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Gavriilaki E, Bousiou Z, Batsis I, Vardi A, Mallouri D, Koravou EE, Konstantinidou G, Spyridis N, Karavalakis G, Noli F, Patriarcheas V, Masmanidou M, Touloumenidou T, Papalexandri A, Poziopoulos C, Yannaki E, Sakellari I, Politou M, Papassotiriou I. Soluble Urokinase-Type Plasminogen Activator Receptor (suPAR) and Growth Differentiation Factor-15 (GDF-15) Levels Are Significantly Associated with Endothelial Injury Indices in Adult Allogeneic Hematopoietic Cell Transplantation Recipients. Int J Mol Sci 2023; 25:231. [PMID: 38203404 PMCID: PMC10778584 DOI: 10.3390/ijms25010231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 12/17/2023] [Accepted: 12/18/2023] [Indexed: 01/12/2024] Open
Abstract
Hematopoietic stem cell transplantation-associated thrombotic microangiopathy (HSCT-TMA) and graft-versus-host disease (GvHD) represent life-threatening syndromes after allogeneic hematopoietic stem cell transplantation (allo-HSCT). In both conditions, endothelial dysfunction is a common denominator, and development of relevant biomarkers is of high importance for both diagnosis and prognosis. Despite the fact that soluble urokinase plasminogen activator receptor (suPAR) and growth differentiation factor-15 (GDF-15) have been determined as endothelial injury indices in various clinical settings, their role in HSCT-related complications remains unexplored. In this context, we used immunoenzymatic methods to measure suPAR and GDF-15 levels in HSCT-TMA, acute and/or chronic GVHD, control HSCT recipients, and apparently healthy individuals of similar age and gender. We found considerably greater SuPAR and GDF-15 levels in HSCT-TMA and GVHD patients compared to allo-HSCT and healthy patients. Both GDF-15 and suPAR concentrations were linked to EASIX at day 100 and last follow-up. SuPAR was associated with creatinine and platelets at day 100 and last follow-up, while GDF-15 was associated only with platelets, suggesting that laboratory values do not drive EASIX. SuPAR, but not GDF-15, was related to soluble C5b-9 levels, a sign of increased HSCT-TMA risk. Our study shows for the first time that suPAR and GDF-15 indicate endothelial damage in allo-HSCT recipients. Rigorous validation of these biomarkers in many cohorts may provide utility for their usefulness in identifying and stratifying allo-HSCT recipients with endothelial cell impairment.
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Affiliation(s)
- Eleni Gavriilaki
- Second Propedeutic Department of Internal Medicine, Hippocration Hospital, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece
| | - Zoi Bousiou
- BMT Unit, Hematology Department, George Papanicolaou General Hospital, 57010 Thessaloniki, Greece; (Z.B.); (I.B.); (A.V.); (D.M.); (E.-E.K.); (G.K.); (N.S.); (G.K.); (F.N.); (V.P.); (M.M.); (T.T.); (A.P.); (E.Y.); (I.S.)
| | - Ioannis Batsis
- BMT Unit, Hematology Department, George Papanicolaou General Hospital, 57010 Thessaloniki, Greece; (Z.B.); (I.B.); (A.V.); (D.M.); (E.-E.K.); (G.K.); (N.S.); (G.K.); (F.N.); (V.P.); (M.M.); (T.T.); (A.P.); (E.Y.); (I.S.)
| | - Anna Vardi
- BMT Unit, Hematology Department, George Papanicolaou General Hospital, 57010 Thessaloniki, Greece; (Z.B.); (I.B.); (A.V.); (D.M.); (E.-E.K.); (G.K.); (N.S.); (G.K.); (F.N.); (V.P.); (M.M.); (T.T.); (A.P.); (E.Y.); (I.S.)
| | - Despina Mallouri
- BMT Unit, Hematology Department, George Papanicolaou General Hospital, 57010 Thessaloniki, Greece; (Z.B.); (I.B.); (A.V.); (D.M.); (E.-E.K.); (G.K.); (N.S.); (G.K.); (F.N.); (V.P.); (M.M.); (T.T.); (A.P.); (E.Y.); (I.S.)
| | - Evaggelia-Evdoxia Koravou
- BMT Unit, Hematology Department, George Papanicolaou General Hospital, 57010 Thessaloniki, Greece; (Z.B.); (I.B.); (A.V.); (D.M.); (E.-E.K.); (G.K.); (N.S.); (G.K.); (F.N.); (V.P.); (M.M.); (T.T.); (A.P.); (E.Y.); (I.S.)
| | - Georgia Konstantinidou
- BMT Unit, Hematology Department, George Papanicolaou General Hospital, 57010 Thessaloniki, Greece; (Z.B.); (I.B.); (A.V.); (D.M.); (E.-E.K.); (G.K.); (N.S.); (G.K.); (F.N.); (V.P.); (M.M.); (T.T.); (A.P.); (E.Y.); (I.S.)
| | - Nikolaos Spyridis
- BMT Unit, Hematology Department, George Papanicolaou General Hospital, 57010 Thessaloniki, Greece; (Z.B.); (I.B.); (A.V.); (D.M.); (E.-E.K.); (G.K.); (N.S.); (G.K.); (F.N.); (V.P.); (M.M.); (T.T.); (A.P.); (E.Y.); (I.S.)
| | - Georgios Karavalakis
- BMT Unit, Hematology Department, George Papanicolaou General Hospital, 57010 Thessaloniki, Greece; (Z.B.); (I.B.); (A.V.); (D.M.); (E.-E.K.); (G.K.); (N.S.); (G.K.); (F.N.); (V.P.); (M.M.); (T.T.); (A.P.); (E.Y.); (I.S.)
| | - Foteini Noli
- BMT Unit, Hematology Department, George Papanicolaou General Hospital, 57010 Thessaloniki, Greece; (Z.B.); (I.B.); (A.V.); (D.M.); (E.-E.K.); (G.K.); (N.S.); (G.K.); (F.N.); (V.P.); (M.M.); (T.T.); (A.P.); (E.Y.); (I.S.)
| | - Vasileios Patriarcheas
- BMT Unit, Hematology Department, George Papanicolaou General Hospital, 57010 Thessaloniki, Greece; (Z.B.); (I.B.); (A.V.); (D.M.); (E.-E.K.); (G.K.); (N.S.); (G.K.); (F.N.); (V.P.); (M.M.); (T.T.); (A.P.); (E.Y.); (I.S.)
| | - Marianna Masmanidou
- BMT Unit, Hematology Department, George Papanicolaou General Hospital, 57010 Thessaloniki, Greece; (Z.B.); (I.B.); (A.V.); (D.M.); (E.-E.K.); (G.K.); (N.S.); (G.K.); (F.N.); (V.P.); (M.M.); (T.T.); (A.P.); (E.Y.); (I.S.)
| | - Tasoula Touloumenidou
- BMT Unit, Hematology Department, George Papanicolaou General Hospital, 57010 Thessaloniki, Greece; (Z.B.); (I.B.); (A.V.); (D.M.); (E.-E.K.); (G.K.); (N.S.); (G.K.); (F.N.); (V.P.); (M.M.); (T.T.); (A.P.); (E.Y.); (I.S.)
| | - Apostolia Papalexandri
- BMT Unit, Hematology Department, George Papanicolaou General Hospital, 57010 Thessaloniki, Greece; (Z.B.); (I.B.); (A.V.); (D.M.); (E.-E.K.); (G.K.); (N.S.); (G.K.); (F.N.); (V.P.); (M.M.); (T.T.); (A.P.); (E.Y.); (I.S.)
| | - Christos Poziopoulos
- Department of Hematology, Metropolitan Hospital, Neo Faliro, 18547 Athens, Greece;
| | - Evangelia Yannaki
- BMT Unit, Hematology Department, George Papanicolaou General Hospital, 57010 Thessaloniki, Greece; (Z.B.); (I.B.); (A.V.); (D.M.); (E.-E.K.); (G.K.); (N.S.); (G.K.); (F.N.); (V.P.); (M.M.); (T.T.); (A.P.); (E.Y.); (I.S.)
| | - Ioanna Sakellari
- BMT Unit, Hematology Department, George Papanicolaou General Hospital, 57010 Thessaloniki, Greece; (Z.B.); (I.B.); (A.V.); (D.M.); (E.-E.K.); (G.K.); (N.S.); (G.K.); (F.N.); (V.P.); (M.M.); (T.T.); (A.P.); (E.Y.); (I.S.)
| | - Marianna Politou
- Hematology Laboratory-Blood Bank, Aretaieion Hospital, School of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece;
| | - Ioannis Papassotiriou
- First Department of Pediatrics, School of Medicine, National and Kapodistrian University of Athens, 15772 Athens, Greece;
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Dandoy CE, Tsong WH, Sarikonda K, McGarvey N, Perales MA. Systematic Review of Signs and Symptoms Associated with Hematopoietic Stem Cell Transplantation-Associated Thrombotic Microangiopathy. Transplant Cell Ther 2023; 29:282.e1-282.e9. [PMID: 36592719 PMCID: PMC11284894 DOI: 10.1016/j.jtct.2022.12.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 12/21/2022] [Accepted: 12/23/2022] [Indexed: 01/01/2023]
Abstract
Hematopoietic stem cell transplantation-associated thrombotic microangiopathy (HSCT-TMA) is a serious complication of the transplantation process that has been consistently associated with substantially greater morbidity and mortality compared with HSCT recipients who do not develop TMA. This study aimed to systematically review published signs and symptoms of HSCT-TMA and compare patients with HSCT-TMA and HSCT recipients who do not develop TMA. Publications were identified using multiple search term variations for stem cell transplantation that were entered into the PubMed, Embase, and CINAHL databases. Two reviewers screened references at the abstract level before reviewing full texts against inclusion and exclusion criteria using a PICOS-T framework. Complication proportions were grouped by organ class and then by complication type. Meta-analyses were conducted using a random-effects model in RevMan 5.4. After 2338 references were screened, a total of 30 studies were included in our analyses. The majority of studies (n = 23; 14 adult, 5 pediatric, 4 both) examined allogeneic transplantations only. Four studies examined autologous transplantation only (all pediatric), and 3 studies included both transplantation types (all pediatric). HSCT-TMA was associated with renal dysfunction (odds ratio [OR], 11.04 for adult, allogeneic and 7.35 for pediatric, all transplantations), renal failure (OR, 2.41 for adult and pediatric, allogeneic), renal replacement therapy (OR, 6.99 for pediatric, all transplantations and 60.85 for adult, allogeneic), and hypertension (OR, 5.44 for adult, allogeneic). HSCT-TMA was associated with respiratory failure (OR, 8.00 for adult and pediatric, allogeneic), pulmonary hypertension (OR, 9.86 for adult and pediatric, allogeneic), need for pleurocentesis (OR, 5.45 for pediatric, all transplantations), noninvasive ventilation (OR, 6.15 for pediatric, all transplantations), and invasive mechanical ventilation (OR, 5.18 for pediatric, all transplantations). Additionally, HSCT-TMA was associated with neurologic symptoms (OR, 2.28 for adult and pediatric, allogeneic), pericardial effusion (OR, 2.56 for adult and pediatric, allogeneic and 8.76 for pediatric, all transplantations), liver injury (OR, 3.87 for adult, allogeneic), infection (OR, 9.25 for adult, allogeneic; 2.06 for pediatric, all transplantations), gastrointestinal (GI) bleeding (OR, 7.78 for adult and pediatric, allogeneic), and acute graft-versus-host disease grade III-IV (OR, 3.29 for adult and pediatric, allogeneic). This study represents the first systematic review of HSCT-TMA signs and symptoms. Current diagnostic criteria systems involve laboratory markers for multiorgan dysfunction, including renal dysfunction, liver injury, and general tissue damage. Diagnostic criteria include neurologic symptoms, increased need for transfusions, and hypertension. This study identified additional associations with HSCT-TMA, including increased pulmonary hypertension, respiratory failure, fever, GI bleeding, and pericardial effusion. These symptoms might be included for evaluation in future diagnostic criteria and current practice.
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Affiliation(s)
- Christopher E Dandoy
- Division of Bone Marrow Transplantation and Immune Deficiency, Cancer and Blood Disease Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio.
| | - Wan H Tsong
- Omeros Corporation, Health Economics and Outcomes Research, Medical Affairs, Seattle, Washington
| | - Kaushik Sarikonda
- BluePath Solutions, Strategic Health Economics and Outcomes Research, Los Angeles, California
| | - November McGarvey
- BluePath Solutions, Strategic Health Economics and Outcomes Research, Los Angeles, California
| | - Miguel-Angel Perales
- Department of Medicine, Adult Bone Marrow Transplantation Service, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
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Othman S, Stranix JT, Piwnica-Worms W, Bauder A, Azoury SC, Elfanagely O, Klifto KM, Levin LS, Kovach SJ. Microvascular free tissue transfer for reconstruction of complex lower extremity trauma: Predictors of complications and flap failure. Microsurgery 2023; 43:5-12. [PMID: 34228378 DOI: 10.1002/micr.30785] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 01/12/2021] [Accepted: 06/25/2021] [Indexed: 01/12/2023]
Abstract
BACKGROUND Despite advanced wound care techniques, open fractures in the setting of lower extremity trauma remain a challenging pathology, particularly when free tissue transfer is required for coverage. We aimed to evaluate factors associated with flap failure in this setting using a large, heterogeneous patient population. METHODS Retrospective review of patients who underwent traumatic lower extremity free flap reconstruction (2002-2019). Demographics wound/vessel injury characteristics, pre and perioperative factors, and flap outcomes were analyzed. RESULTS One hundred eighty-eight free flaps met inclusion criteria, with 23 partial (12.2%) and 13 total (6.9%) flap failures. Angiography was performed in 87 patients, with arterial injury suffered in 43.1% of those evaluated. Time to flap coverage varied within 3 days (4.5%), 10 days (17.3%), or 30 days of injury (42.7%). In all, 41 (21.8%) subjects suffered from major flap complications, including failure and takebacks. Multivariate regression demonstrated the presence of posterior tibial (PT) artery injury predictive of both flap-failure (Odds ratio [OR] = 11.4, p < .015) and major flap complications (OR = 12.1, p < .012). Immunocompromised status was also predictive of flap failure (OR = 12.6, p < .004) and major complications (OR = 11.6, p < .007), while achieving flap coverage within 30 days was protective against flap complications (OR = 0.413, p < .049). Defect size, infection, and injury location were not associated with failure. CONCLUSIONS When examining a large, heterogeneous patient cohort, free flap outcomes in the setting of lower extremity open fractures can be influenced by multiple factors. This presence of PT artery injury, flap coverage beyond 30 days of injury, and immunocompromised status appear predictive of flap complications in this context.
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Affiliation(s)
- Sammy Othman
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - John T Stranix
- Department of Plastic Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - William Piwnica-Worms
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Andrew Bauder
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Saïd C Azoury
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Omar Elfanagely
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Kevin M Klifto
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - L Scott Levin
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA.,Department of Orthopedic Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Stephen J Kovach
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA.,Department of Orthopedic Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
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Yamamoto S, Nagashima T, Akiyama Y, Nagatani K, Iwamoto M, Minota S. Fatal Thrombotic Microangiopathy and Posterior Reversible Encephalopathy Syndrome in a Patient with Anti-melanoma Differentiation-associated Gene 5 Antibody-positive Dermatomyositis. Intern Med 2021; 60:3329-3333. [PMID: 33896869 PMCID: PMC8580758 DOI: 10.2169/internalmedicine.7309-21] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 56-year-old woman presented with dermatomyositis positive for anti-melanoma differentiation-associated gene 5 antibody. No interstitial lung disease was detected. Despite treatment with methylprednisolone pulse therapy and cyclosporine, dysphagia developed. Furthermore, the presence of thrombocytopenia, elevated lactate dehydrogenase levels, and an undetectable haptoglobin level suggested the possibility of thrombotic microangiopathy (TMA). Disturbed consciousness developed shortly after TMA onset, and brain magnetic resonance imaging revealed hyperintensity lesions in the bilateral basal ganglia, thalami, and brainstem. The patient was diagnosed with atypical posterior leukoencephalopathy syndrome before dying of heart failure later that day. In conclusion, early TMA recognition and prompt intensive treatment are critical in such cases.
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Affiliation(s)
- Shotaro Yamamoto
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Jichi Medical University, Japan
| | - Takao Nagashima
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Jichi Medical University, Japan
| | - Yoichiro Akiyama
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Jichi Medical University, Japan
| | - Katsuya Nagatani
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Jichi Medical University, Japan
| | - Masahiro Iwamoto
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Jichi Medical University, Japan
| | - Seiji Minota
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Jichi Medical University, Japan
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Imus PH, Tsai HL, DeZern AE, Jerde K, Swinnen LJ, Bolaños-Meade J, Luznik L, Fuchs EJ, Wagner-Johnston N, Huff CA, Gladstone DE, Ambinder RF, Gocke CB, Ali SA, Borrello IM, Varadhan R, Brodsky R, Jones RJ. Thrombotic Microangiopathy after Post-Transplantation Cyclophosphamide-Based Graft-versus-Host Disease Prophylaxis. Biol Blood Marrow Transplant 2020; 26:2306-2310. [PMID: 32961372 DOI: 10.1016/j.bbmt.2020.09.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 09/02/2020] [Accepted: 09/02/2020] [Indexed: 12/31/2022]
Abstract
Transplant-associated thrombotic microangiopathy (taTMA) is a systemic vascular illness associated with significant morbidity and mortality, resulting from a convergence of risk factors after allogeneic blood or marrow transplantation (alloBMT). The diagnosis of taTMA has been a challenge, but most criteria include an elevated lactate dehydrogenase (LDH), low haptoglobin, and schistocytes on peripheral blood smear. We performed a retrospective review of the 678 consecutive adults who received high-dose post-transplantation cyclophosphamide (PTCy)-based graft-versus-host disease (GVHD) prophylaxis between January 1, 2015, and August 31, 2018. In April 2016, we initiated a monitoring program of weekly LDH and haptoglobin measurements and blood smears when those 2 parameters were both abnormal on all of our adult patients undergoing alloBMT for hematologic malignancies. During the entire period, the 1-year cumulative incidence of taTMA was 1.4% (95% confidence interval, 0.5% to 2.3%). Eight patients were taking tacrolimus at the time of diagnosis, and 1 was not on any immunosuppression. Eight of 9 patients (89%) were hypertensive. Four patients had invasive infections at the time of diagnosis, 4 patients required renal replacement therapy, and 5 of 9 patients were neurologically impaired. Eculizumab was given to 6 patients (0.9%), of whom 2 died and 4 recovered with resolution of end-organ dysfunction. The paucity of events made the determination of risk factors difficult; however, the low incidence of taTMA in this cohort may be related to the limited use of myeloablative conditioning regimens, low incidence of severe GVHD, and use of PTCy. PTCy-based GVHD prophylaxis appears to be associated with a low incidence of severe taTMA.
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Affiliation(s)
- Philip H Imus
- Department of Oncology, Sidney Kimmel Cancer Center, Baltimore, Maryland.
| | - Hua-Ling Tsai
- Department of Oncology Biostatistics, Sidney Kimmel Cancer Center, Baltimore, Maryland
| | - Amy E DeZern
- Department of Oncology, Sidney Kimmel Cancer Center, Baltimore, Maryland
| | - Kevin Jerde
- Department of Oncology, Sidney Kimmel Cancer Center, Baltimore, Maryland
| | - Lode J Swinnen
- Department of Oncology, Sidney Kimmel Cancer Center, Baltimore, Maryland
| | | | - Leo Luznik
- Department of Oncology, Sidney Kimmel Cancer Center, Baltimore, Maryland
| | - Ephraim J Fuchs
- Department of Oncology, Sidney Kimmel Cancer Center, Baltimore, Maryland
| | | | - Carol Ann Huff
- Department of Oncology, Sidney Kimmel Cancer Center, Baltimore, Maryland
| | | | - Richard F Ambinder
- Department of Oncology, Sidney Kimmel Cancer Center, Baltimore, Maryland
| | - Christian B Gocke
- Department of Oncology, Sidney Kimmel Cancer Center, Baltimore, Maryland
| | - Syed Abbas Ali
- Department of Oncology, Sidney Kimmel Cancer Center, Baltimore, Maryland
| | - Ivan M Borrello
- Department of Oncology, Sidney Kimmel Cancer Center, Baltimore, Maryland
| | - Ravi Varadhan
- Department of Oncology Biostatistics, Sidney Kimmel Cancer Center, Baltimore, Maryland
| | - Robert Brodsky
- Division of Hematology, Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Richard J Jones
- Department of Oncology, Sidney Kimmel Cancer Center, Baltimore, Maryland
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Gavriilaki E, Anagnostopoulos A, Mastellos DC. Complement in Thrombotic Microangiopathies: Unraveling Ariadne's Thread Into the Labyrinth of Complement Therapeutics. Front Immunol 2019; 10:337. [PMID: 30891033 PMCID: PMC6413705 DOI: 10.3389/fimmu.2019.00337] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Accepted: 02/08/2019] [Indexed: 12/20/2022] Open
Abstract
Thrombotic microangiopathies (TMAs) are a heterogeneous group of syndromes presenting with a distinct clinical triad: microangiopathic hemolytic anemia, thrombocytopenia, and organ damage. We currently recognize two major entities with distinct pathophysiology: thrombotic thrombocytopenic purpura (TTP) and hemolytic uremic syndrome (HUS). Beyond them, differential diagnosis also includes TMAs associated with underlying conditions, such as drugs, malignancy, infections, scleroderma-associated renal crisis, systemic lupus erythematosus (SLE), malignant hypertension, transplantation, HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets), and disseminated intravascular coagulation (DIC). Since clinical presentation alone is not sufficient to differentiate between these entities, robust pathophysiological features need to be used for early diagnosis and appropriate treatment. Over the last decades, our understanding of the complement system has evolved rapidly leading to the characterization of diseases which are fueled by complement dysregulation. Among TMAs, complement-mediated HUS (CM-HUS) has long served as a disease model, in which mutations of complement-related genes represent the first hit of the disease and complement inhibition is an effective and safe strategy. Based on this knowledge, clinical conditions resembling CM-HUS in terms of phenotype and genotype have been recognized. As a result, the role of complement in TMAs is rapidly expanding in recent years based on genetic and functional studies. Herein we provide an updated overview of key pathophysiological processes underpinning complement activation and dysregulation in TMAs. We also discuss emerging clinical challenges in streamlining diagnostic algorithms and stratifying TMA patients that could benefit more from complement modulation. With the advent of next-generation complement therapeutics and suitable disease models, these translational perspectives could guide a more comprehensive, disease- and target-tailored complement intervention in these disorders.
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Affiliation(s)
- Eleni Gavriilaki
- BMT Unit, Hematology Department, G. Papanicolaou Hospital, Thessaloniki, Greece
| | | | - Dimitrios C Mastellos
- Division of Biodiagnostic Sciences and Technologies, INRASTES, National Center for Scientific Research Demokritos, Athens, Greece
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Wanchoo R, Bayer RL, Bassil C, Jhaveri KD. Emerging Concepts in Hematopoietic Stem Cell Transplantation-Associated Renal Thrombotic Microangiopathy and Prospects for New Treatments. Am J Kidney Dis 2018; 72:857-865. [PMID: 30146419 DOI: 10.1053/j.ajkd.2018.06.013] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2017] [Accepted: 06/06/2018] [Indexed: 12/14/2022]
Abstract
Thrombotic microangiopathy associated with hematopoietic stem cell transplantation (HSCT-TMA) is a well-recognized complication of HSCT that has a high risk for death. Even in patients who survive, HSCT-TMA is associated with long-term morbidity and chronic organ injury. HSCT-TMA is a multisystem disease that often affects the kidneys. Renal manifestations of HSCT-TMA include reduced glomerular filtration rate, proteinuria, and hypertension. Understanding of the pathophysiology of HSCT-TMA has expanded in the last decade. Endothelial injury plays a major role. Recent studies also suggest involvement of complement activation. HSCT-TMA has also been considered by some to be an endothelial variant of graft-versus-host disease. Understanding the pathophysiology of HSCT-TMA and its association with activation of the complement system may aid in developing novel therapeutic options. In this review, we summarize current knowledge focusing on epidemiology and prognosis, evidence of complement activation, and endothelial injury; the possible link to graft-versus-host disease; and treatment options for HSCT-TMA.
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Affiliation(s)
- Rimda Wanchoo
- Division of Kidney Diseases and Hypertension, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY.
| | - Ruthee L Bayer
- Division of Hematology and Oncology and the Northwell Cancer Institute, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Claude Bassil
- Division of Nephrology and Hypertension, University of South Florida, Tampa, FL; Renal Service, H. Lee Moffitt Center, Tampa, FL
| | - Kenar D Jhaveri
- Division of Kidney Diseases and Hypertension, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
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8
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Seaby EG, Gilbert RD. Thrombotic microangiopathy following haematopoietic stem cell transplant. Pediatr Nephrol 2018; 33:1489-1500. [PMID: 28993886 PMCID: PMC6061668 DOI: 10.1007/s00467-017-3803-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Revised: 08/23/2017] [Accepted: 09/01/2017] [Indexed: 12/19/2022]
Abstract
Thrombotic microangiopathy is a potentially lethal complication of haematopoietic stem cell (bone marrow) transplantation. The pathophysiology is incompletely understood, although endothelial damage appears to be central. Platelet activation, neutrophil extracellular traps and complement activation appear to play key roles. Diagnosis may be difficult and universally accepted diagnostic criteria are not available. Treatment remains controversial. In some cases, withdrawal of calcineurin inhibitors is adequate. Rituximab and defibrotide also appear to have been used successfully. In severe cases, complement inhibitors such as eculizumab may play a valuable role. Further research is required to define the pathophysiology and determine both robust diagnostic criteria and the optimal treatment.
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Affiliation(s)
- Eleanor G. Seaby
- Human Genetics and Genomics Department, University of Southampton, Southampton, UK
| | - Rodney D. Gilbert
- Southampton Children’s Hospital and Faculty of Medicine, University of Southampton, Tremona Road, Southampton, SO16 6YD UK
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Gavriilaki E, Sakellari I, Anagnostopoulos A, Brodsky RA. Transplant-associated thrombotic microangiopathy: opening Pandora's box. Bone Marrow Transplant 2017; 52:1355-1360. [PMID: 28287636 DOI: 10.1038/bmt.2017.39] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Revised: 02/01/2017] [Accepted: 02/05/2017] [Indexed: 12/20/2022]
Abstract
Transplant-associated thrombotic microangiopathy (TA-TMA) is an early complication of hematopoietic cell transplantation (HCT). A high mortality rate is documented in patients who are refractory to calcineurin inhibitor cessation. Estimates of TA-TMA prevalence vary significantly and are higher in allogeneic compared with autologous HCT. Furthermore, our understanding of the pathophysiology that is strongly related to diagnosis and treatment options is limited. Recent evidence has linked TA-TMA with atypical hemolytic uremic syndrome, a disease of excessive activation of the alternative pathway of complement, opening the Pandora's box in treatment options. As conventional treatment management is highly inefficient, detection of complement activation may allow for early recognition of patients who will benefit from complement inhibition. Preliminary clinical results showing successful eculizumab administration in children and adults with TA-TMA need to be carefully evaluated. Therefore, realizing the unmet needs of better understanding TA-TMA in this complex setting, we aimed to summarize current knowledge focusing on (1) critical evaluation of diagnostic criteria, (2) epidemiology and prognosis, (3) recent evidence of complement activation and endothelial damage and (4) treatment options.
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Affiliation(s)
- E Gavriilaki
- Hematology Department-Bone Marrow Transplantation Unit, G. Papanicolaou Hospital, Thessaloniki, Greece.,Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - I Sakellari
- Hematology Department-Bone Marrow Transplantation Unit, G. Papanicolaou Hospital, Thessaloniki, Greece
| | - A Anagnostopoulos
- Hematology Department-Bone Marrow Transplantation Unit, G. Papanicolaou Hospital, Thessaloniki, Greece
| | - R A Brodsky
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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10
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Ikezoe T, Yang J, Nishioka C, Umezawa K, Yokoyama A. Thrombomodulin blocks calcineurin inhibitor-induced vascular permeability via inhibition of Src/VE-cadherin axis. Bone Marrow Transplant 2016; 52:245-251. [PMID: 27643869 DOI: 10.1038/bmt.2016.241] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Revised: 07/31/2016] [Accepted: 08/04/2016] [Indexed: 01/02/2023]
Abstract
Recombinant human soluble thrombomodulin (rTM) counteracted capillary leakage and alleviated edema in individuals with sinusoidal obstruction syndrome and engraftment syndrome after hematopoietic stem cell transplantation. We previously showed that rTM increased levels of antiapoptotic protein Mcl-1 and protected endothelial cells from calcineurin inhibitor cyclosporine A (CsA)-induced apoptosis. However, the molecular mechanisms by which rTM enhances barrier function in vascular endothelial cells remain unknown. Here we show that exposure of vascular endothelial EA.hy926 cells to CsA induced phosphorylation of Src/vascular endothelial cadherin (VE-cadherin) and translocation of VE-cadherin from cell surface to cytoplasm, resulting in an increase in vascular permeability. In addition, CsA increased production of inflammatory cytokines, including interleukin (IL)-1β and IL-6, associated with an increase in nuclear levels of nuclear factor-κB (NF-κB) which also enhanced vascular permeability. Importantly, the fourth and fifth regions of epidermal growth factor-like domain of TM (TME45) attenuated CsA-induced p-Src/VE-cadherin and vascular permeability in parallel with a decrease in nuclear levels of NF-κB and cytokine production in EA.hy926 cells. In conclusion, TM, especially TME45, maintains vascular integrity, at least in part, via Src signaling.
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Affiliation(s)
- T Ikezoe
- Department of Hematology and Respiratory Medicine, Kochi Medical School, Kochi University, Kochi, Japan.,Department of Hematology, Fukushima Medical University, Fukushima, Japan
| | - J Yang
- Department of Hematology and Respiratory Medicine, Kochi Medical School, Kochi University, Kochi, Japan
| | - C Nishioka
- Department of Hematology and Respiratory Medicine, Kochi Medical School, Kochi University, Kochi, Japan
| | - K Umezawa
- Department of Molecular Target Medicine Screening, School of Medicine, Aichi Medical University, Aichi, Japan
| | - A Yokoyama
- Department of Hematology and Respiratory Medicine, Kochi Medical School, Kochi University, Kochi, Japan
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11
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Im HJ, Koh KN, Seo JJ. Recent advances in haploidentical hematopoietic stem cell transplantation using ex vivo T cell-depleted graft in children and adolescents. Blood Res 2016; 51:8-16. [PMID: 27104186 PMCID: PMC4828537 DOI: 10.5045/br.2016.51.1.8] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Revised: 03/11/2016] [Accepted: 03/16/2016] [Indexed: 12/21/2022] Open
Abstract
Allogeneic hematopoietic stem cell transplantation (HSCT) is a curative treatment for children and adolescents with various malignant and non-malignant diseases. While human leukocyte antigen (HLA)-identical sibling donor is the preferred choice, matched unrelated volunteer donor is another realistic option for successful HSCT. Unfortunately, it is not always possible to find a HLA-matched donor for patients requiring HSCT, leading to a considerable number of deaths of patients without undergoing transplantation. Alternatively, allogeneic HSCT from haploidentical family members could provide donors for virtually all patients who need HSCT. Although the early attempts at allogeneic HSCT from haploidentical family donor (HFD) were disappointing, recent advances in the effective ex vivo depletion of T cells or unmanipulated in vivo regulation of T cells, better supportive care, and optimal conditioning regimens have significantly improved the outcomes of haploidentical HSCT. The ex vivo techniques used to remove T cells have evolved from the selection of CD34+ hematopoietic stem cell progenitors to the depletion of CD3+ cells, and more recently to the depletion of αβ+ T cells. The recent emerging evidence for ex vivo T cell-depleted haploidentical HSCT has provided additional therapeutic options for pediatric patients with diseases curable by HSCT but has not found a suitable related or unrelated donor. This review discusses recent advances in haploidentical HSCT, focusing on transplant using ex vivo T cell-depleted grafts. In addition, our experiences with this novel approach for the treatment of pediatric patients with malignant and non-malignant diseases are described.
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Affiliation(s)
- Ho Joon Im
- Department of Pediatrics, University of Ulsan College of Medicine, Asan Medical Center Children's Hospital, Seoul, Korea
| | - Kyung-Nam Koh
- Department of Pediatrics, University of Ulsan College of Medicine, Asan Medical Center Children's Hospital, Seoul, Korea
| | - Jong Jin Seo
- Department of Pediatrics, University of Ulsan College of Medicine, Asan Medical Center Children's Hospital, Seoul, Korea
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Fujiwara H, Maeda Y, Sando Y, Nakamura M, Tani K, Ishikawa T, Nishimori H, Matsuoka KI, Fujii N, Kondo E, Tanimoto M. Treatment of thrombotic microangiopathy after hematopoietic stem cell transplantation with recombinant human soluble thrombomodulin. Transfusion 2015; 56:886-92. [PMID: 26711692 DOI: 10.1111/trf.13437] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Revised: 10/14/2015] [Accepted: 10/19/2015] [Indexed: 12/15/2022]
Abstract
BACKGROUND Transplant-associated thrombotic microangiopathy (TA-TMA) after hematopoietic stem cell transplantation (HSCT) remains a severe complication associated with underlying endothelial damage. TMA has a high mortality rate with no definite treatments and effective treatments are needed. STUDY DESIGN AND METHODS The study objective was to retrospectively analyze the outcome of patients receiving recombinant human soluble thrombomodulin (rTM), which has cytoprotective effects against calcineurin inhibitor-induced endothelial cell damage, or other therapeutics for TA-TMA from 254 consecutive HSCT recipients between 2009 to 2014 at a single institution. We hypothesized that patients receiving rTM as a first-line treatment would receive a benefit. RESULTS Sixteen patients were diagnosed as TA-TMA. Of these 16 patients, nine were treated with rTM (rTM group), and seven received treatment other than rTM (control group) as a first-line therapy. Seven of the nine patients in the rTM group recovered from TA-TMA without complications, but none in the control group recovered. The rTM group showed a significantly better overall survival after TA-TMA onset than did the control group (median, 123.0 days vs. 45.5 days, respectively; p = 0.045). The cumulative incidence of acute graft-versus-host disease was the same in both groups (56% vs. 57%, respectively; p = 0.52) on Day 100 after TA-TMA onset. CONCLUSION This is the first report evaluating rTM administration for TA-TMA compared with previous treatments. Our data suggests that rTM might offer a better clinical outcome in patients with TA-TMA.
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Affiliation(s)
- Hideaki Fujiwara
- Department of Hematology, Oncology and Respiratory Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Yoshinobu Maeda
- Department of Hematology, Oncology and Respiratory Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Yasuhisa Sando
- Department of Hematology, Oncology and Respiratory Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Makoto Nakamura
- Department of Hematology, Oncology and Respiratory Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Katsuma Tani
- Department of Hematology, Oncology and Respiratory Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Tatsunori Ishikawa
- Department of Hematology, Oncology and Respiratory Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Hisakazu Nishimori
- Department of Hematology, Oncology and Respiratory Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Ken-Ichi Matsuoka
- Department of Hematology, Oncology and Respiratory Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Nobuharu Fujii
- Department of Hematology, Oncology and Respiratory Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Eisei Kondo
- Department of Hematology, Oncology and Respiratory Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Mitsune Tanimoto
- Department of Hematology, Oncology and Respiratory Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
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Tellez-Hinojosa C, Vazquez-Mellado A, Gómez-Almaguer D. Thrombotic thrombocytopenic purpura. MEDICINA UNIVERSITARIA 2015. [DOI: 10.1016/j.rmu.2015.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Holbro A, Passweg JR. Management of hemolytic anemia following allogeneic stem cell transplantation. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2015; 2015:378-384. [PMID: 26637746 DOI: 10.1182/asheducation-2015.1.378] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Hemolytic anemia (HA) is a frequent condition with variable pathophysiology. Hematopoietic stem cell transplantation (HSCT) is unique because it is performed across the ABO blood group barrier. Thereby, there is a transfer of plasma, red blood cells, and immunocompetent cells from the donor to the recipient, possibly leading to HA, due to red blood cell incompatibility. The underlying disease, drugs (particularly those used for conditioning and immunosuppressants), infections, graft-versus-host disease, and autoimmune diseases may all contribute to the clinical and laboratory picture of HA. Additionally, transplantation-associated thrombotic microangiopathy (TA-TMA) may occur and is associated with significant morbidity and mortality. This review highlights the current knowledge on HA after allogeneic HSCT, particularly due to ABO incompatibility. We follow the timeline of the transplantation process and discuss investigations, differential diagnosis, and prophylactic measures including graft processing to avoid hemolysis in case of ABO incompatibility. Finally, current therapeutic approaches for both TA-TMA and post-HSCT autoimmune HA, which are associated with high morbidity and mortality, are discussed.
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Affiliation(s)
- Andreas Holbro
- Division of Hematology, Department of Internal Medicine, University Hospital, Basel, Switzerland; and Blood Transfusion Centre, Swiss Red Cross, Basel, Switzerland
| | - Jakob R Passweg
- Division of Hematology, Department of Internal Medicine, University Hospital, Basel, Switzerland; and
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15
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Mulay S, Kreuter JD, Bryant SC, Elliott MA, Hogan WJ, Winters JL, Gastineau DA. Outcomes of plasma exchange in patients with transplant-associated thrombotic microangiopathy based on time of presentation since transplant. J Clin Apher 2014; 30:147-53. [DOI: 10.1002/jca.21352] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2013] [Revised: 06/04/2014] [Accepted: 07/21/2014] [Indexed: 11/11/2022]
Affiliation(s)
- Sudhanshu Mulay
- Division of Hematology/Oncology; University of Connecticut School of Medicine; Farmington Connecticut
| | | | - Sandra C. Bryant
- Division of Biomedical Statistics and Informatics; Mayo Clinic; Rochester Minnesota
| | | | | | | | - Dennis A. Gastineau
- Division of Transfusion Medicine; Mayo Clinic; Rochester Minnesota
- Division of Hematology; Mayo Clinic; Rochester Minnesota
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16
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Colombo R, Gallipoli P, Castelli R. Thrombosis and hemostatic abnormalities in hematological malignancies. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2014; 14:441-50. [PMID: 25018062 DOI: 10.1016/j.clml.2014.05.003] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Accepted: 05/19/2014] [Indexed: 01/19/2023]
Abstract
There is a paucity of data that pertain to thrombosis in patients with hematological malignancies. Recent studies showed that patients with lymphoma, multiple myeloma, and acute leukemia have an increased thrombotic risk, particularly at the time of diagnosis and during chemotherapy. We searched the PubMed database for articles on thromboembolic complications in patients with hematological malignancies published between 1996 and 2013. The incidence of thrombotic events is variable, and is influenced by the type and the stage of hematological malignancy, the antitumor therapy, and the use of central venous devices. The pathogenesis of thromboembolic disease in hematological malignancies is multifactorial. Tumor cell-derived procoagulant, fibrinolytic, or proteolytic factors, and inflammatory cytokines affect clotting activation, and chemotherapy and immunomodulatory drugs increase the thrombotic risk in patients with lymphoma, acute leukemia, and multiple myeloma. Infections might also contribute to the pathogenesis of the thromboembolic complications: endotoxins from gram-negative bacteria induce the release of tissue factor, tumor necrosis factor and interleukin-1b, and gram-positive organisms can release bacterial mucopolysaccharides that directly activate factor XII. In the setting of plasma cell dyscrasias, hyperviscosity, decreased fibrinolysis, procoagulant autoantibody production, inflammatory cytokines, acquired activated protein C resistance, and the prothrombotic effects of antimyeloma agents might be the cause of thromboembolic complications. Anticoagulant therapy is very complicated because of high risk of hemorrhage. Therefore, an accurate estimate of a patient's thrombotic risk is essential to allow physicians to target thromboprophylaxis in high-risk patients.
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Affiliation(s)
- Riccardo Colombo
- Department of Pathophysiology and Transplantation, Internal Medicine Section, University of Milan, and Department of Haematology, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - Paolo Gallipoli
- Department of Haematology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - Roberto Castelli
- Department of Pathophysiology and Transplantation, Internal Medicine Section, University of Milan, and Department of Haematology, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy.
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17
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Risk factors for thrombotic microangiopathy in allogeneic hematopoietic stem cell recipients receiving GVHD prophylaxis with tacrolimus plus MTX or sirolimus. Bone Marrow Transplant 2014; 49:684-90. [PMID: 24566710 DOI: 10.1038/bmt.2014.17] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2013] [Revised: 12/16/2013] [Accepted: 12/20/2013] [Indexed: 11/09/2022]
Abstract
Transplantation-associated thrombotic microangiopathy (TA-TMA) is a feared complication of allogeneic hematopoietic SCT (HSCT) owing to its high mortality rate. The use of calcineurin inhibitors or sirolimus (SIR) for GVHD prophylaxis has been suggested as a potential risk factor. However, the impact of tacrolimus (TAC) and SIR combinations on the increased risk of TA-TMA is currently not well defined. We retrospectively analyzed the incidence of TA-TMA in 102 allogeneic HSCT recipients who consecutively received TAC plus SIR (TAC/SIR) (n=68) or plus MTX (TAC/MTX)±ATG (n=34) for GVHD prophylaxis. No significant differences were observed in the incidence of TA-TMA between patients receiving TAC/SIR vs TAC/MTX±ATG (7.4% vs 8.8%, P=0.8). Only grade III-IV acute GVHD, previous HSCT and serum levels of TAC >25 ng/mL were associated with a greater risk of TA-TMA. Patients developing TA-TMA have significantly poorer survival (P<0.001); however, TA-TMA ceased to be an independent prognostic factor when it was included in a multivariate model. In conclusion, the combination of TAC/SIR does not appear to pose a higher risk of TA-TMA. By contrast, we identified three different risk groups for developing TA-TMA.
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18
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Late Effects in Survivors After Hematopoietic Cell Transplantation in Childhood. PEDIATRIC ONCOLOGY 2014. [DOI: 10.1007/978-3-642-39920-6_7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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19
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Czubkowski P, Pawłowska J, Jankowska I, Teisseyre M, Kamińska D, Markiewicz M, Ryżko J. Successful sirolimus rescue in tacrolimus-induced thrombotic microangiopathy after living-related liver transplantation. Pediatr Transplant 2012; 16:E261-4. [PMID: 22066835 DOI: 10.1111/j.1399-3046.2011.01601.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
TMA is a rare complication of tacrolimus. Disruption of endothelial cells, platelet aggregation, and intravascular mechanical fragmentation of red cells are core mechanisms of injury; however, exact pathways of toxicity are not clear. The clinical presentation may vary but TMA is a potentially life-threatening condition usually demanding aggressive treatment. We present the case of TMA in a child after living-related liver transplantation (LRLTx) on tacrolimus-based immunosuppressive regiment successfully converted to sirolimus.
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Affiliation(s)
- Piotr Czubkowski
- Department of Gastroenterology, The Children's Memorial Health Institute, Warsaw, Poland.
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20
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Abboud I, Peraldi MN, Hingorani S. Chronic kidney diseases in long-term survivors after allogeneic hematopoietic stem cell transplantation: monitoring and management guidelines. Semin Hematol 2012; 49:73-82. [PMID: 22221787 DOI: 10.1053/j.seminhematol.2011.10.008] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Chronic kidney disease (CKD) occurs commonly (prevalence of approximately 20% in a large series) after allogeneic hematopoietic stem cell transplantation (HSCT). There are three distinct clinical entities that occur after HSCT: thrombotic microangiopathy (TMA), nephrotic syndrome (NS), and idiopathic or graft-versus-host disease (GVHD)-related CKD. Acute renal function decline occurs in the majority of patients in the first months after transplantation. This acute kidney injury can persist and is a risk factor for the later development of CKD. However, the potentially independent role of GVHD, chronic inflammation, and chronic exposure to calcineurin inhibitors in the development and progression of CKD warrants further investigation. Careful monitoring of blood pressure, renal function, and proteinuria is mandatory in patients undergoing HSCT, especially older patients with pre-existent renal impairment. Renal function should be evaluated before HSCT and monitoring should occur at least every 6 to 12 months in these patients. Renal biopsies are indicated in patients with proteinuria and persistent or progressive rises in serum creatinine to determine etiology and prevent progression to end-stage renal disease (ESRD).
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Affiliation(s)
- Imad Abboud
- Saint Louis Hospital (Assistance Publique-Hôpitaux de Paris), Nephrology, Paris, France.
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21
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Rosenthal J, Pawlowska A, Bolotin E, Cervantes C, Maroongroge S, Thomas SH, Forman SJ. Transplant-associated thrombotic microangiopathy in pediatric patients treated with sirolimus and tacrolimus. Pediatr Blood Cancer 2011; 57:142-6. [PMID: 21557459 PMCID: PMC3307590 DOI: 10.1002/pbc.22861] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2010] [Accepted: 09/13/2010] [Indexed: 11/12/2022]
Abstract
BACKGROUND Transplant-associated thrombotic microangiopathy (TMA) syndromes are reported to occur with increased frequency in transplant patients treated with siroliumus combined with a calcineurin inhibitor. We performed a retrospective study of all pediatric transplant patients at City of Hope who were administered combined tacrolimus/sirolimus (TAC/SIR) to determine the occurrence of TMA. PROCEDURE This analysis includes 41 consecutive patients between the ages of 2 and 20 (median age 9.1) who received an allogeneic hematopoietic stem cell transplant from any source and also received TAC/SIR for prevention or treatment of GVHD. Of those 41 patients, 20 received TAC/SIR as GVHD prohpylaxis and were designated the preventative group (PG), while 21 received TAC/SIR as treatment for GVHD and were designated the therapy group (TG). TMA occurrence in both groups was documented from day -1 of transplant to day 60 for the PG, and until 30 days after last dose for the TG. TMA was defined according to 2005 consensus criteria. RESULTS Five of twenty patients in the PG, and five of twenty one in the TG, experienced TMA, with an overall rate of 23.8% for the population. All ten patients with TMA showed elevated levels of TAC, SIR or both and nine of ten suffered from organ injury due to regimen-related toxicity or GVHD. CONCLUSION Physicians should exercise caution in the use of TAC/SIR in pediatric patients due to a high rate of TMA. It is not recommended for heavily pre-treated patients and peak levels of TAC/SIR must be very carefully controlled.
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Affiliation(s)
| | - Anna Pawlowska
- Department of Pediatrics, City of Hope, Duarte, CA 91010,Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, CA 91010
| | - Ellen Bolotin
- Department of Pediatrics, City of Hope, Duarte, CA 91010,Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, CA 91010
| | | | | | - Sandra H. Thomas
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, CA 91010
| | - Stephen J. Forman
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, CA 91010
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Abstract
Babesia spp. are intraerythrocytic protozoan parasites of animals and humans that cause babesiosis, a zoonotic disease transmitted primarily by tick vectors. Although a variety of species or types of Babesia have been described in the literature as causing infection in humans, the rodent parasite Babesia microti has emerged as the focal point of human disease, especially in the United States. Not only has B. microti become established as a public health concern, this agent is increasingly being transmitted by blood transfusion: estimates suggest that between 70 and 100 cases of transfusion-transmitted Babesia (TTB) have occurred over the last 30 years. A recent upsurge in TTB cases attributable to B. microti, coupled with at least 12 fatalities in transfusion recipients diagnosed with babesiosis, has elevated TTB to a key policy issue in transfusion medicine. Despite clarity on a need to mitigate transmission risk, few options are currently available to prevent the transmission of B. microti by blood transfusion. Future mitigation efforts may stress serological screening of blood donors in regionalized areas of endemicity, with adjunct nucleic acid testing during the summer months, when acute infections are prevalent. However, several hurdles remain, including the absence of a licensed blood screening assay and a thorough cost-benefit analysis of proposed interventions. Despite current obstacles, continued discussion of TTB without proactive intervention is no longer a viable alternative.
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Thrombotic microangiopathy in haematopoietic cell transplantation: an update. Mediterr J Hematol Infect Dis 2010; 2:e2010033. [PMID: 21776339 PMCID: PMC3134219 DOI: 10.4084/mjhid.2010.033] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2010] [Accepted: 10/29/2010] [Indexed: 12/17/2022] Open
Abstract
Allogeneic hematopoietic cell transplantation (HCT) represents a vital procedure for patients with various hematologic conditions. Despite advances in the field, HCT carries significant morbidity and mortality. A rare but potentially devastating complication is transplantation-associated thrombotic microangiopathy (TA-TMA). In contrast to idiopathic TTP, whose etiology is attributed to deficient activity of ADAMTS13, (a member of the A Disintegrin And Metalloprotease with Thrombospondin 1 repeats family of metalloproteases), patients with TA-TMA have > 5% ADAMTS13 activity. Pathophysiologic mechanisms associated with TA-TMA, include loss of endothelial cell integrity induced by intensive conditioning regimens, immunosuppressive therapy, irradiation, infections and graft-versus-host (GVHD) disease. The reported incidence of TA-TMA ranges from 0.5% to 75%, reflecting the difficulty of accurate diagnosis in these patients. Two different groups have proposed consensus definitions for TA-TMA, yet they fail to distinguish the primary syndrome from secondary causes such as infections or medication exposure. Despite treatment, mortality rate in TA-TMA ranges between 60% to 90%. The treatment strategies for TA-TMA remain challenging. Calcineurin inhibitors should be discontinued and replaced with alternative immunosuppressive agents. Daclizumab, a humanized monoclonal anti-CD25 antibody, has shown promising results in the treatment of TA-TMA. Rituximab or the addition of defibrotide, have been reported to induce remission in this patient population. In general, plasma exchange is not recommended.
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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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25
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Transplantation-associated thrombotic microangiopathy: effect of concomitant GVHD on efficacy of therapeutic plasma exchange. Bone Marrow Transplant 2009; 45:699-704. [DOI: 10.1038/bmt.2009.233] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Hingorani S. Chronic kidney disease after pediatric hematopoietic cell transplant. Biol Blood Marrow Transplant 2009; 14:84-7. [PMID: 18162226 DOI: 10.1016/j.bbmt.2007.11.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
There are 3 clearly distinct clinical entities that occur after HCT: TMA, idiopathic CKD, and nephrotic syndrome. The potentially independent role of GVHD and chronic inflammation in the development and progression of idiopathic CKD warrants further investigation. CKD after HCT is a relatively common occurrence. As the indications for and number of transplants performed world wide increases, so will the burden of kidney disease. Identifying those patients at risk for the development of CKD will be important for potential intervention and prevention of CKD and progression to end-stage renal disease in this patient population. There are those patients who will develop CKD that is not related to TBI or the conditioning regimen but rather to complications and/or therapy that occur after HCT, specifically aGVHD and cGVHD and prolonged calcinuerin inhibitor use. The burden of management will fall not only to the nephrologists but the oncologist as well to ensure close monitoring of renal function, blood pressure, and urinalyses posttransplant. It may be that our energies have been misdirected in trying to reduce exposure to TBI, and rather we should try to decrease the inflammatory and cytokine effects of GVHD and reduce exposure to calcineurin inhibitors to prevent CKD in this population of patients.
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Affiliation(s)
- Sangeeta Hingorani
- University of Washington, Children's Hospital and Regional Medical Center, 4800 Sandpoint Way NE, A-7931, Seattle, WA 98105, USA.
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Kennedy GA, Bleakley S, Butler J, Mudie K, Kearey N, Durrant S. Posttransplant thrombotic microangiopathy: sensitivity of proposed new diagnostic criteria. Transfusion 2009; 49:1884-9. [PMID: 19453982 DOI: 10.1111/j.1537-2995.2009.02217.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Objective diagnosis of transplantation-associated thrombotic microangiopathy (TA-TMA) has traditionally been difficult due to the multiple potential etiologies of thrombocytopenia and red blood cell fragmentation occurring after allogeneic hematopoietic stem cell transplantation (SCT). To attempt to address this issue of diagnostic uncertainty, two new diagnostic criteria for TA-TMA have recently been proposed: the Bone Marrow Transplant Clinical Trials Network (BMT-CTN) and the International Working Group (IWG) criteria. However, both newly proposed criteria are yet to be clinically validated. STUDY DESIGN AND METHODS All 15 cases of TA-TMA previously diagnosed at the authors' institution between December 2001 and March 2008 were retrospectively reclassified under the newly proposed BMT-CTN and IWG criteria. RESULTS Potential diagnostic pitfalls were identified in both the BMT-CTN and the IWG TA-TMA criteria. The main limitation of the BMT-CTN criteria appeared to be need for concurrent renal and/or neurologic dysfunction to be manifest at TA-TMA diagnosis, which was present in only 73% of our patient cohort. For the IWG criteria, the main limitation to TA-TMA diagnosis appeared to be the requirement for schistocytosis of more than 4%, which was present in only 27% of these patients. CONCLUSION Our experience suggests that potentially significant diagnostic pitfalls remain with both recently proposed TA-TMA diagnostic criteria, pitfalls that are likely to limit the diagnostic sensitivity of both. It is recommended that further clinical correlation of both the BMT-CTN and the IWG criteria be undertaken before either is routinely adapted into SCT practice.
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Affiliation(s)
- Glen A Kennedy
- Department of Haematology, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia.
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Choi CM, Schmaier AH, Snell MR, Lazarus HM. Thrombotic microangiopathy in haematopoietic stem cell transplantation: diagnosis and treatment. Drugs 2009; 69:183-98. [PMID: 19228075 DOI: 10.2165/00003495-200969020-00004] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Each year in the US, more than 10 000 patients benefit from allogeneic haematopoietic stem cell transplantation (HSCT), a modality that offers an excellent chance of eradicating malignancy but confers a higher risk of treatment-related mortality. An uncommon but devastating consequence of HSCT is transplantation-associated thrombotic microangiopathy (TA-TMA). The incidence of TA-TMA ranges from 0.5% to 76%, with a mortality rate of 60-90% despite treatment. Although there appears to be a consistent treatment approach to idiopathic thrombotic thrombocytopenic purpura (TTP) using plasma exchange, corticosteroids and rituximab, the treatment strategies for TA-TMA are perplexing, in part, because the literature regarding this complex condition does not provide true consensus for incidence, aetiology, diagnostic criteria, classification and optimal therapy. The classic definition of idiopathic TTP includes schistocytes on the peripheral blood smear, thrombocytopenia and increased serum lactate dehydrogenase. Classic idiopathic TTP has been attributed to deficient activity of the metalloproteinase responsible for cleaving ultra-large von Willebrand factor multimers. This protease is a member of the 'a disintegrin and metalloprotease with thrombospondin type 1 motif' family and is subsequently named ADAMTS-13. Severely deficient ADAMTS-13 activity (<5% of normal) is associated with idiopathic TTP in 33-100% of patients. In constrast to the pathophysiology of idiopathic TTP, patients with TA-TMA have >5% ADAMTS-13 serum activity. These data may explain why plasma exchange, a standard treatment modality for idiopathic TTP that restores ADAMTS-13 activity, is not effective in TA-TMA. TA-TMA has a multifactorial aetiology of endothelial damage induced by intensive conditioning therapy, irradiation, immunosuppressants, infection and graft-versus-host disease. Treatment consists of substituting calcineurin inhibitors with an alternative immunosuppressive agent that possesses another mode of action. One candidate may be daclizumab, especially in those with mild to moderate TMA. Rituximab therapy or the addition of defibrotide may also be beneficial. In general, plasma exchange is not recommended.
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Affiliation(s)
- Cecilia M Choi
- Department of Medicine, Division of Hematology/Oncology, University Hospitals Case Medical Center, Cleveland, Ohio, USA
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Changsirikulchai S, Myerson D, Guthrie KA, McDonald GB, Alpers CE, Hingorani SR. Renal thrombotic microangiopathy after hematopoietic cell transplant: role of GVHD in pathogenesis. Clin J Am Soc Nephrol 2009; 4:345-53. [PMID: 19144762 DOI: 10.2215/cjn.02070508] [Citation(s) in RCA: 117] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Thrombotic microangiopathy (TMA) is a known complication of hematopoietic cell transplantation (HCT). The etiology and diagnosis of TMA in this patient population is often difficult because thrombocytopenia, microangiopathic hemolytic anemia, and kidney injury occur frequently in HCT recipients, and are the result of a variety of insults. DESIGN, SETTING, PARTICIPANTS & MEASUREMENTS The authors reviewed renal pathology and clinical data from HCT patients to determine the prevalence of TMA and to identify correlative factors for developing TMA in the kidney. Kidney tissue was evaluated from 314 consecutive autopsies on patients who died after their first HCT (received between 1992 and 1999). Renal pathology was classified into three groups: (1) no renal thrombus (65%), (2) TMA (20%), and (3) isolated thrombosis (15%). Logistic regression models estimated the associations between each histologic category and clinical parameters: donor and recipient gender, patient age, human leukocyte antigen (HLA) matching of the donor and recipient, total body irradiation (TBI), acute graft versus host disease (GVHD), acute kidney injury, medications, and viral infections. RESULTS In a multivariate analysis, TMA correlated with acute GVHD grades II to IV, followed by female recipient/male donor, TBI > 1200 cGy, and adenovirus infection. Grades II to IV acute GVHD and female gender were associated with isolated renal thrombus. CONCLUSIONS TMA in HCT recipients is associated with acute GVHD grades II to IV, recipient/donor mismatch, TBI > 1200 cGy, and adenovirus infection.
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Microvascular free tissue transfer in organ transplantation patients: is it safe? Plast Reconstr Surg 2008; 121:1986-1992. [PMID: 18520886 DOI: 10.1097/prs.0b013e31817123b0] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Traditionally, organ transplantation has been synonymous with patients with poor prognosis and outcome. Surgeons felt that the risks posed by immunosuppressive drugs outweighed the benefits of non-life-threatening procedures. With the enormous advances in the field of organ transplantation, a growing number of transplant patients present for a variety of surgical procedures. The objective of this report was to study the surgical outcome of organ transplantation patients who required reconstructive surgery using free tissue transfer. METHODS A multicenter retrospective study was conducted on organ transplant patients who underwent elective microvascular free flap procedures. Patient chart review included cause of organ failure, medications, reconstruction site, flap choice, days hospitalized, complications, and outcome. RESULTS Five independent medical centers participated in the study. Nineteen organ transplant patients required free flaps. Free flaps were used to reconstruct a variety of surgical defects, including breast, head and neck, and upper and lower extremities. There were no flap losses. Flaps used included musculocutaneous (n = 13), fasciocutaneous (n = 5), and osteocutaneous (n = 1) free flaps. Hospital length of stay ranged from 3 to 17 days. Complications included loss of skin graft, suture line dehiscence, and hematoma formation. Delayed wound healing was observed in two patients. CONCLUSIONS In the properly selected patient, microvascular free tissue transfer can be performed safely and with acceptable surgical outcome. Contrary to popular belief, delayed wound healing from immunosuppressive agents was uncommon. Free tissue transfer in healthy organ transplant patients can be considered in reconstructive surgery decision making.
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Thrombotic microangiopathy after allogeneic hematopoietic stem cell transplantation: an autopsy study. Transplantation 2008; 85:22-8. [PMID: 18192907 DOI: 10.1097/01.tp.0000297998.33418.7e] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Posttransplantation thrombotic microangiopathy (PTMA) is a complication of allogeneic hematopoietic stem cell transplantation (HSCT). However, limited autopsy data are available, and it remains unclear whether PTMA is a discrete clinical and pathologic entity. The aims of this autopsy study were to determine the correlation between clinical and pathologic diagnosis of PTMA, to define the precise morphologic spectrum of PTMA, and to seek for potential etiologic factors. METHODS The study included 20 consecutive patients with HSCT autopsied at the University of Oklahoma, between 1994 and 2005. Applying strict clinical-laboratory criteria, 6 patients were diagnosed clinically with PTMA and treated with plasma exchange. Clinical variables, including underlying disease, conditioning regimen, stem cell donor status, duration and serum level of cyclosporine, infections, and acute graft versus host disease were compared statistically in patients with histologic signs of PTMA (n=8) with those without PTMA (n=12). RESULTS PTMA was verified histologically in all 6 patients with a clinical diagnosis of PTMA but only 2 of the 14 patients who were not clinically diagnosed had histologic evidence of PTMA (P<0.0001). Kidneys were affected in all 8 patients with PTMA, and limited extrarenal involvement by PTMA was observed in 3 of these 8 patients. No statistically significant differences in relevant clinical and morphologic variables were identified between the PTMA and non-PTMA groups. CONCLUSIONS This study documents a strong correlation between the clinical and morphologic diagnosis of PTMA. The kidney is the primary target of PTMA, with dominant glomerular and arteriolar involvement. The etiology is likely to be multifactorial.
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Hingorani S. Chronic kidney disease after liver, cardiac, lung, heart-lung, and hematopoietic stem cell transplant. Pediatr Nephrol 2008; 23:879-88. [PMID: 18414901 PMCID: PMC2335288 DOI: 10.1007/s00467-008-0785-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2007] [Revised: 01/30/2008] [Accepted: 01/31/2008] [Indexed: 11/24/2022]
Abstract
Patient survival after cardiac, liver, and hematopoietic stem cell transplant (HSCT) is improving; however, this survival is limited by substantial pretransplant and treatment-related toxicities. A major cause of morbidity and mortality after transplant is chronic kidney disease (CKD). Although the majority of CKD after transplant is attributed to the use of calcineurin inhibitors, various other conditions such as thrombotic microangiopathy, nephrotic syndrome, and focal segmental glomerulosclerosis have been described. Though the immunosuppression used for each of the transplant types, cardiac, liver and HSCT is similar, the risk factors for developing CKD and the CKD severity described in patients after transplant vary. As the indications for transplant and the long-term survival improves for these children, so will the burden of CKD. Nephrologists should be involved early in the pretransplant workup of these patients. Transplant physicians and nephrologists will need to work together to identify those patients at risk of developing CKD early to prevent its development and progression to end-stage renal disease.
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Affiliation(s)
- Sangeeta Hingorani
- Pediatrics-University of Washington, 4800 Sandpoint Way NE M1-5, Seattle, WA 98015, USA.
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Batts ED, Lazarus HM. Diagnosis and treatment of transplantation-associated thrombotic microangiopathy: real progress or are we still waiting? Bone Marrow Transplant 2007; 40:709-19. [PMID: 17603513 DOI: 10.1038/sj.bmt.1705758] [Citation(s) in RCA: 146] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Transplantation-associated thrombotic microangiopathy (TA-TMA) is an infrequent but devastating syndrome that occurs in allogeneic hematopoietic stem cell transplant recipients, and is associated with a variety of transplantation-related factors, including conditioning regimens, immunosuppressive agents, GVHD and opportunistic infections. Progress in managing this condition has been hampered by lack of a consensus definition and poor understanding of the pathophysiology of the disorder. Two different groups recently have proposed consensus definitions, yet they fail to distinguish the primary syndrome from the secondary causes, such as a variety of infections, medication exposure or other conditions. Increasing evidence suggests that TA-TMA is a multifactorial disorder that is distinct from thrombotic thrombocytopenic purpura (TTP), and likely represents the final common pathway of a number of endothelial cell insults. TA-TMA responds poorly to conventional treatment for TTP, including plasma exchange, but newer agents, including daclizumab and defibrotide show promise. In addition, other agents known to modify endothelial responses to injury, including statins, prostacyclin analogues, endothelin-receptor antagonists and free radical scavengers, may lead to improved outcomes for patients affected by this disorder.
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Affiliation(s)
- E D Batts
- Department of Medicine, Case Medical Center, University Hospitals of Cleveland, Cleveland, OH 44106, USA
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Akamatsu N, Sugawara Y, Tamura S, Togashi J, Kaneko J, Makuuchi M. Late Mortality from Thrombotic Microangiopathy After Liver Transplantation: Report of a Case. Surg Today 2007; 37:345-8. [PMID: 17387572 DOI: 10.1007/s00595-006-3394-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2006] [Accepted: 09/21/2006] [Indexed: 11/25/2022]
Abstract
Thrombotic microangiopathy (TMA) after liver transplantation is thought to be a rare event. We report a case of TMA after living donor liver transplantation for hepatitis C virus-related cirrhosis. The patient was initially placed on a tacrolimus-based immunosuppressive regimen, and received combined ribavirin and interferon treatment as pre-emptive therapy for hepatitis C virus. His post-transplantation course was complicated by cytomegalovirus (CMV) antigenemia, and intra-abdominal hemorrhage after percutaneous liver biopsy, necessitating laparotomy. On postoperative day (POD) 53, we noted a marked thrombocytopenia with a sudden rise in lactate dehydrogenase. Blood smear indicated prominent fractionated erythrocytes. Treatment included immediate conversion from tacrolimus to cyclosporine (CsA) and successive plasma exchange (PE), despite which the TMA progressed. CsA was discontinued 32 days after initiating the PE, and the TMA progression seemed to cease. However, the patient's condition deteriorated and he died of multiple organ failure on POD 119. We report this case to stress that careful management of calcineurin inhibitor administration is critical in TMA.
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Affiliation(s)
- Nobuhisa Akamatsu
- Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
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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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Tashiro Y, Goto M, Takemoto Y, Sato E, Shirahama H, Utsunomiya A, Eizuru Y, Yonezawa S. Epstein-Barr virus-associated enteritis with multiple ulcers after stem cell transplantation: first histologically confirmed case. Pathol Int 2006; 56:530-7. [PMID: 16930333 DOI: 10.1111/j.1440-1827.2006.02001.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The present case involves unique enteritis forming multiple ulcers associated with Epstein-Barr virus (EBV). A 57-year-old man had undergone a reduced intensity allogeneic stem cell transplantation for a relapse of multiple myeloma following sequential autologous peripheral blood stem cell transplantation. The ileum, resected for massive melena, showed multiple irregular ulcers with occasional cobblestone-like appearance. There was inflammation including numerous plasma cells in the ulcer bases and surrounding areas, where many EBV-infected plasma cells were detected by double staining with EBV-encoded small RNA-1 (EBER-1) in situ hybridization and CD79a, while EBV-infected epithelial cells were not noted. The number of EBER-1-positive cells in the ileum (mucosa, 1451 cells/mm(2); submucosa, 465 cells/mm(2)) was much larger than in control samples (malignant lymphoma or leukemia after allogeneic stem cell transplantation, n = 4, range 0-113 cells/mm(2); malignant lymphoma after chemotherapy, n = 14, range 0-0.89 cells/mm(2); colon cancer, n = 12, range 0-3.5 cells/mm(2)). In the mucosa near the ulcers, EBER-1-positive cells often surrounded and involved the glandular epithelium, forming lymphoepithelial-like lesions. The histological findings differ from post-transplant lymphoproliferative disorders or intestinal thrombotic microangiopathy, and this is the first case of EBV-associated enteritis with ulcers characterized by numerous plasma cells and lymphoepithelial-like lesions after stem cell transplantation.
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Affiliation(s)
- Yukie Tashiro
- Department of Pathology, Imakiire General Hospital, Japan
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Peyvandi F, Siboni SM, Lambertenghi Deliliers D, Lavoretano S, De Fazio N, Moroni B, Lambertenghi Deliliers G, Mannuccio Mannucci P. Prospective study on the behaviour of the metalloprotease ADAMTS13 and of von Willebrand factor after bone marrow transplantation. Br J Haematol 2006; 134:187-95. [PMID: 16846477 DOI: 10.1111/j.1365-2141.2006.06126.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Thrombotic microangiopathies (TMAs) are rare but serious complications of bone marrow transplantation (BMT). Clinical manifestations are similar to those of thrombotic thrombocytopenic purpura (TTP), but prognosis is generally poorer despite plasma exchange. The enzymatic activity of the plasma metalloprotease ADAMTS13, which cleaves ultralarge thrombogenic multimers of von Willebrand factor (VWF) derived from activated endothelial cells, is very low or undetectable in patients with classic TTP, and protease deficiency is thought to play a mechanistic role in the formation of platelet thrombi in the microcirculation. This is the first prospective study to evaluate the incidence of TMA in 46 consecutively recruited patients undergoing autologous or allogeneic BMT and explore in parallel the behaviour of ADAMTS13, VWF antigen and VWF multimer size. The incidence of post-BMT TMA was 6% (three of 46); all cases occurred after allogeneic BMT. Compared with baseline values plasma ADAMTS13 activity was significantly reduced in patients undergoing BMT, particularly after the conditioning regimen (mean values: 50 +/- 22 vs. 77 +/- 32%; P < 0.0001). In the three patients who developed TMA, ADAMTS13 decreased after conditioning, but was very low in one case only (8%). VWF antigen levels progressively increased after the conditioning regimen (228 +/- 75 vs. 178 +/- 76% at baseline, P = 0.002). The mean proportion of high-molecular weight VWF multimers did not change in the various stages of BMT, even though ultralarge multimers were transiently found in same cases with and without TMA. Hence, the measurements evaluated in this study are not clinically useful to predict the occurrence of post-BMT TMA.
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Affiliation(s)
- F Peyvandi
- Angelo Bianchi Bonomi Haemophilia and Thrombosis Centre, University of Milan, Luigi Villa Foundation, Department of Medicine and Medical Specialities, IRCCS Maggiore Hospital, Mangiagalli and Regina Elena Foundation, Milan, Italy
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Nakamae H, Yamane T, Hasegawa T, Nakamae M, Terada Y, Hagihara K, Ohta K, Hino M. Risk factor analysis for thrombotic microangiopathy after reduced-intensity or myeloablative allogeneic hematopoietic stem cell transplantation. Am J Hematol 2006; 81:525-31. [PMID: 16755559 DOI: 10.1002/ajh.20648] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Thrombotic microangiopathy (TMA) impairs long-term survival after allogeneic hematopoietic stem cell transplantation (HSCT). As the allogeneic HSCT procedure has developed, addressing risk factors for TMA has become more complicated. The aim of this study was to investigate the impact of transplant-associated factors on TMA incidence in patients who have undergone HSCT in various settings. One hundred twenty-three consecutive allogeneic HSCT patients with hematologic diseases receiving myeloablative and reduced-intensity conditioning were evaluated retrospectively. Of 123 patients, 22 (17.9%) developed TMA after HSCT. Multivariate analysis showed the significance of GVHD grade II-IV, and the use of FK506 and the use of high-dose busulfan (Bu) (16 mg/kg) persisted. The hazard ratios of the use of FK506, the use of high-dose Bu (16 mg/kg), and GVHD grade II-IV for TMA were 8.7 (95% CI 2.0-37), 5.7 (95% CI 1.5-21), and 3.4 (95% CI 1.3-9.1), respectively. In the present study, reduced-intensity conditioning did not have an advantage over myeloablative conditioning in decreasing the incidence of TMA after HSCT. Our results also showed that high-dose Bu (16 mg/kg) for the conditioning and FK506 for the prophylaxis of GVHD might contribute more significantly to TMA onset after HSCT than other agents.
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Affiliation(s)
- Hirohisa Nakamae
- Clinical Hematology and Clinical Diagnostics, Graduate School of Medicine, Osaka City University, Osaka, Japan.
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Hingorani S. Chronic kidney disease in long-term survivors of hematopoietic cell transplantation: epidemiology, pathogenesis, and treatment. J Am Soc Nephrol 2006; 17:1995-2005. [PMID: 16723390 DOI: 10.1681/asn.2006020118] [Citation(s) in RCA: 99] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
High-dose myeloablative hematopoietic cell transplantation is becoming an increasingly common treatment modality for a variety of diseases. Patient survival may be limited by substantial treatment-related toxicities, including chronic kidney disease (CKD). Although the majority of CKD after transplantation is idiopathic, thrombotic microangiopathic syndromes and nephrotic syndrome have been described. Epidemiology, pathogenesis, and potential treatment options for the various clinical syndromes that are associated with CKD in hematopoietic cell transplantation patients is reviewed. As the indications for and the numbers of transplants that are performed worldwide increases, so will the burden of CKD. The nephrologists and oncologists will have to work together to identify patients who are at risk for CKD early to prevent its development and progression to end-stage kidney disease.
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Affiliation(s)
- Sangeeta Hingorani
- University of Washington School of Medicine, Department of Pediatrics, and the Fred Hutchinson Cancer Research Center, Seattle, Washington, USA.
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Abstract
PURPOSE OF REVIEW Acute graft-versus-host disease is one of the commonest complications after allogeneic stem cell transplantation. Recent advances in its prevention and therapy are giving new hope to patients with this disease. This review covers the major advances in prophylaxis and therapy for this problem. RECENT FINDINGS The use of novel approaches for prophylaxis such as posttransplant cyclophosphamide and non-methotrexate-containing regimens is discussed. The results of therapy with new agents such as pentostatin, pulse cyclophosphamide, long-wavelength ultraviolet A phototherapy, and monoclonal antibodies such as denileukin diftitox or etanercept are reviewed. SUMMARY Without question, outcome in patients who develop graft-versus-host disease is improving. With better supportive care, and more effective prophylaxis and therapy, these patients have an improved chance for full recovery. Patients should be enrolled, when possible, in studies aimed to prevent and treat graft-versus-host disease.
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Affiliation(s)
- Javier Bolaños-Meade
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD 21231, USA.
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Hale GA, Bowman LC, Rochester RJ, Benaim E, Heslop HE, Krance RA, Horwitz EM, Cunningham JM, Tong X, Srivastava DK, Handgretinger R, Jones DP. Hemolytic uremic syndrome after bone marrow transplantation: clinical characteristics and outcome in children. Biol Blood Marrow Transplant 2006; 11:912-20. [PMID: 16275594 DOI: 10.1016/j.bbmt.2005.07.012] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2004] [Accepted: 07/28/2005] [Indexed: 12/13/2022]
Abstract
Hemolytic uremic syndrome (HUS) is an uncommon but potentially life-threatening complication of hematopoietic stem cell transplantation. We retrospectively studied the medical records of 293 children who underwent allogeneic bone marrow transplantation at St. Jude Children's Research Hospital between 1992 and 1999 to describe the clinical course of and to identify risk factors for transplant-associated HUS. Conditioning regimens included cyclophosphamide, cytarabine, and total body irradiation for patients with hematologic malignancies (n = 244); patients with nonmalignant diseases (n = 49) received disease-specific regimens. Grafts from unrelated or mismatched related donors were depleted of T lymphocytes, whereas matched sibling grafts were unmanipulated. All patients received cyclosporine as prophylaxis for graft-versus-host disease. Recipients of grafts from matched siblings also received pentoxifylline or short-course methotrexate. HUS developed in 28 (9.6%) patients at a median of 171 days after transplantation. We identified older donor age (P = .029), use of antithymocyte globulin in the conditioning regimen (P = .008), and recipient CMV seronegativity (P = .011) as being associated with an increased risk of HUS. With a multiple regression analysis, the use of antithymocyte globulin (beta = .86; P = .04) and recipient cytomegalovirus seronegativity (beta = .93; P = .035) remained significant risk factors for the development of HUS.
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Affiliation(s)
- Gregory A Hale
- Division of Stem Cell Transplantation, St. Jude Children's Research Hospital, Memphis, Tennessee 38105-2794, USA.
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Ho VT, Cutler C, Carter S, Martin P, Adams R, Horowitz M, Ferrara J, Soiffer R, Giralt S. Blood and marrow transplant clinical trials network toxicity committee consensus summary: thrombotic microangiopathy after hematopoietic stem cell transplantation. Biol Blood Marrow Transplant 2005; 11:571-5. [PMID: 16041306 DOI: 10.1016/j.bbmt.2005.06.001] [Citation(s) in RCA: 289] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The syndrome of microangiopathic hemolysis associated with renal failure, neurologic impairment, or both is a recognized complication of hematopoietic stem cell transplantation. This entity is often called hemolytic uremic syndrome (HUS) or thrombotic thrombocytopenic purpura (TTP), yet it is clear that the pathophysiology of transplant-associated HUS/TTP is different from that of classic HUS or TTP. Furthermore, the incidence of this syndrome varies from 0.5% to 76% in different transplant series, primarily because of the lack of a uniform definition. The toxicity committee of the Blood and Marrow Transplant Clinical Trials Network has reviewed the current literature on transplant-related HUS/TTP and recommends that it be henceforth renamed posttransplantation thrombotic microangiopathy (TMA). An operational definition for TMA based on the presence of microangiopathic hemolysis and renal and/or neurologic dysfunction is proposed. The primary intervention after diagnosis of TMA should be withdrawal of calcineurin inhibitors. Plasma exchange, although frequently used in this condition, has not been proven to be effective. In the absence of definitive trials, plasma exchange cannot be considered a standard of care for TMA. It is hoped that these positions will improve the identification and reporting of this devastating complication after hematopoietic stem cell transplantation and facilitate future clinical studies for its prevention and treatment.
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Affiliation(s)
- Vincent T Ho
- Blood and Marrow Transplant Clinical Trials Network Toxicity Committee, Boston, Massachusetts, USA.
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Martinez MT, Bucher C, Stussi G, Heim D, Buser A, Tsakiris DA, Tichelli A, Gratwohl A, Passweg JR. Transplant-associated microangiopathy (TAM) in recipients of allogeneic hematopoietic stem cell transplants. Bone Marrow Transplant 2005; 36:993-1000. [PMID: 16184183 DOI: 10.1038/sj.bmt.1705160] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
We studied occurrence, risk factors and outcome of patients with transplant-associated microangiopathy (TAM) after allogeneic stem cell transplantation (HSCT). A total of 221 consecutive patients were transplanted between 1995 and 2002. TAM is defined as evidence of hemolysis and schistocytes in the first 100 days. Outcomes analyzed included TAM and overall survival. Of 221 patients, 68 had TAM. The cumulative incidence was 31 (25-38)% at 100 days. Patients with TAM had higher LDH, higher bilirubin, higher creatinine and more often neurologic symptoms. TAM was not associated with stem cell source, cyclosporine levels and was not more frequent in recent years. In multivariate analysis, risk factors for TAM included donor type, age, gender, ABO-incompatibility and acute graft-versus-host disease (aGvHD). In patients with TAM, 1-year survival was lower than in patients without TAM (27 +/- 18% for TAM with high schistocyte counts; 53 +/- 15% for TAM with low schistocyte counts; vs 78 +/- 7% in patients without TAM; P<0.0001). TAM was independently associated with mortality adjusting for donor type, age and aGvHD occurrence and severity. TAM is frequent after HSCT and is associated with mortality even after adjustment for aGvHD grade. Risk factors of TAM are similar to aGvHD. TAM may represent endothelial damage driven by donor-host interactions.
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Affiliation(s)
- M T Martinez
- Hematology Division, Basel University Hospitals, Switzerland
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Cable RG, Leiby DA. Risk and prevention of transfusion-transmitted babesiosis and other tick-borne diseases. Curr Opin Hematol 2004; 10:405-11. [PMID: 14564169 DOI: 10.1097/00062752-200311000-00002] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Tick-borne diseases have increasingly been recognized in the United States as public health problems. The importance of tick-borne diseases has been accelerated by increases in animal populations, as well as increased human recreation in wooded environments that are conducive to tick bites. Babesiosis, usually caused by the intraerythrocytic parasite, Babesia microti and transmitted by the same tick as Lyme disease, has important transfusion implications. Although Lyme disease has not been reported from blood transfusion, newly identified tick-borne diseases such as ehrlichiosis raise additional questions about the role of the tick in transfusion-transmitted diseases. RECENT FINDINGS The risk of transfusion-transmitted babesiosis is higher than usually appreciated and in endemic areas represents a major threat to the blood supply. Furthermore, the geographic range of B. microti is expanding, other Babesia spp. have been implicated in transfusion transmission in the western United States, and the movement of blood donors and donated blood components may result in the appearance of transfusion babesiosis in areas less familiar with these parasites. Consequently, a higher degree of clinical suspicion will allow early recognition and treatment of this important transfusion complication. SUMMARY In endemic areas transfusion-transmitted babesiosis is more prevalent than usually believed. The extension of the geographic range of various Babesia spp. and the movement of donors and blood products around the United States has resulted in the risk extending to non-endemic areas. Clinicians should maintain a high degree of clinical suspicion for transfusion-transmitted babesiosis.
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Affiliation(s)
- Ritchard G Cable
- American Red Cross, Connecticut Blood Services, Farmington, and University of Connecticut Health Center, Farmington, Connecticut 06032, USA.
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Reynolds JC, Agodoa LY, Yuan CM, Abbott KC. Thrombotic microangiopathy after renal transplantation in the United States. Am J Kidney Dis 2004; 42:1058-68. [PMID: 14582050 DOI: 10.1016/j.ajkd.2003.07.008] [Citation(s) in RCA: 139] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Analysis of the incidence, time to event, and risk factors for thrombotic microangiopathy (TMA) after renal transplantation (RT), has not been reported in a national population. METHODS This is a historical cohort study of 15,870 RT recipients in the United States Renal Data System (USRDS) with Medicare as their primary payer between January 1, 1998, and July 31, 2000, followed until December 31, 2000. Patients with Medicare claims with a diagnosis of TMA (International Classification of Diseases, 9th Revision, codes 283.11x or 446.6x) after RT were assessed by Cox regression. RESULTS Among patients with end-stage renal disease owing to hemolytic uremic syndrome (HUS), 29.2% later had TMA versus 0.8% of patients with ESRD owing to other causes. The incidence of TMA in RT recipients was 5.6 episodes per 1,000 person-years (PY; 189/1,000 PY; for recurrent TMA versus 4.9/1,000 PY for de novo TMA). The risk of TMA was highest for the first 3 months after transplant. Risk factors for de novo TMA included younger recipient age, older donor age, female recipient, and initial use of sirolimus. Patient survival rate after TMA was approximately 50% at 3 years. CONCLUSION De novo TMA is uncommon and may occur later after RT than previously reported. Risk factors for de novo TMA were also identified.
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Affiliation(s)
- Joel C Reynolds
- Nephrology Service, Walter Reed Army Medical Center, Washington, DC 20307-5001, USA
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George JN, Li X, McMinn JR, Terrell DR, Vesely SK, Selby GB. Thrombotic thrombocytopenic purpura-hemolytic uremic syndrome following allogeneic HPC transplantation: a diagnostic dilemma. Transfusion 2004; 44:294-304. [PMID: 14962323 DOI: 10.1111/j.1537-2995.2004.00700.x] [Citation(s) in RCA: 172] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Thrombotic thrombocytopenic purpura-hemolytic uremic syndrome (TTP-HUS) has been described as a specific sequela of allogeneic HPC transplantation (HPCT). Nevertheless, because multiple transplant-related sequela can cause the characteristic clinical features of TTP-HUS, the diagnosis is difficult. STUDY DESIGN AND METHODS All English-language articles describing patients with TTP-HUS following HPCT were identified. Articles reporting five or more total patients, including at least one patient diagnosed with TTP-HUS following allogeneic HPCT, were reviewed. All articles describing autopsies of patients diagnosed with TTP-HUS following allogeneic HPCT were also reviewed. RESULTS Thirty-five articles reporting 5 or more total patients described 447 patients diagnosed with TTP-HUS following allogeneic HPCT. The frequency of diagnosis of TTP-HUS following allogeneic HPCT varied by 125-fold (0.5%-63.6%). Twenty-eight different sets of diagnostic criteria were described in the 35 articles; 25 articles included both RBC fragmentation and increased serum LDH. Many risk factors described as correlating with the diagnosis of TTP-HUS also predict greater risk for multiple transplant-related complications. Benefit of plasma exchange treatment could not be documented. Survival information was reported for 379 patients, 232 (61%) died, and reported mortality rates varied from 0 to 100 percent. Autopsies have been reported for 35 patients who were diagnosed with TTP-HUS following allogeneic HPCT; none had systemic thrombotic microangiopathy, the diagnostic abnormality of TTP-HUS; and infection (19 patients) was the most commonly reported cause of death. CONCLUSIONS The clinical features of TTP-HUS following allogeneic HPCT may be caused by common transplant-related complications; the benefit from plasma exchange treatment is uncertain.
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Affiliation(s)
- James N George
- Department of Medicine, College of Medicine, The University of Oklahoma Health Sciences Center, Oklahoma City 73190, USA.
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Current awareness in pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2003; 12:431-46. [PMID: 12899122 DOI: 10.1002/pds.791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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