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Liu W, Zhu X, Xiao Y. Neurological involvement in hematopoietic stem cell transplantation-associated thrombotic microangiopathy. Ann Hematol 2024:10.1007/s00277-024-05798-6. [PMID: 38763940 DOI: 10.1007/s00277-024-05798-6] [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: 11/21/2023] [Accepted: 05/08/2024] [Indexed: 05/21/2024]
Abstract
Transplantation-associated thrombotic microangiopathy (TA-TMA) is a well-recognized serious complication of hematopoietic stem cell transplantation (HSCT). The understanding of TA-TMA pathophysiology has expanded in recent years. Dysregulation of the complement system is thought to cause endothelial injury and, consequently, microvascular thrombosis and tissue damage. TA-TMA can affect multiple organs, and each organ exhibits specific features of injury. Central nervous system (CNS) manifestations of TA-TMA include posterior reversible encephalopathy syndrome, seizures, and encephalopathy. The development of neurological dysfunction is associated with a significantly lower overall survival in patients with TA-TMA. However, there are currently no established histopathological or radiological criteria for the diagnosis of CNS TMA. Patients who receive total body irradiation (TBI), calcineurin inhibitors (CNI), and severe acute and chronic graft-versus-host disease (GVHD) are at a high risk of experiencing neurological complications related to TA-TMA and should be considered for directed TA-TMA therapy. However, the incidence and clinical manifestations of TA-TMA neurotoxicity remain unclear. Studies specifically examining the involvement of CNS in TMA syndromes are limited. In this review, we discuss clinical manifestations and imaging abnormalities in patients with nervous system involvement in TA-TMA. We summarize the mechanisms underlying TA-TMA and its neurological complications, including endothelial injury, evidence of complement activation, and treatment options for TA-TMA.
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Affiliation(s)
- Wanying Liu
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Xiaojian Zhu
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China.
| | - Yi Xiao
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China.
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Evangelidis P, Evangelidis N, Kalmoukos P, Kourti M, Tragiannidis A, Gavriilaki E. Genetic Susceptibility in Endothelial Injury Syndromes after Hematopoietic Cell Transplantation and Other Cellular Therapies: Climbing a Steep Hill. Curr Issues Mol Biol 2024; 46:4787-4802. [PMID: 38785556 PMCID: PMC11119915 DOI: 10.3390/cimb46050288] [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: 04/13/2024] [Revised: 05/10/2024] [Accepted: 05/14/2024] [Indexed: 05/25/2024] Open
Abstract
Hematopoietic stem cell transplantation (HSCT) remains a cornerstone in the management of patients with hematological malignancies. Endothelial injury syndromes, such as HSCT-associated thrombotic microangiopathy (HSCT-TMA), veno-occlusive disease/sinusoidal obstruction syndrome (SOS/VOD), and capillary leak syndrome (CLS), constitute complications after HSCT. Moreover, endothelial damage is prevalent after immunotherapy with chimeric antigen receptor-T (CAR-T) and can be manifested with cytokine release syndrome (CRS) or immune effector cell-associated neurotoxicity syndrome (ICANS). Our literature review aims to investigate the genetic susceptibility in endothelial injury syndromes after HSCT and CAR-T cell therapy. Variations in complement pathway- and endothelial function-related genes have been associated with the development of HSCT-TMA. In these genes, CFHR5, CFHR1, CFHR3, CFI, ADAMTS13, CFB, C3, C4, C5, and MASP1 are included. Thus, patients with these variations might have a predisposition to complement activation, which is also exaggerated by other factors (such as acute graft-versus-host disease, infections, and calcineurin inhibitors). Few studies have examined the genetic susceptibility to SOS/VOD syndrome, and the implicated genes include CFH, methylenetetrahydrofolate reductase, and heparinase. Finally, specific mutations have been associated with the onset of CRS (PFKFB4, CX3CR1) and ICANS (PPM1D, DNMT3A, TE2, ASXL1). More research is essential in this field to achieve better outcomes for our patients.
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Affiliation(s)
- Paschalis Evangelidis
- 2nd Propedeutic Department of Internal Medicine, Hippocration Hospital, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece; (P.E.); (N.E.); (P.K.)
| | - Nikolaos Evangelidis
- 2nd Propedeutic Department of Internal Medicine, Hippocration Hospital, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece; (P.E.); (N.E.); (P.K.)
| | - Panagiotis Kalmoukos
- 2nd Propedeutic Department of Internal Medicine, Hippocration Hospital, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece; (P.E.); (N.E.); (P.K.)
| | - Maria Kourti
- 3rd Department of Pediatrics, Hippocration Hospital, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece;
| | - Athanasios Tragiannidis
- 2nd Department of Pediatrics, AHEPA University Hospital, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece;
| | - Eleni Gavriilaki
- 2nd Propedeutic Department of Internal Medicine, Hippocration Hospital, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece; (P.E.); (N.E.); (P.K.)
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Tran MH, Patel S, Desai S, Ciurea S, Lee BJ, Hanna R. Thrombotic microangiopathy - the importance of a multidisciplinary approach. Curr Opin Nephrol Hypertens 2024; 33:247-256. [PMID: 38018789 DOI: 10.1097/mnh.0000000000000954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2023]
Abstract
PURPOSE OF REVIEW The purpose of this review is to highlight the importance of a multidisciplinary thrombotic microangiopathies (TMA) Team. This goal will be accomplished through review of the complement system, discuss various causes of thrombotic microangiopathies (TMA), and aspects of their diagnosis and management. In so doing, readers will gain an appreciation for the complexity of this family of disorders and realize the benefit of a dedicated multidisciplinary TMA Team. RECENT FINDINGS TMA causes derive from multiple specialty areas, are difficult to timely recognize, pose complex challenges, and require multidisciplinary management. Hematopoietic stem cell transplant-associated TMA (TA-TMA) and TA-TMA related multiorgan dysfunction syndrome (TA-TMA MODS) are areas of burgeoning research; use of complement testing and eculizumab precision-dosing has been found to better suppress complement activity in TA-TMA than standard eculizumab dosing. Newer tests are available to risk-stratify obstetric patients at risk for severe pre-eclampsia, whose features resemble those of TA-TMA MODS. Numerous disorders may produce TMA-like findings, and a systematic approach aids in their identification. TMA Teams elevate institutional awareness of increasingly recognized TMAs, will help expedite diagnostic and therapeutic interventions, and create pathways to future TMA-related research and facilitate access to clinical trials. SUMMARY Establishment of a TMA-Team is valuable in developing the necessary institutional expertise needed to promptly recognize and appropriately manage patients with TMA.
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Affiliation(s)
- Minh-Ha Tran
- University of California-Irvine, Department of Pathology-Division of Transfusion Medicine
| | - Samir Patel
- University of California Irvine, Department of Medicine - Division of Nephrology
| | - Sheetal Desai
- University of California-Irvine, Department of Medicine- Division of Rheumatology
| | - Stefan Ciurea
- University of California Irvine, Department of Medicine- Division of Hematology-Oncology-HSCT/CT Program
| | - Benjamin J Lee
- University of California Irvine, Department of Pharmacy, Irvine, California, USA
| | - Ramy Hanna
- University of California Irvine, Department of Medicine - Division of Nephrology
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Gavriilaki E, Bousiou Z, Batsis I, Vardi A, Mallouri D, Koravou EE, Konstantinidou G, Spyridis N, Karavalakis G, Noli F, Patriarcheas V, Masmanidou M, Touloumenidou T, Papalexandri A, Poziopoulos C, Yannaki E, Sakellari I, Politou M, Papassotiriou I. Soluble Urokinase-Type Plasminogen Activator Receptor (suPAR) and Growth Differentiation Factor-15 (GDF-15) Levels Are Significantly Associated with Endothelial Injury Indices in Adult Allogeneic Hematopoietic Cell Transplantation Recipients. Int J Mol Sci 2023; 25:231. [PMID: 38203404 PMCID: PMC10778584 DOI: 10.3390/ijms25010231] [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: 11/21/2023] [Revised: 12/17/2023] [Accepted: 12/18/2023] [Indexed: 01/12/2024] Open
Abstract
Hematopoietic stem cell transplantation-associated thrombotic microangiopathy (HSCT-TMA) and graft-versus-host disease (GvHD) represent life-threatening syndromes after allogeneic hematopoietic stem cell transplantation (allo-HSCT). In both conditions, endothelial dysfunction is a common denominator, and development of relevant biomarkers is of high importance for both diagnosis and prognosis. Despite the fact that soluble urokinase plasminogen activator receptor (suPAR) and growth differentiation factor-15 (GDF-15) have been determined as endothelial injury indices in various clinical settings, their role in HSCT-related complications remains unexplored. In this context, we used immunoenzymatic methods to measure suPAR and GDF-15 levels in HSCT-TMA, acute and/or chronic GVHD, control HSCT recipients, and apparently healthy individuals of similar age and gender. We found considerably greater SuPAR and GDF-15 levels in HSCT-TMA and GVHD patients compared to allo-HSCT and healthy patients. Both GDF-15 and suPAR concentrations were linked to EASIX at day 100 and last follow-up. SuPAR was associated with creatinine and platelets at day 100 and last follow-up, while GDF-15 was associated only with platelets, suggesting that laboratory values do not drive EASIX. SuPAR, but not GDF-15, was related to soluble C5b-9 levels, a sign of increased HSCT-TMA risk. Our study shows for the first time that suPAR and GDF-15 indicate endothelial damage in allo-HSCT recipients. Rigorous validation of these biomarkers in many cohorts may provide utility for their usefulness in identifying and stratifying allo-HSCT recipients with endothelial cell impairment.
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Affiliation(s)
- Eleni Gavriilaki
- Second Propedeutic Department of Internal Medicine, Hippocration Hospital, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece
| | - Zoi Bousiou
- BMT Unit, Hematology Department, George Papanicolaou General Hospital, 57010 Thessaloniki, Greece; (Z.B.); (I.B.); (A.V.); (D.M.); (E.-E.K.); (G.K.); (N.S.); (G.K.); (F.N.); (V.P.); (M.M.); (T.T.); (A.P.); (E.Y.); (I.S.)
| | - Ioannis Batsis
- BMT Unit, Hematology Department, George Papanicolaou General Hospital, 57010 Thessaloniki, Greece; (Z.B.); (I.B.); (A.V.); (D.M.); (E.-E.K.); (G.K.); (N.S.); (G.K.); (F.N.); (V.P.); (M.M.); (T.T.); (A.P.); (E.Y.); (I.S.)
| | - Anna Vardi
- BMT Unit, Hematology Department, George Papanicolaou General Hospital, 57010 Thessaloniki, Greece; (Z.B.); (I.B.); (A.V.); (D.M.); (E.-E.K.); (G.K.); (N.S.); (G.K.); (F.N.); (V.P.); (M.M.); (T.T.); (A.P.); (E.Y.); (I.S.)
| | - Despina Mallouri
- BMT Unit, Hematology Department, George Papanicolaou General Hospital, 57010 Thessaloniki, Greece; (Z.B.); (I.B.); (A.V.); (D.M.); (E.-E.K.); (G.K.); (N.S.); (G.K.); (F.N.); (V.P.); (M.M.); (T.T.); (A.P.); (E.Y.); (I.S.)
| | - Evaggelia-Evdoxia Koravou
- BMT Unit, Hematology Department, George Papanicolaou General Hospital, 57010 Thessaloniki, Greece; (Z.B.); (I.B.); (A.V.); (D.M.); (E.-E.K.); (G.K.); (N.S.); (G.K.); (F.N.); (V.P.); (M.M.); (T.T.); (A.P.); (E.Y.); (I.S.)
| | - Georgia Konstantinidou
- BMT Unit, Hematology Department, George Papanicolaou General Hospital, 57010 Thessaloniki, Greece; (Z.B.); (I.B.); (A.V.); (D.M.); (E.-E.K.); (G.K.); (N.S.); (G.K.); (F.N.); (V.P.); (M.M.); (T.T.); (A.P.); (E.Y.); (I.S.)
| | - Nikolaos Spyridis
- BMT Unit, Hematology Department, George Papanicolaou General Hospital, 57010 Thessaloniki, Greece; (Z.B.); (I.B.); (A.V.); (D.M.); (E.-E.K.); (G.K.); (N.S.); (G.K.); (F.N.); (V.P.); (M.M.); (T.T.); (A.P.); (E.Y.); (I.S.)
| | - Georgios Karavalakis
- BMT Unit, Hematology Department, George Papanicolaou General Hospital, 57010 Thessaloniki, Greece; (Z.B.); (I.B.); (A.V.); (D.M.); (E.-E.K.); (G.K.); (N.S.); (G.K.); (F.N.); (V.P.); (M.M.); (T.T.); (A.P.); (E.Y.); (I.S.)
| | - Foteini Noli
- BMT Unit, Hematology Department, George Papanicolaou General Hospital, 57010 Thessaloniki, Greece; (Z.B.); (I.B.); (A.V.); (D.M.); (E.-E.K.); (G.K.); (N.S.); (G.K.); (F.N.); (V.P.); (M.M.); (T.T.); (A.P.); (E.Y.); (I.S.)
| | - Vasileios Patriarcheas
- BMT Unit, Hematology Department, George Papanicolaou General Hospital, 57010 Thessaloniki, Greece; (Z.B.); (I.B.); (A.V.); (D.M.); (E.-E.K.); (G.K.); (N.S.); (G.K.); (F.N.); (V.P.); (M.M.); (T.T.); (A.P.); (E.Y.); (I.S.)
| | - Marianna Masmanidou
- BMT Unit, Hematology Department, George Papanicolaou General Hospital, 57010 Thessaloniki, Greece; (Z.B.); (I.B.); (A.V.); (D.M.); (E.-E.K.); (G.K.); (N.S.); (G.K.); (F.N.); (V.P.); (M.M.); (T.T.); (A.P.); (E.Y.); (I.S.)
| | - Tasoula Touloumenidou
- BMT Unit, Hematology Department, George Papanicolaou General Hospital, 57010 Thessaloniki, Greece; (Z.B.); (I.B.); (A.V.); (D.M.); (E.-E.K.); (G.K.); (N.S.); (G.K.); (F.N.); (V.P.); (M.M.); (T.T.); (A.P.); (E.Y.); (I.S.)
| | - Apostolia Papalexandri
- BMT Unit, Hematology Department, George Papanicolaou General Hospital, 57010 Thessaloniki, Greece; (Z.B.); (I.B.); (A.V.); (D.M.); (E.-E.K.); (G.K.); (N.S.); (G.K.); (F.N.); (V.P.); (M.M.); (T.T.); (A.P.); (E.Y.); (I.S.)
| | - Christos Poziopoulos
- Department of Hematology, Metropolitan Hospital, Neo Faliro, 18547 Athens, Greece;
| | - Evangelia Yannaki
- BMT Unit, Hematology Department, George Papanicolaou General Hospital, 57010 Thessaloniki, Greece; (Z.B.); (I.B.); (A.V.); (D.M.); (E.-E.K.); (G.K.); (N.S.); (G.K.); (F.N.); (V.P.); (M.M.); (T.T.); (A.P.); (E.Y.); (I.S.)
| | - Ioanna Sakellari
- BMT Unit, Hematology Department, George Papanicolaou General Hospital, 57010 Thessaloniki, Greece; (Z.B.); (I.B.); (A.V.); (D.M.); (E.-E.K.); (G.K.); (N.S.); (G.K.); (F.N.); (V.P.); (M.M.); (T.T.); (A.P.); (E.Y.); (I.S.)
| | - Marianna Politou
- Hematology Laboratory-Blood Bank, Aretaieion Hospital, School of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece;
| | - Ioannis Papassotiriou
- First Department of Pediatrics, School of Medicine, National and Kapodistrian University of Athens, 15772 Athens, Greece;
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