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Han HJ, Kim M, Lee J, Suh HS. The Risk of Venous Thromboembolism and Ischemic Stroke Stratified by VTE Risk Following Multiple Myeloma: A Korean Population-Based Cohort Study. J Clin Med 2024; 13:2829. [PMID: 38792371 PMCID: PMC11121838 DOI: 10.3390/jcm13102829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2024] [Revised: 04/23/2024] [Accepted: 05/09/2024] [Indexed: 05/26/2024] Open
Abstract
Background: Multiple myeloma (MM) is associated with high morbidity and mortality, with elevated rates of arterial thrombosis and venous thromboembolism (VTE) and ischemic stroke (IS). We aimed to estimate the incidence of VTE and IS categorized by the VTE risk grade among individuals with MM in Korea. Additionally, we explored the potential of the IMPEDE VTE score as a tool for assessing IS risk in patients with MM. Methods: This retrospective cohort study comprised 37,168 individuals aged ≥ 18 years newly diagnosed with MM between January 2008 and December 2021 using the representative claims database of the Korean population. The risk of the incidence of VTE and IS within 6 months after MM diagnosis was stratified based on high-risk (IMPEDE VTE score ≥ 8) and low-risk (<8) categories. The hazard ratios (HRs) were estimated using Cox proportional hazard models. Results: The VTE incidence was 120.4 per 1000 person-years and IS incidence was 149.3 per 1000 person-years. Statistically significant differences were observed in the cumulative incidence rates of VTE between groups with high and low VTE scores (p < 0.001) and between individuals aged ≤ 65 years (p < 0.001) and those with a Charlson comorbidity index (CCI) ≥ 3 compared to lower scores (p < 0.001). Additionally, the cumulative incidence rate of IS differed significantly across all groups (p < 0.001). The HR for the high-risk group in VTE and IS occurrence was 1.59 (95% CI, 1.26-2.00) and 3.47 (95% CI, 2.99-4.02), respectively. Conclusions: It is important to screen and manage high-risk groups for the early development of VTE or IS in patients with newly diagnosed MM.
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Affiliation(s)
- Hyun Jin Han
- Department of Regulatory Science, Graduate School, Kyung Hee University, Seoul 02447, Republic of Korea; (H.J.H.); (J.L.)
- Institute of Regulatory Innovation through Science, Kyung Hee University, Seoul 02447, Republic of Korea;
| | - Miryoung Kim
- Institute of Regulatory Innovation through Science, Kyung Hee University, Seoul 02447, Republic of Korea;
- College of Pharmacy, Pusan National University, Busan 46241, Republic of Korea
| | - Jiyeon Lee
- Department of Regulatory Science, Graduate School, Kyung Hee University, Seoul 02447, Republic of Korea; (H.J.H.); (J.L.)
- Institute of Regulatory Innovation through Science, Kyung Hee University, Seoul 02447, Republic of Korea;
| | - Hae Sun Suh
- Department of Regulatory Science, Graduate School, Kyung Hee University, Seoul 02447, Republic of Korea; (H.J.H.); (J.L.)
- Institute of Regulatory Innovation through Science, Kyung Hee University, Seoul 02447, Republic of Korea;
- College of Pharmacy, Kyung Hee University, Seoul 02447, Republic of Korea
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2
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Ghansah H, Orbán-Kálmándi R, Debreceni IB, Katona É, Rejtő L, Váróczy L, Lóczi L, de Laat B, Huskens D, Kappelmayer J, Bagoly Z. Low factor XIII levels and altered fibrinolysis in patients with multiple myeloma. Thromb Res 2024; 234:12-20. [PMID: 38134612 DOI: 10.1016/j.thromres.2023.12.004] [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: 07/24/2023] [Revised: 11/13/2023] [Accepted: 12/11/2023] [Indexed: 12/24/2023]
Abstract
BACKGROUND Acquired factor FXIII (FXIII) deficiency can be immune- or non-immune mediated and may cause severe bleeding symptoms. The incidence of acquired FXIII deficiency and its etiology in patients with multiple myeloma (MM) are poorly understood. OBJECTIVES To assess FXIII levels and the balance of fibrinolysis in newly diagnosed, untreated MM and monoclonal gammopathy of undetermined significance (MGUS) patients. METHODS FXIII activity, mixing studies, FXIII-A2B2 antigen, total FXIII-B antigen were measured in platelet-poor plasma from 17 untreated MM patients, 33 untreated MGUS patients, and 30 age and sex-matched healthy controls. Besides routine laboratory measurements, the balance of coagulation and fibrinolysis was evaluated using quantitative fibrin monomer (FM) test, thrombin-antithrombin assay, α2-antiplasmin activity, plasmin-α2-antiplasmin (PAP) complex, D-dimer, plasmin generation assay, clot lysis assay, and ClotPro-TPA test. RESULTS FXIII-A2B2 levels were significantly lower in MM patients compared to controls [median (IQR):14.6 (11.2-19.4) vs. 21.8 (17.1-26.4) mg/L, p = 0.0015], whereas total FXIII-B did not differ between groups. Decrease in FXIII activity was parallel to the decrease in FXIII-A2B2. An immune-mediated inhibitory mechanism was ruled out. Free/total FXIII-B was significantly higher in MM patients compared to MGUS and healthy controls, suggesting an etiology of FXIII-A consumption. In MM and MGUS patients, FM, D-dimer, and PAP complex were significantly elevated compared to controls, indicating hypercoagulability and ongoing fibrinolysis. CONCLUSIONS Low FXIII levels due to consumption were observed in MM patients at diagnosis. Hypercoagulability and ongoing fibrinolysis were detected in MM and MGUS, indicating that a disturbed hemostasis balance is already present in the latter benign condition.
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Affiliation(s)
- Harriet Ghansah
- Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary; Kálmán Laki Doctoral School, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Rita Orbán-Kálmándi
- Department of Laboratory Medicine, Faculty of Medicine, Division of Clinical Laboratory Sciences, University of Debrecen, Debrecen, Hungary
| | - Ildikó Beke Debreceni
- Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Éva Katona
- Department of Laboratory Medicine, Faculty of Medicine, Division of Clinical Laboratory Sciences, University of Debrecen, Debrecen, Hungary
| | - László Rejtő
- Department of Hematology, Jósa András Teaching Hospital, Nyíregyháza, Hungary
| | - László Váróczy
- Department of Internal Medicine, Division of Hematology, University of Debrecen, Debrecen, Hungary
| | - Linda Lóczi
- Department of Laboratory Medicine, Faculty of Medicine, Division of Clinical Laboratory Sciences, University of Debrecen, Debrecen, Hungary
| | - Bas de Laat
- Synapse Research Institute, Maastricht, the Netherlands
| | - Dana Huskens
- Synapse Research Institute, Maastricht, the Netherlands
| | - János Kappelmayer
- Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Zsuzsa Bagoly
- Department of Laboratory Medicine, Faculty of Medicine, Division of Clinical Laboratory Sciences, University of Debrecen, Debrecen, Hungary; Hungarian Research Network (HUN-REN-DE) Cerebrovascular Research Group, Debrecen, Hungary.
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3
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Ghansah H, Debreceni IB, Váróczy L, Rejtő L, Lóczi L, Bagoly Z, Kappelmayer J. Patients with multiple myeloma and monoclonal gammopathy of undetermined significance have variably increased thrombin generation and different sensitivity to the anticoagulant effect of activated protein C. Thromb Res 2023; 223:44-52. [PMID: 36708689 DOI: 10.1016/j.thromres.2023.01.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 01/02/2023] [Accepted: 01/11/2023] [Indexed: 01/24/2023]
Abstract
BACKGROUND Patients with multiple myeloma (MM) are at high risk of thrombosis especially when receiving immunomodulatory therapy. Thrombotic risk in patients with monoclonal gammopathy of undetermined significance (MGUS) may also be increased. Although activated protein C (APC) resistance has been linked to an increased risk of thrombosis in MM, little is known about how APC influences thrombotic risk in MGUS. We compared thrombin generation (TG) in MM and MGUS patients to that of healthy controls (HCs) and investigated the exogenous effect of APC on TG in these groups. METHODS Hemostasis tests including factor VIII (FVIII) and von Willebrand factor (vWF) levels were measured in platelet-poor plasma in 14 untreated MM patients, 34 MGUS patients, and 30 age and sex-matched HCs. TG assay was performed with or without the addition of APC. RESULTS Peak thrombin and velocity index were significantly higher in MM and MGUS patients compared to HCs, while MM patients also had elevated endogenous thrombin potential (ETP). In MGUS cases, ETP and peak thrombin values significantly correlated with FVIII and vWF levels. In the presence of APC, peak thrombin and ETP were reduced in MGUS and control plasmas whereas lagtime and time to peak were significantly prolonged. In contrast, adding APC to MM plasma had no effect on any TG parameters. CONCLUSIONS Hypercoagulability was observed in MM and even in MGUS cases with very low monoclonal protein concentration. In MM patients, APC had no effect on TG, but it attenuated TG in MGUS patients.
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Affiliation(s)
- Harriet Ghansah
- Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary; Kálmán Laki Doctoral School, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Ildikó Beke Debreceni
- Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - László Váróczy
- Department of Internal Medicine, Division of Hematology, University of Debrecen, Debrecen, Hungary
| | - László Rejtő
- Department of Hematology, Jósa András Teaching Hospital, Nyíregyháza, Hungary
| | - Linda Lóczi
- Division of Clinical Laboratory Sciences, University of Debrecen, Debrecen, Hungary
| | - Zsuzsa Bagoly
- Division of Clinical Laboratory Sciences, University of Debrecen, Debrecen, Hungary
| | - János Kappelmayer
- Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary.
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4
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Fotiou D, Gavriatopoulou M, Ntanasis-Stathopoulos I, Migkou M, Dimopoulos MA, Terpos E. Updates on thrombotic events associated with multiple myeloma. Expert Rev Hematol 2019; 12:355-365. [DOI: 10.1080/17474086.2019.1604214] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Despina Fotiou
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Maria Gavriatopoulou
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Ioannis Ntanasis-Stathopoulos
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Magdalini Migkou
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Meletios A. Dimopoulos
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Evangelos Terpos
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
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5
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Cornell RF, Goldhaber SZ, Engelhardt BG, Moslehi J, Jagasia M, Patton D, Harrell S, Hall R, Wyatt H, Piazza G. Apixaban for Primary Prevention of Venous Thromboembolism in Patients With Multiple Myeloma Receiving Immunomodulatory Therapy. Front Oncol 2019; 9:45. [PMID: 30873378 PMCID: PMC6401636 DOI: 10.3389/fonc.2019.00045] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Accepted: 01/17/2019] [Indexed: 12/21/2022] Open
Abstract
Immunomodulatory drugs (IMiDs), including thalidomide, lenalidomide, and pomalidomide, have improved survival of patients with multiple myeloma (MM). However, these therapies are associated with an increased risk of venous thromboembolism (VTE). Apixaban has been approved for treatment of acute VTE and for risk reduction of recurrent VTE following initial therapy. In this phase IV single-arm study (NCT02958969), we aim to prospectively evaluate the safety and efficacy of apixaban for primary prevention of VTE in patients with MM. The primary efficacy objective of this trial is to determine the rate of symptomatic VTE, including deep vein thrombosis (DVT) and pulmonary embolism (PE), over 6 months. The primary safety objective is to determine the rate of major bleeding in MM patients receiving apixaban prophylaxis. If proven safe and effective, apixaban will emerge as a promising option for oral VTE prophylaxis in MM patients.
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Affiliation(s)
- Robert Frank Cornell
- Division of Hematology and Oncology, Department of Medicine, Vanderbilt University Medical Center Nashville, TN, United States
| | - Samuel Z Goldhaber
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School Boston, MA, United States
| | - Brian G Engelhardt
- Division of Hematology and Oncology, Department of Medicine, Vanderbilt University Medical Center Nashville, TN, United States
| | - Javid Moslehi
- Cardio-Oncology Program, Vanderbilt University Medical Center Nashville, TN, United States
| | - Madan Jagasia
- Division of Hematology and Oncology, Department of Medicine, Vanderbilt University Medical Center Nashville, TN, United States
| | - Daryl Patton
- Vanderbilt Institute for Clinical and Translational Research Nashville, TN, United States
| | - Shelton Harrell
- Division of Hematology and Oncology, Department of Medicine, Vanderbilt University Medical Center Nashville, TN, United States
| | - Robert Hall
- Division of Hematology and Oncology, Department of Medicine, Vanderbilt University Medical Center Nashville, TN, United States
| | - Houston Wyatt
- Division of Hematology and Oncology, Department of Medicine, Vanderbilt University Medical Center Nashville, TN, United States
| | - Greg Piazza
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School Boston, MA, United States
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Nielsen T, Kristensen SR, Gregersen H, Teodorescu EM, Christiansen G, Pedersen S. Extracellular vesicle-associated procoagulant phospholipid and tissue factor activity in multiple myeloma. PLoS One 2019; 14:e0210835. [PMID: 30640949 PMCID: PMC6331130 DOI: 10.1371/journal.pone.0210835] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 01/02/2019] [Indexed: 11/18/2022] Open
Abstract
Multiple myeloma (MM) patients have increased risk of developing venous thromboembolism, but the underlying mechanisms and the effect on the coagulation system of the disease and the current cancer therapies are not known. It is possible that cancer-associated extracellular vesicles (EV), carrying tissue factor (TF) and procoagulant phospholipids (PPL) may play a role in thrombogenesis. The aim of this study was to perform an in-depth analysis of procoagulant activity of small and large EVs isolated from 20 MM patients at diagnosis and after receiving first-line treatment compared with 20 healthy control subjects. Differential ultracentrifugation at 20,000 × g and 100,000 × g were used to isolate EVs for quantitative and phenotypical analysis through nanoparticle tracking analysis, Western blotting and transmission electron microscopy. The isolated EVs were analyzed for procoagulant activity using the calibrated automated thrombogram technique, a factor Xa-based activity assay, and the STA Procoag-PPL assay. In general, MM patients contained more EVs, and immunoelectron microscopy confirmed the presence of CD9- and CD38-positive EVs. EVs in the 20,000 × g pellets from MM patients exerted procoagulant activity visualized by increased thrombin generation and both TF and PPL activity. This effect diminished during treatment, with the most prominent effect observed in the high-dose chemotherapy eligible patients after induction therapy with bortezomib, cyclophosphamide, and dexamethasone. In conclusion, the EVs in patients with MM carrying TF and PPL are thus capable of exerting procoagulant activity.
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Affiliation(s)
- Thøger Nielsen
- Department of Clinical Biochemistry, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Faculty of Medicine, Aalborg University Hospital, Aalborg, Denmark
| | - Søren Risom Kristensen
- Department of Clinical Biochemistry, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Faculty of Medicine, Aalborg University Hospital, Aalborg, Denmark
| | - Henrik Gregersen
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Faculty of Medicine, Aalborg University Hospital, Aalborg, Denmark
- Department of Haematology, Aalborg University Hospital, Aalborg, Denmark
| | - Elena Manuela Teodorescu
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Faculty of Medicine, Aalborg University Hospital, Aalborg, Denmark
- Department of Haematology, Aalborg University Hospital, Aalborg, Denmark
| | | | - Shona Pedersen
- Department of Clinical Biochemistry, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Faculty of Medicine, Aalborg University Hospital, Aalborg, Denmark
- * E-mail:
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7
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Zhuang Q, Xiang L, Xu H, Fang F, Xing C, Liang B, Yu K, Feng J. The independent association of mean platelet volume with overall survival in multiple myeloma. Oncotarget 2018; 7:62640-62646. [PMID: 27566590 PMCID: PMC5308753 DOI: 10.18632/oncotarget.11551] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Accepted: 08/13/2016] [Indexed: 11/25/2022] Open
Abstract
We retrospectively analyzed the association between mean platelet volume (MPV) and prognosis in 62 newly diagnosed multiple myeloma (MM) patients. The associations between MPV and clinical characteristics were assessed. The log-rank test and the Cox proportional hazards model were used to evaluate the effect of MPV on survival. A MPV value of 8.50 fl was considered to be the optimal cut-off value for prognosis. MPV was associated with IgA isotype (P=0.012), serum creatinine concentration > 176.8 μmol/L (P=0.025) and IgH rearrangement (P=0.008). The log-rank test demonstrated that patients with low MPV experienced a shorter overall survival (OS) (P=0.0397). The multivariate analysis demonstrated that low MPV was an independent prognostic factor for OS [hazard ratio (HR)=2.44, P=0.026]. Therefore, we demonstrated that low MPV predicted an unfavorable prognosis in patients with MM.
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Affiliation(s)
- Qiang Zhuang
- Department of Hematology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, PR China
| | - Lina Xiang
- Department of Emergency Medicine, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, PR China
| | - Hanyan Xu
- Department of Pneumology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, PR China
| | - Fang Fang
- Department of Hematology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, PR China
| | - Chongyun Xing
- Department of Hematology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, PR China
| | - Bin Liang
- Department of Hematology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, PR China
| | - Kang Yu
- Department of Hematology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, PR China
| | - Jianhua Feng
- Department of Hematology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, PR China.,Department of Pediatric Hematology-Oncology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, PR China
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8
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Intracranial hemorrhage as initial manifestation of plasma cell myeloma: A case report. J Clin Neurosci 2018; 50:133-135. [PMID: 29428262 DOI: 10.1016/j.jocn.2018.01.054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 01/08/2018] [Indexed: 11/23/2022]
Abstract
This is the case of a previously healthy 48 year-old male whom presented with mild confusion, low-grade headache, and left sided weakness. Computed tomography of the head revealed a large acute right frontal lobe intracranial hemorrhage (ICH) and intraventricular extension, with normal vascular imaging. Initial laboratory testing was inconsequential. The patient required emergent evacuation, with pathology revealing only elements of a hematoma. Further laboratory testing and bone marrow biopsy results confirmed the diagnosis of plasma cell myeloma. Other systemic signs/symptoms of this disease were notably absent. This report provides the first description of an ICH as the presenting manifestation of plasma cell myeloma (PCM; multiple myeloma).
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9
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Nomura S, Ito T, Yoshimura H, Hotta M, Nakanishi T, Fujita S, Nakaya A, Satake A, Ishii K. Evaluation of thrombosis-related biomarkers before and after therapy in patients with multiple myeloma. J Blood Med 2018; 9:1-7. [PMID: 29403323 PMCID: PMC5783022 DOI: 10.2147/jbm.s147743] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Background Thrombosis is one of the complications in the clinical course of multiple myeloma (MM). Vascular endothelial cells and/or the hemostatic-coagulatory system are thought to play an important role in thrombosis of MM. In addition to melphalan-prednisone (Mel-P) therapy, several new therapeutic drugs such as lenalidomide or bortezomib have been developed and show effectiveness against MM. However, these new drugs also have risk of therapy-related thrombosis. Methods We assessed 103 MM patients and 30 healthy controls, using enzyme-linked immunosorbent assays to evaluate five biomarkers: platelet-derived microparticles (PDMP), plasminogen activator inhibitor-1 (PAI-1), high mobility group box protein-1 (HMGB1), endothelial protein C receptor (EPCR), and soluble vascular cell adhesion molecule-1 (sVCAM-1). The effects of Mel-P, bortezomib, and lenalidomide on the plasma concentrations of these biomarkers were investigated. Results The plasma concentrations of PDMP, PAI-1, HMGB1, EPCR, and sVCAM-1 were higher in MM patients than in healthy controls. Mel-P, bortezomib, and lenalidomide therapies all reduced biomarker levels after treatment. However, when only patients with higher levels of EPCR were compared, differences were seen between the three therapies in the elevation of PDMP, HMGB1, and PAI-1. Conclusion These results suggest that both MM and therapies for MM can induce a hypercoagulable state. The elevated risk of thrombosis conferred by hypercoagulability increases patient morbidity and mortality. Attention should be paid to therapy-related thrombosis when new therapeutic regimens are selected for MM patients.
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Affiliation(s)
- Shosaku Nomura
- First Department of Internal Medicine, Kansai Medical University, Osaka, Japan
| | - Tomoki Ito
- First Department of Internal Medicine, Kansai Medical University, Osaka, Japan
| | - Hideaki Yoshimura
- First Department of Internal Medicine, Kansai Medical University, Osaka, Japan
| | - Masaaki Hotta
- First Department of Internal Medicine, Kansai Medical University, Osaka, Japan
| | - Takahisa Nakanishi
- First Department of Internal Medicine, Kansai Medical University, Osaka, Japan
| | - Shinya Fujita
- First Department of Internal Medicine, Kansai Medical University, Osaka, Japan
| | - Aya Nakaya
- First Department of Internal Medicine, Kansai Medical University, Osaka, Japan
| | - Atsushi Satake
- First Department of Internal Medicine, Kansai Medical University, Osaka, Japan
| | - Kazuyoshi Ishii
- First Department of Internal Medicine, Kansai Medical University, Osaka, Japan
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10
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Rodon P, Hulin C, Daley L, Dauriac C, Hacini M, Decaux O, Eisemann JC, Fitoussi O, Lioure B, Voillat L, Slama B, Al Jijakli A, Benramdane R, Chaleteix C, Costello R, Thyss A, Mathiot C, Eileen B, Maloisel F, Stoppa AM, Kolb B, Michallet M, Lamblin A, Natta P, Facon T, Elalamy I, Fermand JP, Moreau P, Leleu X. MELISSE, a large multicentric observational study to determine risk factors of venous thromboembolism in patients with multiple myeloma treated with immunomodulatory drugs. Thromb Haemost 2017; 110:844-51. [DOI: 10.1160/th13-02-0140] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2013] [Accepted: 06/22/2013] [Indexed: 01/06/2023]
Abstract
SummaryImmunomodulatory drugs (IMiDs) are associated with an increased risk of venous thromboembolism (VTE) in multiple myeloma (MM) patients. We designed MELISSE, a multicentre prospective observational study, to evaluate VTE incidence and identify risk factors in IMiDstreated MM. Our objective was to determine the real-life practice of VTE prophylaxis strategy. A total of 524 MM patients were included, and we planned to collect information at baseline, at four and at 12 months, on MM therapy, on VTE risk factors and management. VTE incidence was 7% (n=31), including 2.5% pulmonary embolism (PE) (n=11), similar at four or 12 months. VTE was observed at all risk assessment levels, although the increased risk assessment level correlated to a lower rate of VTE, maybe due to the implemented thromboprophylaxis strategy. VTE occurred in 7% on aspirin vs 3% on lowmolecular- weight heparin (LMWH) prophylaxis, and none on vitamin K antagonists (VKA). New risk factors for VTE in IMiDs-treated MM were identified. In conclusion, VTE prophylaxis is compulsory in IMiDstreated MM, based on individualised VTE risk assessment. Anticoagulation prophylaxis with LMWH should clearly be prioritised in MM patients with high VTE risk, along with VKA. Further prospective studies will identify most relevant VTE risk factors in IMiDs-treated MM to select accurately which MM patients should receive LMWH prophylaxis and for which duration to optimise VTE risk reduction.
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11
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Gutwein O, Rahimi-Levene N, Herzog-Tzarfati K, Garach-Jehoshua O, Nagler A, Izak M, Koren-Michowitz M. Low Protein Z levels in patients with plasma cell neoplasms are inversely correlated with IL-6 levels. Leuk Res 2017; 62:104-107. [PMID: 29031125 DOI: 10.1016/j.leukres.2017.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Revised: 08/16/2017] [Accepted: 09/24/2017] [Indexed: 11/27/2022]
Abstract
Patients with multiple myeloma (MM) have an increased thrombotic risk, but pathogenesis remains uncertain. Low levels of Protein Z (PZ), a vitamin K-dependent plasma protein, are associated with venous as well as arterial thrombosis. The purpose of this study was to analyze PZ levels in patients with plasma cell neoplasms. PATIENTS AND METHODS The study consisted of 64 plasma cells neoplasm patients and 42 healthy individuals. Clinical investigations included measurement of plasma PZ and IL-6 levels. RESULTS PZ levels in patients with plasma cell neoplasms were significantly lower compared to healthy controls in the entire cohort (1392±659 vs.2010±603ng/mL, P<0.01), as well as in specific disease subgroups; symptomatic MM (1428±652ng/mL, p<0.01), smoldering MM (1437±883ng/mL, p=0.045) and monoclonal gammopathy of undetermined significance (MGUS) (1247±593ng/mL, p=0.01). PZ was negatively correlated with IL-6 levels in MM patients (r=-0.7, P<0.01). There was no significant difference in PZ levels between patients with or without thrombotic event. CONCLUSION Plasma cell neoplasm patients have low levels of PZ. This is presumably related to the increased IL-6 production by the bone marrow microenvironment, and could have a potential role in the increased thrombotic tendency in those patients.
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Affiliation(s)
- O Gutwein
- Division of Hematology, Assaf Harofeh Medical Center, Zerifin, Israel; Sackler Faculty of Medicine, Tel Aviv University, Israel.
| | - N Rahimi-Levene
- Division of Hematology, Assaf Harofeh Medical Center, Zerifin, Israel; Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - K Herzog-Tzarfati
- Division of Hematology, Assaf Harofeh Medical Center, Zerifin, Israel; Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - O Garach-Jehoshua
- Division of Hematology, Assaf Harofeh Medical Center, Zerifin, Israel; Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - A Nagler
- Sackler Faculty of Medicine, Tel Aviv University, Israel; Division of Hematology, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - M Izak
- Division of Hematology, Assaf Harofeh Medical Center, Zerifin, Israel; Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - M Koren-Michowitz
- Division of Hematology, Assaf Harofeh Medical Center, Zerifin, Israel; Sackler Faculty of Medicine, Tel Aviv University, Israel
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12
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Nowak W, Treliński J, Chojnowski K, Matczak J, Robak M, Misiewicz M, Nowak P. Assessment of oxidative/nitrative modifications of plasma proteins, selected ROTEM parameters and kinetics of fibrinogen polymerization in patients with multiple myeloma at diagnosis. Med Oncol 2016; 34:4. [DOI: 10.1007/s12032-016-0856-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Accepted: 11/18/2016] [Indexed: 10/20/2022]
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13
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Fotiou D, Gerotziafas G, Kastritis E, Dimopoulos MA, Terpos E. A review of the venous thrombotic issues associated with multiple myeloma. Expert Rev Hematol 2016; 9:695-706. [DOI: 10.1080/17474086.2016.1194750] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
- Despina Fotiou
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Grigoris Gerotziafas
- INSERM U938, Faculté de Médecine Pierre et Marie Curie, Université Paris VI, Paris, France
- Thrombosis Center, Service d’Hématologie Biologique Hôpital Tenon, Hôpitaux Universitaires de l’Est Parisien, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Efstathios Kastritis
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Meletios A. Dimopoulos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Evangelos Terpos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
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14
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Colombo R, Gallipoli P, Castelli R. Thrombosis and hemostatic abnormalities in hematological malignancies. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2014; 14:441-50. [PMID: 25018062 DOI: 10.1016/j.clml.2014.05.003] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Accepted: 05/19/2014] [Indexed: 01/19/2023]
Abstract
There is a paucity of data that pertain to thrombosis in patients with hematological malignancies. Recent studies showed that patients with lymphoma, multiple myeloma, and acute leukemia have an increased thrombotic risk, particularly at the time of diagnosis and during chemotherapy. We searched the PubMed database for articles on thromboembolic complications in patients with hematological malignancies published between 1996 and 2013. The incidence of thrombotic events is variable, and is influenced by the type and the stage of hematological malignancy, the antitumor therapy, and the use of central venous devices. The pathogenesis of thromboembolic disease in hematological malignancies is multifactorial. Tumor cell-derived procoagulant, fibrinolytic, or proteolytic factors, and inflammatory cytokines affect clotting activation, and chemotherapy and immunomodulatory drugs increase the thrombotic risk in patients with lymphoma, acute leukemia, and multiple myeloma. Infections might also contribute to the pathogenesis of the thromboembolic complications: endotoxins from gram-negative bacteria induce the release of tissue factor, tumor necrosis factor and interleukin-1b, and gram-positive organisms can release bacterial mucopolysaccharides that directly activate factor XII. In the setting of plasma cell dyscrasias, hyperviscosity, decreased fibrinolysis, procoagulant autoantibody production, inflammatory cytokines, acquired activated protein C resistance, and the prothrombotic effects of antimyeloma agents might be the cause of thromboembolic complications. Anticoagulant therapy is very complicated because of high risk of hemorrhage. Therefore, an accurate estimate of a patient's thrombotic risk is essential to allow physicians to target thromboprophylaxis in high-risk patients.
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Affiliation(s)
- Riccardo Colombo
- Department of Pathophysiology and Transplantation, Internal Medicine Section, University of Milan, and Department of Haematology, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - Paolo Gallipoli
- Department of Haematology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - Roberto Castelli
- Department of Pathophysiology and Transplantation, Internal Medicine Section, University of Milan, and Department of Haematology, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy.
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15
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Undas A, Zubkiewicz-Usnarska L, Helbig G, Woszczyk D, Kozińska J, Dmoszyńska A, Podolak-Dawidziak M, Kuliczkowski K. Altered plasma fibrin clot properties and fibrinolysis in patients with multiple myeloma. Eur J Clin Invest 2014; 44:557-66. [PMID: 24738991 DOI: 10.1111/eci.12269] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2013] [Accepted: 04/11/2014] [Indexed: 12/15/2022]
Abstract
BACKGROUND Multiple myeloma (MM) is associated with increased risk of venous and arterial thromboembolism. Formation of denser and poorly lysable fibrin clots is observed in patients with arterial and venous thromboembolism. We investigated fibrin clot properties and their determinants in MM patients. MATERIALS AND METHODS Ex vivo plasma fibrin clot permeability, turbidity and susceptibility to lysis were evaluated in 106 MM patients at the time of diagnosis vs. 100 age- and sex-matched controls. MM patients had lower clot permeability (Ks ), compaction, indicating denser fibrin clots, impaired fibrin polymerization with longer lag phase and lower final turbidity (D-Dmax ), combined with hypofibrinolysis reflected by longer lysis time and slower rate of D-dimer release from fibrin clots (D-Drate ) compared with controls (all P < 0·001). RESULTS Patients with IgG MM had lower Ks compared with IgA MM [5·9 (5·1-6·4) vs. 6·3 (5·9-7·2) 10(-9) cm(2) ; P = 0·007] and longer lysis time compared with light-chain-disease patients [11·4 (10·9-12·3) vs. 10·7 (9·8-11·9) min; P = 0·022]. Of the fibrin variables, only Ks was significantly lower in patients with International Staging System (ISS) grade III than in those with ISS grade I and II [5·9 (4·9-6·6) vs. 6·2 (5·7-6·8) 10(-9) cm(2) ; P = 0·015]. Multivariate analysis adjusted for age and fibrinogen showed that in MM patients elevated peak thrombin levels determine Ks and D-Dmax , while thrombin-activatable fibrinolysis inhibitor (TAFI) activity predicts Ks , t50% , D-Drate and lag phase. CONCLUSIONS Our study demonstrates prothrombotic fibrin clot phenotype in patients with MM, with a significant impact of increased thrombin formation and TAFI activity.
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Affiliation(s)
- Anetta Undas
- Institute of Cardiology, Jagiellonian University Medical College, and John Paul II Hospital, Krakow, Poland
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16
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Assessment of rotation thromboelastometry (ROTEM) parameters in patients with multiple myeloma at diagnosis. Thromb Res 2014; 133:667-70. [DOI: 10.1016/j.thromres.2014.01.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2013] [Revised: 12/19/2013] [Accepted: 01/06/2014] [Indexed: 11/18/2022]
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17
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Dri AP, Politou M, Gialeraki A, Bagratuni T, Kanellias N, Terpos E. Decreased incidence of EPCR 4678G/C SNP in multiple myeloma patients with thrombosis. Thromb Res 2013; 132:400-1. [PMID: 23993723 DOI: 10.1016/j.thromres.2013.07.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Revised: 07/30/2013] [Accepted: 07/30/2013] [Indexed: 10/26/2022]
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18
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Fouquet G, Tardy S, Demarquette H, Bonnet S, Gay J, Debarri H, Herbaux C, Guidez S, Michel J, Perrot A, Serrier C, Miljkovic D, Avet Loiseau H, Facon T, Hulin C, Leleu X. Efficacy and safety profile of long-term exposure to lenalidomide in patients with recurrent multiple myeloma. Cancer 2013; 119:3680-6. [DOI: 10.1002/cncr.28274] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2013] [Revised: 05/15/2013] [Accepted: 05/22/2013] [Indexed: 02/02/2023]
Affiliation(s)
| | | | - Hélène Demarquette
- Hematology Department; Huriez Regional University Hospital; Lille France
| | - Sarah Bonnet
- Hematology Department; Huriez Regional University Hospital; Lille France
| | - Julie Gay
- Hematology Department; Huriez Regional University Hospital; Lille France
| | - Houria Debarri
- Hematology Department; Huriez Regional University Hospital; Lille France
| | - Charles Herbaux
- Hematology Department; Huriez Regional University Hospital; Lille France
| | - Stéphanie Guidez
- Hematology Department; Huriez Regional University Hospital; Lille France
| | | | | | | | | | | | - Thierry Facon
- Hematology Department; Huriez Regional University Hospital; Lille France
| | | | - Xavier Leleu
- Hematology Department; Huriez Regional University Hospital; Lille France
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