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Wiegley N, Arora S, Norouzi S, Rovin B. A Comprehensive and Practical Approach to the Management of Lupus Nephritis in the Current Era. ADVANCES IN KIDNEY DISEASE AND HEALTH 2024; 31:234-245. [PMID: 39004463 DOI: 10.1053/j.akdh.2023.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 09/27/2023] [Accepted: 11/29/2023] [Indexed: 07/16/2024]
Abstract
Lupus nephritis (LN) is a severe complication of systemic lupus erythematosus (SLE) and is one of the leading causes of morbidity and mortality in patients with SLE. It is estimated that up to 60% of individuals with SLE will develop LN, which can manifest at any stage of a patient's life; however, it commonly emerges early in the course of SLE and tends to exhibit a more aggressive phenotype in men compared to women. Black and Hispanic patients are more likely to progress to kidney failure than white patients. LN is characterized by kidney inflammation and chronic parenchymal damage, leading to impaired kidney function and potential progression to kidney failure. This article provides a comprehensive overview of the epidemiology, pathogenesis, clinical presentation, diagnosis, and management of LN, highlighting the importance of early recognition and treatment of LN to prevent progressive, irreversible kidney damage and improve patient outcomes. Additionally, the article discusses current and emerging therapies for LN, including traditional immunosuppressive agents, biological agents, and novel therapies targeting specific pathways involved in LN pathogenesis, to provide a practical guide for clinicians in properly diagnosing LN and determining a patient-centered treatment plan.
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Affiliation(s)
- Nasim Wiegley
- Division of Nephrology, University of California, Davis School of Medicine, Sacramento, CA.
| | - Swati Arora
- Division of Nephrology, Allegheny Health Network, Pittsburgh, PA
| | - Sayna Norouzi
- Division of Nephrology, Loma Linda University Medical Center, Loma Linda, CA
| | - Brad Rovin
- Division of Nephrology, Ohio State University, Columbus, OH
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2
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Rovin BH, Ayoub IM, Chan TM, Liu ZH, Mejía-Vilet JM, Floege J. KDIGO 2024 Clinical Practice Guideline for the management of LUPUS NEPHRITIS. Kidney Int 2024; 105:S1-S69. [PMID: 38182286 DOI: 10.1016/j.kint.2023.09.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 09/07/2023] [Indexed: 01/07/2024]
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3
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Tang ZC, Hui H, Shi C, Chen X. New findings in preventing recurrence and improving renal function in AHUS patients after renal transplantation treated with eculizumab: a systemic review and meta-analyses. Ren Fail 2023; 45:2231264. [PMID: 37563792 PMCID: PMC10424606 DOI: 10.1080/0886022x.2023.2231264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 04/24/2023] [Accepted: 04/22/2023] [Indexed: 08/12/2023] Open
Abstract
BACKGROUND The long-term mortality of kidney transplantation patients with atypical hemolytic uremic syndrome remains high, and the efficacy of the main treatment eculizumab is still controversial. OBJECTIVE A comprehensive systematic review and meta-analysis of clinical trials using eculizumab in renal transplant patients with atypical hemolytic uremic syndrome was conducted to evaluate the efficacy of this therapy and its impact on renal function. METHODS A comprehensive systematic search was conducted across multiple reputable databases, including Ovid (MEDLINE, EMBASE), PubMed, and the Cochrane Library (since database inception), to identify relevant studies exploring the use of eculizumab in patients with atypical hemolytic uremic kidney transplantation. Various renal function parameters, such as dialysis, rejection, glomerular filtration rate, serum creatinine, lactate dehydrogenase, and platelet count, along with patient relapse rates, were extracted and summarized using a combination of robust statistical methods, including fixed effects, random effects, and general inverse variance methods. RESULT Eighteen trials with 618 subjects were analyzed. Our analysis suggests that the use of eculizumab is associated with a reduced likelihood of AHUS recurrence (odds ratio (OR) = 0.05, 95% CI: 0.00-0.13), as well as a significant reduction in the need for dialysis (odds ratio (OR) = 0.13, 95% CI: 0.01-0.32). Additionally, eculizumab treatment led to lower serum creatinine levels (mean differences (MD) = 126.931μmoI/L, 95% CI: 115.572μmoI/L-138.290μmoI/L) and an improved glomerular filtration rate (mean differences (MD) = 59.571 ml/min, 95% CI: 57.876 ml/min-61.266 mL/min). Our results also indicate that the use of eculizumab reduces the likelihood of rejection (odds ratio (OR) = 0.09, 95% CI: 0.01-0.22). Furthermore, the drug was effective in improving platelet counts (×10∧9/L) (mean differences (MD) = 163.421, 95% CI: 46.998-279.844) and lactate dehydrogenase levels (mean differences (MD) = 336.608 U/L, 95% CI: 164.816 U/L-508.399 U/L). CONCLUSIONS Based on the meta-analysis, treatment with eculizumab can reduce dialysis rates and improve patients' quality of life by enhancing renal function.
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Affiliation(s)
| | - Huang Hui
- Guangdong Pharmaceutical University, Guangzhou, China
| | - Chunru Shi
- Guangdong Pharmaceutical University, Guangzhou, China
| | - Xiangmei Chen
- Renal Medicine Department, Chinese PLA General Hospital, Beijing, China
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4
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Aklilu AM, Shirali AC. Chemotherapy-Associated Thrombotic Microangiopathy. KIDNEY360 2023; 4:409-422. [PMID: 36706238 PMCID: PMC10103319 DOI: 10.34067/kid.0000000000000061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 12/22/2022] [Indexed: 01/28/2023]
Abstract
Thrombotic microangiopathy (TMA) is a syndrome of microangiopathic hemolytic anemia and thrombocytopenia with end-organ dysfunction. Although the advent of plasma exchange, immunosuppression, and complement inhibition has improved morbidity and mortality for primary TMAs, the management of secondary TMAs, particularly drug-induced TMA, remains less clear. TMA related to cancer drugs disrupts the antineoplastic treatment course, increasing the risk of cancer progression. Chemotherapeutic agents such as mitomycin-C, gemcitabine, and platinum-based drugs as well as targeted therapies such as antiangiogenesis agents and proteasome inhibitors have been implicated in oncotherapy-associated TMA. Among TMA subtypes, drug-induced TMA is less well-understood. Treatment generally involves withdrawal of the offending agent and supportive care targeting blood pressure and proteinuria reduction. Immunosuppression and therapeutic plasma exchange have not shown clear benefit. The terminal complement inhibitor, eculizumab, has shown promising results in some cases of chemotherapy-associated TMA including in re-exposure. However, the data are limited, and unlike in primary atypical hemolytic uremic syndrome, the role of complement in the pathogenesis of drug-induced TMA is unclear. Larger multicenter studies and unified definitions are needed to elucidate the extent of the problem and potential treatment strategies.
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Affiliation(s)
- Abinet M. Aklilu
- Section of Nephrology, Yale University School of Medicine, New Haven, Connecticut
| | - Anushree C. Shirali
- Section of Nephrology, Yale University School of Medicine, New Haven, Connecticut
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5
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Rovin BH, Adler SG, Barratt J, Bridoux F, Burdge KA, Chan TM, Cook HT, Fervenza FC, Gibson KL, Glassock RJ, Jayne DR, Jha V, Liew A, Liu ZH, Mejía-Vilet JM, Nester CM, Radhakrishnan J, Rave EM, Reich HN, Ronco P, Sanders JSF, Sethi S, Suzuki Y, Tang SC, Tesar V, Vivarelli M, Wetzels JF, Floege J. KDIGO 2021 Clinical Practice Guideline for the Management of Glomerular Diseases. Kidney Int 2021; 100:S1-S276. [PMID: 34556256 DOI: 10.1016/j.kint.2021.05.021] [Citation(s) in RCA: 699] [Impact Index Per Article: 233.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 05/25/2021] [Indexed: 12/13/2022]
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6
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Galstyan GM, Maschan AA, Klebanova EE, Kalinina II. [Treatment of thrombotic thrombocytopenic purpura]. TERAPEVT ARKH 2021; 93:826-829. [PMID: 36286735 DOI: 10.26442/00403660.2021.07.200914] [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: 07/21/2021] [Accepted: 07/21/2021] [Indexed: 11/22/2022]
Abstract
The review discusses approaches to treatment of congenital thrombotic thrombocytopenic purpura (TTP) or Upshaw-Schulman syndrome. In congenital TTP, plasma transfusions are sufficient. Such treatment options as plasma exchange, administration of clotting factor VIII concentrate, recombinant ADAMTS13, are also used. Separately discussed issues of management of patients with TTP during pregnancy, and pediatric patients with TTP.
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Affiliation(s)
| | - A A Maschan
- Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology
| | | | - I I Kalinina
- Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology
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7
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Galstyan GM, Maschan AA, Klebanova EE, Kalinina II. [Treatment of thrombotic thrombocytopenic purpura]. TERAPEVT ARKH 2021; 93:736-745. [PMID: 36286842 DOI: 10.26442/00403660.2021.06.200894] [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: 07/10/2021] [Accepted: 07/10/2021] [Indexed: 11/22/2022]
Abstract
The review discusses approaches to treatment of acquired thrombotic thrombocytopenic purpuгa (aTTP). In patients with aTTP plasma exchanges, glucocorticosteroids allow to stop an acute attack of TTP, and use of rituximab allows to achieve remission. In recent years, caplacizumab has been used. Treatment options such as cyclosporin A, bortezomib, splenectomy, N-acetylcysteine, recombinant ADAMTS13 are also described. Separately discussed issues of management of patients with TTP during pregnancy, and pediatric patients with TTP.
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Affiliation(s)
| | - A A Maschan
- Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology
| | | | - I I Kalinina
- Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology
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Ardissino G, Cresseri D, Tel F, Giussani A, Salardi S, Sgarbanti M, Strumbo B, Testa S, Capone V, Griffini S, Grovetti E, Cugno M, Belingheri M, Tamburello C, Rodrigues EM, Perrone M, Cardillo M, Corti G, Consonni D, Furian L, Tedeschi S, Messa P, Beretta C. Kidney transplant in patients with atypical hemolytic uremic syndrome in the anti-C5 era: single-center experience with tailored Eculizumab. J Nephrol 2021; 34:2027-2036. [PMID: 33956337 DOI: 10.1007/s40620-021-01045-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 04/02/2021] [Indexed: 11/26/2022]
Abstract
RATIONALE AND OBJECTIVE Patients with atypical hemolytic uremic syndrome (aHUS) have long been considered ineligible for kidney transplantation (KTx) in several centers due to the high risk of disease recurrence, graft loss and life-threatening complications. The availability of Eculizumab (ECU) has now overcome this problem. However, the best approach towards timing, maintenance schedule, the possibility of discontinuation and patient monitoring has not yet been clearly established. STUDY DESIGN This is a single center case series presenting our experience with KTx in aHUS. SETTING AND PARTICIPANTS This study included 26 patients (16 females) with a diagnosis of aHUS, who spent a median of 5.5 years on kidney replacement therapy before undergoing KTx. We compared the aHUS relapse rate in three groups of patients who underwent KTx: patients who received no prophylaxis, patients who underwent plasma exchange, those who received Eculizumab prophylaxis. Complement factor H-related disease was by far the most frequent etiology (n = 19 patients). RESULTS Untreated patients and patients undergoing pre-KTx plasma exchange prophylaxis had a relapse rate of 0.81 (CI 0.30-1.76) and 3.1 (CI 0.64-9.16) events per 10 years cumulative observation, respectively, as opposed to 0 events among patients receiving Eculizumab prophylaxis. The time between Eculizumab doses was tailored based on classic complement pathway activity (target to < 30%). Using this strategy, 12 patients are currently receiving Eculizumab every 28 days, 5 every 24-25 days, and 3 every 21 days. CONCLUSION Our experience supports the prophylactic use of Eculizumab in patients with a previous history of aHUS undergoing KTx, especially when complement dysregulation is well documented by molecular biology.
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Affiliation(s)
- Gianluigi Ardissino
- Pediatric Nephrology, Dialysis and Transplantation Unit, Center for HUS Control, Prevention and Management, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, V. Commenda, 9, 20122, Milan, Italy.
| | - Donata Cresseri
- Nephrology Unit, Center for HUS Prevention, Control and Management, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Francesca Tel
- Pediatric Nephrology, Dialysis and Transplantation Unit, Center for HUS Control, Prevention and Management, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, V. Commenda, 9, 20122, Milan, Italy
| | - Antenore Giussani
- Kidney Transplant Unit, Center for HUS Prevention, Control and Management, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Stefania Salardi
- Molecular Biology Laboratory, Center for HUS Prevention, Control and Management, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Martina Sgarbanti
- Molecular Biology Laboratory, Center for HUS Prevention, Control and Management, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Bice Strumbo
- Molecular Biology Laboratory, Center for HUS Prevention, Control and Management, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Sara Testa
- Pediatric Nephrology, Dialysis and Transplantation Unit, Center for HUS Control, Prevention and Management, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, V. Commenda, 9, 20122, Milan, Italy
| | - Valentina Capone
- Pediatric Nephrology, Dialysis and Transplantation Unit, Center for HUS Control, Prevention and Management, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, V. Commenda, 9, 20122, Milan, Italy
| | - Samantha Griffini
- Internal Medicine, Center for HUS Prevention, Control and Management, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Elena Grovetti
- Internal Medicine, Center for HUS Prevention, Control and Management, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Massimo Cugno
- Internal Medicine, Center for HUS Prevention, Control and Management, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Mirco Belingheri
- Nephrology Unit, Center for HUS Prevention, Control and Management, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Chiara Tamburello
- Pediatric Nephrology, Dialysis and Transplantation Unit, Center for HUS Control, Prevention and Management, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, V. Commenda, 9, 20122, Milan, Italy
| | - Evangeline Millicent Rodrigues
- Pediatric Nephrology, Dialysis and Transplantation Unit, Center for HUS Control, Prevention and Management, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, V. Commenda, 9, 20122, Milan, Italy
| | - Michela Perrone
- Neonatal Intensive Care Unit, Center for HUS Prevention, Control and Management, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Massimo Cardillo
- North Italian Transplant, Center for HUS Prevention, Control and Management, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Grazia Corti
- Pharmacy, Center for HUS Prevention, Control and Management, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Dario Consonni
- Epidemiology Unit, Center for HUS Prevention, Control and Management, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Silvana Tedeschi
- Molecular Biology Laboratory, Center for HUS Prevention, Control and Management, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Piergiorgio Messa
- Nephrology Unit, Center for HUS Prevention, Control and Management, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Claudio Beretta
- Kidney Transplant Unit, Center for HUS Prevention, Control and Management, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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Pisklakova A, Barbir J, Sambataro JP, Almanzar C, Manji F. Silent Thrombotic Thrombocytopenic Purpura: PLASMIC, Lessons Learned, and Current Management Overview. Cureus 2021; 13:e13803. [PMID: 33842174 PMCID: PMC8027957 DOI: 10.7759/cureus.13803] [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] [Indexed: 12/04/2022] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a rare, life-threatening autoimmune or hereditary thrombotic microangiopathy (TMA) that may be difficult to recognize given the wide spectrum of presenting symptoms. The clinical diagnosis of TTP is based on thrombocytopenia, microangiopathic hemolytic anemia and is confirmed by a disintegrin-like and metalloproteinase with thrombospondin type one motif, member 13 (ADAMTS13) <10%. However, the latter confirmation is not rapidly available, and treatment is typically initiated based on the degree of clinical suspicion. The PLASMIC score was recently developed to distinguish between TMA patients with and without severe ADAMTS13 deficiency and used as an adjunct in the diagnosis of TTP when the clinical picture is not clear. Here we present the case of a completely asymptomatic female with no past medical history diagnosed with TTP after evaluation for thrombocytopenia found on a routine wellness visit. A high PLASMIC score was crucial in the decision to initiate treatment given an unusual asymptomatic presentation.
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Affiliation(s)
| | - Joshua Barbir
- Internal Medicine, Brandon Regional Hospital, Tampa, USA
| | | | | | - Faiza Manji
- Oncology, Brandon Regional Hospital, Tampa, USA
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Aminimoghaddam S, Afrooz N, Nasiri S, Motaghi Nejad O, Mahmoudzadeh F. A COVID-19 pregnant patient with thrombotic thrombocytopenic purpura: a case report. J Med Case Rep 2021; 15:104. [PMID: 33648584 PMCID: PMC7919244 DOI: 10.1186/s13256-020-02577-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 11/03/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Pregnancy seems to increase the risk of thrombotic thrombocytopenic purpura (TTP) relapses and make the TTP more severe in any of the pregnancy trimesters, or even during the postpartum period. CASE PRESENTATION This study highlights details of treating a COVID-19 pregnant patient who survived. This 21-year addicted White woman was admitted at her 29th week and delivered a stillbirth. She was transferred to another hospital after showing signs of TTP, which was caused by a viral infection. CONCLUSION This viral infection caused fever and dyspnea, and the patient was tested positive for COVID-19 infection. A chest computed tomography scan showed diffuse multiple bilateral consolidations and interlobar septal thickening. She stayed at the Intensive Care Unit for 20 days and treated with plasmapheresis. As far as we know, this is the first report of a TTP pregnant patient with COVID-19 infection.
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MESH Headings
- Acute Kidney Injury/therapy
- Amphetamine-Related Disorders
- Antiviral Agents/therapeutic use
- COVID-19/diagnosis
- COVID-19/therapy
- Drug Combinations
- Erythrocyte Transfusion
- Female
- Hemoglobins/metabolism
- Humans
- Hydroxychloroquine/therapeutic use
- Intensive Care Units
- L-Lactate Dehydrogenase/metabolism
- Lopinavir/therapeutic use
- Methamphetamine
- Plasmapheresis
- Pregnancy
- Pregnancy Complications, Hematologic/diagnosis
- Pregnancy Complications, Hematologic/metabolism
- Pregnancy Complications, Hematologic/therapy
- Pregnancy Complications, Infectious/diagnosis
- Pregnancy Complications, Infectious/metabolism
- Pregnancy Complications, Infectious/therapy
- Purpura, Thrombotic Thrombocytopenic/diagnosis
- Purpura, Thrombotic Thrombocytopenic/metabolism
- Purpura, Thrombotic Thrombocytopenic/therapy
- Renal Dialysis
- Ritonavir/therapeutic use
- SARS-CoV-2
- Stillbirth
- Tomography, X-Ray Computed
- Young Adult
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Affiliation(s)
- Soheila Aminimoghaddam
- Department of Gynecology and Oncology, Iran University of Medical Sciences, Tehran, Iran
| | - Narjes Afrooz
- Department of Gynecology and Oncology, Iran University of Medical Sciences, Tehran, Iran
| | - Setare Nasiri
- Department of Gynecology and Oncology, Iran University of Medical Sciences, Tehran, Iran
| | - Ozra Motaghi Nejad
- Department of Gynecology and Oncology, Iran University of Medical Sciences, Tehran, Iran
| | - Fatemeh Mahmoudzadeh
- Department of Emergency Medicine, Tehran University of Medical Sciences, Tehran, Iran
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Browning S, Bahar B, Lee AI, Gorshein E. Spontaneous recovery in a patient with acquired thrombotic thrombocytopenic purpura (TTP): observation of a 'subclinical' TTP state. ACTA ACUST UNITED AC 2021; 25:473-477. [PMID: 33269995 DOI: 10.1080/16078454.2020.1848973] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVES Thrombotic thrombocytopenic purpura (TTP) is a thrombotic microangiopathy that can have high mortality rates without prompt treatment. Standard treatment is urgent plasma exchange (PLEX), which leads to disease remission in the vast majority of patients. Deficiency of ADAMTS13 (a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13) alone is not sufficient to cause the clinical manifestations characteristic of TTP. We present a case of acquired TTP, where spontaneous recovery was observed prior to initiation of any TTP-specific therapy. CLINICAL PRESENTATION A 73-year-old asymptomatic female presented with new-onset mild haemolytic anaemia and thrombocytopenia. Further testing revealed a significantly reduced ADAMTS13 activity level and an ADAMTS13 inhibitor, concerning for acquired TTP. On reassessment, the patient's haematologic parameters had been corrected prior to initiation of therapy. During subsequent follow-up three months later, she developed acute worsening thrombocytopenia indicative of relapsed, acute TTP. The patient was then successfully managed with PLEX and rituximab and achieved a sustained remission. DISCUSSION AND CONCLUSION TTP is a haematologic emergency that requires urgent therapy to reduce morbidity and mortality. However, it is well documented that individuals with hereditary TTP and a proportion with acquired TTP in clinical remission can have low or nearly absent ADAMTS13 activity levels without evidence of microangiopathic haemolytic anaemia (MAHA) or thrombotic manifestations. Our patient represents a unique case of confirmed ADAMTS13 deficiency due to a documented inhibitor, leading to mild haemolytic anaemia and thrombocytopenia both of which recovered spontaneously. We propose that this scenario could represent a 'subclinical' TTP state that precedes the development of clinically significant disease.
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Affiliation(s)
- Sabrina Browning
- Section of Hematology, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Burak Bahar
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT, USA.,Department of Pathology and Laboratory Medicine, George Washington University, Children's National Hospital, Washington DC, USA
| | - Alfred Ian Lee
- Section of Hematology, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Elan Gorshein
- Section of Hematology, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
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Goranta S, Deliwala SS, Haykal T, Bachuwa G. Severe primary refractory thrombotic thrombocytopenic purpura (TTP) in the post plasma exchange (PEX) and rituximab era. BMJ Case Rep 2020; 13:13/6/e234091. [PMID: 32532908 DOI: 10.1136/bcr-2019-234091] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Acute acquired thrombotic thrombocytopenic purpura (TTP) requires prompt recognition and initiation of plasma exchange (PEX) therapy and immunosuppression. When PEX fails, mortality nears 100%, making finding an effective treatment crucial. Primary refractory TTP occurs when initial therapies fail or if exacerbations occur during PEX therapy, both signifying the need for treatment intensification to achieve clinical remission. Rituximab helps treat most of the refractory TTP cases, except those that are severely refractory. A paucity of studies guiding severely refractory TTP makes management arbitrary and individualised, highlighting the value of isolated reports. We present an extremely rare case of primary refractory TTP with an insufficient platelet response to numerous types of treatments, including emerging therapies such as caplacizumab, on the background of repeated PEX and immunosuppressive therapies.
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Affiliation(s)
- Sowmya Goranta
- Department of Internal Medicine, Michigan State University at Hurley Medical Center, Flint, Michigan, USA
| | - Smit S Deliwala
- Department of Internal Medicine, Michigan State University at Hurley Medical Center, Flint, Michigan, USA
| | - Tarek Haykal
- Department of Internal Medicine, Michigan State University at Hurley Medical Center, Flint, Michigan, USA
| | - Ghassan Bachuwa
- Department of Internal Medicine, Michigan State University at Hurley Medical Center, Flint, Michigan, USA
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Sharma P, Gurung A, Dahal S. Connective Tissue Disorders in Patients With Thrombotic Thrombocytopenic Purpura: A Retrospective Analysis Using a National Database. J Clin Med Res 2019; 11:509-514. [PMID: 31236170 PMCID: PMC6575126 DOI: 10.14740/jocmr3850] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 05/27/2019] [Indexed: 11/11/2022] Open
Abstract
Background Prior reports have shown acquired thrombotic thrombocytopenic purpura (TTP) co-existing with connective tissue disorders (CTD). However, these are mainly limited to case reports and case-series reports, and the patient characteristics and clinical outcomes in these patients are not well known. Methods We used National Inpatient Sample and Nationwide Inpatient Sample (NIS) database for the years 2009 to 2016 to identify all adult patients with TTP and searched for either the presence or absence of any co-existing CTD. These two cohorts of TTP patients were then compared using statistical methods for baseline patient characteristics and clinical outcomes. The primary outcome of interest was the all-cause in-hospital mortality and the secondary outcomes were in-hospital length of stay, in-hospital total charge and in-hospital complications. Results Of the 14,400 cases of TTP diagnosed between 2009 and 2016, nearly 9% (n = 1,247) had one or more underlying CTD. Patients with TTP were more likely to be young, black, female, with more than one comorbidity and with private insurance if they had an underlying CTD than when they did not have any underlying CTD. There was no difference in regards to the size, location or type of the hospital, or the time taken to initiate plasmapheresis. Patients being managed for TTP had a longer mean length of hospital stay and a greater mean total inpatient stay charge if they had underlying CTD. There was however no difference in the risks of inpatient mortality, acute coronary syndrome, cardiac arrest, acute stroke, need for mechanical ventilation or hemodialysis. Conclusion TTP and CTD frequently co-existed and contributed to a longer hospital stay and a greater hospital charge.
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Affiliation(s)
- Pratibha Sharma
- Department of Medicine, Maimonides Medical Center, Brooklyn, NY, USA
| | - Aveena Gurung
- Department of Internal Medicine, New York University School of Medicine, Woodhull Medical and Mental Health Center, Brooklyn, NY, USA
| | - Sumit Dahal
- Hospitalist Service, St. Joseph Hospital, Bangor, ME, USA
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14
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Nguyen TC, Stegmayr B, Busund R, Bunchman TE, Carcillo JA. Plasma Therapies in Thrombotic Syndromes. Int J Artif Organs 2018; 28:459-65. [PMID: 15883960 DOI: 10.1177/039139880502800506] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Background Plasma therapies are being applied to thombotic syndromes, but there are limited controlled studies. Objective To review the evidence and the current practices for plasma therapies in thrombotic syndromes. Methods Expert-enhanced evidence-based analysis. Evidence obtained as of Dec 31, 2002 using Pub Med electronic reference library and expert-obtained library for a total of > 3,000 references obtained using the terms plasma therapy or plasma exchange or plasmapheresis or plasmafiltration or sorbents each combined with the words thrombotic syndrome or sepsis or septic shock. The authors screened the abstracts, reviewed the agreed set of papers, and compiled the recommendations. Results Plasma therapies, which alter the plasma components in patients, have been applied in thrombotic syndromes worldwide. In these patients, there is a biologic plausibility for plasma therapies since they have molecules that are prothrombotic and/or antifibrinolytic which would put them at risk for microvascular thrombosis and end-organ damage. There are respectively one randomized controlled trial (RCT) in primary thrombotic syndrome, and secondary thrombotic syndrome, which showed an improvement in mortality in applying plasma therapies (plasma exchange by centrifugation). However, there are numerous non-randomized and case series. Plasma exchange is accepted as the standard therapy for primary thrombotic syndrome as in thrombotic thrombocytopenic purpura (TTP). However, no consensus has been reached for plasma exchange in secondary thrombotic syndromes such as in sepsis, hemolytic uremic syndrome (HUS), thrombocytopenia associated multiple organ failure, TTP/HUS, s/p bone marrow or solid organ transplant, HELLP syndrome, immunologic disorders, drug exposure, or pancreatitis. Conclusions As we understand more about the pathophysiology of thrombotic syndromes, specific plasma therapies can be applied for the specific need of a particular patient population. There are sufficient preliminary data to recommend a definitive RCT to evaluate the efficacy of the different types of plasma therapies in secondary thrombotic syndromes.
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Affiliation(s)
- T C Nguyen
- Section of Critical Care, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
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15
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Sun F, Wang X, Wu W, Wang K, Chen Z, Li T, Ye S. TMA secondary to SLE: rituximab improves overall but not renal survival. Clin Rheumatol 2017; 37:213-218. [DOI: 10.1007/s10067-017-3793-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Revised: 07/19/2017] [Accepted: 08/14/2017] [Indexed: 12/19/2022]
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16
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Clinical dissection of thrombotic microangiopathy. Ann Hematol 2017; 96:1715-1726. [PMID: 28752391 DOI: 10.1007/s00277-017-3063-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Accepted: 07/04/2017] [Indexed: 10/19/2022]
Abstract
Differential treatment strategies are applied in thrombotic microangiopathy (TMA) according to the sub-classifications. Hence, it is worthwhile to overview clinical manifestations and outcomes of overall TMA patients according to sub-classifications. We analyzed TMA patients whose serum lactate dehydrogenase levels >250 IU/L, with the presence of schistocytes in their peripheral blood smear, or with typical vascular pathologic abnormalities in their renal biopsy. We compared clinical manifestations including overall survival (OS) and renal survival according to TMA causes. A total of 117 TMA patients (57 primary and 60 secondary TMA) were analyzed. Renal symptom was the most common manifestation in whole patients, while renal function at diagnosis was worst in pregnancy-related TMA group. Primary TMA patients had more frequent CNS symptom and hematologic manifestation compared to secondary TMAs. Among secondary TMAs, pregnancy- and HSCT-related TMA patients showed prevalent hemolytic features. During 150.2 months of follow-up, 5-year OS rate was 64.8%. Poor prognostic factors included older age, combined hematologic and solid organ malignancies, lower hemoglobin levels, and lower serum albumin levels. There was no significant difference in OS between primary and secondary TMAs. Seventy-eight percent of patients experienced AKI during TMA. Five-year death-censored renal survival rate was poor with only 69.2%. However, excellent renal outcome was observed in pregnancy-associated TMA. TMA showed various clinical manifestations according to their etiology. Notably, both OS and renal survival were poor regardless of their etiologies except pregnancy-associated TMA. Physicians should differentiate a variety of TMA categories and properly manage this complex disease entity.
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Abstract
Rituximab, a monoclonal antibody targeting the B cell marker CD20, was initially approved in 1997 by the United States Food and Drug Administration (FDA) for the treatment of non-Hodgkin lymphoma. Since that time, rituximab has been FDA-approved for rheumatoid arthritis and vasculitides, such as granulomatosis with polyangiitis and microscopic polyangiitis. Additionally, rituximab has been used off-label in the treatment of numerous other autoimmune diseases, with notable success in pemphigus, an autoantibody-mediated skin blistering disease. The efficacy of rituximab therapy in pemphigus has spurred interest in its potential to treat other autoantibody-mediated diseases. This review summarizes the efficacy of rituximab in pemphigus and examines its off-label use in other select autoantibody-mediated diseases.
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Affiliation(s)
- Nina A Ran
- Department of Dermatology, University of Pennsylvania, 1009 Biomedical Research Building, 421 Curie Boulevard, PA, USA
| | - Aimee S Payne
- Department of Dermatology, University of Pennsylvania, 1009 Biomedical Research Building, 421 Curie Boulevard, PA, USA
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18
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Abu-Hishmeh M, Sattar A, Zarlasht F, Ramadan M, Abdel-Rahman A, Hinson S, Hwang C. Systemic Lupus Erythematosus Presenting as Refractory Thrombotic Thrombocytopenic Purpura: A Diagnostic and Management Challenge. A Case Report and Concise Review of the Literature. AMERICAN JOURNAL OF CASE REPORTS 2016; 17:782-787. [PMID: 27777394 PMCID: PMC5083062 DOI: 10.12659/ajcr.898955] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Thrombotic thrombocytopenic purpura (TTP) is one of the thrombotic microangiopathic (TMA) syndromes, caused by severely reduced activity of the vWF-cleaving protease ADAMTS13. Systemic lupus erythematosus (SLE), on the other hand, is an autoimmune disease that affects various organs in the body, including the hematopoietic system. SLE can present with TMA, and differentiating between SLE and TTP in those cases can be very challenging, particularly in patients with no prior history of SLE. Furthermore, an association between these 2 diseases has been described in the literature, with most of the TTP cases occurring after the diagnosis of SLE. In rare cases, TTP may precede the diagnosis of SLE or occur concurrently. CASE REPORT We present a case of a previously healthy 34-year-old female who presented with dizziness and flu-like symptoms and was found to have thrombocytopenia, hemolytic anemia, and schistocytes in the peripheral smear. She was subsequently diagnosed with TTP and started on plasmapheresis and high-dose steroids, but without a sustained response. A diagnosis of refractory TTP was made, and she was transferred to our facility for further management. Initially, the patient was started on rituximab, but her condition continued to deteriorate, with worsening thrombocytopenia. Later, she also fulfilled the Systemic Lupus International Collaborating Clinics (SLICC) criteria for diagnosis of SLE. Treatment of TTP in SLE patients is generally similar to that in the general population, but in refractory cases there are few reports in the literature that show the efficacy of cyclophosphamide. We started our patient on cyclophosphamide and noticed a sustained improvement in the platelet count in the following weeks. CONCLUSIONS Thrombotic thrombocytopenic purpura is a life-threatening hematological emergency which must be diagnosed and treated in a timely manner. Refractory cases of TTP have been described in the literature, but without clear evidence-based guidelines for its management, and is solely based on expert opinion and previous case reports. Further studies are needed to establish guidelines for its management. We present this case to highlight the role that cyclophosphamide might carry in those cases and to be a foundation for these future studies.
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Affiliation(s)
- Mohammad Abu-Hishmeh
- Department of Internal Medicine, Lincoln Medical and Mental Health Center, Bronx, NY, USA
| | - Alamgir Sattar
- Department of Internal Medicine, Lincoln Medical and Mental Health Center, Bronx, NY, USA
| | - Fnu Zarlasht
- Department of Internal Medicine, Lincoln Medical and Mental Health Center, Bronx, NY, USA
| | - Mohamed Ramadan
- Department of Internal Medicine, Lincoln Medical and Mental Health Center, Bronx, NY, USA
| | - Aisha Abdel-Rahman
- Department of Internal Medicine, Lincoln Medical and Mental Health Center, Bronx, NY, USA
| | - Shante Hinson
- Internal Medicine, Lincoln Medical and Mental Health Center, Bronx, USA
| | - Caroline Hwang
- Department of Internal Medicine, Lincoln Medical and Mental Health Center, Bronx, NY, USA
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19
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Goel R, King KE, Takemoto CM, Ness PM, Tobian AAR. Prognostic risk-stratified score for predicting mortality in hospitalized patients with thrombotic thrombocytopenic purpura: nationally representative data from 2007 to 2012. Transfusion 2016; 56:1451-8. [PMID: 27079482 DOI: 10.1111/trf.13586] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Revised: 02/12/2016] [Accepted: 02/13/2016] [Indexed: 12/23/2022]
Abstract
BACKGROUND Despite proven efficacy and increased availability of therapeutic plasma exchange (TPE), mortality for patients with thrombotic thrombocytopenic purpura (TTP) remains high with a limited understanding of those at highest risk of death. STUDY DESIGN AND METHODS This study utilized the Nationwide Inpatient Sample (2007-2012) to derive a prognostic score for mortality in hospitalized TTP patients. Odds ratios of death with various putative risk factors adjusted for age, sex, and race were calculated (adjOR). Weighted mean of adjOR estimates were incorporated in a risk-stratified score. RESULTS Among 8203 hospitalizations with TTP as primary admission diagnosis who underwent TPE, 613 deaths were identified (all-cause mortality, 7.5%; median time-to-death, 9 days; interquartile range, 4-14 days). In multivariable logistic regression, arterial thrombosis (adjOR 6.7, 95% confidence interval [CI], 1.1-40.9), intracranial hemorrhage (adjOR, 6.1; 95% CI, 1.6-23.2), age at least 60 years (adjOR, 3.5; 95% CI, 2.1-5.6), renal failure (adjOR, 2.6; 95% CI, 1.5-4.5), ischemic stroke (adjOR, 2.4; 95% CI, 1.2-5.0), platelet (PLT) transfusions (adjOR, 2.2; 95% CI, 1.2-4.1), and myocardial infarction (adjOR, 2.3; 95% CI, 1.2-4.6) were significant independent predictors of mortality in TTP patients who underwent TPE. A prognostic weighted mortality prediction scoring system incorporating arterial thrombosis, intracranial hemorrhage, age, renal failure, ischemic stroke, PLT transfusion, and myocardial infarction showed very good discrimination and was predictive of 78.6% deaths. CONCLUSIONS Early and targeted therapy for high-risk individuals should be used to guide management of TTP patients for improved survival outcomes.
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Affiliation(s)
- Ruchika Goel
- Division of Pediatric Hematology.,Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University, Baltimore, Maryland
| | - Karen E King
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University, Baltimore, Maryland
| | | | - Paul M Ness
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University, Baltimore, Maryland
| | - Aaron A R Tobian
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University, Baltimore, Maryland
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Igarashi T, Ito S, Sako M, Saitoh A, Hataya H, Mizuguchi M, Morishima T, Ohnishi K, Kawamura N, Kitayama H, Ashida A, Kaname S, Taneichi H, Tang J, Ohnishi M. Guidelines for the management and investigation of hemolytic uremic syndrome. Clin Exp Nephrol 2016; 18:525-57. [PMID: 25099085 DOI: 10.1007/s10157-014-0995-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Takashi Igarashi
- National Center for Child Health and Development (NCCHD), 2-10-1 Okura, Setagaya-ku, Tokyo, 157-8535, Japan,
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21
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El-agwany AS. A complicated case of antepartum eclamptic fit with HELLP syndrome, acute renal failure and multiple intracranial hemorrhages: A mortality report. EGYPTIAN JOURNAL OF ANAESTHESIA 2016. [DOI: 10.1016/j.egja.2015.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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22
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Connell NT, Cheves T, Sweeney JD. Effect of ADAMTS13 activity turnaround time on plasma utilization for suspected thrombotic thrombocytopenic purpura. Transfusion 2015; 56:354-9. [DOI: 10.1111/trf.13359] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Revised: 07/22/2015] [Accepted: 08/31/2015] [Indexed: 11/27/2022]
Affiliation(s)
- Nathan T. Connell
- Hematology Division; Brigham and Women's Hospital; Boston Massachusetts
| | - Tracey Cheves
- Department of Pathology & Laboratory Medicine; Rhode Island Hospital; Providence Rhode Island
| | - Joseph D. Sweeney
- Department of Pathology & Laboratory Medicine; Rhode Island Hospital; Providence Rhode Island
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23
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Bienholz A, Wilde B, Kribben A. From the nephrologist's point of view: diversity of causes and clinical features of acute kidney injury. Clin Kidney J 2015; 8:405-14. [PMID: 26251707 PMCID: PMC4515898 DOI: 10.1093/ckj/sfv043] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Accepted: 05/19/2015] [Indexed: 12/19/2022] Open
Abstract
Acute kidney injury (AKI) is a clinical syndrome with multiple entities. Although AKI implies renal damage, functional impairment or both, diagnosis is solely based on the functional parameters of serum creatinine and urine output. The latest definition was provided by the Kidney Disease Improving Global Outcomes (KDIGO) working group in 2012. Independent of the underlying disease, and even in the case of full recovery, AKI is associated with an increased morbidity and mortality. Awareness of the patient's individual risk profile and the diversity of causes and clinical features of AKI is pivotal for optimization of prophylaxes, diagnosis and therapy of each form of AKI. A differentiated and individualized approach is required to improve patient mortality, morbidity, long-term kidney function and eventually the quality of life. In this review, we provide an overview of the different clinical settings in which specific forms of AKI may occur and point out possible diagnostic as well as therapeutic approaches. Secifically AKI is discussed in the context of non-kidney organ failure, organ transplantation, sepsis, malignancy and autoimmune disease.
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Affiliation(s)
- Anja Bienholz
- Clinic of Nephrology , University Hospital Essen, University Duisburg-Essen , Essen , Germany
| | - Benjamin Wilde
- Clinic of Nephrology , University Hospital Essen, University Duisburg-Essen , Essen , Germany
| | - Andreas Kribben
- Clinic of Nephrology , University Hospital Essen, University Duisburg-Essen , Essen , Germany
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24
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Murugapandian S, Bijin B, Mansour I, Daheshpour S, Pillai BG, Thajudeen B, Salahudeen AK. Improvement in Gemcitabine-Induced Thrombotic Microangiopathy with Rituximab in a Patient with Ovarian Cancer: Mechanistic Considerations. Case Rep Nephrol Dial 2015; 5:160-7. [PMID: 26266248 PMCID: PMC4519601 DOI: 10.1159/000435807] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Gemcitabine is a potent and widely used anticancer drug. We report a case of gemcitabine-induced thrombotic microangiopathy (GCI-TMA), a known but not widely recognized complication of gemcitabine use, and our experience of treating GCI-TMA with rituximab. A 74-year-old woman was referred to our clinic for an evaluation of worsening renal function. She has recently been treated for ovarian cancer (diagnosed in 2011) with surgery (tumor debulking and bilateral salpingo-oophorectomy) along with cisplatin chemotherapy in 2012, followed by carboplatin/doxorubicin in 2013 and recent therapy for resistant disease with gemcitabine. Laboratory tests showed anemia, normal platelets and elevated lactate dehydrogenase. A peripheral smear revealed numerous schistocytes, and a kidney biopsy showed acute as well as chronic TMA. The patient continued on gemcitabine therapy, and treatment with plasma exchange was started. Since there was no response to treatment even after 5 sessions of plasma exchange, one dose of rituximab was given, which was associated with a drop in the creatinine level to 2 mg/dl. The pathogenesis of renal injury could be the effect of direct injury to the endothelium mediated by cytokines. Usual treatment includes withdrawing the drug and initiation of treatment with plasmapheresis with or without steroids. In cases resistant to plasmapheresis, treatment with rituximab can be tried. The mechanism of action of rituximab might be due to the reduced production of B-cell-dependent cytokines that drive endothelial dysfunction by depleting B cells. Patients receiving gemcitabine chemotherapy should be monitored for the development of TMA, and early treatment with plasma exchange along with rituximab might benefit these patients who already have a bad prognosis.
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Affiliation(s)
| | - Babitha Bijin
- Department of Nephrology, University of Arizona Medical Center, Tucson, Ariz., USA
| | - Iyad Mansour
- Department of Medicine, University of Arizona Medical Center, Tucson, Ariz., USA
| | - Sepehr Daheshpour
- Department of Medicine, University of Arizona Medical Center, Tucson, Ariz., USA
| | - Biju G Pillai
- Department of Nephrology, University of Arizona Medical Center, Tucson, Ariz., USA
| | - Bijin Thajudeen
- Department of Nephrology, University of Arizona Medical Center, Tucson, Ariz., USA
| | - Abdulla K Salahudeen
- Department of Nephrology, University of Arizona Medical Center, Tucson, Ariz., USA
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25
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The role of hematologists in a changing United States health care system. Blood 2015; 125:2467-70. [PMID: 25746327 DOI: 10.1182/blood-2014-12-615047] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Accepted: 02/12/2015] [Indexed: 01/08/2023] Open
Abstract
Major and ongoing changes in health care financing and delivery in the United States have altered opportunities and incentives for new physicians to specialize in nonmalignant hematology. At the same time, effective clinical tools and strategies continue to rapidly emerge. Consequently, there is an imperative to foster workforce innovation to ensure sustainable professional roles for hematologists, reliable patient access to optimal hematology expertise, and optimal patient outcomes. The American Society of Hematology is building a collection of case studies to guide the creation of institutionally supported systems-based clinical hematologist positions that predominantly focus on nonmalignant hematology. These roles offer a mix of guidance regarding patient management and the appropriate use and stewardship of clinical resources, as well as development of new testing procedures and protocols.
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26
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Wayhs SY, Wottrich J, Uggeri DP, Dias FS. Spontaneous acute subdural hematoma and intracerebral hemorrhage in a patient with thrombotic microangiopathy during pregnancy. Rev Bras Ter Intensiva 2015; 25:175-80. [PMID: 23917984 PMCID: PMC4031834 DOI: 10.5935/0103-507x.20130030] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2012] [Accepted: 05/27/2013] [Indexed: 12/01/2022] Open
Abstract
Preeclampsia, HELLP syndrome (hemolysis, elevated liver enzymes, and low-platelet
count), and acute fatty liver of pregnancy are the main causes of thrombotic
microangiopathy and severe liver dysfunction during pregnancy and represent different
manifestations of the same pathological continuum. The case of a 35-week pregnant
woman who was admitted to an intensive care unit immediately after a Cesarean section
due to fetal death and the presence of nausea, vomiting, and jaundice is reported.
Postpartum preeclampsia and acute fatty liver of pregnancy were diagnosed. The
patient developed an acute subdural hematoma and an intracerebral hemorrhage, which
were subjected to neurosurgical treatment. The patient died from refractory hemolytic
anemia and spontaneous bleeding of multiple organs. Preeclampsia, HELLP syndrome, and
acute fatty liver of pregnancy might overlap and be associated with potentially fatal
complications, including intracranial hemorrhage, as in the present case. Early
detection and diagnosis are crucial to ensure appropriate management and treatment
success.
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Affiliation(s)
- Sâmia Yasin Wayhs
- Adult Intensive Care Unit, Hospital de Caridade de Ijuí- HCI - Ijuí RS, Brazil.
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27
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Schwameis M, Schörgenhofer C, Assinger A, Steiner MM, Jilma B. VWF excess and ADAMTS13 deficiency: a unifying pathomechanism linking inflammation to thrombosis in DIC, malaria, and TTP. Thromb Haemost 2014; 113:708-18. [PMID: 25503977 DOI: 10.1160/th14-09-0731] [Citation(s) in RCA: 95] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Accepted: 10/27/2014] [Indexed: 12/15/2022]
Abstract
Absent or severely diminished activity of ADAMTS13 (A Disintegrin And Metalloprotease with a ThromboSpondin type 1 motif, member 13) resulting in the intravascular persistence and accumulation of highly thrombogenic ultra large von Willebrand factor (UL-VWF) multimers is the pathophysiological mechanism underlying thrombotic thrombocytopenic purpura. Reduced VWF-cleaving protease levels, however, are not uniquely restricted to primary thrombotic microangiopathy (TMA), e. g. thrombotic thrombocytopenic purpura, but also occur in other life-threatening thrombocytopenic conditions: severely decreased ADAMTS13 activity is seen in severe sepsis, disseminated intravascular coagulation (DIC) and complicated malarial infection. The clinical relevance of these secondary thrombotic microangiopathies is increasingly recognised, but its therapeutic implications have not yet been determined. The presence of a secondary TMA in certain diseases may define patient groups which possibly could benefit from ADAMTS13 replacement or a VWF-targeting therapy. This short-review focuses on the role of UL-VWF multimers in secondary TMA and discusses the potential of investigational therapies as candidates for the treatment of TTP. In conclusion, prospective clinical trials on the effectiveness of protease replacementin vivo seem reasonable. Carefully selected patients with secondary TMA may benefit from therapies primarily intended for the use in patients with TTP.
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Affiliation(s)
| | | | | | | | - Bernd Jilma
- Bernd Jilma, MD, Department of Clinical Pharmacology, Medical University of Vienna, Währinger Gürtel 18-20, A-1090 Vienna, Austria, Tel.: +43 1 40400 29810, Fax: +43 1 40400 29990, E-mail:
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Patel RD, Vanikar AV, Gumber MR, Kanodia KV, Suthar KS, Patel HV, Trivedi HL. Diagnosis and management of atypical hemolytic uremic syndrome in children: single centre experience. Indian J Hematol Blood Transfus 2014; 30:342-6. [PMID: 25435739 DOI: 10.1007/s12288-013-0262-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2011] [Accepted: 04/19/2013] [Indexed: 11/25/2022] Open
Abstract
Atypical hemolytic uremic syndrome (aHUS) although rare is the commonest cause of acute renal failure (ARF) in children and has poor prognosis. We present single centre experience of aHUS. Thirty six children (29 males, 7 females) with mean age, 7.9 years presented with ARF, 2 children also had tonic-clonic type convulsions. Their hematology examination revealed hemolytic anemia with s. creatinine (SCr), 5.54 mg/dl. Acute HUS was observed in 75 %, acute on chronic HUS in 19.4 % and patchy cortical necrosis (PCN) in 5.6 % biopsies. Mean 5.4 plasma exchanges (PE) were carried out. Supportive management of anti-hypertensives and prednisone was also given. Recovery end points were establishment of urine output, improvement of SCr and hematological profile. Hematology and renal function profile improved variably in all children, 5.6 % died, relapse was observed in 80.5 % over mean 70 days; 13.9 % children are doing well over mean follow-up of 268.8 days. Thus poor prognosis was observed in 86.1 % children. Children with acute on chronic HUS and PCN did not recover. Six children who recovered had acute HUS. aHUS in Indian children occurs at an older age of around 8 years and chronic/irreversible changes on histopathology examination are harbingers of poor prognosis. PE is life-saving however further research for developing strategies to improve long-term survival is needed.
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Affiliation(s)
- Rashmi D Patel
- Department of Pathology, Laboratory Medicine and Transfusion Services and Immunohematology, G. R. Doshi and K. M. Mehta Institute Of Kidney Diseases and Research Centre (IKDRC)-Dr. H.L. Trivedi Institute Of Transplantation Sciences (ITS), Civil Hospital Campus, Asarwa, Ahmedabad, 380016 Gujarat India
| | - Aruna V Vanikar
- Department of Pathology, Laboratory Medicine and Transfusion Services and Immunohematology, G. R. Doshi and K. M. Mehta Institute Of Kidney Diseases and Research Centre (IKDRC)-Dr. H.L. Trivedi Institute Of Transplantation Sciences (ITS), Civil Hospital Campus, Asarwa, Ahmedabad, 380016 Gujarat India
| | - Manoj R Gumber
- Department of Nephrology and Transplantation Medicine, G. R. Doshi and K. M. Mehta Institute Of Kidney Diseases and Research Centre (IKDRC)-Dr. H.L. Trivedi Institute Of Transplantation Sciences (ITS), Civil Hospital Campus, Asarwa, Ahmedabad, 380016 Gujarat India
| | - Kamal V Kanodia
- Department of Pathology, Laboratory Medicine and Transfusion Services and Immunohematology, G. R. Doshi and K. M. Mehta Institute Of Kidney Diseases and Research Centre (IKDRC)-Dr. H.L. Trivedi Institute Of Transplantation Sciences (ITS), Civil Hospital Campus, Asarwa, Ahmedabad, 380016 Gujarat India
| | - Kamlesh S Suthar
- Department of Pathology, Laboratory Medicine and Transfusion Services and Immunohematology, G. R. Doshi and K. M. Mehta Institute Of Kidney Diseases and Research Centre (IKDRC)-Dr. H.L. Trivedi Institute Of Transplantation Sciences (ITS), Civil Hospital Campus, Asarwa, Ahmedabad, 380016 Gujarat India
| | - Himanshu V Patel
- Department of Nephrology and Transplantation Medicine, G. R. Doshi and K. M. Mehta Institute Of Kidney Diseases and Research Centre (IKDRC)-Dr. H.L. Trivedi Institute Of Transplantation Sciences (ITS), Civil Hospital Campus, Asarwa, Ahmedabad, 380016 Gujarat India
| | - Hargovind L Trivedi
- Department of Nephrology and Transplantation Medicine, G. R. Doshi and K. M. Mehta Institute Of Kidney Diseases and Research Centre (IKDRC)-Dr. H.L. Trivedi Institute Of Transplantation Sciences (ITS), Civil Hospital Campus, Asarwa, Ahmedabad, 380016 Gujarat India
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Sengul Samanci N, Ayer M, Gursu M, Ar MC, Yel K, Ergen A, Dogan EE, Karadag S, Cebeci E, Toptas M, Kazancioglu R, Ozturk S. Patients treated with therapeutic plasma exchange: a single center experience. Transfus Apher Sci 2014; 51:83-9. [PMID: 25457747 DOI: 10.1016/j.transci.2014.10.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2014] [Accepted: 10/06/2014] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Therapeutic Plasma Exchange (TPE) is a therapeutic procedure that is used to remove high molecular weight substances from plasma. We analyzed data of patients who received TPE during the last 7 years, and focused on the efficiency of TPE in various disease groups. MATERIAL AND METHODS We studied 110 patients treated with TPE by membrane plasma separation technique from 2007 to 2013. We examined the demographic data, underlying disease, biochemical parameters, volume and type of replacement fluid, complications, concomitant treatment, the need for hemodialysis and number of TPE sessions. RESULTS One hundred ten patients, 58 male, 52 female were included. The mean age was 47.3 ± 17.6 years. A total of 734 TPE sessions were performed and the mean number of TPE sessions per patient was 6.6 ± 4.3. The underlying disease was renal transplantation in 26 patients, ANCA-associated vasculitis in 18, rapidly progressive glomerulonephritis in 17, hemolytic uremic syndrome in 11, thrombotic thrombocytopenic purpura in 9, autoimmunic hemolytic anemia in 6, focal segmental glomerulosclerosis in 6 and other diseases. Partial and complete remission was obtained in 65 (59.1%) and 24 patients (21.8%) respectively, while 14 (12.7%) patients had no response and 7 (6.4%) patients died. Complications were muscle cramps (6.4%), allergic reactions (4.5%), severe hypotension (3.6%), fever (1.8%), unconsciousness (0.9%), leukopenia (0.9%) and catheter related hematoma (0.9%). CONCLUSION According to our 7 years of experience in TPE, we can say that therapeutic plasma exchange by membrane separation technique is a useful, easy, available and effective life-saving therapeutic treatment.
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Affiliation(s)
- Nilay Sengul Samanci
- Department of Internal Medicine, Haseki Training and Research Hospital, Istanbul, Turkey.
| | - Mesut Ayer
- Department of Hematology, Haseki Training and Research Hospital, Istanbul, Turkey
| | - Meltem Gursu
- Department of Nephrology, Haseki Training and Research Hospital, Istanbul, Turkey
| | - Muhlis Cem Ar
- Department of Hematology, Istanbul University Cerrahpasa Medical Faculty, Istanbul, Turkey
| | - Kubra Yel
- Department of Internal Medicine, Haseki Training and Research Hospital, Istanbul, Turkey
| | - Abdulkadir Ergen
- Department of Internal Medicine, Haseki Training and Research Hospital, Istanbul, Turkey
| | - Elif Ece Dogan
- Department of Internal Medicine, Haseki Training and Research Hospital, Istanbul, Turkey
| | - Serhat Karadag
- Department of Nephrology, Haseki Training and Research Hospital, Istanbul, Turkey
| | - Egemen Cebeci
- Department of Nephrology, Haseki Training and Research Hospital, Istanbul, Turkey
| | - Mehmet Toptas
- Department of Intensive Care Medicine, Haseki Training and Research Hospital, Istanbul, Turkey
| | - Rumeyza Kazancioglu
- Department of Nephrology, Bezmialem Vakif University Medical Faculty, Istanbul, Turkey
| | - Savas Ozturk
- Department of Nephrology, Haseki Training and Research Hospital, Istanbul, Turkey
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Approach to management of thrombotic thrombocytopenic purpura at university of cincinnati. Adv Hematol 2013; 2013:195746. [PMID: 24396345 PMCID: PMC3876823 DOI: 10.1155/2013/195746] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2013] [Revised: 11/14/2013] [Accepted: 11/28/2013] [Indexed: 11/17/2022] Open
Abstract
Thrombotic Thrombocytopenic Purpura (TTP) is a rare hematologic emergency, congenital or acquired, characterized by ischemic damage of various organs because of platelet aggregation. It is the common name for adults with microangiopathic hemolytic anemia, thrombocytopenia, with or without neurologic or renal abnormalities, and without another etiology; children without renal failure are also described as TTP. Plasma exchange (PE) is the main stay of treatment in combination with steroids and immunosuppressive therapies. The monoclonal antibody against CD20 Rituximab decreases the production of antibodies from B lymphocytes and it is used for antibodies-mediated diseases including TTP. We present our data on retrospective analysis of rituximab in treatment of TTP at University of Cincinnati in a series of 22 patients from 1997 to 2009. Our results showed that PE with immunosuppressive therapy resulted in decreased duration of PE, relapse rate, and increased duration of remission in patients with TTP.
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Kim J, Kim I, Oh K, Yoon S, Oh M, Song YW, Heo DS, Bang Y, Han K, Han JS, Park S, Kim BK. Therapeutic plasma exchange in patients with thrombotic thrombocytopenic purpura–hemolytic uremic syndrome: the 10‐year experience of a single center. Hematology 2013; 16:73-9. [DOI: 10.1179/102453311x12902908411995] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Affiliation(s)
- Ji‐Won Kim
- Department of Internal Medicine College of Medicine, Seoul National University, Seoul, Korea
- Cancer Research InstituteCollege of Medicine, Seoul National University, Seoul, Korea
- Diagnostic DNA Chip Center the Ilchun Molecular Research Center, College of Medicine, Seoul National University, Seoul, Korea
| | - Inho Kim
- Department of Internal Medicine College of Medicine, Seoul National University, Seoul, Korea
- Cancer Research InstituteCollege of Medicine, Seoul National University, Seoul, Korea
- Diagnostic DNA Chip Center the Ilchun Molecular Research Center, College of Medicine, Seoul National University, Seoul, Korea
| | - Kook‐Hwan Oh
- Department of Internal Medicine College of Medicine, Seoul National University, Seoul, Korea
| | - Sung‐Soo Yoon
- Department of Internal Medicine College of Medicine, Seoul National University, Seoul, Korea
- Cancer Research InstituteCollege of Medicine, Seoul National University, Seoul, Korea
| | - Myoung‐Don Oh
- Department of Internal Medicine College of Medicine, Seoul National University, Seoul, Korea
| | - Yeong Wook Song
- Department of Internal Medicine College of Medicine, Seoul National University, Seoul, Korea
| | - Dae Seog Heo
- Department of Internal Medicine College of Medicine, Seoul National University, Seoul, Korea
- Cancer Research InstituteCollege of Medicine, Seoul National University, Seoul, Korea
| | - Yung‐Jue Bang
- Department of Internal Medicine College of Medicine, Seoul National University, Seoul, Korea
- Cancer Research InstituteCollege of Medicine, Seoul National University, Seoul, Korea
| | - Kyou‐Sup Han
- Department of Laboratory MedicineCollege of Medicine, Seoul National University, Seoul, Korea
| | - Jin Suk Han
- Department of Internal Medicine College of Medicine, Seoul National University, Seoul, Korea
| | - Seonyang Park
- Department of Internal Medicine College of Medicine, Seoul National University, Seoul, Korea
- Cancer Research InstituteCollege of Medicine, Seoul National University, Seoul, Korea
- Diagnostic DNA Chip Center the Ilchun Molecular Research Center, College of Medicine, Seoul National University, Seoul, Korea
| | - Byoung Kook Kim
- Department of Internal Medicine College of Medicine, Seoul National University, Seoul, Korea
- Cancer Research InstituteCollege of Medicine, Seoul National University, Seoul, Korea
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Basic-Jukic N, Kes P, Bubic-Filipi L, Brunetta B. Treatment of thrombotic microangiopathies with plasma exchange. Hematology 2013; 12:63-7. [PMID: 17364995 DOI: 10.1080/10245330600938687] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
Thrombotic microangiopathy (TMA) is a syndrome characterized by thrombocytopenia, microangiopathic hemolytic anemia, neurologic abnormalities, fever and renal dysfunction. This retrospective analysis sought to determine the clinical characteristics and outcome of patients with TMA treated with plasma exchange at the Department of Dialysis, University Hospital Zagreb. From 1982 to July 2005, 17 patients (10 male and 7 female, age ranging from 18 to 74 years) have been diagnosed with TMA. The most common presenting symptom was purpura in 76.5%, followed by neurologic disturbance in 70.5%, renal function abnormality in 41.1%, and fever in 29.4% of patients. Patients were treated with a daily plasma exchange, which was continued until the normalization of platelet count with minimal hemolysis. Plasma exchange treatment was first tapered and later discontinued with careful monitoring of laboratory parameters. Of the 17 patients, 13 achieved complete remission after 5-32 sessions, two had partial response, and two had no response and died of progressive disease. Four patients developed chronic relapsing TMA, and three of them progressed to end-stage renal disease. Survival at 1 year in our series exceeds 88%, but decreased with duration of follow-up. Overall, with the median follow up of 5 years, 6 patients died from consequences of TMA (35.3%); three with chronic TMA, and 2 in the acute phase of progressive disease. A 74-year old male who developed TMA after prostate cancer died from disseminated malignant disease. Our results demonstrate a high incidence of renal function abnormalities in patients with TMA at presentation, but also during long term follow-up. Development of end-stage renal disease was associated with poor prognosis. Further studies, long term follow-up and establishment of international registries are needed to clarify many dilemmas associated with the diagnosis, treatment and outcomes of patients with TMA.
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Dose kidney transplant nephrectomy stop disease progression in plasma exchange resistant post transplant hemolytic uremic syndrome? A case report. J Nephropathol 2013; 2:85-9. [DOI: 10.5812/nephropathol.8944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2012] [Revised: 05/25/2012] [Accepted: 05/30/2012] [Indexed: 11/16/2022] Open
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Efficacy of rituximab in acute refractory or chronic relapsing non-familial idiopathic thrombotic thrombocytopenic purpura: a systematic review with pooled data analysis. J Thromb Thrombolysis 2012; 34:347-59. [DOI: 10.1007/s11239-012-0723-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
This review summarizes the clinical evidence and practical details for the use of plasmapheresis and other apheresis modalities for each indication in nephrology. Updated information on the molecular biology and immunology of each renal disease is discussed in relation to the rationale for apheresis therapy and its place amid other available treatments. Autoantibody-mediated diseases, such as anti-GBM (anti-glomerular basement membrane) glomerulonephritis (GN), ANCA (antineutrophil cytoplasmic antibody)-related GN and the antibody-mediated type of TTP (thrombotic thrombocytopenic purpura), and alloantibody-mediated diseases such as kidney transplant sensitization and humoral rejection, can be treated by various plasmapheresis methods. These include standard plasmapheresis with a replacement volume, or plasmapheresis with online plasma purification using adsorption columns or secondary filtration. However, it should be noted that the pathogenic molecules implicated in FSGS (focal segmental glomerulosclerosis), myeloma cast nephropathy, and perhaps other diseases are too small to be removed by most online purification methods. A great majority of controlled trials and series on which evidence-based treatment recommendations are made were performed using centrifugal plasmapheresis; it is presumed that membrane-separation plasmapheresis is equally efficacious. For some rarer diseases, such as MPGN (membranoproliferative GN) type 2 with factor H abnormalities or C3Nef (C3 nephritic factor) autoantibodies, there are only a few case reports, but enough scientific understanding to warrant a trial of plasmapheresis in severe cases. Photopheresis, which is effective for cell-mediated rejection in heart and lung transplantation, has not yet found a place in the routine treatment of kidney transplant rejection.
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Affiliation(s)
- Amber P Sanchez
- Department of Medicine, Division of Nephrology, University of California, and Therapeutic Apheresis Program, UCSD Medical Center, San Diego, California 92103-8781, USA
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Postendoscopic retrograde cholangiopancreatography pancreatitis: a rare cause of thrombotic thrombocytopenic purpura-hemolytic uremic syndrome. Eur J Gastroenterol Hepatol 2011; 23:825-7. [PMID: 21716116 DOI: 10.1097/meg.0b013e328348e73a] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
Endothelial injury is perhaps the inciting factor leading to the microangiopathic process that initiates thrombotic thrombocytopenic purpura-hemolytic uremic syndrome (TTP-HUS). TTP-HUS after postendoscopic retrograde cholangiopancreatography (ERCP) pancreatitis is extremely rare, but potentially is life threatening. Here, we describe a case of a 23-year-old man with a history of choledocholithiasis, who developed TTP-HUS, 2 days after the onset of post-ERCP pancreatitis. It is important that physicians recognize TTP-HUS as one of the potential causes of acute kidney injury in cases of acute pancreatitis and post-ERCP pancreatitis for adult patients, especially when there is concomitant thrombocytopenia and hemolytic anemia. The early initiation of plasma exchange has a major impact on the survival and preservation of renal function. Exchange transfusion of fresh frozen plasma remains the cornerstone treatment of TTP-HUS.
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Pérez-Sáez MJ, Toledo K, Ojeda R, Crespo R, Soriano S, Alvarez de Lara MA, Martín-Malo A, Aljama P. Tandem plasmapheresis and hemodialysis: efficacy and safety. Ren Fail 2011; 33:765-9. [PMID: 21770855 DOI: 10.3109/0886022x.2011.599912] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Hemodialysis (HD) and plasmapheresis (PE) are usually performed independently on patients who require renal replacement therapy. We analyzed our experience using a technique that performs both modalities simultaneously. METHODS Thirty-six patients who were treated with 287 tandem PE and HD (TPH) sessions (mean 7.97 ± 5.6 per patient) were included. PE was connected 30 min after HD started. The mean HD blood flow was 313.7 ± 44 mL/min, the mean PE blood flow was 141 ± 25 mL/min, and the duration of TPH was no longer than 240 min. The heparin dose was similar to that used for a standard HD procedure. RESULTS In 287 TPH sessions performed, 10.45% experienced minor complications. There were significant changes in mean blood pressure after connection of the PE system. However, these differences were not clinically relevant since patients remained asymptomatic and they did not require saline infusion. At the end of treatment, 38.9% of patients were no longer dependent on dialysis. CONCLUSIONS Our results suggest that TPH is a safe and effective treatment that decreases exposure to an extracorporeal circuit, reducing the risks that are associated with anticoagulation agents and improving the comfortability of the patient.
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Veljkovic D. Use fresh-frozen plasma in newborns, older infants and adolescents on the outcome of bleeding. ACTA ACUST UNITED AC 2011. [DOI: 10.1111/j.1751-2824.2011.01482.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Hong MJ, Lee HG, Hur M, Kim SY, Cho YH, Yoon SY. Slow, but complete, resolution of mitomycin-induced refractory thrombotic thrombocytopenic purpura after rituximab treatment. THE KOREAN JOURNAL OF HEMATOLOGY 2011; 46:45-8. [PMID: 21461304 PMCID: PMC3065627 DOI: 10.5045/kjh.2011.46.1.45] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/16/2010] [Revised: 11/16/2010] [Accepted: 01/26/2011] [Indexed: 11/17/2022]
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a critical complication of treatment with mitomycin C. We retrospectively describe the case of a patient with progressive renal cell carcinoma and mitomycin-induced TTP refractory to plasma exchange and glucocorticoids; we describe the clinical course, successful management of TTP with rituximab, and follow-up of this case. Mitomycin-induced TTP resolved completely by a total of 4 infusions of rituximab 375 mg/m2 on a weekly basis, and it took up to 12 months to obtain a platelet count of >100,000/µL. Rituximab is indicated for the treatment of mitomycin-induced TTP refractory to plasma exchange and glucocorticoids, and it could improve the patient's quality of life despite the presence of underlying malignancy.
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Affiliation(s)
- Mi Jin Hong
- Division of Hematology-Oncology, Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea
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Abstract
Thrombotic microangiopathies (TMAs) are syndromes associated with thrombocytopenia and multiple organ failure. Plasma exchange is a proven therapy for primary TMA such as thrombotic thrombocytopenic purpura (TTP). There is growing evidence that plasma exchange therapy might also facilitate resolution of organ dysfunction and improve outcomes for secondary TMAs such as disseminated intravascular coagulation (DIC) and systemic inflammation-induced TTP. In this review, we survey the current available evidence and practice of plasma exchange therapy for TMAs.
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Affiliation(s)
- Trung C Nguyen
- Section of Critical Care, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA.
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Tripathi SP, Deshpande AS, Khadse S, Kulkarni RK. Case of TTP with cerebral infarct secondary to platelet transfusion. Indian J Pediatr 2011; 78:109-11. [PMID: 20882432 DOI: 10.1007/s12098-010-0224-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2010] [Accepted: 05/12/2010] [Indexed: 11/26/2022]
Abstract
BACKGROUND Thrombotic thrombocytopenic purpura (TTP) is a rare disease in children with significant mortality in cases who do not receive appropriate treatment. CASE The author describe a 3-year-old child who presented with skin bleeds, microangiopathic anemia, thrombocytopenia and right sided hemi paresis with aphasia and altered sensorium following platelet transfusion. CONCLUSION A diagnosis of thrombotic thrombocytopenic purpura was made and the child recovered dramatically after giving fresh frozen plasma and steroids.
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Affiliation(s)
- Sushil P Tripathi
- Department of Pediatrics, B.J. Medical College, Maharashtra, 411001, Pune, India
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Waters AM, Licht C. aHUS caused by complement dysregulation: new therapies on the horizon. Pediatr Nephrol 2011; 26:41-57. [PMID: 20556434 PMCID: PMC2991208 DOI: 10.1007/s00467-010-1556-4] [Citation(s) in RCA: 103] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2010] [Revised: 04/23/2010] [Accepted: 04/26/2010] [Indexed: 12/19/2022]
Abstract
Atypical hemolytic uremic syndrome (aHUS) is a heterogeneous disease that is caused by defective complement regulation in over 50% of cases. Mutations have been identified in genes encoding both complement regulators [complement factor H (CFH), complement factor I (CFI), complement factor H-related proteins (CFHR), and membrane cofactor protein (MCP)], as well as complement activators [complement factor B (CFB) and C3]. More recently, mutations have also been identified in thrombomodulin (THBD), an anticoagulant glycoprotein that plays a role in the inactivation of C3a and C5a. Inhibitory autoantibodies to CFH account for an additional 5-10% of cases and can occur in isolation or in association with mutations in CFH, CFI, CFHR 1, 3, 4, and MCP. Plasma therapies are considered the mainstay of therapy in aHUS secondary to defective complement regulation and may be administered as plasma infusions or plasma exchange. However, in certain cases, despite initiation of plasma therapy, renal function continues to deteriorate with progression to end-stage renal disease and renal transplantation. Recently, eculizumab, a humanized monoclonal antibody against C5, has been described as an effective therapeutic strategy in the management of refractory aHUS that has failed to respond to plasma therapy. Clinical trials are now underway to further evaluate the efficacy of eculizumab in the management of both plasma-sensitive and plasma-resistant aHUS.
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Affiliation(s)
- Aoife M. Waters
- Department of Nephrology, Great Ormond Street Hospital, London, WC1N 3JH UK ,University College London, Institute of Child Health, London, UK
| | - Christoph Licht
- Division of Nephrology, Hospital for Sick Children, Toronto, ON Canada ,Department of Paediatrics, University of Toronto, Toronto, ON Canada
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Szczepiorkowski ZM, Winters JL, Bandarenko N, Kim HC, Linenberger ML, Marques MB, Sarode R, Schwartz J, Weinstein R, Shaz BH. Guidelines on the use of therapeutic apheresis in clinical practice--evidence-based approach from the Apheresis Applications Committee of the American Society for Apheresis. J Clin Apher 2010; 25:83-177. [PMID: 20568098 DOI: 10.1002/jca.20240] [Citation(s) in RCA: 352] [Impact Index Per Article: 25.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The American Society for Apheresis (ASFA) Apheresis Applications Committee is charged with a review and categorization of indications for therapeutic apheresis. Beginning with the 2007 ASFA Special Issue (fourth edition), the subcommittee has incorporated systematic review and evidence-based approach in the grading and categorization of indications. This Fifth ASFA Special Issue has further improved the process of using evidence-based medicine in the recommendations by refining the category definitions and by adding a grade of recommendation based on widely accepted GRADE system. The concept of a fact sheet was introduced in the Fourth edition and is only slightly modified in this current edition. The fact sheet succinctly summarizes the evidence for the use of therapeutic apheresis. The article consists of 59 fact sheets devoted to each disease entity currently categorized by the ASFA as category I through III. Category IV indications are also listed.
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Affiliation(s)
- Zbigniew M Szczepiorkowski
- Transfusion Medicine Service, Department of Pathology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire 03756, USA.
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Yamauchi Y, Nagatoya K, Okuno A, Fujii N, Inoue T. Successful treatment for thrombotic thrombocytopenic purpura complicated with myeloperoxidase anti-neutrophil cytoplasmic autoantibody-associated vasculitis. NDT Plus 2010; 3:279-281. [PMID: 28657029 PMCID: PMC5477948 DOI: 10.1093/ndtplus/sfq013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2010] [Accepted: 02/02/2010] [Indexed: 12/04/2022] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) complicated with myeloperoxidase anti-neutrophil cytoplasmic autoantibody (MPO-ANCA)-associated vasculitis is rare and generally has a serious prognosis. We report a case wherein TTP was successfully treated with repeated plasma exchange (PE) and MPO-ANCA-associated vasculitis with corticosteroids. The renal function consequently improved such that haemodialysis could be discontinued and the patient was discharged without any significant complications.
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Affiliation(s)
- Yoko Yamauchi
- Department of Nephrology, Hyogo Prefectural Nishinomiya Hospital, Hyogo, Japan.,Department of Nephrology, Osaka Medical College, Osaka, Japan
| | | | - Ayako Okuno
- Department of Nephrology, Hyogo Prefectural Nishinomiya Hospital, Hyogo, Japan
| | - Naohiko Fujii
- Department of Nephrology, Hyogo Prefectural Nishinomiya Hospital, Hyogo, Japan
| | - Toru Inoue
- Department of Nephrology, Osaka Medical College, Osaka, Japan
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Taylor CM, Machin S, Wigmore SJ, Goodship THJ. Clinical practice guidelines for the management of atypical haemolytic uraemic syndrome in the United Kingdom. Br J Haematol 2009; 148:37-47. [PMID: 19821824 DOI: 10.1111/j.1365-2141.2009.07916.x] [Citation(s) in RCA: 140] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Atypical haemolytic uraemic syndrome (aHUS) is associated with a poor prognosis with regard to survival at presentation, recovery of renal function and transplantation. It is now established that aHUS is a disease of complement dysregulation with mutations in the genes encoding both complement regulators and activators, and autoantibodies against the complement regulator factor H. Identification of the underlying molecular abnormality in an individual patient can now help to guide their future management. In these guidelines we make recommendations for the investigation and management of aHUS patients both at presentation and in the long-term. We particularly address the role of renal transplantation alone and combined liver-kidney transplantation.
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Affiliation(s)
- C Mark Taylor
- Institute of Human Genetics, Newcastle University, Central Parkway, Newcastle upon Tyne, UK
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Rituximab-based therapy for gemcitabine-induced hemolytic uremic syndrome in a patient with metastatic pancreatic adenocarcinoma: a case report. Cancer Chemother Pharmacol 2008; 64:177-81. [PMID: 19116715 DOI: 10.1007/s00280-008-0900-x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2008] [Accepted: 12/07/2008] [Indexed: 12/20/2022]
Abstract
PURPOSE The purpose of this report is to describe the management and outcome of an unusual complication of a commonly used chemotherapeutic agent. Gemcitabine is a known risk factor for hemolytic uremic syndrome (HUS), which can often have a rapidly fatal clinical course despite intervention with steroids, plasmapheresis and hemodialysis. METHODS A retrospective report of the first case of gemcitabine-related HUS, in a patient with metastatic pancreatic adenocarcinoma, treated with a variety of standard therapies in addition to rituximab is presented. The hematologic response parameters and clinical outcomes to each of the therapies given are described. RESULTS Chemotherapy-induced HUS was aggressively treated with plasmapheresis, high-dose steroids, vincristine and rituximab. Platelet recovery and clinical improvement coincided with administration of rituximab. In addition, aggressive supportive measures to manage renal failure (hemodialysis) and labile hypertension, allowed this patient to have an extended survival as a result of successful therapy for this complication despite an underlying rapidly fatal malignancy. CONCLUSION This case highlights the importance of timely application of aggressive measures even in patients with known diagnosis of a fatal malignancy as these interventions can prolong life and be of palliative benefit.
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Nagai Y, Itabashi M, Mizutani M, Ogawa T, Yumura W, Tsuchiya K, Nitta K. A case report of uncompensated alkalosis induced by daily plasmapheresis in a patient with thrombotic thrombocytopenic purpura. Ther Apher Dial 2008; 12:86-90. [PMID: 18257819 DOI: 10.1111/j.1744-9987.2007.00547.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Plasmapheresis (PP) is widely known as the standard therapy for thrombotic thrombocytopenic purpura (TTP). Citrate is used as an anticoagulant in fresh frozen plasma, and the large amount of citrate infused during PP induces metabolic alkalosis. A 29-year-old woman was diagnosed with TTP associated with systemic lupus erythematosus, and was treated by daily PP in addition to a steroid, an immunosuppressant, vincristine, and cyclophosphamide. Uncompensated alkalosis caused by a combination of metabolic and respiratory alkalosis developed after artificial ventilation was discontinued. Her metabolic status improved after controlling her respiratory status and the activity of the TTP. Metabolic alkalosis is a common complication in TTP patients treated by frequent PP, but several factors that affect metabolic status may aggravate the alkalosis and induce uncompensated alkalosis.
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Affiliation(s)
- Yoshiko Nagai
- Department of Medicine IV, Tokyo Women's Medical University, Tokyo, Japan
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49
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Srinivas S. Acute Toxicities of Therapy: Urologic Complications. Oncology 2007. [DOI: 10.1007/0-387-31056-8_80] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Kojouri K, George JN. Thrombotic microangiopathy following allogeneic hematopoietic stem cell transplantation. Curr Opin Oncol 2007; 19:148-54. [PMID: 17272988 DOI: 10.1097/cco.0b013e3280148a2f] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The aim of this article is to assess the current understanding and uncertainties about the evaluation and management of thrombotic microangiopathy that occurs following allogeneic hematopoietic stem cell transplantation. RECENT FINDINGS Current data may not be sufficient to establish posttransplantation thrombotic microangiopathy as a discrete clinical or pathologic entity, distinct from other well recognized transplant-related complications. Analysis of case series of posttransplantation thrombotic microangiopathy illustrates uncertainties regarding incidence, risk factors, diagnosis, treatment, and survival. These studies have suggested the lack of efficacy of plasma exchange treatment and have identified other transplant-related complications, such as acute graft-versus-host disease and opportunistic infections, as the predominant causes of death in patients who had been diagnosed with posttransplantation thrombotic microangiopathy. Recently consensus diagnostic criteria were proposed by two independent groups to provide more uniform identification of patients with posttransplantation thrombotic microangiopathy; these criteria may result in a clearer definition of this syndrome. SUMMARY Posttransplantation thrombotic microangiopathy remains a diagnostic and therapeutic challenge. Further studies are required to determine if it is a specific entity and to define its relation to other transplant-related complications.
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Affiliation(s)
- Kiarash Kojouri
- Hematology-Oncology Section, Department of Medicine, College of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma 73104, USA
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