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Cataland SR, Coppo P, Scully M, Lämmle B. Thrombotic thrombocytopenic purpura: 100 years of research on Moschcowitz syndrome. Blood 2024; 144:1143-1152. [PMID: 38958481 DOI: 10.1182/blood.2023022277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Revised: 06/21/2024] [Accepted: 06/23/2024] [Indexed: 07/04/2024] Open
Abstract
ABSTRACT In the 100 years since Eli Moschcowitz reported the first case of thrombotic thrombocytopenic purpura (TTP), there has been remarkable awareness and progress in the diagnosis and management of this rare blood disorder. This progress initially was the result of careful clinical observations followed by well thought-out therapeutic interventions, with dual goals of both improving outcomes and discerning the pathophysiology of TTP. The discovery of the ADAMTS13 protease set in motion the efforts to more accurately define the specific etiologies of thrombotic microangiopathies (TMAs) based on objective, scientific data rather than clinical characterizations alone. This accurate differentiation led to better and more revealing clinical trials and advancements in the treatment of TTP and other TMAs. Further advances followed and included improvements in immune-suppressive therapy and targeted therapies of immune-mediated TTP (iTTP; caplacizumab) and congenital TTP (cTTP; recombinant ADAMTS13). The longitudinal study of patients with TTP revealed the unexpected risk for long-term complications in both patients with iTTP and those with cTTP in remission. Ongoing studies aim to further understand the prevalence, mechanisms, and appropriate screening for these mood disorders, neurocognitive deficits, and cardiovascular complications that develop at remarkably high rates and are associated with a decreased life expectancy. These discoveries are a result of the collaborative efforts of investigators worldwide that have been fostered by the frequent interactions of investigators via the International TTP Working Group meetings and TMA workshops held regularly at international meetings. These efforts will support the rapid pace of discovery and improved understanding of this rare disease.
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Affiliation(s)
| | - Paul Coppo
- Centre de Référence des Microangiopathies Thrombotiques, Service d'Hématologie, Hôpital Saint-Antoine, Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Marie Scully
- Department of Clinical Haematology, University College London Hospitals NHS Foundation Trust, London, United Kingdom
- National Institute for Health Research University College London Hospital/University College London Biomedical Research Centre, London, United Kingdom
| | - Bernhard Lämmle
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Haj Mohamad H, Toubah AM, Audi F, Nouh A, Jaber A, Hashimi O, Shaheen M. A Rare Intersection: Managing Thrombotic Thrombocytopenic Purpura in the Context of Dengue Fever. Cureus 2024; 16:e68818. [PMID: 39371874 PMCID: PMC11456337 DOI: 10.7759/cureus.68818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2024] [Indexed: 10/08/2024] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a rare, life-threatening condition that can lead to severe morbidity and mortality if untreated. This case report discusses a 31-year-old male with dengue fever who developed TTP, resulting in fatality despite timely diagnosis and comprehensive treatment. The patient presented with worsening symptoms, including body aches, gastrointestinal bleeding, and neurological issues. Initial treatment focused on managing dengue hemorrhagic fever, but TTP was later suspected, leading to the cessation of platelet transfusions and initiation of plasma exchange, steroids, and rituximab. Despite these efforts, the patient's condition deteriorated. This case underscores the challenges in managing TTP, especially when triggered by infections like dengue. The use of the PLASMIC score can be highly effective in suspecting TTP in these patients, allowing for the initiation of early management. While standard treatments include plasma exchange and immunosuppressive therapy, emerging treatments such as caplacizumab and the potential use of splenectomy may offer hope for better outcomes in the future.
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Affiliation(s)
| | | | - Fatima Audi
- Internal Medicine, Al Qassimi Hospital, Sharjah, ARE
| | | | | | - Obaid Hashimi
- Internal Medicine, Al Qassimi Hospital, Sharjah, ARE
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Vorobev A, Bitsadze V, Yagubova F, Khizroeva J, Solopova A, Tretyakova M, Gashimova N, Grigoreva K, Einullaeva S, Drozhzhina M, Hajiyeva A, Khalilulina E, Cherepanov A, Kapanadze D, Egorova E, Kuneshko N, Gris JC, Elalamy I, Ay C, Makatsariya A. The Phenomenon of Thrombotic Microangiopathy in Cancer Patients. Int J Mol Sci 2024; 25:9055. [PMID: 39201740 PMCID: PMC11354439 DOI: 10.3390/ijms25169055] [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: 05/13/2024] [Revised: 06/19/2024] [Accepted: 08/15/2024] [Indexed: 09/03/2024] Open
Abstract
Thrombotic microangiopathy (TMA) encompasses a range of disorders characterized by blood clotting in small blood vessels, leading to organ damage. It can manifest as various syndromes, including thrombotic thrombocytopenic purpura (TTP), hemolytic-uremic syndrome (HUS), and others, each with distinct causes and pathophysiology. Thrombo-inflammation plays a significant role in TMA pathogenesis: inflammatory mediators induce endothelial injury and activation of platelet and coagulation cascade, contributing to microvascular thrombosis. Primary TMA, such as TTP, is primarily caused by deficient ADAMTS13 metalloproteinase activity, either due to antibody-mediated inhibition or intrinsic enzyme synthesis defects. In cancer patients, a significant reduction in ADAMTS13 levels and a corresponding increase in VWF levels is observed. Chemotherapy further decreased ADAMTS13 levels and increased VWF levels, leading to an elevated VWF/ADAMTS13 ratio and increased thrombotic risk. Drug-induced TMA (DITMA) can result from immune-mediated or non-immune-mediated mechanisms. Severe cases of COVID-19 may lead to a convergence of syndromes, including disseminated intravascular coagulation (DIC), systemic inflammatory response syndrome (SIRS), and TMA. Treatment of TMA involves identifying the underlying cause, implementing therapies to inhibit complement activation, and providing supportive care to manage complications. Plasmapheresis may be beneficial in conditions like TTP. Prompt diagnosis and treatment are crucial to prevent serious complications and improve outcomes.
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Affiliation(s)
- Alexander Vorobev
- Department of Obstetrics, Gynecology and Perinatal Medicine, I.M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (A.V.); (V.B.); (F.Y.); (J.K.); (A.S.); (M.T.); (K.G.); (S.E.); (A.C.); (E.E.); (J.-C.G.); (I.E.); (C.A.); (A.M.)
| | - Victoria Bitsadze
- Department of Obstetrics, Gynecology and Perinatal Medicine, I.M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (A.V.); (V.B.); (F.Y.); (J.K.); (A.S.); (M.T.); (K.G.); (S.E.); (A.C.); (E.E.); (J.-C.G.); (I.E.); (C.A.); (A.M.)
| | - Fidan Yagubova
- Department of Obstetrics, Gynecology and Perinatal Medicine, I.M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (A.V.); (V.B.); (F.Y.); (J.K.); (A.S.); (M.T.); (K.G.); (S.E.); (A.C.); (E.E.); (J.-C.G.); (I.E.); (C.A.); (A.M.)
| | - Jamilya Khizroeva
- Department of Obstetrics, Gynecology and Perinatal Medicine, I.M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (A.V.); (V.B.); (F.Y.); (J.K.); (A.S.); (M.T.); (K.G.); (S.E.); (A.C.); (E.E.); (J.-C.G.); (I.E.); (C.A.); (A.M.)
| | - Antonina Solopova
- Department of Obstetrics, Gynecology and Perinatal Medicine, I.M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (A.V.); (V.B.); (F.Y.); (J.K.); (A.S.); (M.T.); (K.G.); (S.E.); (A.C.); (E.E.); (J.-C.G.); (I.E.); (C.A.); (A.M.)
| | - Maria Tretyakova
- Department of Obstetrics, Gynecology and Perinatal Medicine, I.M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (A.V.); (V.B.); (F.Y.); (J.K.); (A.S.); (M.T.); (K.G.); (S.E.); (A.C.); (E.E.); (J.-C.G.); (I.E.); (C.A.); (A.M.)
| | - Nilufar Gashimova
- Department of Obstetrics, Gynecology and Perinatal Medicine, I.M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (A.V.); (V.B.); (F.Y.); (J.K.); (A.S.); (M.T.); (K.G.); (S.E.); (A.C.); (E.E.); (J.-C.G.); (I.E.); (C.A.); (A.M.)
| | - Kristina Grigoreva
- Department of Obstetrics, Gynecology and Perinatal Medicine, I.M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (A.V.); (V.B.); (F.Y.); (J.K.); (A.S.); (M.T.); (K.G.); (S.E.); (A.C.); (E.E.); (J.-C.G.); (I.E.); (C.A.); (A.M.)
| | - Sabina Einullaeva
- Department of Obstetrics, Gynecology and Perinatal Medicine, I.M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (A.V.); (V.B.); (F.Y.); (J.K.); (A.S.); (M.T.); (K.G.); (S.E.); (A.C.); (E.E.); (J.-C.G.); (I.E.); (C.A.); (A.M.)
| | - Maria Drozhzhina
- Faculty of General Medicine, Russian University of Medicine, 4th Dolgorukovskaya Str., 127006 Moscow, Russia;
| | - Aygun Hajiyeva
- Faculty of General Medicine, I.M. Sechenov First State Moscow Medical University Baku Branch, Huseyn Javid, Yasamal, Baku AZ1141, Azerbaijan;
| | - Emilia Khalilulina
- Faculty of General Medicine, Pirogov Russian National Research Medical University, Ulitsa Ostrovityanova 1, 117997 Moscow, Russia;
| | - Alexander Cherepanov
- Department of Obstetrics, Gynecology and Perinatal Medicine, I.M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (A.V.); (V.B.); (F.Y.); (J.K.); (A.S.); (M.T.); (K.G.); (S.E.); (A.C.); (E.E.); (J.-C.G.); (I.E.); (C.A.); (A.M.)
| | - Daredzhan Kapanadze
- Center of Pathology of Pregnancy and Hemostasis «Medlabi», 340112 Tbilisi, Georgia;
| | - Elena Egorova
- Department of Obstetrics, Gynecology and Perinatal Medicine, I.M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (A.V.); (V.B.); (F.Y.); (J.K.); (A.S.); (M.T.); (K.G.); (S.E.); (A.C.); (E.E.); (J.-C.G.); (I.E.); (C.A.); (A.M.)
| | - Nart Kuneshko
- Moscow’s Region Odintsovo Maternity Hospital, 143003 Odintsovo, Russia;
| | - Jean-Christophe Gris
- Department of Obstetrics, Gynecology and Perinatal Medicine, I.M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (A.V.); (V.B.); (F.Y.); (J.K.); (A.S.); (M.T.); (K.G.); (S.E.); (A.C.); (E.E.); (J.-C.G.); (I.E.); (C.A.); (A.M.)
- Faculty of Pharmaceutical and Biological Sciences, Montpellier University, 34093 Montpellier, France
| | - Ismail Elalamy
- Department of Obstetrics, Gynecology and Perinatal Medicine, I.M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (A.V.); (V.B.); (F.Y.); (J.K.); (A.S.); (M.T.); (K.G.); (S.E.); (A.C.); (E.E.); (J.-C.G.); (I.E.); (C.A.); (A.M.)
- Department Hematology and Thrombosis Center, Medicine Sorbonne University, 75012 Paris, France
- Hospital Tenon, 4 Rue de la Chine, 75020 Paris, France
| | - Cihan Ay
- Department of Obstetrics, Gynecology and Perinatal Medicine, I.M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (A.V.); (V.B.); (F.Y.); (J.K.); (A.S.); (M.T.); (K.G.); (S.E.); (A.C.); (E.E.); (J.-C.G.); (I.E.); (C.A.); (A.M.)
- Department of Medicine I, Clinical Division of Hematology and Hemostaseology, Medical University of Vienna, 1080 Vienna, Austria
| | - Alexander Makatsariya
- Department of Obstetrics, Gynecology and Perinatal Medicine, I.M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (A.V.); (V.B.); (F.Y.); (J.K.); (A.S.); (M.T.); (K.G.); (S.E.); (A.C.); (E.E.); (J.-C.G.); (I.E.); (C.A.); (A.M.)
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Trisolini SM, Laganà A, Capria S. Immune Thrombotic Thrombocytopenic Purpura: Pathophysiology, Diagnosis, Therapy and Open Issues. Mediterr J Hematol Infect Dis 2024; 16:e2024060. [PMID: 38984099 PMCID: PMC11232686 DOI: 10.4084/mjhid.2024.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 06/19/2024] [Indexed: 07/11/2024] Open
Abstract
Immune thrombotic thrombocytopenic purpura (iTTP) is a life-threatening thrombotic microangiopathy characterized by microangiopathic hemolytic anemia, thrombocytopenia, and ischemic end-organ injury due to microvascular platelet-rich thrombi. iTTP pathophysiology is based on a severe ADAMTS13 deficiency, the specific von Willebrand factor (vWF)-cleaving protease, due to anti-ADAMTS13 autoantibodies. Early diagnosis and treatment reduce the mortality. Frontline therapy includes daily plasma exchange (PEX) with fresh frozen plasma replacement and immunosuppression with corticosteroids. Caplacizumab has recently been added to frontline therapy. Caplacizumab is a nanobody that binds to the A1 domain of vWF, blocking the interaction of ultra-large vWF multimers with the platelet and thereby preventing the formation of platelet-rich thrombi. Caplacizumab reduces mortality due to ischemic events, refractoriness, and exacerbations after PEX discontinuation. Until now, the criteria for response to treatment mainly took into account the normalization of platelet count and discontinuation of PEX; with the use of caplacizumab leading to rapid normalization of platelet count, it has been necessary to redefine the response criteria, taking into account also the underlying autoimmune disease. Monitoring of ADAMTS13 activity is important to identify cases with a low value of activity (<10IU/L), requiring the optimization of immunosuppressive therapy with the addition of Rituximab. Rituximab is effective in patients with refractory disease or relapsing disease. Currently, the use of Rituximab has expanded, both in frontline treatment and during follow-up, as a pre-emptive approach. Some patients do not achieve ADAMTS13 remission following the acute phase despite steroids and rituximab treatment, requiring an individualized immunosuppressive approach to prevent clinical relapse. In iTTP, there is an increased risk of venous thrombotic events (VTEs) as well as arterial thrombotic events, and most occur after platelet normalization. Until now, there has been no consensus on the use of pharmacological thromboprophylaxis in patients on caplacizumab because the drug is known to increase bleeding risk.
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Affiliation(s)
- Silvia Maria Trisolini
- Hematology, Department of Translational and Precision Medicine; "Sapienza" University of Rome, Italy
| | - Alessandro Laganà
- Resident Doctor at the Department of Hematology, University "Sapienza" of Rome, Rome, Italy
| | - Saveria Capria
- Hematology, Department of Translational and Precision Medicine; "Sapienza" University of Rome, Italy
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Zheng XL. Novel mechanisms of action of emerging therapies of hereditary thrombotic thrombocytopenic purpura. Expert Rev Hematol 2024; 17:341-351. [PMID: 38752747 PMCID: PMC11209763 DOI: 10.1080/17474086.2024.2356763] [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: 03/12/2024] [Accepted: 05/14/2024] [Indexed: 05/21/2024]
Abstract
INTRODUCTION Hereditary thrombotic thrombocytopenic purpura (hTTP) is caused by deficiency of plasma ADAMTS13 activity, resulting from ADAMTS13 mutations. ADAMTS13 cleaves ultra large von Willebrand factor (VWF), thus reducing its multimer sizes. Hereditary deficiency of plasma ADAMTS13 activity leads to the formation of excessive platelet-VWF aggregates in small arterioles and capillaries, resulting in hTTP. AREAS COVERED PubMed search from 1956 to 2024 using thrombotic thrombocytopenic purpura and therapy identified 3,675 articles. Only the articles relevant to the topic were selected for discussion, which focuses on pathophysiology, clinical presentations, and mechanisms of action of emerging therapeutics for hTTP. Current therapies include infusion of plasma, or coagulation factor VIII, or recombinant ADAMTS13. Emerging therapies include anti-VWF A1 aptamers or nanobody and gene therapies with adeno-associated viral vector or self-inactivated lentiviral vector or a sleeping beauty transposon system for a long-term expression of a functional ADAMTS13 enzyme. EXPERT OPINION Frequent plasma infusion remains to be the standard of care in most parts of the world, while recombinant ADAMTS13 has become the treatment of choice for hTTP in some of the Western countries. The success of gene therapies in preclinical models may hold a promise for future development of these novel approaches for a cure of hTTP.
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Affiliation(s)
- X. Long Zheng
- Department of Pathology and Laboratory Medicine and Institute of Reproductive Medicine and Developmental Sciences, the University of Kansas Medical Center, Kansas City, Kansas 66160, USA
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Yada N, Zhang Q, Bignotti A, Gralnek SH, Sosnovske D, Hogan K, Ye Z, Zheng L, Zheng XL. Targeting neutrophil extracellular trap accumulation under flow in patients with immune-mediated thrombotic thrombocytopenic purpura. Blood Adv 2024; 8:2536-2551. [PMID: 38513079 PMCID: PMC11131081 DOI: 10.1182/bloodadvances.2023011617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 02/12/2024] [Accepted: 02/12/2024] [Indexed: 03/23/2024] Open
Abstract
ABSTRACT Neutrophil NETosis is a unique form of cell death, characterized by the release of decondensed chromatin and antimicrobial contents to the extracellular space, which is involved in inflammation and thrombosis. However, the role of NETosis in the pathogenesis of immune-mediated thrombotic thrombocytopenic purpura (iTTP) and how a targeted therapy affects the accumulation of neutrophil extracellular traps (NETs) under flow remain unknown. Flow cytometry demonstrated that the percentage of neutrophils undergoing NETosis in whole blood from patients with iTTP on admission was significantly increased, with a concurrent decrease in the capacity of inducible NETosis by shigatoxin. After therapy, the percentage of H3Cit+MPO+ neutrophils was significantly reduced, with an improvement in inducible NETosis in these patients. Additionally, little to no NET and thrombus formation was detected underflow in the whole blood from patients with iTTP when platelet counts were very low, but the NET and thrombus formation was dramatically increased following therapy when platelet counts rose to ≥50 × 109/L or were restored to normal with donor platelets. Similarly, there was no thrombus or NET accumulation under flow in the whole blood from vwf-/- mice, but NET accumulation was significantly higher in Adamts13-/- mice than in wild-type mice. Finally, recombinant ADAMTS13 or caplacizumab (or anfibatide) prevented NET and thrombus formation under flow in whole blood from patients with iTTP or from Adamts13-/- mice. These results indicate that neutrophil NETosis and NET formation depend on platelets and von Willebrand factor (VWF) in iTTP, and a targeted therapy such as recombinant ADAMTS13 or caplacizumab may prevent NET and thrombus formation under flow in iTTP.
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Affiliation(s)
- Noritaka Yada
- Department of Pathology and Laboratory Medicine, The University of Kansas Medical Center, Kansas City, KS
| | - Quan Zhang
- Department of Pathology and Laboratory Medicine, The University of Kansas Medical Center, Kansas City, KS
| | - Antonia Bignotti
- Department of Pathology and Laboratory Medicine, The University of Kansas Medical Center, Kansas City, KS
| | - Sarah H. Gralnek
- Department of Pathology and Laboratory Medicine, The University of Kansas Medical Center, Kansas City, KS
| | - Dennis Sosnovske
- Department of Pathology and Laboratory Medicine, The University of Kansas Medical Center, Kansas City, KS
| | - Keenan Hogan
- Department of Pathology and Laboratory Medicine, The University of Kansas Medical Center, Kansas City, KS
| | - Zhan Ye
- Department of Pathology and Laboratory Medicine, The University of Kansas Medical Center, Kansas City, KS
| | - Liang Zheng
- Department of Pathology and Laboratory Medicine, The University of Kansas Medical Center, Kansas City, KS
- Institute of Reproductive Medicine and Developmental Sciences, The University of Kansas Medical Center, Kansas City, KS
| | - X. Long Zheng
- Department of Pathology and Laboratory Medicine, The University of Kansas Medical Center, Kansas City, KS
- Institute of Reproductive Medicine and Developmental Sciences, The University of Kansas Medical Center, Kansas City, KS
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Wiegley N, Arora S, Norouzi S, Rovin B. A Comprehensive and Practical Approach to the Management of Lupus Nephritis in the Current Era. ADVANCES IN KIDNEY DISEASE AND HEALTH 2024; 31:234-245. [PMID: 39004463 DOI: 10.1053/j.akdh.2023.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 09/27/2023] [Accepted: 11/29/2023] [Indexed: 07/16/2024]
Abstract
Lupus nephritis (LN) is a severe complication of systemic lupus erythematosus (SLE) and is one of the leading causes of morbidity and mortality in patients with SLE. It is estimated that up to 60% of individuals with SLE will develop LN, which can manifest at any stage of a patient's life; however, it commonly emerges early in the course of SLE and tends to exhibit a more aggressive phenotype in men compared to women. Black and Hispanic patients are more likely to progress to kidney failure than white patients. LN is characterized by kidney inflammation and chronic parenchymal damage, leading to impaired kidney function and potential progression to kidney failure. This article provides a comprehensive overview of the epidemiology, pathogenesis, clinical presentation, diagnosis, and management of LN, highlighting the importance of early recognition and treatment of LN to prevent progressive, irreversible kidney damage and improve patient outcomes. Additionally, the article discusses current and emerging therapies for LN, including traditional immunosuppressive agents, biological agents, and novel therapies targeting specific pathways involved in LN pathogenesis, to provide a practical guide for clinicians in properly diagnosing LN and determining a patient-centered treatment plan.
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Affiliation(s)
- Nasim Wiegley
- Division of Nephrology, University of California, Davis School of Medicine, Sacramento, CA.
| | - Swati Arora
- Division of Nephrology, Allegheny Health Network, Pittsburgh, PA
| | - Sayna Norouzi
- Division of Nephrology, Loma Linda University Medical Center, Loma Linda, CA
| | - Brad Rovin
- Division of Nephrology, Ohio State University, Columbus, OH
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Hafez W, Rashid A, Abuelsaoud HM, Jose M, Kishk S, Gador M, Emoshe T, Abdulaal F, Nair N, Ahmad M, Rashid VJ, Faheem Y, John S, Ahmed S, Daraghmi A, Soliman R, Abdelrahman A, Mohamed AA, Ghanem M. Evaluating the potential mediating role of ADAMTS13 activity in the relationship between obesity and the severity of COVID-19: A retrospective cohort study. Medicine (Baltimore) 2024; 103:e37806. [PMID: 38608066 PMCID: PMC11018207 DOI: 10.1097/md.0000000000037806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 03/14/2024] [Indexed: 04/14/2024] Open
Abstract
Obesity and low enzyme A disintegrin and metalloproteinase with thrombospondin type-1 motif-13 (ADAMTS13) activity have been linked to poor coronavirus disease 2019 (COVID-19). Given that obesity may influence ADAMTS13 activity, it is feasible; however, it remains unclear whether ADAMTS13 activity acts as a mediator between obesity and COVID-19 outcomes. We investigated the link between body mass index (BMI) and COVID-19 outcomes, using ADAMTS13 activity as a mediator. ADAMTS13 activity was measured in 86 hospitalized COVID-19 patients. BMI, ADAMTS13 activity, and COVID-19 outcomes were assessed. Obese patients had a high odds ratio for low ADAMTS13 levels. When different levels of ADAMTS13 activity were considered, the severity of COVID-19 in obese patients was 4.5 times that in the normal BMI group. Furthermore, increased coagulopathy indicators correlated with low ADAMTS13 activity. Patients with elevated ALT and AST levels showed a 3 to 4-fold increase in the chances of low ADAMTS13 activity (OR:3.19, 95% CI:1.22-8.90, P = .021; OR:2.17, 95% CI:0.91-5.27, P = .082, respectively). When ADAMTS13 activity was considered, obese patients had greater COVID-19 severity and slower viral clearance than those with normal BMI. Low ADAMTS13 activity and impaired liver function are associated with poor COVID-19 outcomes. These findings encourage researchers to use molecular component identification to study the effects of obesity on the von Willebrand factor (VWF)/ADAMTS13 axis, COVID-19 pathogenesis, and outcomes.
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Affiliation(s)
- Wael Hafez
- NMC Royal Hospital, Khalifa City, Abu Dhabi, United Arab Emirates
- Internal Medicine Department, Medical Research and Clinical Studies Institute; The National Research Centre, Cairo, Egypt
| | - Asrar Rashid
- NMC Royal Hospital, Khalifa City, Abu Dhabi, United Arab Emirates
| | | | - Mohan Jose
- NMC Royal Hospital, Khalifa City, Abu Dhabi, United Arab Emirates
| | - Samy Kishk
- NMC Royal Hospital, Khalifa City, Abu Dhabi, United Arab Emirates
| | - Muneir Gador
- NMC Royal Hospital, Khalifa City, Abu Dhabi, United Arab Emirates
| | | | - Fatema Abdulaal
- NMC Royal Hospital, Khalifa City, Abu Dhabi, United Arab Emirates
| | - Nivedita Nair
- NMC Royal Hospital, Khalifa City, Abu Dhabi, United Arab Emirates
| | - Muhammad Ahmad
- NMC Royal Hospital, Khalifa City, Abu Dhabi, United Arab Emirates
| | | | - Youmna Faheem
- NMC Royal Hospital, Khalifa City, Abu Dhabi, United Arab Emirates
| | - Steffi John
- NMC Royal Hospital, Khalifa City, Abu Dhabi, United Arab Emirates
| | - Sabah Ahmed
- NMC Royal Hospital, Khalifa City, Abu Dhabi, United Arab Emirates
| | - Ahmed Daraghmi
- NMC Royal Hospital, Khalifa City, Abu Dhabi, United Arab Emirates
| | - Rami Soliman
- NMC Royal Hospital, Khalifa City, Abu Dhabi, United Arab Emirates
- National Institute of Chest and Allergy, Egypt
| | - Ahmed Abdelrahman
- NMC Royal Hospital, Khalifa City, Abu Dhabi, United Arab Emirates
- Internal Medicine Department, Zagazig Faculty of Medicine, Zagazig, Egypt
| | - Ahmed Ali Mohamed
- NMC Royal Hospital, Khalifa City, Abu Dhabi, United Arab Emirates
- Intensive Care Department, Theodor Bilharz Research Institute, AL Warak, Giza Governorate, Egypt
| | - Mirvat Ghanem
- NMC Royal Hospital, Khalifa City, Abu Dhabi, United Arab Emirates
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9
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Abou-Ismail MY, Zhang C, Presson AP, Chaturvedi S, Antun AG, Farland AM, Woods R, Metjian A, Park YA, de Ridder G, Gibson B, Kasthuri RS, Liles DK, Akwaa F, Clover T, Kreuziger LB, Sridharan M, Go RS, McCrae KR, Upreti HV, Gangaraju R, Kocher NK, Zheng XL, Raval JS, Masias C, Cataland SR, Johnson AD, Davis E, Evans MD, Mazepa M, Lim MY. A machine learning approach to predict mortality due to immune-mediated thrombotic thrombocytopenic purpura. Res Pract Thromb Haemost 2024; 8:102388. [PMID: 38651093 PMCID: PMC11033197 DOI: 10.1016/j.rpth.2024.102388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Accepted: 03/11/2024] [Indexed: 04/25/2024] Open
Abstract
Background Mortality due to immune-mediated thrombotic thrombocytopenic purpura (iTTP) remains significant. Predicting mortality risk may potentially help individualize treatment. The French Thrombotic Microangiopathy (TMA) Reference Score has not been externally validated in the United States. Recent advances in machine learning technology can help analyze large numbers of variables with complex interactions for the development of prediction models. Objectives To validate the French TMA Reference Score in the United States Thrombotic Microangiopathy (USTMA) iTTP database and subsequently develop a novel mortality prediction tool, the USTMA TTP Mortality Index. Methods We analyzed variables available at the time of initial presentation, including demographics, symptoms, and laboratory findings. We developed our model using gradient boosting machine, a machine learning ensemble method based on classification trees, implemented in the R package gbm. Results In our cohort (n = 419), the French score predicted mortality with an area under the receiver operating characteristic curve of 0.63 (95% CI: 0.50-0.77), sensitivity of 0.35, and specificity of 0.84. Our gradient boosting machine model selected 8 variables to predict acute mortality with a cross-validated area under the receiver operating characteristic curve of 0.77 (95% CI: 0.71-0.82). The 2 cutoffs corresponded to sensitivities of 0.64 and 0.50 and specificities of 0.76 and 0.87, respectively. Conclusion The USTMA Mortality Index was acceptable for predicting mortality due to acute iTTP in the USTMA registry, but not sensitive enough to rule out death. Identifying patients at high risk of iTTP-related mortality may help individualize care and ultimately improve iTTP survival outcomes. Further studies are needed to provide external validation. Our model is one of many recent examples where machine learning models may show promise in clinical prediction tools in healthcare.
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Affiliation(s)
- Mouhamed Yazan Abou-Ismail
- Division of Hematology and Hematologic Malignancies, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Chong Zhang
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Angela P. Presson
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Shruti Chaturvedi
- The Department of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Ana G. Antun
- Department of Medicine, Emory University, Atlanta, Georgia, USA
| | - Andrew M. Farland
- Department of Medicine, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Ryan Woods
- Department of Medicine, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Ara Metjian
- Department of Medicine, University of Colorado, Denver, Colorado, USA
| | - Yara A. Park
- Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Gustaaf de Ridder
- Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
- Geisinger Medical Laboratories, Danville, Pennsylvania, USA
| | - Briana Gibson
- Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
- Department of Pathology and Laboratory Medicine, Emory University, Atlanta, Georgia, USA
| | - Raj S. Kasthuri
- Department of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Darla K. Liles
- Department of Medicine, East Carolina University, Greenville, North Carolina, USA
| | - Frank Akwaa
- Department of Medicine, University of Rochester, Rochester, New York, USA
| | | | - Lisa Baumann Kreuziger
- Versiti, Milwaukee, Wisconsin, USA
- Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Meera Sridharan
- Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Ronald S. Go
- Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Keith R. McCrae
- Department of Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Harsh Vardhan Upreti
- The Department of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Radhika Gangaraju
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Nicole K. Kocher
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - X. Long Zheng
- Department of Pathology and Laboratory Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
- Institute of Reproductive Medicine and Developmental Sciences, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Jay S. Raval
- Department of Pathology, University of New Mexico, Albuquerque, New Mexico, USA
| | | | - Spero R. Cataland
- Department of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Andrew D. Johnson
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Elizabeth Davis
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Michael D. Evans
- Clinical & Translational Science Institute, University of Minnesota, Minneapolis, Minnesota, USA
| | - Marshall Mazepa
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Ming Y. Lim
- Division of Hematology and Hematologic Malignancies, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA
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10
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Waleed MS, Dhulipalla L, Niazi M, Terjanian T, Dhar M. COVID-Induced Thrombotic Thrombocytopenic Purpura: A Case Report and Treatment-Focused Review. Cureus 2024; 16:e57252. [PMID: 38686279 PMCID: PMC11057214 DOI: 10.7759/cureus.57252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2024] [Indexed: 05/02/2024] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a rare disease that is part of a vast spectrum of thrombotic microangiopathies (TMAs). Despite the rarity of TTP, clinicians must maintain a high suspicion of this disease. The condition is characterized by fever, low platelets, hemolytic anemia, renal abnormalities, and neurological dysfunction. However, all these symptoms are not necessarily present in all the patients. In this review, we describe a case of a 51-year-old female who presented to the emergency department (ED) with chief complaints of dizziness and lightheadedness, subsequently leading to a diagnosis of TTP, caused as a result of COVID-19. This review raises awareness so that there is early recognition of any hematological manifestations associated with COVID-19, reducing the morbidity and mortality associated with the disease. Due to the unpredictability of COVID-19 and its complications, robust research is needed to understand the mechanism and determine which patients are more at risk for adverse outcomes.
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Affiliation(s)
| | | | - Muhammad Niazi
- Internal Medicine, Northwell Health/Staten Island University Hospital, Staten Island, USA
| | - Terenig Terjanian
- Hematology and Oncology, Staten Island University Hospital, Staten Island, USA
| | - Meekoo Dhar
- Hematology and Oncology, Staten Island University Hospital, Staten Island, USA
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11
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Leisring J, Brodsky SV, Parikh SV. Clinical Evaluation and Management of Thrombotic Microangiopathy. Arthritis Rheumatol 2024; 76:153-165. [PMID: 37610060 DOI: 10.1002/art.42681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 05/17/2023] [Accepted: 08/17/2023] [Indexed: 08/24/2023]
Abstract
Thrombotic microangiopathy (TMA) refers to a diverse group of diseases that share clinical and histopathologic features. TMA is clinically characterized by microangiopathic hemolytic anemia, consumptive thrombocytopenia, and organ injury that stems from endothelial damage and vascular occlusion. There are several disease states with distinct pathophysiological mechanisms that manifest as TMA. These conditions are associated with significant morbidity and mortality and require urgent recognition and treatment. Thrombotic thrombocytopenic purpura and hemolytic uremic syndrome are traditionally considered to be primary forms of TMA, but TMA more commonly occurs in association with a coexisting condition such as infection, pregnancy, autoimmune disease, or malignant hypertension, among others. Determining the cause of TMA is a diagnostic challenge because of limited availability of disease-specific testing. However, identifying the underlying etiology is imperative as treatment strategies differ. Our understanding of the conditions that cause TMA is evolving. Recent advances have led to improved comprehension of the varying pathogenic mechanisms that drive TMA. Development of targeted therapeutics has resulted in significant improvements in patient outcomes. In this article, we review the pathogenesis and clinical features of the different TMA-causing conditions. We outline a practical approach to diagnosis and management and discuss empiric and disease-specific treatment strategies.
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Affiliation(s)
- Joshua Leisring
- The Ohio State University Wexner Medical Center, Columbus, Ohio
| | | | - Samir V Parikh
- The Ohio State University Wexner Medical Center, Columbus, Ohio
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12
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Rovin BH, Ayoub IM, Chan TM, Liu ZH, Mejía-Vilet JM, Floege J. KDIGO 2024 Clinical Practice Guideline for the management of LUPUS NEPHRITIS. Kidney Int 2024; 105:S1-S69. [PMID: 38182286 DOI: 10.1016/j.kint.2023.09.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 09/07/2023] [Indexed: 01/07/2024]
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13
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Dimopoulos K, Tripodi A, Goetze JP. Laboratory investigation and diagnosis of thrombotic thrombocytopenic purpura. Crit Rev Clin Lab Sci 2023; 60:625-639. [PMID: 37452521 DOI: 10.1080/10408363.2023.2232039] [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: 12/23/2022] [Revised: 04/04/2023] [Accepted: 06/27/2023] [Indexed: 07/18/2023]
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a rare and potentially fatal disease for which rapid diagnosis is crucial for patient outcomes. Deficient activity (< 10%) of the liver enzyme, ADAMTS13, is the pathophysiological hallmark of TTP, and measurement of the enzyme activity can establish the diagnosis of TTP with high accuracy. Thus, along with the clinical history, appropriate laboratory assessment of a suspected case of TTP is essential for diagnosis and treatment. Here, we present a review of the available laboratory tests that can assist clinicians in establishing the diagnosis of TTP, with special focus on ADAMTS13 assays, including the measurement of the antigen and activity, and detection of autoantibodies to ADAMTS13.
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Affiliation(s)
- Konstantinos Dimopoulos
- Department of Clinical Biochemistry, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Armando Tripodi
- IRCCS Maggiore Hospital Foundation, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milano, Italy
| | - Jens P Goetze
- Department of Clinical Biochemistry, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
- Department of Biomedical Sciences, Faculty of Health, Copenhagen University, Copenhagen, Denmark
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14
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Qureshi ZA, Altaf F, Khanzada M, Thet A, Espinosa L. Ceftriaxone-Induced Thrombotic Thrombocytopenic Purpura Treated Successfully With Plasmapheresis and Eculizumab: A Rare Case Report. Cureus 2023; 15:e48898. [PMID: 38024015 PMCID: PMC10653270 DOI: 10.7759/cureus.48898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/16/2023] [Indexed: 12/01/2023] Open
Abstract
Thrombotic Thrombocytopenic Purpura (TTP) is a subtype of thrombotic microangiopathy (TMA) resulting in thrombocytopenia, anemia, fever, renal and neurological deficits. Although many drugs have been associated with drug-induced TTP, ceftriaxone has never been reported. Our case reports a patient who was started on ceftriaxone and developed TTP. Peripheral smear showed schistocytes and thrombocytopenia. Surprisingly, antibody formation against the metalloproteinase (ADAMTS13) levels were low-normal. The patient was treated with plasmapheresis and eczulimab, leading to platelet recovery and symptom resolution. TTP is a rare disorder and can be acquired or idiopathic. TTP can be diagnosed with normal ADAMTS13 as well. Further research is required to assess the mechanism by which ceftriaxone causes TTP. Physicians should consider the possibility of TTP in patients with similar presentations following ceftriaxone therapy and use it for timely diagnosis and treatment. Early diagnosis and treatment of ceftriaxone-induced TTP can prevent devastating consequences.
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Affiliation(s)
- Zaheer A Qureshi
- Internal Medicine, The Frank H. Netter M.D. School of Medicine at Quinnipiac University, Bridgeport, USA
- Internal Medicine, BronxCare Health System, Bronx, USA
- Internal Medicine, St. Vincent Medical Center, Bridgeport, USA
| | - Faryal Altaf
- Internal Medicine, BronxCare Health System, Bronx, USA
| | | | - Aung Thet
- Internal Medicine, BronxCare Health System, Bronx, USA
| | - Luis Espinosa
- Internal Medicine, BronxCare Health System, Bronx, USA
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15
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Scully M, Rayment R, Clark A, Westwood JP, Cranfield T, Gooding R, Bagot CN, Taylor A, Sankar V, Gale D, Dutt T, McIntyre J, Lester W. A British Society for Haematology Guideline: Diagnosis and management of thrombotic thrombocytopenic purpura and thrombotic microangiopathies. Br J Haematol 2023; 203:546-563. [PMID: 37586700 DOI: 10.1111/bjh.19026] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 07/21/2023] [Accepted: 07/26/2023] [Indexed: 08/18/2023]
Abstract
The objective of this guideline is to provide healthcare professionals with clear, up-to-date and practical guidance on the management of thrombotic thrombocytopenic purpura (TTP) and related thrombotic microangiopathies (TMAs), including complement-mediated haemolytic uraemic syndrome (CM HUS); these are defined by thrombocytopenia, microangiopathic haemolytic anaemia (MAHA) and small vessel thrombosis. Within England, all TTP cases should be managed within designated regional centres as per NHSE commissioning for highly specialised services.
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Affiliation(s)
- M Scully
- Department of Haematology, UCLH and Haematology Programme, University College London Hospitals Biomedical Research Centre, National Institute for Health Research, London, UK
| | - R Rayment
- Department of Haematology, University Hospital of Wales, Cardiff, UK
| | - A Clark
- Department of Haematology, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | | | - T Cranfield
- Department of Haematology, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - R Gooding
- Haematology Department, Belfast City Hospital, Belfast H&SC Trust, Belfast, UK
| | - C N Bagot
- Glasgow Royal Infirmary, Glasgow, UK
| | - A Taylor
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - V Sankar
- Department of Critical Care Medicine, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - D Gale
- Department of Renal Medicine, University College London, London, UK
| | - T Dutt
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | | | - W Lester
- Department of Haematology, University Hospitals Birmingham, Birmingham, UK
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16
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Imanifard Z, Liguori L, Remuzzi G. TMA in Kidney Transplantation. Transplantation 2023; 107:2329-2340. [PMID: 36944606 DOI: 10.1097/tp.0000000000004585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
Thrombotic microangiopathy (TMA) is a rare and devastating complication of kidney transplantation, which often leads to graft failure. Posttransplant TMA (PT-TMA) may occur either de novo or as a recurrence of the disease. De novo TMA can be triggered by immunosuppressant drugs, antibody-mediated rejection, viral infections, and ischemia/reperfusion injury in patients with no evidence of the disease before transplantation. Recurrent TMA may occur in the kidney grafts of patients with a history of atypical hemolytic uremic syndrome (aHUS) in the native kidneys. Studies have shown that some patients with aHUS carry genetic abnormalities that affect genes that code for complement regulators (CFH, MCP, CFI) and components (C3 and CFB), whereas in 10% of patients (mostly children), anti-FH autoantibodies have been reported. The incidence of aHUS recurrence is determined by the underlying genetic or acquired complement abnormality. Although treatment of the causative agents is usually the first line of treatment for de novo PT-TMA, this approach might be insufficient. Plasma exchange typically resolves hematologic abnormalities but does not improve kidney function. Targeted complement inhibition is an effective treatment for recurrent TMA and may be effective in de novo PT-TMA as well, but it is necessary to establish which patients can benefit from different therapeutic options and when and how these can be applied.
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Affiliation(s)
- Zahra Imanifard
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Clinical Research Center for Rare Diseases Aldo e Cele Daccò, Ranica, Italy
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17
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Geist N, Nagel F, Delcea M. Molecular interplay of ADAMTS13-MDTCS and von willebrand Factor-A2: deepened insights from extensive atomistic simulations. J Biomol Struct Dyn 2023; 41:8201-8214. [PMID: 36271641 DOI: 10.1080/07391102.2022.2135138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 09/24/2022] [Indexed: 10/24/2022]
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a rare and life-threatening disease. One hallmark is severe ADAMTS13 deficiency, causing ultra-large von Willebrand factor (VWF) multimers to accumulate, leading to microthrombi and lastly to microangiopathic hemolytic anemia and severe thrombocytopenia. Despite great success in recent decades, the molecular picture of the interaction between VWF and ADAMTS13 remains vague. Here, we utilized modern replica-exchange molecular dynamics simulations with the TIGER2h method to sample a vast configurational space of the isolated ADAMTS13-MDTCS domains and the exposure to its substrate and activating cofactor - the unraveled VWF-A2 domain. The sampling of binding sites and conformations was guided and filtered in agreement with available experimental evidence. We provide comprehensive information on exosites for each domain and direct pairs of interacting amino acids, for the first time. The major binding cluster for the active site of the MP domain contrasts the previous mapping of VWF-A2 residues and reciprocal binding pockets. Two major binding modes are revealed and provide access to conformational changes of an extended gatekeeper tetrad upon overcoming local latency during substrate binding and to a dedicated recruitment mechanism. Our work adds the first molecular interaction model that places previous experimental results in perspective to better understand disease-related mutations towards improved therapies. Numerous empirical targets are proposed to verify the given binding modes, to refine the overall picture of MP binding pockets, the role of Dis binding in MP activation and the passage of the Cys-rich domain through VWF-A2, thus deepening the understanding of a highly dynamic interplay.Communicated by Ramaswamy H. Sarma.
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Affiliation(s)
- Norman Geist
- University of Greifswald, Biophysical Chemistry, Institute of Biochemistry, Greifswald, Germany
| | - Felix Nagel
- University of Greifswald, Biophysical Chemistry, Institute of Biochemistry, Greifswald, Germany
| | - Mihaela Delcea
- University of Greifswald, Biophysical Chemistry, Institute of Biochemistry, Greifswald, Germany
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18
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Völker LA, Brinkkoetter PT, Cataland SR, Masias C. Five years of caplacizumab - lessons learned and remaining controversies in immune-mediated thrombotic thrombocytopenic purpura. J Thromb Haemost 2023; 21:2718-2725. [PMID: 37562668 DOI: 10.1016/j.jtha.2023.07.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 07/24/2023] [Accepted: 07/29/2023] [Indexed: 08/12/2023]
Abstract
Immune-mediated thrombotic thrombocytopenic purpura (iTTP) is a rare hematologic disease caused by autoantibodies against ADAMTS-13 that trigger microangiopathic hemolytic anemia. Therapeutic plasma exchange and glucocorticoids have been the mainstay of treatment for the past 30 years. In 2019, caplacizumab was approved as an addition to this regimen for the acute treatment of iTTP. Randomized controlled trials and real-world evidence have shown that caplacizumab reduces the time to platelet count normalization, refractoriness, and exacerbations of the disease, with an acceptable safety profile. In the past 5 years, there have been arguments against the upfront use of caplacizumab in all patients with iTTP, particularly related to the perceived lack of clinical benefit, safety concerns related to bleeding risk, and high costs. This perspective aimed to address these concerns in the context of the experience of expert centers that have used the drug for >5 years.
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Affiliation(s)
- Linus Alexander Völker
- Department II of Internal Medicine, Center for Molecular Medicine Cologne, Faculty of Medicine, University Hospital Cologne, University of Cologne, Cologne, Germany; Cologne Cluster of Excellence on Cellular Stress Responses in Ageing-Associated Diseases, Cologne, Germany.
| | - Paul Thomas Brinkkoetter
- Department II of Internal Medicine, Center for Molecular Medicine Cologne, Faculty of Medicine, University Hospital Cologne, University of Cologne, Cologne, Germany; Cologne Cluster of Excellence on Cellular Stress Responses in Ageing-Associated Diseases, Cologne, Germany
| | - Spero R Cataland
- Department of Medicine, The Ohio State University, Columbus, Ohio, USA
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19
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Bonnez Q, Sakai K, Vanhoorelbeke K. ADAMTS13 and Non-ADAMTS13 Biomarkers in Immune-Mediated Thrombotic Thrombocytopenic Purpura. J Clin Med 2023; 12:6169. [PMID: 37834813 PMCID: PMC10573396 DOI: 10.3390/jcm12196169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 09/20/2023] [Accepted: 09/21/2023] [Indexed: 10/15/2023] Open
Abstract
Immune-mediated thrombotic thrombocytopenic purpura (iTTP) is a rare medical emergency for which a correct and early diagnosis is essential. As a severe deficiency in A Disintegrin And Metalloproteinase with ThromboSpondin type 1 repeats, member 13 (ADAMTS13) is the underlying pathophysiology, diagnostic strategies require timely monitoring of ADAMTS13 parameters to differentiate TTP from alternative thrombotic microangiopathies (TMAs) and to guide initial patient management. Assays for conventional ADAMTS13 testing focus on the enzyme activity and presence of (inhibitory) anti-ADAMTS13 antibodies to discriminate immune-mediated TTP (iTTP) from congenital TTP and guide patient management. However, diagnosis of iTTP remains challenging when patients present borderline ADAMTS13 activity. Therefore, additional biomarkers would be helpful to support correct clinical judgment. Over the last few years, the evaluation of ADAMTS13 conformation has proven to be a valuable tool to confirm the diagnosis of acute iTTP when ADAMST13 activity is between 10 and 20%. Screening of ADAMTS13 conformation during long-term patient follow-up suggests it is a surrogate marker for undetectable antibodies. Moreover, some non-ADAMTS13 parameters gained notable interest in predicting disease outcome, proposing meticulous follow-up of iTTP patients. This review summarizes non-ADAMTS13 biomarkers for which inclusion in routine clinical testing could largely benefit differential diagnosis and follow-up of iTTP patients.
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Affiliation(s)
- Quintijn Bonnez
- Department of Chemistry, KU Leuven Campus Kulak Kortrijk, 8500 Kortrijk, Belgium
| | - Kazuya Sakai
- Department of Chemistry, KU Leuven Campus Kulak Kortrijk, 8500 Kortrijk, Belgium
- Department of Blood Transfusion Medicine, Nara Medical University, Kashihara 634-8522, Japan
| | - Karen Vanhoorelbeke
- Department of Chemistry, KU Leuven Campus Kulak Kortrijk, 8500 Kortrijk, Belgium
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20
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Sukumar S, Mazepa MA, Chaturvedi S. Cardiovascular Disease and Stroke in Immune TTP-Challenges and Opportunities. J Clin Med 2023; 12:5961. [PMID: 37762903 PMCID: PMC10531888 DOI: 10.3390/jcm12185961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 08/29/2023] [Accepted: 09/09/2023] [Indexed: 09/29/2023] Open
Abstract
Advances in the management of immune thrombotic thrombocytopenic purpura (iTTP) have dramatically improved outcomes of acute TTP episodes, and TTP is now treated as a chronic, relapsing disorder. It is now recognized that iTTP survivors are at high risk for vascular disease, with stroke and myocardial infarction occurring at younger ages than in the general population, and cardiovascular disease is the leading cause of premature death in this population. iTTP appears to have a phenotype of accelerated vascular aging with a particular predilection for cerebral circulation, and stroke is much more common than myocardial infarction. In addition to traditional cardiovascular risk factors, low ADAMTS13 activity during clinical remission may be a risk factor for some of these outcomes, such as stroke. Recent studies also suggest that Black patients, who are disproportionately affected by iTTP in the United States, are at higher risk of adverse cardiovascular outcomes, likely due to multifactorial reasons. Additional research is required to establish the risk factors and mechanisms underlying these complications in order to institute optimal screening strategies and identify interventions to improve outcomes.
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Affiliation(s)
- Senthil Sukumar
- Division of Hematology/Oncology, Department of Medicine, Baylor College of Medicine, Houston, TX 77098, USA;
| | - Marshall A. Mazepa
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA;
| | - Shruti Chaturvedi
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
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21
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Falter T, Rossmann H, de Waele L, Dekimpe C, von Auer C, Müller-Calleja N, Häuser F, Degreif A, Marandiuc D, Messmer X, Sprinzl M, Lackner KJ, Jurk K, Vanhoorelbeke K, Lämmle B. A novel von Willebrand factor multimer ratio as marker of disease activity in thrombotic thrombocytopenic purpura. Blood Adv 2023; 7:5091-5102. [PMID: 37399489 PMCID: PMC10471935 DOI: 10.1182/bloodadvances.2023010028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 06/02/2023] [Accepted: 06/02/2023] [Indexed: 07/05/2023] Open
Abstract
Immune-mediated thrombotic thrombocytopenic purpura (iTTP), an autoantibody-mediated severe ADAMTS13 deficiency, is caused by insufficient proteolytic processing of von Willebrand factor (VWF) multimers (MMs) and microvascular thrombi. Recurrence of acute iTTP is associated with persistence or reappearance of ADAMTS13 deficiency. Some patients remain in remission despite recurring or persisting severe ADAMTS13 deficiency. In a prospective 2-year observational study, we investigated VWF MM patterns and ADAMTS13 in patients with iTTP in remission and at acute episodes. Of the 83 patients with iTTP, 16 suffered 22 acute episodes whereas 67 remained in clinical remission during follow-up, including 13 with ADAMTS13 <10% and 54 with ADAMTS13 ≥10%. High -molecular weight to low-molecular weight VWF MM ratio based on sodium dodecyl sulfate-agarose gel electrophoresis was compared with ADAMTS13 activity. VWF MM ratio was significantly higher in patients in remission with <10% compared with ≥10% ADAMTS13 activity. Fourteen samples obtained from 13 to 50 days (interquartile range; median, 39) before acute iTTP onset (ADAMTS13 <10% in 9 patients and 10%-26% in 5) showed VWF MM ratios significantly higher than those from 13 patients remaining in remission with ADAMTS13 <10%. At acute iTTP onset, VWF MM ratio decreased significantly and was low in all patients despite <10% ADAMTS13. The VWF MM ratio does not depend exclusively on ADAMTS13 activity. The disappearance of high molecular weight VWF MMs resulting in low VWF MM ratio at iTTP onset may be explained by consumption of larger VWF MMs in the microcirculation. The very high VWF MM ratio preceding acute iTTP recurrence suggests that VWF processing is hampered more than in patients remaining in remission.
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Affiliation(s)
- Tanja Falter
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Heidi Rossmann
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Laure de Waele
- Laboratory for Thrombosis Research, Interdisciplinary Research Facility, KU Leuven Campus Kortrijk, Kortrijk, Belgium
| | - Charlotte Dekimpe
- Laboratory for Thrombosis Research, Interdisciplinary Research Facility, KU Leuven Campus Kortrijk, Kortrijk, Belgium
| | - Charis von Auer
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
- Department of Hematology, Oncology and Pneumology, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Nadine Müller-Calleja
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Friederike Häuser
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Adriana Degreif
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Dana Marandiuc
- Transfusion Center, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Xavier Messmer
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Martin Sprinzl
- Medical Department I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Karl J. Lackner
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Kerstin Jurk
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Karen Vanhoorelbeke
- Laboratory for Thrombosis Research, Interdisciplinary Research Facility, KU Leuven Campus Kortrijk, Kortrijk, Belgium
| | - Bernhard Lämmle
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
- University Clinic of Hematology & Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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22
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Sui J, Zheng L, Zheng XL. ADAMTS13 Biomarkers in Management of Immune Thrombotic Thrombocytopenic Purpura. Arch Pathol Lab Med 2023; 147:974-979. [PMID: 36223210 PMCID: PMC11033696 DOI: 10.5858/arpa.2022-0050-ra] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/24/2022] [Indexed: 11/06/2022]
Abstract
CONTEXT.— Immune thrombotic thrombocytopenic purpura (iTTP) is a rare but potentially fatal blood disorder resulting from acquired deficiency of plasma ADAMTS13, a metalloprotease that cleaves endothelium-derived ultralarge von Willebrand factor. Standard of care for iTTP including therapeutic plasma exchange, caplacizumab, and immunosuppressives, known as triple therapy, has led to a significant reduction in the disease-related mortality rate. The first International Society of Thrombosis and Haemostasis TTP guideline stresses the importance of having plasma ADAMTS13 activity testing in the algorithm for diagnosis and management of iTTP. However, the predictive role of assessing plasma ADAMTS13 activity and inhibitors or other ADAMTS13-related parameters in patients with acute iTTP and during remission has not been systematically evaluated. OBJECTIVE.— To review and assess the predictive values of testing plasma ADAMTS13 activity, antigen, and inhibitors or anti-ADAMTS13 immunoglobulin G at various stages of disease in outcomes of iTTP. DATA SOURCES.— Peer-reviewed publications and personal experience. CONCLUSIONS.— We conclude that assessing ADAMTS13 biomarkers is not only essential for establishing the initial diagnosis, but also crucial for risk stratification and the early detection of disease recurrence. This may guide therapeutic interventions during acute episodes and for long-term follow-up of iTTP patients.
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Affiliation(s)
- Jingrui Sui
- From the Department of Hematology, Yantai Yu Huang Ding Hospital Affiliated to Qingdao University, Shandong Province, China (Sui)
| | - Liang Zheng
- The Department of Pathology & Laboratory Medicine, University of Kansas Medical Center, Kansas City (L. Zheng, X. L. Zheng)
| | - X Long Zheng
- The Department of Pathology & Laboratory Medicine, University of Kansas Medical Center, Kansas City (L. Zheng, X. L. Zheng)
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23
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Butt A, Allen C, Purcell A, Ito S, Goshua G. Global Health Resource Utilization and Cost-Effectiveness of Therapeutics and Diagnostics in Immune Thrombotic Thrombocytopenic Purpura (TTP). J Clin Med 2023; 12:4887. [PMID: 37568288 PMCID: PMC10420213 DOI: 10.3390/jcm12154887] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 06/28/2023] [Accepted: 07/21/2023] [Indexed: 08/13/2023] Open
Abstract
In this review, we examine the current landscape of health resource utilization and cost-effectiveness data in the care of patient populations with immune thrombotic thrombocytopenic purpura. We focus on the therapeutic (therapeutic plasma exchange, glucocorticoids, rituximab, caplacizumab) and diagnostic (ADAMTS13 assay) health technologies employed in the care of patients with this rare disease. Health resource utilization and cost-effectiveness data are limited to the high-income country context. Measurement of TTP-specific utility weights in the high-income country context and collection of health resource utilization data in the low- and middle-income country settings would enable an evaluation of country-specific quality-adjusted life expectancy and cost-effectiveness of these therapeutic and diagnostic health technologies. This quantification of value is one way to mitigate cost concerns where they exist.
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Affiliation(s)
- Ayesha Butt
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT 06510, USA
| | - Cecily Allen
- Division of Hematology, Department of Medicine, Johns Hopkins University, Baltimore, MD 21218, USA
| | | | - Satoko Ito
- Section of Hematology, Department of Internal Medicine, Yale School of Medicine, New Haven, CT 06510, USA
| | - George Goshua
- Section of Hematology, Department of Internal Medicine, Yale School of Medicine, New Haven, CT 06510, USA
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24
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Español I, Leal JD, Blanquer M, García-Candel F, Heredia A, Gómez-Espuch J, González C, Montserrat J, Díaz-Carrasco MS, Martínez A, Moraleda JM. N-Acetylcistein for thrombotic thrombocytopenic purpura: an observational case series study. Ann Hematol 2023:10.1007/s00277-023-05248-9. [PMID: 37171598 PMCID: PMC10176284 DOI: 10.1007/s00277-023-05248-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Accepted: 04/25/2023] [Indexed: 05/13/2023]
Abstract
Acquired thrombotic thrombocytopenic purpura (TTP) is a life-threatening disorder. N-Acetylcysteine (NAC) rapidly degrades ultra-large von Willebrand factor multimers by disrupting the disulfide bonds. We report a series of twelve consecutive patients diagnosed with acquired TTP successfully treated with high-dose NAC (150 mg/kg/day) in combination with plasma exchange and steroids. Eight patients also received rituximab. Two patients presented refractory TTP. All patients achieved a quick clinical response in a median time of 5.5 days after starting NAC and are alive after a median follow-up of 29 months. The treatment was feasible and well tolerated. These data provide further evidence of the potential benefit and safety of adding NAC to the standard of care.
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Affiliation(s)
- Ignacio Español
- Hematology Department, University Hospital Virgen de la Arrixaca, IMIB-Pascual Parilla, Carretera Madrid-Cartagena s/n, 30120 El Palmar, Murcia, Spain.
| | - Juan Diego Leal
- Hematology Department, University Hospital Virgen de la Arrixaca, IMIB-Pascual Parilla, Carretera Madrid-Cartagena s/n, 30120 El Palmar, Murcia, Spain
| | - Miguel Blanquer
- Hematology Department, University Hospital Virgen de la Arrixaca, IMIB-Pascual Parilla, Carretera Madrid-Cartagena s/n, 30120 El Palmar, Murcia, Spain
| | - Faustino García-Candel
- Hematology Department, University Hospital Virgen de la Arrixaca, IMIB-Pascual Parilla, Carretera Madrid-Cartagena s/n, 30120 El Palmar, Murcia, Spain
| | - Angela Heredia
- Hematology Department, University Hospital Virgen de la Arrixaca, IMIB-Pascual Parilla, Carretera Madrid-Cartagena s/n, 30120 El Palmar, Murcia, Spain
| | - Joaquín Gómez-Espuch
- Hematology Department, University Hospital Virgen de la Arrixaca, IMIB-Pascual Parilla, Carretera Madrid-Cartagena s/n, 30120 El Palmar, Murcia, Spain
| | - Celia González
- Pharmacy Department, IMIB-Pascual Parrilla, University of Murcia, Murcia, Spain
| | - Jorge Montserrat
- Hematology Department, University Hospital Virgen de la Arrixaca, IMIB-Pascual Parilla, Carretera Madrid-Cartagena s/n, 30120 El Palmar, Murcia, Spain
| | | | - Antonio Martínez
- Hematology Department, University Hospital Virgen de la Arrixaca, IMIB-Pascual Parilla, Carretera Madrid-Cartagena s/n, 30120 El Palmar, Murcia, Spain
| | - José M Moraleda
- Hematology Department, University Hospital Virgen de la Arrixaca, IMIB-Pascual Parilla, Carretera Madrid-Cartagena s/n, 30120 El Palmar, Murcia, Spain
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25
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Sakai K, Matsumoto M. Clinical Manifestations, Current and Future Therapy, and Long-Term Outcomes in Congenital Thrombotic Thrombocytopenic Purpura. J Clin Med 2023; 12:3365. [PMID: 37240470 PMCID: PMC10219024 DOI: 10.3390/jcm12103365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 05/05/2023] [Accepted: 05/08/2023] [Indexed: 05/28/2023] Open
Abstract
Congenital thrombotic thrombocytopenic purpura (cTTP) is an extremely rare disease characterized by the severe deficiency of a disintegrin and metalloproteinase with thrombospondin type 1 motifs 13 (ADAMTS13), caused by ADAMTS13 mutations. While ADAMTS13 supplementation by fresh frozen plasma (FFP) infusion immediately corrects platelet consumption and resolves thrombotic symptoms in acute episodes, FFP treatment can lead to intolerant allergic reactions and frequent hospital visits. Up to 70% of patients depend on regular FFP infusions to normalize their platelet counts and avoid systemic symptoms, including headache, fatigue, and weakness. The remaining patients do not receive regular FFP infusions, mainly because their platelet counts are maintained within the normal range or because they are symptom-free without FFP infusions. However, the target peak and trough levels of ADAMTS13 to prevent long-term comorbidity with prophylactic FFP and the necessity of treating FFP-independent patients in terms of long-term clinical outcomes are yet to be determined. Our recent study suggests that the current volumes of FFP infusions are insufficient to prevent frequent thrombotic events and long-term ischemic organ damage. This review focuses on the current management of cTTP and its associated issues, followed by the importance of upcoming recombinant ADAMTS13 therapy.
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Affiliation(s)
- Kazuya Sakai
- Department of Blood Transfusion Medicine, Nara Medical University, Kashihara 634-8522, Japan;
| | - Masanori Matsumoto
- Department of Blood Transfusion Medicine, Nara Medical University, Kashihara 634-8522, Japan;
- Department of Hematology, Nara Medical University, Kashihara 634-8521, Japan
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26
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Ring A, Sieber WA, Studt JD, Schuepbach RA, Ganter CC, Manz MG, Müller AMS, David S. Indications and Outcomes of Patients Receiving Therapeutic Plasma Exchange under Critical Care Conditions: A Retrospective Eleven-Year Single-Center Study at a Tertiary Care Center. J Clin Med 2023; 12:2876. [PMID: 37109212 PMCID: PMC10141205 DOI: 10.3390/jcm12082876] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Revised: 04/11/2023] [Accepted: 04/12/2023] [Indexed: 04/29/2023] Open
Abstract
Background: Therapeutic plasma exchange (TPE) is frequently performed in critical care settings for heterogenous indications. However, specific intensive care unit (ICU) data regarding TPE indications, patient characteristics and technical details are sparse. Methods: We performed a retrospective, single-center study using data from January 2010 until August 2021 for patients treated with TPE in an ICU setting at the University Hospital Zurich. Data collected included patient characteristics and outcomes, ICU-specific parameters, as well as apheresis-specific technical parameters and complications. Results: We identified n = 105 patients receiving n = 408 TPEs for n = 24 indications during the study period. The most common was thrombotic microangiopathies (TMA) (38%), transplant-associated complications (16.3%) and vasculitis (14%). One-third of indications (35.2%) could not be classified according to ASFA. Anaphylaxis was the most common TPE-related complication (6.7%), while bleeding complications were rare (1%). The median duration of ICU stay was 8 ± 14 days. Ventilator support, renal replacement therapy or vasopressors were required in 59 (56.2%), 26 (24.8%), and 35 (33.3%) patients, respectively, and 6 (5.7%) patients required extracorporeal membrane oxygenation. The overall hospital survival rate was 88.6%. Conclusion: Our study provides valuable real-world data on heterogenous TPE indications for patients in the ICU setting, potentially supporting decision-making.
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Affiliation(s)
- Alexander Ring
- Institute of Intensive Care Medicine, University Hospital Zurich, 8091 Zurich, Switzerland; (A.R.)
- Department of Medical Oncology and Hematology, University Hospital Zurich, 8091 Zurich, Switzerland
| | | | - Jan-Dirk Studt
- Department of Medical Oncology and Hematology, University Hospital Zurich, 8091 Zurich, Switzerland
| | - Reto A. Schuepbach
- Institute of Intensive Care Medicine, University Hospital Zurich, 8091 Zurich, Switzerland; (A.R.)
| | - Christoph Camille Ganter
- Institute of Intensive Care Medicine, University Hospital Zurich, 8091 Zurich, Switzerland; (A.R.)
| | - Markus Gabriel Manz
- Department of Medical Oncology and Hematology, University Hospital Zurich, 8091 Zurich, Switzerland
| | | | - Sascha David
- Institute of Intensive Care Medicine, University Hospital Zurich, 8091 Zurich, Switzerland; (A.R.)
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27
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Fuhrman DY, Thadani S, Hanson C, Carcillo JA, Kellum JA, Park HJ, Lu L, Kim-Campbell N, Horvat CM, Arikan AA. Therapeutic Plasma Exchange Is Associated With Improved Major Adverse Kidney Events in Children and Young Adults With Thrombocytopenia at the Time of Continuous Kidney Replacement Therapy Initiation. Crit Care Explor 2023; 5:e0891. [PMID: 37066071 PMCID: PMC10097539 DOI: 10.1097/cce.0000000000000891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/18/2023] Open
Abstract
Therapeutic plasma exchange (TPE) has been shown to improve organ dysfunction and survival in patients with thrombotic microangiopathy and thrombocytopenia associated with multiple organ failure. There are no known therapies for the prevention of major adverse kidney events after continuous kidney replacement therapy (CKRT). The primary objective of this study was to evaluate the effect of TPE on the rate of adverse kidney events in children and young adults with thrombocytopenia at the time of CKRT initiation. DESIGN Retrospective cohort. SETTING Two large quaternary care pediatric hospitals. PATIENTS All patients less than or equal to 26 years old who received CKRT between 2014 and 2020. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We defined thrombocytopenia as a platelet count less than or equal to 100,000 (cell/mm3) at the time of CKRT initiation. We ascertained major adverse kidney events at 90 days (MAKE90) after CKRT initiation as the composite of death, need for kidney replacement therapy, or a greater than or equal to 25% decline in estimated glomerular filtration rate from baseline. We performed multivariable logistic regression and propensity score weighting to analyze the relationship between the use of TPE and MAKE90. After excluding patients with a diagnosis of thrombotic thrombocytopenia purpura and atypical hemolytic uremic syndrome (n = 6) and with thrombocytopenia due to a chronic illness (n = 2), 284 of 413 total patients (68.8%) had thrombocytopenia at CKRT initiation (51% female). Of the patients with thrombocytopenia, the median (interquartile range) age was 69 months (13-128 mo). MAKE90 occurred in 69.0% and 41.5% received TPE. The use of TPE was independently associated with reduced MAKE90 by multivariable analysis (odds ratio [OR], 0.35; 95% CI, 0.20-0.60) and by propensity score weighting (adjusted OR, 0.31; 95% CI, 0.16-0.59). CONCLUSIONS Thrombocytopenia is common in children and young adults at CKRT initiation and is associated with increased MAKE90. In this subset of patients, our data show benefit of TPE in reducing the rate of MAKE90.
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Affiliation(s)
- Dana Y Fuhrman
- Department of Critical Care Medicine, Division of Pediatric Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
- Department of Pediatrics, Division of Nephrology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
- The Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Sameer Thadani
- Department of Pediatrics, Division of Nephrology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Claire Hanson
- Department of Critical Care Medicine, Division of Pediatric Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Joseph A Carcillo
- Department of Critical Care Medicine, Division of Pediatric Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
- The Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - John A Kellum
- The Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Hyun Jung Park
- Department of Human Genetics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Liling Lu
- Department of Biostatistics, University of Pittsburgh, Pittsburgh, PA
| | - Nahmah Kim-Campbell
- Department of Critical Care Medicine, Division of Pediatric Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Christopher M Horvat
- Department of Critical Care Medicine, Division of Pediatric Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
- Department of Pediatrics, Division of Health Informatics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Ayse Akcan Arikan
- Department of Pediatrics, Division of Nephrology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
- Department of Pediatrics, Division of Critical Care Medicine, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
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28
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Woods AI, Paiva J, Dos Santos C, Alberto MF, Sánchez-Luceros A. From the Discovery of ADAMTS13 to Current Understanding of Its Role in Health and Disease. Semin Thromb Hemost 2023; 49:284-294. [PMID: 36368692 DOI: 10.1055/s-0042-1758059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
ADAMTS13 (a disintegrin-like metalloprotease domain with thrombospondin type 1 motif, member 13) is a protease of crucial importance in the regulation of the size of von Willebrand factor multimers. Very low ADAMTS13 activity levels result in thrombotic thrombocytopenic purpura, a rare and life-threatening disease. The mechanisms involved can either be acquired (immune-mediated thrombotic thrombocytopenic purpura [iTTP]) or congenital (cTTP, Upshaw-Schulman syndrome) caused by the autosomal recessive inheritance of disease-causing variants (DCVs) located along the ADAMTS13 gene, which is located in chromosome 9q34. Apart from its role in TTP, and as a regulator of microthrombosis, ADAMTS13 has begun to be identified as a prognostic and/or diagnostic marker of other diseases, such as those related to inflammatory processes, liver damage, metastasis of malignancies, sepsis, and different disorders related to angiogenesis. Since its first description almost 100 years ago, the improvement of laboratory tests and the description of novel DCVs along the ADAMTS13 gene have contributed to a better and faster diagnosis of patients under critical conditions. The ability of ADAMTS13 to dissolve platelet aggregates in vitro and its antithrombotic properties makes recombinant human ADAMTS13 treatment a potential therapeutic approach targeting not only patients with cTTP but also other medical conditions.
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Affiliation(s)
- Adriana Inés Woods
- Laboratorio de Hemostasia y Trombosis, IMEX-CONICET-Academia Nacional de Medicina de Buenos Aires, CABA, Argentina
| | - Juvenal Paiva
- Departamento de Hemostasia y Trombosis, Instituto de Investigaciones Hematológicas, Academia Nacional de Medicina de Buenos Aires, CABA, Argentina
| | - Celia Dos Santos
- Laboratorio de Hemostasia y Trombosis, IMEX-CONICET-Academia Nacional de Medicina de Buenos Aires, CABA, Argentina
| | - María Fabiana Alberto
- Departamento de Hemostasia y Trombosis, Instituto de Investigaciones Hematológicas, Academia Nacional de Medicina de Buenos Aires, CABA, Argentina
| | - Analía Sánchez-Luceros
- Laboratorio de Hemostasia y Trombosis, IMEX-CONICET-Academia Nacional de Medicina de Buenos Aires, CABA, Argentina.,Departamento de Hemostasia y Trombosis, Instituto de Investigaciones Hematológicas, Academia Nacional de Medicina de Buenos Aires, CABA, Argentina
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29
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Mocanu A, Bogos RA, Lazaruc TI, Cianga AL, Lupu VV, Ioniuc I, Alecsa M, Lupu A, Ivanov AV, Miron IC, Starcea IM. Pitfalls of Thrombotic Microangiopathies in Children: Two Case Reports and Literature Review. Diagnostics (Basel) 2023; 13:diagnostics13071228. [PMID: 37046448 PMCID: PMC10093431 DOI: 10.3390/diagnostics13071228] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 03/21/2023] [Accepted: 03/22/2023] [Indexed: 04/14/2023] Open
Abstract
Thrombotic microangiopathy can present itself in the form of several clinical entities, representing a real challenge for diagnosis and treatment in pediatric practice. Our article aims to explore the evolution of two rare cases of pediatric thrombotic thrombocytopenic purpura (TTP) and atypical hemolytic uremic syndrome (aHUS) with extremely similar clinical pictures, which, coincidentally, presented at approximately the same time in our hospital. These cases and our literature review demonstrate the multiple facets of thrombotic microangiopathy, which can produce various determinations and salient manifestations even among the pediatric population. TTP and aHUS may represent genuine diagnostic pitfalls through the overlap of their clinical and biological findings, although they develop through fundamentally different mechanisms that require different therapeutic approaches. As a novelty, we underline that COVID-19 infection cannot be excluded as potential trigger for TTP and aHUS in our patients and we predict that other reports of such an association will follow, raising a complex question of COVID-19's implication in the occurrence and evolution of thrombotic microangiopathies. On this matter, we conducted literature research that resulted in 15 cases of COVID-19 pediatric infections associated with either TTP or aHUS. Taking into consideration the morbidity associated with TTP and aHUS, an elaborate differential diagnosis and prompt intervention are of the essence.
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Affiliation(s)
- Adriana Mocanu
- Mother and Child Medicine Department, Discipline of Pediatrics, "Grigore T. Popa" University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
- Nephrology Division, St. Mary's Emergency Children Hospital, 700309 Iasi, Romania
| | - Roxana Alexandra Bogos
- Mother and Child Medicine Department, Discipline of Pediatrics, "Grigore T. Popa" University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
- Nephrology Division, St. Mary's Emergency Children Hospital, 700309 Iasi, Romania
| | - Tudor Ilie Lazaruc
- Mother and Child Medicine Department, Discipline of Pediatrics, "Grigore T. Popa" University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
| | - Anca Lavinia Cianga
- Mother and Child Medicine Department, Discipline of Pediatrics, "Grigore T. Popa" University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
| | - Vasile Valeriu Lupu
- Mother and Child Medicine Department, Discipline of Pediatrics, "Grigore T. Popa" University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
| | - Ileana Ioniuc
- Mother and Child Medicine Department, Discipline of Pediatrics, "Grigore T. Popa" University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
| | - Mirabela Alecsa
- Mother and Child Medicine Department, Discipline of Pediatrics, "Grigore T. Popa" University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
| | - Ancuta Lupu
- Mother and Child Medicine Department, Discipline of Pediatrics, "Grigore T. Popa" University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
| | - Anca Viorica Ivanov
- Mother and Child Medicine Department, Discipline of Pediatrics, "Grigore T. Popa" University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
| | - Ingrith Crenguta Miron
- Mother and Child Medicine Department, Discipline of Pediatrics, "Grigore T. Popa" University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
| | - Iuliana Magdalena Starcea
- Mother and Child Medicine Department, Discipline of Pediatrics, "Grigore T. Popa" University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
- Nephrology Division, St. Mary's Emergency Children Hospital, 700309 Iasi, Romania
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30
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Vyas A, Isaac S, Kaur D, Yadav U. Role of the PLASMIC Score in the Management of Thrombotic Thrombocytopenic Purpura. Cureus 2023; 15:e36188. [PMID: 37065284 PMCID: PMC10104422 DOI: 10.7759/cureus.36188] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2023] [Indexed: 03/17/2023] Open
Abstract
We report the case of a middle-aged male presenting with fatigue and abdominal pain. Prompt investigations demonstrated microangiopathic hemolytic anemia and thrombocytopenia on a peripheral blood smear. Thrombotic thrombocytopenic purpura was suspected based on the PLASMIC score. The patient significantly improved with therapeutic plasma exchange and prednisone within the next few days. The disintegrin and metalloprotease with a thrombospondin type 1 motif, member 13 levels reduction is a definitive hallmark leading to microvascular thrombosis. However, some medical centers in the United States do not promptly have quick allowance to the levels. Hence, the PLASMIC score becomes imminent in initiating immediate management and preventing life-threatening complications.
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Selvakumar S, Liu A, Chaturvedi S. Immune thrombotic thrombocytopenic purpura: Spotlight on long-term outcomes and survivorship. Front Med (Lausanne) 2023; 10:1137019. [PMID: 36926315 PMCID: PMC10011081 DOI: 10.3389/fmed.2023.1137019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 02/03/2023] [Indexed: 03/06/2023] Open
Abstract
Advances in diagnosis and treatment have dramatically improved survival of acute immune thrombotic thrombocytopenic purpura (iTTP) and iTTP has evolved from an acute fatal condition to a chronic relapsing disorder. In addition to the risk of iTTP relapse, iTTP survivors are at risk of multiple adverse health outcomes including higher than expected rates of all-cause mortality, increased rates of stroke and other cardiovascular disease, and higher rates of morbidities such as obesity, hypertension, and autoimmune disorders. iTTP survivors also report neurocognitive impairment, depression, and reduced quality of life. Women with iTTP are at risk for recurrent iTTP, preeclampsia, and other maternal and fetal complications in subsequent pregnancies. ADAMTS13 activity during clinical remission has emerged as an important targetable risk factor for iTTP relapse and other outcomes including stroke and all-cause mortality. This review summarizes current literature regarding the epidemiology and potential mechanisms for adverse long-term sequelae of iTTP, outlines current best practices in iTTP survivorship care, and highlights a research agenda to improve long-term iTTP outcomes.
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Affiliation(s)
- Sruthi Selvakumar
- Dr. Kiran C. Patel College of Allopathic Medicine, Nova Southeastern University, Fort Lauderdale, FL, United States
| | - Angela Liu
- Division of Hematology and Oncology, Mount Sinai School of Medicine, New York, NY, United States
| | - Shruti Chaturvedi
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
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Lin HC, Huang J, Huang J, Zhang LJ, Yin XW, Yang JC, Huang XY. Concurrence of immune thrombocytopenic purpura and thrombotic thrombocytopenic purpura: a case report and review of the literature. J Med Case Rep 2023; 17:38. [PMID: 36750960 PMCID: PMC9905008 DOI: 10.1186/s13256-023-03762-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 01/04/2023] [Indexed: 02/09/2023] Open
Abstract
BACKGROUND Immune thrombocytopenic purpura and thrombotic thrombocytopenic purpura are both causes of thrombocytopenia. Recognizing thrombotic thrombocytopenic purpura is crucial for subsequent treatment and prognosis. In clinical practice, corticosteroids and rituximab can be used to treat both immune thrombocytopenic purpura and thrombotic thrombocytopenic purpura; plasma exchange therapy is the first-line treatment in thrombotic thrombocytopenic purpura, while corticosteroids are strongly recommended as first-line treatment in immune thrombocytopenic purpura. The differential diagnosis of immune thrombocytopenic purpura and thrombotic thrombocytopenic purpura is essential in clinical practice. However, case reports have suggested that immune thrombocytopenic purpura and thrombotic thrombocytopenic purpura can occur concurrently. CASE PRESENTATION We report the case of a 32-year-old Asian female without previous disease who presented with pancytopenia, concurrent with immune thrombocytopenic purpura and thrombotic thrombocytopenic purpura. The morphology of the megakaryocytes in the bone marrow indicated immune-mediated thrombocytopenia. The patient received glucocorticoid treatment, and her platelet count increased; however, schistocytes remained high during the course of the therapy. Further investigations revealed ADAMTS13 activity deficiency and positive ADAMTS13 antibodies. The high titer of antinuclear antibody and positive anti-U1-ribonucleoprotein/Smith antibody indicated a potential autoimmune disease. However, the patient did not fulfill the current criteria for systemic lupus erythematosus or mixed connective tissue disease. The patient responded well to plasma exchange therapy, and her platelet count remained normal on further follow-up. CONCLUSIONS Concurrence of immune thrombocytopenic purpura and thrombotic thrombocytopenic purpura is rare, but clinicians should be aware of this entity to ensure prompt medical intervention. Most of the reported cases involve young women. Human immunodeficiency virus infection, pregnancy, and autoimmune disease are the most common underlying conditions.
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Affiliation(s)
- Hung-Chen Lin
- grid.440671.00000 0004 5373 5131Division of Cardiology, Department of Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China ,grid.440671.00000 0004 5373 5131Department of Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Jinxiang Huang
- grid.440671.00000 0004 5373 5131Department of Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China ,grid.440671.00000 0004 5373 5131Division of Rheumatology, Department of Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Jing Huang
- grid.440671.00000 0004 5373 5131Department of Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China ,grid.440671.00000 0004 5373 5131Division of Hematology, Department of Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Li-Jun Zhang
- grid.440671.00000 0004 5373 5131Division of Rheumatology, Department of Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Xiao-Wu Yin
- grid.440671.00000 0004 5373 5131Department of Pathology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Jian-Cheng Yang
- grid.440671.00000 0004 5373 5131Division of Cardiology, Department of Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China ,grid.440671.00000 0004 5373 5131Department of Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Xiao-Yan Huang
- Department of Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China. .,Division of Rheumatology, Department of Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China.
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Thrombotic Microangiopathy in the Setting of Colorectal Cancer: A Therapeutic Challenge with a Bad Prognosis. Hematol Rep 2023; 15:9-16. [PMID: 36648880 PMCID: PMC9844426 DOI: 10.3390/hematolrep15010002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 10/08/2022] [Accepted: 12/30/2022] [Indexed: 01/05/2023] Open
Abstract
While most cases of thrombotic microangiopathic hemolytic anemias are idiopathic, some can occur in the setting of a malignancy. Differentiating both conditions is crucial to initiate the appropriate treatment. In this case report and literature review, we discuss the occurrence of a thrombotic microangiopathy in a 61-year-old male patient with a treatment-refractory metastatic colorectal cancer invading his bone marrow. Plasmapheresis does not constitute the mainstay of treatment in this setting, as targeting the primary disease is the ultimate management. Treating the condition of our patient has been challenging as multiple lines of treatments of his primary disease had been exhausted. The discrepancy in KRAs status obtained between PCR and later NGS offered a new treatment line with Cetuximab. In this article, we will discuss the different factors that differentiate between idiopathic and cancer-induced microangiopathy. We will emphasize on the fact that the treatment of the primary disease constitutes the most important step in the treatment of cancer-induced thrombotic microangiopathy. We will also raise several explanations to target the disagreement in KRAS status obtained by the different technical modalities.
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Genest DS, Patriquin CJ, Licht C, John R, Reich HN. Renal Thrombotic Microangiopathy: A Review. Am J Kidney Dis 2022; 81:591-605. [PMID: 36509342 DOI: 10.1053/j.ajkd.2022.10.014] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 10/03/2022] [Indexed: 12/14/2022]
Abstract
Thrombotic microangiopathy (TMA), a pathological lesion observed in a wide spectrum of diseases, is triggered by endothelial injury and/or dysfunction. Although TMA lesions are often accompanied by clinical features of microangiopathic hemolytic anemia, thrombocytopenia, and ischemic end-organ injury, renal-limited forms of TMA are not infrequently encountered in clinical practice. The presence of renal-limited manifestations can be diagnostically challenging, often delaying the initiation of targeted therapy. Prompt investigation and empirical treatment of TMA is warranted to reduce associated morbidity and mortality. Major advances have been made with respect to the pathophysiology of primary TMA entities, with the subsequent development of novel diagnostic tools and lifesaving therapies for diseases like thrombotic thrombocytopenic purpura and complement-mediated TMA. This article will review the clinical presentation and pathologic hallmarks of TMA involving the kidney, and the disease-specific mechanisms that contribute to the endothelial injury that characterizes TMA lesions. Diagnostic approach and both empirical and disease-specific treatment strategies will be discussed, along with the potential role for emerging targeted disease-specific therapies.
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Affiliation(s)
- Dominique Suzanne Genest
- Division of Nephrology, University Health Network, Toronto, Ontario, Canada; Department of Medicine, Université de Montréal, Montreal, Quebec, Canada
| | - Christopher J Patriquin
- Division of Medical Oncology & Hematology, University Health Network, Toronto, Ontario, Canada; Department of Medicine, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada
| | - Christoph Licht
- Division of Nephrology, University Health Network, Toronto, Ontario, Canada; Department of Medicine, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada; Division of Nephrology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Rohan John
- Division of Laboratory Medicine and Pathology, University Health Network, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada
| | - Heather N Reich
- Division of Nephrology, University Health Network, Toronto, Ontario, Canada; Department of Medicine, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada.
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George JN. Thrombotic Thrombocytopenic Purpura: From 1972 to 2022 and Beyond. Semin Thromb Hemost 2022; 48:926-936. [PMID: 35793688 DOI: 10.1055/s-0042-1749589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
This review tells the story of my personal experience with thrombotic thrombocytopenic purpura (TTP). It begins with my first encounter with TTP 50 years ago when 2 sisters presented 2 years apart, both pregnant and both died. At that time, I knew nothing about hereditary TTP (hTTP), the risks of pregnancy, or effective treatments. In 1991, a year after I moved to Oklahoma, therapeutic plasma exchange (TPE) was established as an effective treatment. With the availability of effective treatment, the number of patients presenting with suspected TTP soared. The diagnosis of TTP was imprecise. I worked with the Oklahoma Blood Institute (OBI) to understand the management of TTP. Because the OBI provided all TPE procedures for most of Oklahoma, we saw all consecutive patients within a defined geographic area who were identified at a uniform time early in the course of their TTP, without selection or referral bias. It was an inception cohort; this became the Oklahoma TTP Registry. In 2001, we began a very successful collaboration with the University of Bern, Switzerland, to measure ADAMTS13 activity in all of our patients. From our patients, we learned that acquired, autoimmune TTP (iTTP) is a chronic disease with risks for cognitive impairment and depression. Recognition in 2012 of three sisters with hTTP was reminiscent of the beginning of my story. hTTP has risks for multiple severe morbidities, beginning at birth and especially during pregnancy. Future management of both iTTP and hTTP will be more effective and more convenient.
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Affiliation(s)
- James N George
- Department of Biostatistics and Epidemiology, Hudson College of Public Health, Hematology-Oncology Section, Department of Medicine, College of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
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Brown J, Potugari B, Mazepa MA, Kohli R, Moliterno AR, Brodsky RA, Vaught JA, Burwick R, Chaturvedi S. Maternal and fetal outcomes of pregnancy occurring after a diagnosis of immune-mediated thrombotic thrombocytopenic purpura. Ann Hematol 2022; 101:2159-2167. [PMID: 35932324 PMCID: PMC11060143 DOI: 10.1007/s00277-022-04936-2] [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: 06/17/2022] [Accepted: 07/23/2022] [Indexed: 11/25/2022]
Abstract
Pregnancy is a well-established trigger for a first episode or relapse of immune thrombotic thrombocytopenic purpura (iTTP). Other outcomes of subsequent pregnancy after a diagnosis of iTTP are less well described. We conducted this retrospective cohort study to evaluate maternal and fetal outcomes of pregnancy in women with prior iTTP from the Johns Hopkins Thrombotic Microangiopathy Cohort. Of 168 women in the cohort, 102 were of reproductive age at diagnosis. Fourteen pregnancies (in 9 women) that occurred after the initial iTTP episode were included in the analysis. iTTP relapse occurred in 9 (64%) pregnancies. Out of the 9 instances of relapse, 5 relapses occurred in 2 women. Seven pregnancies (50%) ended in fetal death or miscarriage in the setting of iTTP relapse and three were electively terminated due to fear of relapse. Four pregnancies (50% of the 8 that progressed beyond 20 weeks) were complicated by preeclampsia or HELLP syndrome, which is over ten-fold higher than that of the general population. No maternal deaths occurred. Only 4 pregnancies resulted in live births, of which, 2 were pre-term. Pregnancy in women with prior iTTP is associated with a substantial risk of iTTP relapse and fetal loss. Preeclampsia and HELLP syndrome is also more common than that in the general population. ADAMTS13 monitoring and preemptive therapy may improve pregnancy outcomes, which needs to be evaluated prospectively.
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Affiliation(s)
- Jenna Brown
- Johns Hopkins University, Baltimore, MD, USA
| | - Bindu Potugari
- Division of Hematology and Oncology, Saint Joseph Mercy Ann Arbor Hospital, Ann Arbor, MI, USA
| | - Marshall A Mazepa
- Division Hematology and Oncology, University of Minnesota School of Medicine, Minneapolis, MN, USA
| | - Ruhail Kohli
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Alison R Moliterno
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, 720 Ross Research Building Rutland Avenue, Room 1025, Baltimore, MD, 21205, USA
| | - Robert A Brodsky
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, 720 Ross Research Building Rutland Avenue, Room 1025, Baltimore, MD, 21205, USA
| | - Jason A Vaught
- Department of Obstetrics and Gynecology, Johns Hopkins University, Baltimore, MD, USA
| | - Richard Burwick
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Shruti Chaturvedi
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, 720 Ross Research Building Rutland Avenue, Room 1025, Baltimore, MD, 21205, USA.
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COVID-19-Associated Thrombotic Thrombocytopenic Purpura: A Case Report and Systematic Review. Hematol Rep 2022; 14:253-260. [PMID: 35997402 PMCID: PMC9397065 DOI: 10.3390/hematolrep14030035] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 06/28/2022] [Accepted: 07/19/2022] [Indexed: 12/03/2022] Open
Abstract
Introduction: The proliferation of literature regarding the COVID-19 pandemic has served to highlight a wide spectrum of disease manifestations and complications, such as thrombotic microangiopathies. Our review with a brief case presentation highlights the increasing recognition of TTP in COVID-19 and describes its salient characteristics. Methods: We screened the available literature in PubMed, EMBASE, and Cochrane databases from inception until April 2022 of articles mentioning COVID-19-associated TTP in English language. Results: From 404 records, we included 8 articles mentioning data of 11 patients in our review. TTP was predominantly reported in females (72%) with a mean age of 48.2 years (SD 15.1). Dyspnea was the most common symptom in one third of patients (36.6%). Neurological symptoms were reported in 27.3% of cases. The time to diagnosis of TTP was 10 days (SD 5.8) from onset of COVID-19. All 11 cases underwent plasma exchange (PLEX), with a mean of 12 sessions per patient, whereas 6 cases received Rituximab (54.5%), and 3 received Caplacizumab (27.3%). One patient died from the illness. Conclusion: This review of available literature highlights the atypical and refractory nature of COVID-19-associated TTP. It required longer sessions of PLEX, with half of the patients receiving at least one immunosuppressant.
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Mingot Castellano ME, Pascual Izquierdo C, González A, Viejo Llorente A, Valcarcel Ferreiras D, Sebastián E, García Candel F, Sarmiento Palao H, Gómez Seguí I, de la Rubia J, Cid J, Martínez Nieto J, Hernández Mateo L, Goterris Viciedo R, Fidalgo T, Salinas R, Del Rio-Garma J. Recommendations for the diagnosis and treatment of patients with thrombotic thrombocytopenic purpura. Med Clin (Barc) 2022; 158:630.e1-630.e14. [PMID: 34266669 DOI: 10.1016/j.medcli.2021.03.040] [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: 02/06/2021] [Revised: 03/10/2021] [Accepted: 03/16/2021] [Indexed: 11/09/2022]
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a thrombotic microangiopathy (TMA) characterized by the development of microangiopathic haemolytic anaemia, thrombocytopenia, and ischaemic organ dysfunction associated with ADAMTS13 levels lower than 10% in most cases. Recently there have been numerous advances in the field of PTT, new, rapid and accessible techniques capable of quantifying ADAMTS13 activity and inhibitors. The massive sequencing systems facilitate the identification of polymorphisms in the ADAMTS13 gene. In addition, new drugs such as caplacizumab have appeared and relapse prevention strategies are being proposed with the use of rituximab. The existence of TTP patient registries allow a deeper understanding of this disease but the great variability in the diagnosis and treatment makes it necessary to elaborate guidelines that homogenize terminology and clinical practice. The recommendations set out in this document were prepared following the AGREE methodology. The research questions were formulated according to the PICO format. A search of the literature published during the last 10 years was carried out. The recommendations were established by consensus among the entire group, specifying the existing strengths and limitations according to the level of evidence obtained. In conclusion, this document contains recommendations on the management, diagnosis, and treatment of TTP with the ultimate objective of developing guidelines based on the evidence published to date that allow healthcare professionals to optimize TTP treatment.
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Affiliation(s)
| | | | - Ataulfo González
- Servicio de Hematología y Hemoterapia, Hospital Universitario de San Carlos, Madrid, España
| | - Aurora Viejo Llorente
- Servicio de Hematología, Área de Hemoterapia, Hospital Universitario La Paz, Madrid, España
| | - David Valcarcel Ferreiras
- Unidad de Hematología Intensiva y Terapia Celular, Departamento de Hematología, Instituto de Oncología Vall d'Hebron (VHIO), Hospital Universitario Vall d'Hebron, Barcelona, España
| | - Elena Sebastián
- Servicio de Hematología y Hemoterapia, Hospital Infantil Universitario Niño Jesús, Madrid, España
| | - Faustino García Candel
- Sección de Hemostasia y Trombosis, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, España
| | | | - Inés Gómez Seguí
- Servicio de Hematología, Hospital Universitario y Politécnico La Fe, Valencia, España
| | - Javier de la Rubia
- Servicio de Hematología, Hospital Universitario y Politécnico La Fe, Valencia, España
| | - Joan Cid
- Unidad de Aféresis y Terapia Celular, Servicio de Hemoterapia y Hemostasia, Institut Clínic de Malalties Hematològiques i Oncològiques (ICMHO). Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universidad de Barcelona, Hospital Clínic i Provincial de Barcelona, Barcelona, España
| | - Jorge Martínez Nieto
- Servicio de Hematología y Hemostasia, Hospital Universitario Clínico San Carlos. Instituto de Investigación Sanitaria San Carlos (IdissC), Madrid, España
| | - Luis Hernández Mateo
- Servicio de Hematología y Hemoterapia, Hospital General de Alicante, Valencia, España
| | - Rosa Goterris Viciedo
- Servicio de Hematología y Hemoterapia, Hospital Clínico Valencia. INCLIVA, Valencia, España
| | - Teresa Fidalgo
- Departamento de Hematología Clínica, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Ramon Salinas
- Banc de Sang i Teixits de Catalunya, Barcelona, España
| | - Julio Del Rio-Garma
- Servicio de Transfusión. Servicio de Hematología. Complexo Hospitalario Universitario de Ourense, Galicia, España.
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George JN. Thrombotic thrombocytopenic purpura: Crossing to safety. Transfusion 2022; 62:1166-1170. [PMID: 35680719 DOI: 10.1111/trf.16928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 05/06/2022] [Indexed: 11/30/2022]
Affiliation(s)
- James N George
- Department of Biostatistics & Epidemiology, Hudson College of Public Health, Hematology-Oncology Section, Department of Medicine, College of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
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Graça NAG, Joly BS, Voorberg J, Vanhoorelbeke K, Béranger N, Veyradier A, Coppo P. TTP: From empiricism for an enigmatic disease to targeted molecular therapies. Br J Haematol 2022; 197:156-170. [PMID: 35146746 PMCID: PMC9304236 DOI: 10.1111/bjh.18040] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 12/29/2021] [Accepted: 12/31/2021] [Indexed: 12/19/2022]
Abstract
The 100th anniversary of the first description of Thrombotic Thrombocytopenic Purpura (TTP) as a disease by Dr. Eli Moschcowitz approaches. For many decades, TTP remained mostly a mysterious fatal condition, where diagnosis was often post-mortem. Initially a pentad of symptoms was identified, a pattern that later revealed to be fallible. Sporadic observations led to empiric interventions that allowed for the first impactful breakthrough in TTP treatment, almost 70 years after its first description: the introduction of plasma exchange and infusions as treatments. The main body of knowledge within the field was gathered in the latest three decades: patient registries were set and proved crucial for advancements; the general mechanisms of disease have been described; the diagnosis was refined; new treatments and biomarkers with improvements on prognosis and management were introduced. Further changes and improvements are expected in the upcoming decades. In this review, we provide a brief historic overview of TTP, as an illustrative example of the success of translational medicine enabling to rapidly shift from a management largely based on empiricism to targeted therapies and personalized medicine, for the benefit of patients. Current management options and present and future perspectives in this still evolving field are summarized.
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Affiliation(s)
- Nuno A. G. Graça
- Department of Molecular Hematology, Sanquin‐Academic Medical CenterLandsteiner LaboratoryAmsterdamThe Netherlands
| | - Bérangère S. Joly
- Service d'hématologie biologique and EA3518‐ Institut universitaire d'hématologieGroupe Hospitalier Saint Louis‐Lariboisière, AP‐HP, Université Paris DiderotParisFrance
- Centre de Référence des Microangiopathies ThrombotiquesHôpital Saint‐Antoine, AP‐HPParisFrance
| | - Jan Voorberg
- Department of Molecular Hematology, Sanquin‐Academic Medical CenterLandsteiner LaboratoryAmsterdamThe Netherlands
- Department of Experimental Vascular MedicineAmsterdam UMCAmsterdamThe Netherlands
| | - Karen Vanhoorelbeke
- Laboratory for Thrombosis Research, IRF Life SciencesKU Leuven Campus Kulak KortrijkKortrijkBelgium
| | - Nicolas Béranger
- Service d'hématologie biologique and EA3518‐ Institut universitaire d'hématologieGroupe Hospitalier Saint Louis‐Lariboisière, AP‐HP, Université Paris DiderotParisFrance
- Centre de Référence des Microangiopathies ThrombotiquesHôpital Saint‐Antoine, AP‐HPParisFrance
| | - Agnès Veyradier
- Service d'hématologie biologique and EA3518‐ Institut universitaire d'hématologieGroupe Hospitalier Saint Louis‐Lariboisière, AP‐HP, Université Paris DiderotParisFrance
- Centre de Référence des Microangiopathies ThrombotiquesHôpital Saint‐Antoine, AP‐HPParisFrance
| | - Paul Coppo
- Centre de Référence des Microangiopathies ThrombotiquesHôpital Saint‐Antoine, AP‐HPParisFrance
- Service d'HématologieHôpital Saint‐Antoine, AP‐HPParisFrance
- Sorbonne UniversitéUPMC Univ ParisParisFrance
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Koneczny I, Tzartos J, Mané-Damas M, Yilmaz V, Huijbers MG, Lazaridis K, Höftberger R, Tüzün E, Martinez-Martinez P, Tzartos S, Leypoldt F. IgG4 Autoantibodies in Organ-Specific Autoimmunopathies: Reviewing Class Switching, Antibody-Producing Cells, and Specific Immunotherapies. Front Immunol 2022; 13:834342. [PMID: 35401530 PMCID: PMC8986991 DOI: 10.3389/fimmu.2022.834342] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 02/28/2022] [Indexed: 12/24/2022] Open
Abstract
Organ-specific autoimmunity is often characterized by autoantibodies targeting proteins expressed in the affected tissue. A subgroup of autoimmunopathies has recently emerged that is characterized by predominant autoantibodies of the IgG4 subclass (IgG4-autoimmune diseases; IgG4-AID). This group includes pemphigus vulgaris, thrombotic thrombocytopenic purpura, subtypes of autoimmune encephalitis, inflammatory neuropathies, myasthenia gravis and membranous nephropathy. Although the associated autoantibodies target specific antigens in different organs and thus cause diverse syndromes and diseases, they share surprising similarities in genetic predisposition, disease mechanisms, clinical course and response to therapies. IgG4-AID appear to be distinct from another group of rare immune diseases associated with IgG4, which are the IgG4-related diseases (IgG4-RLD), such as IgG4-related which have distinct clinical and serological properties and are not characterized by antigen-specific IgG4. Importantly, IgG4-AID differ significantly from diseases associated with IgG1 autoantibodies targeting the same organ. This may be due to the unique functional characteristics of IgG4 autoantibodies (e.g. anti-inflammatory and functionally monovalent) that affect how the antibodies cause disease, and the differential response to immunotherapies of the IgG4 producing B cells/plasmablasts. These clinical and pathophysiological clues give important insight in the immunopathogenesis of IgG4-AID. Understanding IgG4 immunobiology is a key step towards the development of novel, IgG4 specific treatments. In this review we therefore summarize current knowledge on IgG4 regulation, the relevance of class switching in the context of health and disease, describe the cellular mechanisms involved in IgG4 production and provide an overview of treatment responses in IgG4-AID.
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Affiliation(s)
- Inga Koneczny
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - John Tzartos
- Neuroimmunology, Tzartos NeuroDiagnostics, Athens, Greece
- 2nd Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Marina Mané-Damas
- Research Group Neuroinflammation and Autoimmunity, Department of Psychiatry and Neuropsychology, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, Netherlands
| | - Vuslat Yilmaz
- Department of Neuroscience, Aziz Sancar Institute of Experimental Medicine, Istanbul University, Istanbul, Turkey
| | - Maartje G. Huijbers
- Department of Human Genetics, Leiden University Medical Center, Leiden, Netherlands
- Department of Neurology, Leiden University Medical Center, Leiden, Netherlands
| | - Konstantinos Lazaridis
- Department of Immunology, Laboratory of Immunology, Hellenic Pasteur Institute, Athens, Greece
| | - Romana Höftberger
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Erdem Tüzün
- Department of Neuroscience, Aziz Sancar Institute of Experimental Medicine, Istanbul University, Istanbul, Turkey
| | - Pilar Martinez-Martinez
- Research Group Neuroinflammation and Autoimmunity, Department of Psychiatry and Neuropsychology, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, Netherlands
| | - Socrates Tzartos
- Neuroimmunology, Tzartos NeuroDiagnostics, Athens, Greece
- Department of Neurobiology, Hellenic Pasteur Institute, Athens, Greece
| | - Frank Leypoldt
- Neuroimmunology, Institute of Clinical Chemistry and Department of Neurology, UKSH Kiel/Lübeck, Kiel University, Kiel, Germany
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42
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Vitkauskaitė M, Vinikovas A, Miglinas M, Rimševičius L, Čerkauskaitė A, Mačionienė E, Ašakienė E. Complement inhibitor eculizumab in thrombotic microangiopathy: Single-center case series. Clin Case Rep 2022; 10:e05573. [PMID: 35317070 PMCID: PMC8922540 DOI: 10.1002/ccr3.5573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 01/16/2022] [Accepted: 02/16/2022] [Indexed: 11/07/2022] Open
Abstract
Our case series showed that eculizumab is efficacious and safe in treating thrombotic microangiopathy, as well as it has positive effects on quality of life. Further extensive studies are required to develop unified treatment guidelines.
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Affiliation(s)
| | - Artūras Vinikovas
- Faculty of Medicine Vilnius University Vilnius Lithuania
- Clinic of Gastroenterology, Nephro-Urology and Surgery Faculty of Medicine Institute of Clinical Medicine Vilnius University Vilnius Lithuania
| | - Marius Miglinas
- Faculty of Medicine Vilnius University Vilnius Lithuania
- Clinic of Gastroenterology, Nephro-Urology and Surgery Faculty of Medicine Institute of Clinical Medicine Vilnius University Vilnius Lithuania
| | - Laurynas Rimševičius
- Faculty of Medicine Vilnius University Vilnius Lithuania
- Clinic of Gastroenterology, Nephro-Urology and Surgery Faculty of Medicine Institute of Clinical Medicine Vilnius University Vilnius Lithuania
| | - Agnė Čerkauskaitė
- Faculty of Medicine Vilnius University Vilnius Lithuania
- Clinic of Gastroenterology, Nephro-Urology and Surgery Faculty of Medicine Institute of Clinical Medicine Vilnius University Vilnius Lithuania
| | - Ernesta Mačionienė
- Faculty of Medicine Vilnius University Vilnius Lithuania
- Clinic of Gastroenterology, Nephro-Urology and Surgery Faculty of Medicine Institute of Clinical Medicine Vilnius University Vilnius Lithuania
| | - Eglė Ašakienė
- Faculty of Medicine Vilnius University Vilnius Lithuania
- Clinic of Gastroenterology, Nephro-Urology and Surgery Faculty of Medicine Institute of Clinical Medicine Vilnius University Vilnius Lithuania
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43
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Ghogale PR, Pandey AK, Praveen EP, Yadav P, Pathak S. Thrombotic Thrombocytopenic Purpura: A Tale of Two Cases. Cureus 2022; 14:e21853. [PMID: 35291531 PMCID: PMC8897657 DOI: 10.7759/cureus.21853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/02/2022] [Indexed: 11/05/2022] Open
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44
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Subhan M, Scully M. Advances in the management of TTP. Blood Rev 2022; 55:100945. [DOI: 10.1016/j.blre.2022.100945] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 02/07/2022] [Accepted: 02/11/2022] [Indexed: 12/16/2022]
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45
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Palma LMP, Vaisbich-Guimarães MH, Sridharan M, Tran CL, Sethi S. Thrombotic microangiopathy in children. Pediatr Nephrol 2022; 37:1967-1980. [PMID: 35041041 PMCID: PMC8764494 DOI: 10.1007/s00467-021-05370-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 11/12/2021] [Accepted: 11/15/2021] [Indexed: 11/19/2022]
Abstract
The syndrome of thrombotic microangiopathy (TMA) is a clinical-pathological entity characterized by microangiopathic hemolytic anemia, thrombocytopenia, and end organ involvement. It comprises a spectrum of underlying etiologies that may differ in children and adults. In children, apart from ruling out shigatoxin-associated hemolytic uremic syndrome (HUS) and other infection-associated TMA like Streptococcus pneumoniae-HUS, rare inherited causes including complement-associated HUS, cobalamin defects, and mutations in diacylglycerol kinase epsilon gene must be investigated. TMA should also be considered in the setting of solid organ or hematopoietic stem cell transplantation. In this review, acquired and inherited causes of TMA are described with a focus on particularities of the main causes of TMA in children. A pragmatic approach that may help the clinician tailor evaluation and management is provided. The described approach will allow for early initiation of treatment while waiting for the definitive diagnosis of the underlying TMA.
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Affiliation(s)
- Lilian Monteiro P. Palma
- grid.411087.b0000 0001 0723 2494Department of Pediatrics, Pediatric Nephrology, State University of Campinas (UNICAMP), Rua Tessalia Vieira de Camargo, 126, Cidade Universitaria, Campinas, SP 13,083–887 Brazil
| | | | - Meera Sridharan
- grid.66875.3a0000 0004 0459 167XHematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN USA
| | - Cheryl L. Tran
- grid.66875.3a0000 0004 0459 167XPediatric Nephrology, Department of Pediatrics, Mayo Clinic, Rochester, MN USA
| | - Sanjeev Sethi
- grid.66875.3a0000 0004 0459 167XDepartment of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN USA
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AlHejazi A, AlBeihany A, AlHashmi H, Alzahrani H, Motabi I, El-Hemaidi I, Alsaleh K, El Tayeb K, Rabea M, Khallaf M, Qari M. Approaches to acquired thrombotic thrombocytopenic purpura management in Saudi Arabia. JOURNAL OF APPLIED HEMATOLOGY 2022. [DOI: 10.4103/joah.joah_46_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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47
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Residues R1075, D1090, R1095, and C1130 Are Critical in ADAMTS13 TSP8-Spacer Interaction Predicted by Molecular Dynamics Simulation. Molecules 2021; 26:molecules26247525. [PMID: 34946607 PMCID: PMC8703438 DOI: 10.3390/molecules26247525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 12/07/2021] [Accepted: 12/08/2021] [Indexed: 11/17/2022] Open
Abstract
ADAMTS13 (A Disintegrin and Metalloprotease with Thrombospondin type 1 repeats, member 13) cleaves von Willebrand Factor (VWF) multimers to limit the prothrombotic function of VWF. The deficiency of ADAMTS13 causes a lethal thrombotic microvascular disease, thrombotic thrombocytopenic purpura (TTP). ADAMTS13 circulates in a “closed” conformation with the distal domain associating the Spacer domain to avoid off-target proteolysis or recognition by auto-antibodies. However, the interactions of the distal TSP8 domain and the Spacer domain remain elusive. Here, we constructed the TSP8-Spacer complex by a combination of homology modelling and flexible docking. Molecular dynamics simulation was applied to map the binding sites on the TSP8 or Spacer domain. The results predicted that R1075, D1090, R1095, and C1130 on the TSP8 domain were key residues that interacted with the Spacer domain. R1075 and R1095 bound exosite-4 tightly, D1090 formed multiple hydrogen bonds and salt bridges with exosite-3, and C1130 interacted with both exosite-3 and exosite-4. Specific mutations of exosite-3 (R568K/F592Y/R660K/Y661F/Y665F) or the four key residues (R1075A/D1090A/R1095A/C1130A) impaired the binding of the TSP8 domain to the Spacer domain. These results shed new light on the understanding of the auto-inhibition of ADAMTS13.
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Brodsky MA, Sukumar S, Selvakumar S, Yanek L, Hussain S, Mazepa MA, Braunstein EM, Moliterno AR, Kickler TS, Brodsky RA, Cataland SR, Chaturvedi S. Major adverse cardiovascular events in survivors of immune-mediated thrombotic thrombocytopenic purpura. Am J Hematol 2021; 96:1587-1594. [PMID: 34460124 DOI: 10.1002/ajh.26341] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 08/24/2021] [Accepted: 08/25/2021] [Indexed: 12/12/2022]
Abstract
Cardiovascular disease is a leading cause of death in survivors of immune-mediated thrombotic thrombocytopenic purpura (iTTP), but the epidemiology of major adverse cardiovascular events (MACE) in iTTP survivors is unknown. We evaluated the prevalence and risk factors for MACE, defined as the composite of non-fatal or fatal myocardial infarction (MI), stroke, and cardiac revascularization, during clinical remission in two large iTTP cohorts (Johns Hopkins University and Ohio State University). Of 181 patients followed for ≥ 3 months after recovery from acute iTTP, 28.6% had a MACE event over a median follow up of 7.6 years. Stroke was the most common type of MACE (18.2%), followed by non-fatal MI (6.6%), cardiac revascularization (4.9%) and fatal MI (0.6%). Compared to the general United States population, iTTP survivors were younger at first stroke in remission (males [56.5 years vs. 68.6 years, p = 0.031], females [49.7 years vs. 72.9 years, p < 0.001]) or MI in remission (males [56.5 years vs. 65.6 years, p < 0.001] and females [53.1 years vs. 72.0 years, p < 0.001]). Age (HR 1.03 [95% CI 1.002-1.054]), race (Black/Other vs. White) (HR 2.32 [95% CI 1.12-4.82]), and diabetes mellitus (HR 2.37 [95% CI 1.09-0.03]) were associated with MACE in a Cox regression model also adjusted for sex, hypertension, obesity, hyperlipidemia, chronic kidney disease, atrial fibrillation, autoimmune disease, and relapsing iTTP. Remission ADAMTS13 activity was not significantly associated with MACE. In conclusion, iTTP survivors experience high rates of MACE and may benefit from aggressively screening for and managing cardiovascular risk factors.
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Affiliation(s)
- Max A. Brodsky
- Department of Medicine Johns Hopkins University School of Medicine Baltimore Maryland USA
| | - Senthil Sukumar
- Division of Hematology, Department of Medicine The Ohio State University College of Medicine Columbus Ohio USA
| | - Sruthi Selvakumar
- Nova Southeastern University School of Medicine Fort Lauderdale Florida USA
| | - Lisa Yanek
- Department of Medicine Johns Hopkins University School of Medicine Baltimore Maryland USA
| | - Sarah Hussain
- Division of Hematology, Department of Medicine Johns Hopkins University School of Medicine Baltimore Maryland USA
| | - Marshall A. Mazepa
- Division of Hematology and Oncology University of Minnesota School of Medicine Minneapolis Minnesota USA
| | - Evan M. Braunstein
- Division of Hematology, Department of Medicine Johns Hopkins University School of Medicine Baltimore Maryland USA
| | - Alison R. Moliterno
- Division of Hematology, Department of Medicine Johns Hopkins University School of Medicine Baltimore Maryland USA
| | - Thomas S. Kickler
- Division of Hematology, Department of Medicine Johns Hopkins University School of Medicine Baltimore Maryland USA
| | - Robert A. Brodsky
- Division of Hematology, Department of Medicine Johns Hopkins University School of Medicine Baltimore Maryland USA
| | - Spero R. Cataland
- Division of Hematology, Department of Medicine The Ohio State University College of Medicine Columbus Ohio USA
| | - Shruti Chaturvedi
- Division of Hematology, Department of Medicine Johns Hopkins University School of Medicine Baltimore Maryland USA
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49
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Updates on thrombotic thrombocytopenic purpura: Recent developments in pathogenesis, treatment and survivorship. THROMBOSIS UPDATE 2021. [DOI: 10.1016/j.tru.2021.100062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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50
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Yang F, Tian J, Peng L, Zhang L, Liu J, Tian X, Zhang W, Li M, Zhao Y, Zhang F, Zeng X, Wang L, Leng X. Thrombocytopenia Is an Independent Risk Factor for the Prognosis of Thrombotic Microangiopathy in Chinese Patients With Systemic Lupus Erythematosus. Front Med (Lausanne) 2021; 8:772607. [PMID: 34820404 PMCID: PMC8606658 DOI: 10.3389/fmed.2021.772607] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 10/05/2021] [Indexed: 11/13/2022] Open
Abstract
Objectives: This study aims to describe clinical characteristics and outcome of thrombotic microangiopathy (TMA) in Chinese patients with systemic lupus erythematosus (SLE), and investigate the risk factors. Methods: We conducted a retrospective single-center cohort and enrolled patients of TMA associated with SLE between January 2015 and December 2018. Demographic characteristics, clinical features, laboratory profiles, therapeutic strategies, and outcomes were collected. The risk factors of TMA in patients with SLE for mortality using multivariate analysis were estimated. Results: A total of 119 patients with a diagnosis of TMA were enrolled within the study period in our center, and SLE was found in 72 (60.5%) patients. The mean age was 29.2 ± 10.1 and 65 (92.3%) were women. Only 15 patients were found with definite causes, the other 57 cases remained with unclear reasons. Sixty-two patients got improved, while 10 patients died after treatment (mortality rate: 13.9%). Compared with the survival group, the deceased group had a higher prevalence of neuropsychiatric manifestations, infection with two or more sites, increased levels of C-reaction protein (CRP) and D-Dimer, and decreased platelet count. Multivariate analysis showed that the decrease of platelet count is the independent risk factor for in-hospital mortality for TMA in patients with SLE. The receiver operating characteristic (ROC) curve analysis displayed that a cutoff value of <18 × 109/L for platelet count could significantly increase the risk of death. Conclusions: Thrombotic microangiopathy often occurs in patients with active SLE with high mortality (13.9%), and thrombocytopenia, especially when the platelet count is lower than 18 × 109/L, is the risk factor for death.
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Affiliation(s)
- Fan Yang
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences and Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Junwei Tian
- Department of Rheumatology and Nephrology, The First Hospital of Changsha, Hunan, China
| | - Linyi Peng
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences and Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Li Zhang
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences and Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Jia Liu
- Department of Medical Science and Technology Evaluation, Institute of Medical Information, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xinping Tian
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences and Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Wen Zhang
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences and Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Mengtao Li
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences and Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Yan Zhao
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences and Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Fengchun Zhang
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences and Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Xiaofeng Zeng
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences and Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Li Wang
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences and Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Xiaomei Leng
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences and Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
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