models in comparison with relapsed aTTP, (MITS median, 1 r: 1-4 vs 0 r: 1-2, P = .038 and French TMA Reference Center Score median, 2 r: 1-3 vs 1 r: 0-1, P = .006). The prevalence of neurological symptoms was significantly higher in the first episodes (P = .001) and patients >60 years old were more common in this group (P = .013), which may have been related to the results. Platelet count at presentation was higher in recurrences than in the first disease episode (P = .016) and ADAMTS13 activity <5% was more frequent in the last group (P = .016). There was no significant difference in the rate of refractoriness or exacerbations. In conclusion, first aTTP episodes had a higher probability of short-term mortality compared to relapsed aTTP episodes according to the MITS and French TMA Reference Center Score.
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Affiliation(s)
- Amalia Domingo-González
- Servicio de Hematología y Hemoterapia. Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Isabel Regalado-Artamendi
- Servicio de Hematología y Hemoterapia. Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Reyes María Martín-Rojas
- Servicio de Hematología y Hemoterapia. Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Gloria Pérez-Rus
- Servicio de Hematología y Hemoterapia. Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Universidad Complutense de Madrid, Madrid, Spain
| | - Ana Pérez-Corral
- Servicio de Hematología y Hemoterapia. Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - José Luis Díez-Martín
- Servicio de Hematología y Hemoterapia. Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Universidad Complutense de Madrid, Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Cristina Pascual-Izquierdo
- Servicio de Hematología y Hemoterapia. Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
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Schmidt J, Zafrani L, Lemiale V, Stepanian A, Joly B, Azoulay E, Mariotte E. The clinical picture of thrombotic microangiopathy in patients older than 60 years of age. Br J Haematol 2020; 192:e25-e28. [PMID: 33216950 DOI: 10.1111/bjh.17176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Julien Schmidt
- Medical Intensive Care Unit, Saint-Louis Hospital, APHP, Paris, France
| | - Lara Zafrani
- Medical Intensive Care Unit, Saint-Louis Hospital, APHP, Paris, France
| | - Virginie Lemiale
- Medical Intensive Care Unit, Saint-Louis Hospital, APHP, Paris, France
| | - Alain Stepanian
- Hematology and Hemostasis Laboratory, APHP, Lariboisière Hospital, Paris, France
| | - Bérangère Joly
- Hematology and Hemostasis Laboratory, APHP, Lariboisière Hospital, Paris, France
| | - Elie Azoulay
- Medical Intensive Care Unit, Saint-Louis Hospital, APHP, Paris, France
| | - Eric Mariotte
- Medical Intensive Care Unit, Saint-Louis Hospital, APHP, Paris, France
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Liu A, Dhaliwal N, Upreti H, Kasmani J, Dane K, Moliterno A, Braunstein E, Brodsky R, Chaturvedi S. Reduced sensitivity of PLASMIC and French scores for the diagnosis of thrombotic thrombocytopenic purpura in older individuals. Transfusion 2020; 61:266-273. [PMID: 33179792 DOI: 10.1111/trf.16188] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 08/27/2020] [Accepted: 09/01/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND Thrombotic thrombocytopenic purpura (TTP) is a life-threatening disorder characterized by thrombocytopenia, microangiopathic hemolysis, and ischemic organ failure. The PLASMIC and French TTP scores can help guide clinical decisions when ADAMTS13 testing is not immediately available. Older individuals often present atypically, but the impact of age on these tools is not known. STUDY DESIGN AND METHODS We calculated the sensitivity and specificity of the PLASMIC and French TTP scores in patients enrolled in the Johns Hopkins thrombotic microangiopathy (TMA) registry. RESULTS Of 257 patients with TMA enrolled in the registry, we excluded patients less than 18 years of age (n = 19), with prior TMA (n = 81) or who initially presented at another hospital (n = 25). The remaining 132 patients (75 with TTP and 57 with other TMA) were analyzed. Sensitivity of a French score of 2 decreased with age and was 72.2%, 61.5%, and 46.2% for ages 18 to 39, 40 to 59, and ≥ 60 years old, respectively. A PLASMIC score ≥ 5 had higher sensitivity than the French score but this also decreased with age; sensitivity was 91.4% (95% confidence interval [CI], 76.9-98.2), 78.3% (95% CI, 56.3-92.5), and 76.9% (95% CI, 46.2-95.0) for patients 18 to 39, 40 to 59, and ≥ 60 years old, respectively. Older patients had higher platelet counts and serum creatinine than the youngest group, contributing to the loss in sensitivity. CONCLUSION The PLASMIC and French TTP scores have reduced sensitivity at age ≥ 60 years and are less reliable in identifying TTP in older patients. A high index of suspicion and availability of rapid ADAMTS13 assays is required to correctly diagnose all patients with TTP.
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Affiliation(s)
- Angela Liu
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Noor Dhaliwal
- Maulana Azad Medical College, University of Delhi, New Delhi, India
| | | | - Jamil Kasmani
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kathryn Dane
- Department of Pharmacy, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Alison Moliterno
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Evan Braunstein
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Robert Brodsky
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Shruti Chaturvedi
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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