1
|
Smith J, Hans V, Yacyshyn E, Rouhi A, Oliver M. Systemic lupus erythematosus presenting with atypical hemolytic uremic syndrome: a case report and review of the literature. Rheumatol Int 2024; 44:2213-2225. [PMID: 38502235 DOI: 10.1007/s00296-024-05558-9] [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: 01/07/2024] [Accepted: 02/09/2024] [Indexed: 03/21/2024]
Abstract
Systemic lupus erythematosus (SLE) can present with a diverse array of hematologic manifestations, among which atypical hemolytic uremic syndrome (aHUS) is a rare entity. SLE-triggered aHUS has significant morbidity and mortality without timely intervention, yet its frequency remains uncertain and optimal strategies for complement-directed therapies are largely expert-driven. We performed a comprehensive literature review and present a case of a 23-year-old female newly diagnosed with SLE/class IV lupus nephritis who developed aHUS that rapidly responded to the C5 antagonist, eculizumab. Review of the current literature identified forty-nine published cases of SLE with concurrent aHUS and revealed a predilection for aHUS in younger SLE patients, concurrent presentation with lupus nephritis, anti-dsDNA positivity, and complement system abnormalities. Over seventy percent of cases used eculizumab as complement-directed therapy with a trend towards faster time to improvement in laboratory parameters, though reported outcomes were highly variable. Early recognition of aHUS in SLE is pivotal in guiding appropriate therapeutic interventions, and prompt initiation of eculizumab may reduce the potential morbidity associated with plasmapheresis and additional immunosuppression. While eculizumab showcases promising results, its optimal timing and duration remain elusive. An understanding of a patients' complement genetics could aid management strategies, and ongoing research into complement-targeted therapies offers promising avenues for both SLE and aHUS treatment.
Collapse
Affiliation(s)
- Justin Smith
- Department of Medicine, University of Alberta, 8-130 Clinical Sciences Building, 11350 83 Avenue NW, Edmonton, AB, T6G 2G3, Canada.
| | - Varinder Hans
- Department of Medicine, University of Alberta, 8-130 Clinical Sciences Building, 11350 83 Avenue NW, Edmonton, AB, T6G 2G3, Canada
| | - Elaine Yacyshyn
- Department of Medicine, University of Alberta, 8-130 Clinical Sciences Building, 11350 83 Avenue NW, Edmonton, AB, T6G 2G3, Canada
| | - Azin Rouhi
- Department of Medicine, University of Alberta, 8-130 Clinical Sciences Building, 11350 83 Avenue NW, Edmonton, AB, T6G 2G3, Canada
| | - Monika Oliver
- Department of Medicine, Division of Hematology, University of Alberta, Edmonton, Canada
| |
Collapse
|
2
|
Meiring M, Khemisi M, Louw S, Krishnan P. Autoantibodies to ADAMTS13 in human immunodeficiency virus-associated thrombotic thrombocytopenic purpura. Vox Sang 2024. [PMID: 39293938 DOI: 10.1111/vox.13738] [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: 02/19/2024] [Revised: 08/13/2024] [Accepted: 09/04/2024] [Indexed: 09/20/2024]
Abstract
BACKGROUND AND OBJECTIVES Thrombotic thrombocytopenic purpura (TTP) is a potentially fatal thrombotic microangiopathic disorder that can result from human immunodeficiency virus (HIV) infection. The pathogenesis involves a deficiency of the von Willebrand factor (vWF) cleaving protease ADAMTS13 (a disintegrin and metalloprotease with thrombospondin motifs member 13) and the presence of anti-ADAMTS13 autoantibodies. However, there is insufficient information regarding the epitope specificity and reactivity of these autoantibodies. This study aimed to perform epitope-mapping analysis to provide novel insights into the specific epitopes on ADAMTS13 domains affected by autoantibodies. MATERIALS AND METHODS The study analysed 59 frozen citrate plasma samples from HIV-associated TTP patients in South Africa, measuring ADAMTS13 activity using Technozyme® ADAMTS13 activity test, total immunoglobulin (Ig) M and IgA antibodies levels using ELISA kit and purifying IgG antibodies using NAb™ Protein G spin columns. A synthetic ADAMTS13 peptide library was used for epitope mapping. RESULTS Overall, 90% of samples showed anti-ADAMTS13 IgG autoantibodies, with 64% of these antibodies being inhibitory, as revealed by mixing studies. Samples with ADAMTS13 antigen levels below 5% showed high anti-ADAMTS13 IgG autoantibody titres (≥50 IU/mL), whereas those with 5%-10% levels had low autoantibody titres (<50 IU/mL).The metalloprotease, cysteine-rich and spacer domains were 100% involved in binding anti-ADAMTS13 IgG antibodies, with 58% of samples containing antibodies binding to the C-terminal part of the ADAMTS13 disintegrin-like domain, indicating different pathogenic mechanisms. CONCLUSION The metalloprotease, cysteine-rich and spacer domains are the primary targets for anti-ADAMTS13 IgG autoantibodies in patients with HIV-associated TTP. These findings suggest potential effects on the proteolytic activity of ADAMTS13, highlighting the complex nature of the pathogenic mechanisms involved.
Collapse
Affiliation(s)
- Muriel Meiring
- Department of Haematology and Cell Biology, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa
- Universitas Business Unit, National Health Laboratory Service, Bloemfontein, South Africa
| | - Mmakgabu Khemisi
- Department of Haematology and Cell Biology, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa
- Universitas Business Unit, National Health Laboratory Service, Bloemfontein, South Africa
| | - Susan Louw
- Universitas Business Unit, National Health Laboratory Service, Bloemfontein, South Africa
- Department of Molecular Medicine and Haematology, University of the Witwatersrand, Johannesburg, South Africa
| | - Palanisamy Krishnan
- Department of Haematology and Cell Biology, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa
| |
Collapse
|
3
|
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.
Collapse
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.)
| |
Collapse
|
4
|
Sarani N, Dasgupta A, Enders M, Rowan L, Elsarraj H, Gralnek S, Shay M, Lemar LR, Simpson SQ, Cunningham MT, Zheng XL. Clinical Utility of Recently Food and Drug Administration-Approved IntelliSep Test (Sepsis Biomarker) for Early Diagnosis of Sepsis: Comparison with Other Biomarkers. J Clin Med 2024; 13:4852. [PMID: 39200994 PMCID: PMC11355800 DOI: 10.3390/jcm13164852] [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: 05/29/2024] [Revised: 08/13/2024] [Accepted: 08/14/2024] [Indexed: 09/02/2024] Open
Abstract
Context: IntelliSep by Cytovale has received United States (U.S.) Food and Drug Administration (FDA) approval as a sepsis biomarker test. However, the clinical utility of this new test is not assessed in emergency departments. Objective: We investigated the clinical utility of this test using 44 patients visiting the emergency department at The University of Kansas Medical Center by comparing it with the monocyte distribution width (MDW) and other biomarkers including the von Willebrand factor (vWF) and ADAMTS13. Design and Methods: IntelliSep assesses the cellular host response via deformability cytometry of biophysical leukocyte properties and produces a score (IntelliSep Index; ISI: from 0.1 (lowest risk) to 10 (highest risk). We measured the ISI in 44 patients (19 high probability and 25 low probability of sepsis groups) using EDTA-anticoagulated blood. Left over plasma was used for measuring the plasma von Willebrand factor (vWF) and ADAMTS13 antigen by ELISA assays. The MDW was obtained during routine CBC analysis using a Beckman hematology analyzer. The lactate and high-sensitivity troponin I levels were measured using a Beckman analyzer. Procalcitonin was measured using a Cobas e801 analyzer. Results: The median ISI was twofold higher in the high-probability group than in the low-probability group (p < 0.01) while the median MDW was 34.5% higher in the high-probability group than in the low-probability group (p < 0.01). However, the correlation between the ISI and MDW was only modest (r = 0.66). In addition, significantly higher levels of plasma vWF antigen but lower levels of plasma ADAMTS13 antigen in the high-probability group were found, resulting in significantly higher vWF/ADAMTS13 ratios in the high-probability group than in the low-probability group. Conclusions: The new IntelliSep test along with vWF/ADAMTS13 ratios may be useful for the early diagnosis of sepsis in patients visiting the emergency department, which appears to be superior to the traditional marker, MDW.
Collapse
Affiliation(s)
- Nima Sarani
- Department of Emergency Medicine, The University of Kansas Medical Center, Kansas City, KS 66160, USA; (N.S.); (M.E.); (L.R.); (L.R.L.)
| | - Amitava Dasgupta
- Department of Pathology and Laboratory Medicine, The University of Kansas Medical Center, Kansas City, KS 66160, USA; (A.D.); (H.E.); (S.G.); (M.S.); (M.T.C.)
| | - Maria Enders
- Department of Emergency Medicine, The University of Kansas Medical Center, Kansas City, KS 66160, USA; (N.S.); (M.E.); (L.R.); (L.R.L.)
| | - Lauren Rowan
- Department of Emergency Medicine, The University of Kansas Medical Center, Kansas City, KS 66160, USA; (N.S.); (M.E.); (L.R.); (L.R.L.)
| | - Hanan Elsarraj
- Department of Pathology and Laboratory Medicine, The University of Kansas Medical Center, Kansas City, KS 66160, USA; (A.D.); (H.E.); (S.G.); (M.S.); (M.T.C.)
| | - Sarah Gralnek
- Department of Pathology and Laboratory Medicine, The University of Kansas Medical Center, Kansas City, KS 66160, USA; (A.D.); (H.E.); (S.G.); (M.S.); (M.T.C.)
| | - Madison Shay
- Department of Pathology and Laboratory Medicine, The University of Kansas Medical Center, Kansas City, KS 66160, USA; (A.D.); (H.E.); (S.G.); (M.S.); (M.T.C.)
| | - Lucas R. Lemar
- Department of Emergency Medicine, The University of Kansas Medical Center, Kansas City, KS 66160, USA; (N.S.); (M.E.); (L.R.); (L.R.L.)
| | - Steven Q. Simpson
- Department of Internal Medicine, The University of Kansas Medical Center, Kansas City, KS 66160, USA;
| | - Mark T. Cunningham
- Department of Pathology and Laboratory Medicine, The University of Kansas Medical Center, Kansas City, KS 66160, USA; (A.D.); (H.E.); (S.G.); (M.S.); (M.T.C.)
| | - X. Long Zheng
- Department of Pathology and Laboratory Medicine, The University of Kansas Medical Center, Kansas City, KS 66160, USA; (A.D.); (H.E.); (S.G.); (M.S.); (M.T.C.)
- Institute of Reproductive Medicine and Developmental Sciences, The University of Kansas Medical Center, Kansas City, KS 66160, USA
| |
Collapse
|
5
|
Franchini M, Focosi D, Pezzo MP, Mannucci PM. Catastrophic Thrombosis: A Narrative Review. Semin Thromb Hemost 2024. [PMID: 39151904 DOI: 10.1055/s-0044-1788790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/19/2024]
Abstract
Catastrophic thrombosis is a severe condition characterized by a hypercoagulable tendency, leading to multiple thromboembolic events in different blood vessels, usually within a short timeframe. Several conditions have been associated with the development of catastrophic thrombosis, including the catastrophic antiphospholipid syndrome, thrombotic anti-platelet factor 4 immune disorders, thrombotic microangiopathies, cancers, the hyper-eosinophilic syndrome, pregnancy, infections, trauma, and drugs. Thrombotic storm represents a medical emergency whose management represents a serious challenge for physicians. Besides the prompt start of anticoagulation, a patient's prognosis depends on early recognition and possible treatment of the underlying condition. In this narrative review, we summarize the main characteristics of catastrophic thrombosis, analyzing the various conditions triggering such life-threatening complication. Finally, an algorithm with the diagnostic workup and the initial management of patients with catastrophic thrombosis is presented.
Collapse
Affiliation(s)
- Massimo Franchini
- Department of Transfusion Medicine and Hematology, Carlo Poma Hospital, Mantova, Italy
| | - Daniele Focosi
- North-Western Tuscany Blood Bank, Pisa University Hospital, Italy
| | | | - Pier Mannuccio Mannucci
- Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico and University of Milan, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
| |
Collapse
|
6
|
Satoh K, Wada T, Tampo A, Takahashi G, Hoshino K, Matsumoto H, Taira T, Kazuma S, Masuda T, Tagami T, Ishikura H. Practical approach to thrombocytopenia in patients with sepsis: a narrative review. Thromb J 2024; 22:67. [PMID: 39039520 PMCID: PMC11265094 DOI: 10.1186/s12959-024-00637-0] [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: 02/05/2024] [Accepted: 07/08/2024] [Indexed: 07/24/2024] Open
Abstract
Thrombocytopenia frequently occurs in patients with sepsis. Disseminated intravascular coagulation (DIC) may be a possible cause of thrombocytopenia owing to its high prevalence and association with poor outcomes; however, it is important to keep the presence of other diseases in mind in sepsis practice. Thrombotic microangiopathy (TMA), which is characterized by thrombotic thrombocytopenic purpura, Shiga toxin-producing Escherichia coli hemolytic uremic syndrome (HUS), and complement-mediated HUS, is characterized by thrombocytopenia, microangiopathic hemolytic anemia, and organ damage. TMA has become widely recognized in recent years because of the development of specific treatments. Previous studies have reported a remarkably lower prevalence of TMA than DIC; however, its epidemiology is not well defined, and there may be cases in which TMA is not correctly diagnosed, resulting in poor outcomes. Therefore, it is important to differentiate DIC from TMA. Nevertheless, differentiating between DIC and TMA remains a challenge as indicated by previous reports that most patients with TMA can be diagnosed as DIC using the universal coagulation scoring system. Several algorithms to differentiate sepsis-related DIC from TMA have been suggested, contributing to improving the care of septic patients with thrombocytopenia; however, it may be difficult to apply these algorithms to patients with coexisting DIC and TMA, which has recently been reported. This review describes the disease characteristics, including epidemiology, pathophysiology, and treatment, of DIC, TMA, and other diseases with thrombocytopenia and proposes a novel practical approach flow, which is characterized by the initiation of the diagnosis of TMA in parallel with the diagnosis of DIC. This practical flow also refers to the longitudinal diagnosis and treatment flow with TMA in mind and real clinical timeframes. In conclusion, we aim to widely disseminate the results of this review that emphasize the importance of incorporating consideration of TMA in the management of septic DIC. We anticipate that this practical new approach for the diagnostic and treatment flow will lead to the appropriate diagnosis and treatment of complex cases, improve patient outcomes, and generate new epidemiological evidence regarding TMA.
Collapse
Affiliation(s)
- Kasumi Satoh
- Advanced Emergency and Critical Care Center, Akita University Hospital, Akita, Japan
| | - Takeshi Wada
- Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Faculty of Medicine, Kita 15, Nishi 7, Kita-ku, Sapporo, 060-8638, Japan.
| | - Akihito Tampo
- Department of Emergency Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Gaku Takahashi
- Department of Critical Care, Disaster and General Medicine, School of Medicine, Iwate Medical University, Iwate, Japan
| | - Kota Hoshino
- Department of Emergency and Critical Care Medicine, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Hironori Matsumoto
- Department of Emergency and Critical Care Medicine, Ehime University Graduate School of Medicine, Toon, Japan
| | - Takayuki Taira
- Department of Emergency and Critical Care Medicine, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Satoshi Kazuma
- Department of Intensive Care Medicine, School of Medicine, Sapporo Medical University, Sapporo, Hokkaido, Japan
| | - Takamitsu Masuda
- Department of Emergency Medicine, Emergency and Critical Care Center, Fujieda Municipal General Hospital, Fujieda, Japan
| | - Takashi Tagami
- Department of Emergency and Critical Care Medicine, Nippon Medical School Musashikosugi Hospital, Tokyo, Japan
| | - Hiroyasu Ishikura
- Department of Emergency and Critical Care Medicine, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| |
Collapse
|
7
|
Bobrova LA, Kozlovskaya NL. [Lupus nephritis and thrombotic microangiopathy: A review]. TERAPEVT ARKH 2024; 96:628-634. [PMID: 39106505 DOI: 10.26442/00403660.2024.06.202731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2024] [Accepted: 07/07/2024] [Indexed: 08/09/2024]
Abstract
Lupus nephritis (LN) is one of the most common organ-specific manifestations of systemic lupus erythematosus (SLE). Various clinical signs of LN develop in at least 50% of patients with SLE. In addition to LN, the spectrum of renal lesions associated with SLE also includes vascular pathology. One of the variants of renal microvascular injury is thrombotic microangiopathy (TMA), the mechanisms of which are diverse. The review focuses on the main forms of TMA, including antiphospholipid syndrome and nephropathy associated with antiphospholipid syndrome, TMA caused by complement system regulation disorders and deficiency of ADAMTS13. In most cases, these forms of TMA are combined with LN. However, they may also exist as a single form of kidney damage. This article discusses the TMA pathogenesis, the impact on kidney prognosis, and treatment options.
Collapse
Affiliation(s)
- L A Bobrova
- Sechenov First Moscow State Medical University (Sechenov University)
| | - N L Kozlovskaya
- Patrice Lumumba People's Friendship University of Russia
- Yeramishantsev City Clinical Hospital
| |
Collapse
|
8
|
Yamada S, Sakai K, Kubo M, Okumura H, Asakura H, Miyamoto T, Matsumoto M. Excessive cleavage of von Willebrand factor multimers by ADAMTS13 may predict the progression of transplant-associated thrombotic microangiopathy. Res Pract Thromb Haemost 2024; 8:102517. [PMID: 39247211 PMCID: PMC11378204 DOI: 10.1016/j.rpth.2024.102517] [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: 04/03/2024] [Revised: 05/28/2024] [Accepted: 06/17/2024] [Indexed: 09/10/2024] Open
Abstract
Background Transplant-associated thrombotic microangiopathy (TA-TMA) is a fatal complication of hematopoietic stem cell transplantation and is characterized by severe thrombocytopenia, hemolytic anemia, and organ dysfunction. In response to several possible triggers, dynamic multimetric change in von Willebrand factor (VWF) may contribute to inducing microthrombi in circulation in TA-TMA. Objectives By performing VWF multimer analysis and measuring VWF-degradation product (DP), we unraveled the relationship between multimeric changes in circulating VWF and the pathogenesis of TA-TMA. Methods This study analyzed 135 plasma samples from 14 patients who underwent allogeneic hematopoietic stem cell transplantation at a single institute. VWF-associated markers, namely VWF:antigen (VWF:Ag), VWF-DP/VWF:Ag ratio, VWF:ristocetin cofactor activity, VWF:ristocetin cofactor activity/VWF:Ag ratio, and ADAMTS13 activity, were analyzed in these samples collected every 7 days. Results There were 2 patients with definite thrombotic microangiopathy (TMA) and 6 patients who presented with probable TMA that did not progress to definite TMA. Each plasma sample was classified into 3 groups: definite TMA, probable TMA, and non-TMA. VWF multimer analysis showed the absence of high-molecular-weight VWF multimers in probable TMA, whereas the appearance of unusually large VWF multimers was observed in definite TMA. The median value of the VWF-DP/VWF:Ag ratio in probable TMA was elevated to 4.17, suggesting that excessive cleavage of VWF multimers by VWF cleaving enzyme, ADAMTS13, resulted in the loss of high-molecular-weight VWF multimers. Conclusion During the transition from probable to definite TMA, drastic VWF multimer changes imply a switch from bleeding to thrombotic tendencies. Extensive VWF-DP and VWF multimer analyses provided novel insights.
Collapse
Affiliation(s)
- Shinya Yamada
- Department of Hematology, Kanazawa University, Kanazawa City, Ishikawa, Japan
- Department of Blood Transfusion Medicine, Nara Medical University, Kashihara City, Nara, Japan
- Department of Hematology, Toyama Prefectural Central Hospital, Toyama City, Toyama, Japan
| | - Kazuya Sakai
- Department of Blood Transfusion Medicine, Nara Medical University, Kashihara City, Nara, Japan
| | - Masayuki Kubo
- Department of Blood Transfusion Medicine, Nara Medical University, Kashihara City, Nara, Japan
- Department of Hematology, Nara Medical University, Kashihara City, Nara, Japan
| | - Hirokazu Okumura
- Department of Hematology, Toyama Prefectural Central Hospital, Toyama City, Toyama, Japan
| | - Hidesaku Asakura
- Department of Hematology, Kanazawa University, Kanazawa City, Ishikawa, Japan
| | - Toshihiro Miyamoto
- Department of Hematology, Kanazawa University, Kanazawa City, Ishikawa, Japan
| | - Masanori Matsumoto
- Department of Blood Transfusion Medicine, Nara Medical University, Kashihara City, Nara, Japan
- Department of Hematology, Nara Medical University, Kashihara City, Nara, Japan
| |
Collapse
|
9
|
Obata S, Hullekes F, Riella LV, Cravedi P. Recurrent complement-mediated Hemolytic uremic syndrome after kidney transplantation. Transplant Rev (Orlando) 2024; 38:100857. [PMID: 38749097 DOI: 10.1016/j.trre.2024.100857] [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: 03/13/2024] [Revised: 04/25/2024] [Accepted: 04/26/2024] [Indexed: 06/16/2024]
Abstract
Hereditary forms of hemolytic uremic syndrome (HUS), formerly known as atypical HUS, typically involve mutations in genes encoding for components of the alternative pathway of complement, therefore they are often referred to as complement-mediated HUS (cHUS). This condition has a high risk of recurrence in the transplanted kidney, leading to accelerated graft loss. The availability of anti-complement component C5 antibody eculizumab has enabled successful transplantation with a notably reduced recurrence rate and improved prognosis. Open questions are related to the potential for complement inhibitor discontinuation, ideal timing of treatment withdrawal, and patient selection based on genetic abnormalities. Our review delves into the pathophysiology, classification, genetic predispositions, and management strategies for cHUS in the native and transplant kidneys.
Collapse
Affiliation(s)
- Shota Obata
- Precision Immunology Institute, Translational Transplant Research Center, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Frank Hullekes
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Leonardo V Riella
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America; Department of Medicine, Nephrology Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Paolo Cravedi
- Precision Immunology Institute, Translational Transplant Research Center, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America.
| |
Collapse
|
10
|
Sugita H, Nakanuma S, Munesue S, Ishikawa T, Tokoro T, Takei R, Okazaki M, Kato K, Takada S, Makino I, Ozaki N, Yamamoto Y, Yagi S. Cilostazol improves the prognosis after hepatectomy in rats with sinusoidal obstruction syndrome. J Gastroenterol Hepatol 2024; 39:1413-1421. [PMID: 38348885 DOI: 10.1111/jgh.16508] [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: 12/13/2023] [Revised: 01/08/2024] [Accepted: 01/23/2024] [Indexed: 07/13/2024]
Abstract
BACKGROUND AND AIM Safe radical hepatectomy is important for patients with colorectal liver metastases complicated by sinusoidal obstruction syndrome (SOS) after oxaliplatin-based chemotherapy. This study aimed to investigate the impact of preoperative administration of cilostazol (CZ), an oral selective phosphodiesterase III inhibitor, on hepatectomy in rat SOS model. MATERIAL AND METHODS Rats were divided into NL (normal liver), SOS (monocrotaline [MCT]-treated), and SOS + CZ (MCT + CZ-treated) groups. MCT or CZ was administered orally, and a 30% partial hepatectomy was performed 48 h after MCT administration. Postoperative survival rates were evaluated (n = 9, for each). Other rats were sacrificed on postoperative days (POD) 1 and 3 and evaluated histologically, immunohistochemically, biochemically, and using transmission electron microscopy (TEM), focusing particularly on SOS findings, liver damage, and liver sinusoidal endothelial cell (LSEC) injury. RESULTS The cumulative 10-day postoperative survival rate was significantly higher in the SOS + CZ group than in the SOS group (88.9% vs 33.3%, P = 0.001). Total SOS scores were significantly lower in the SOS + CZ group than in the SOS group on both POD 1 and 3. Serum biochemistry and immunohistochemistry showed that CZ reduced liver damage after hepatectomy. TEM revealed that LSECs were significantly preserved morphologically in the SOS + CZ group than in the SOS group on POD 1 (86.1 ± 8.2% vs 63.8 ± 9.3%, P = 0.003). CONCLUSION Preoperative CZ administration reduced liver injury by protecting LSECs and improved the prognosis after hepatectomy in rats with SOS.
Collapse
Affiliation(s)
- Hiroaki Sugita
- Department of Hepato-Biliary-Pancreatic Surgery and Transplantation, Kanazawa University, 13-1 Takara-Machi, Kanazawa, 920-8641, Japan
| | - Shinichi Nakanuma
- Department of Hepato-Biliary-Pancreatic Surgery and Transplantation, Kanazawa University, 13-1 Takara-Machi, Kanazawa, 920-8641, Japan
| | - Seiichi Munesue
- Department of Biochemistry and Molecular Vascular Biology, Kanazawa University Graduate School of Medical Sciences, 13-1 Takara-machi, Kanazawa, 920-8640, Japan
| | - Tatsuya Ishikawa
- Department of Functional Anatomy, Kanazawa University Graduate School of Medical Sciences, 13-1 Takara-machi, Kanazawa, 920-8640, Japan
| | - Tomokazu Tokoro
- Department of Hepato-Biliary-Pancreatic Surgery and Transplantation, Kanazawa University, 13-1 Takara-Machi, Kanazawa, 920-8641, Japan
| | - Ryohei Takei
- Department of Hepato-Biliary-Pancreatic Surgery and Transplantation, Kanazawa University, 13-1 Takara-Machi, Kanazawa, 920-8641, Japan
| | - Mitsuyoshi Okazaki
- Department of Hepato-Biliary-Pancreatic Surgery and Transplantation, Kanazawa University, 13-1 Takara-Machi, Kanazawa, 920-8641, Japan
| | - Kaichiro Kato
- Department of Hepato-Biliary-Pancreatic Surgery and Transplantation, Kanazawa University, 13-1 Takara-Machi, Kanazawa, 920-8641, Japan
| | - Satoshi Takada
- Department of Hepato-Biliary-Pancreatic Surgery and Transplantation, Kanazawa University, 13-1 Takara-Machi, Kanazawa, 920-8641, Japan
| | - Isamu Makino
- Department of Hepato-Biliary-Pancreatic Surgery and Transplantation, Kanazawa University, 13-1 Takara-Machi, Kanazawa, 920-8641, Japan
| | - Noriyuki Ozaki
- Department of Functional Anatomy, Kanazawa University Graduate School of Medical Sciences, 13-1 Takara-machi, Kanazawa, 920-8640, Japan
| | - Yasuhiko Yamamoto
- Department of Biochemistry and Molecular Vascular Biology, Kanazawa University Graduate School of Medical Sciences, 13-1 Takara-machi, Kanazawa, 920-8640, Japan
| | - Shintaro Yagi
- Department of Hepato-Biliary-Pancreatic Surgery and Transplantation, Kanazawa University, 13-1 Takara-Machi, Kanazawa, 920-8641, Japan
| |
Collapse
|
11
|
Fang W, Sun W, Fang W, Zhao S, Wang C. Clinical features, treatment, and outcomes of patients with carfilzomib induced thrombotic microangiopathy. Int Immunopharmacol 2024; 134:112178. [PMID: 38728883 DOI: 10.1016/j.intimp.2024.112178] [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: 02/15/2024] [Revised: 04/25/2024] [Accepted: 04/27/2024] [Indexed: 05/12/2024]
Abstract
BACKGROUND Thrombotic microangiopathy (TMA) is associated with carfilzomib, and knowledge of carfilzomib-induced TMA is based mainly on case reports. This study investigated the clinical characteristics of patients with carfilzomib-induced TMA and provided a reference for the rational use of carfilzomib. METHODS Reports of carfilzomib-induced TMA were collected for retrospective analysis by searching the Chinese and English databases from inception to January 31, 2024. RESULTS Sixty-six patients were included, with a median age of 63 years (range 39, 85). The median time to onset of TMA was 42 days (range 1, 1825) from initial administration, and the median number of cycles was 3 cycles (range 1, 15). Hemolytic anemia was recorded in 64 patients, with a median of 8.3 g/dL (range 4.6, 13). Sixty-three patients had thrombocytopenia with a median of 18 × 109/L (range 1, 139). The median value of increased LDH was 1192 IU/L (range 141, 5378). ADAMTS13 activity was normal in 41 (62.1 %) of the 42 patients. Mutations were found in 9 (13.6 %) of the 15 patients. Fifty-seven patients achieved a clinical response after discontinuing carfilzomib and receiving therapeutic plasma exchange (53.0 %), eculizumab (24.2 %), or hemodialysis (39.4 %). CONCLUSION Carfilzomib-induced TMA is an important adverse event that should be considered in patients receiving carfilzomib for multiple myeloma with anemia, thrombocytopenia, and acute kidney injury. Withdrawal of carfilzomib and treatment with eculizumab have proven successful in some patients.
Collapse
Affiliation(s)
- Weilun Fang
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, Hunan 410013, China; College of Pharmacy, Changsha Medical University, Changsha, Hunan 410219, China
| | - Wei Sun
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, Hunan 410013, China
| | - Weijin Fang
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, Hunan 410013, China
| | - Shaoli Zhao
- Department of Endocrinology, The Third Xiangya Hospital, Central South University, China
| | - Chunjiang Wang
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, Hunan 410013, China.
| |
Collapse
|
12
|
Iwai S, Akahane T, Takaya H, Kubo T, Tomooka F, Shibamoto A, Suzuki J, Tsuji Y, Fujinaga Y, Nishimura N, Kitagawa K, Kaji K, Kawaratani H, Namisaki T, Matsumoto M, Yoshiji H. Ratio of von Willebrand factor to ADAMTS13 is a useful predictor of esophagogastric varices progression after sustained virologic response in patients with hepatitis C virus-related liver cirrhosis. Hepatol Res 2024. [PMID: 38838066 DOI: 10.1111/hepr.14077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2024] [Revised: 05/16/2024] [Accepted: 05/19/2024] [Indexed: 06/07/2024]
Abstract
AIM Esophagogastric varices (EGV) are a serious complication of hepatitis C virus (HCV)-related liver cirrhosis (HCV-LC). In most cases, portal hypertension improves after a sustained virologic response (SVR) is achieved with direct-acting antiviral (DAA) treatment; however, in some cases, EGV exacerbation occurs after HCV elimination. We investigated whether von Willebrand factor (VWF) and a disintegrin-like metalloproteinase with thrombospondin type-1 motif 13 (ADAMTS13) can predict EGV progression with HCV-LC after SVR achievement. METHODS This retrospective study enrolled 47 patients with HCV-LC who achieved an SVR after DAA treatment. Eighteen patients experienced EGV progression after the SVR was achieved (EGV progression group). Twenty-nine patients did not experience EGV progression after the SVR was achieved (non-EGV progression group). Plasma VWF antigen levels and ADAMTS13 activity were measured the day before DAA treatment. RESULTS The EGV progression group had significantly higher plasma VWF antigen levels (p = 0.00331) and VWF-to-ADAMTS13 ratios (p = 0.000249) than the non-EGV progression group. Multivariate logistic regression models found that a VWF-to-ADAMTS13 ratio >2.3 was the only risk factor for EGV progression after the SVR was achieved (hazard ratio [HR], 18.4; 95% confidence interval [CI], 3.08-109; p = 0.00138). During the observation period, patients with a VWF-to-ADAMTS13 ratio >2.3 had a significantly higher cumulative incidence of EGV progression after SVR achievement than patients with a VWF-to-ADAMTS13 ratio ≤2.3 (HR, 6.4; 95% CI, 1.78-22.96; p = 0.0044). CONCLUSIONS The VWF-to-ADAMTS13 ratio before DAA treatment for HCV could predict EGV progression after SVR achievement.
Collapse
Affiliation(s)
- Satoshi Iwai
- Department of Gastroenterology, Nara Medical University, Kashihara, Japan
| | - Takemi Akahane
- Department of Gastroenterology, Nara Medical University, Kashihara, Japan
| | - Hiroaki Takaya
- Department of Gastroenterology, Nara Medical University, Kashihara, Japan
| | - Takahiro Kubo
- Department of Gastroenterology, Nara Medical University, Kashihara, Japan
| | - Fumimasa Tomooka
- Department of Gastroenterology, Nara Medical University, Kashihara, Japan
| | - Akihiko Shibamoto
- Department of Gastroenterology, Nara Medical University, Kashihara, Japan
| | - Junya Suzuki
- Department of Gastroenterology, Nara Medical University, Kashihara, Japan
| | - Yuki Tsuji
- Department of Gastroenterology, Nara Medical University, Kashihara, Japan
| | - Yukihisa Fujinaga
- Department of Gastroenterology, Nara Medical University, Kashihara, Japan
| | - Norihisa Nishimura
- Department of Gastroenterology, Nara Medical University, Kashihara, Japan
| | - Koh Kitagawa
- Department of Gastroenterology, Nara Medical University, Kashihara, Japan
| | - Kosuke Kaji
- Department of Gastroenterology, Nara Medical University, Kashihara, Japan
| | - Hideto Kawaratani
- Department of Gastroenterology, Nara Medical University, Kashihara, Japan
| | - Tadashi Namisaki
- Department of Gastroenterology, Nara Medical University, Kashihara, Japan
| | | | - Hitoshi Yoshiji
- Department of Gastroenterology, Nara Medical University, Kashihara, Japan
| |
Collapse
|
13
|
Seccia TM, Rossitto G, Rossi GP. A Worrying and Puzzling Case of Hypertension Presenting to the Emergency Department. Hypertension 2024; 81:1179-1185. [PMID: 38748766 DOI: 10.1161/hypertensionaha.123.22108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/04/2024]
Affiliation(s)
- Teresa M Seccia
- Internal Emergency Medicine Unit, Department of Medicine-DIMED, University of Padua, Specialized Center for Blood Pressure Disorders-Regione Veneto, Italy
| | - Giacomo Rossitto
- Internal Emergency Medicine Unit, Department of Medicine-DIMED, University of Padua, Specialized Center for Blood Pressure Disorders-Regione Veneto, Italy
| | - Gian Paolo Rossi
- Internal Emergency Medicine Unit, Department of Medicine-DIMED, University of Padua, Specialized Center for Blood Pressure Disorders-Regione Veneto, Italy
| |
Collapse
|
14
|
Java A, Burwick R, Chang A. Thrombotic Microangiopathies and the Kidney. ADVANCES IN KIDNEY DISEASE AND HEALTH 2024; 31:255-264. [PMID: 39004465 DOI: 10.1053/j.akdh.2023.09.003] [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: 07/06/2023] [Revised: 08/27/2023] [Accepted: 09/12/2023] [Indexed: 07/16/2024]
Abstract
Thrombotic microangiopathy (TMA) is a pathological lesion that occurs due to endothelial injury. It can be seen in a heterogenous group of disorders, typically characterized by microangiopathic hemolytic anemia, thrombocytopenia, and end-organ ischemia. TMA can also be renal limited with no systemic manifestations. There are multiple etiologies of a TMA with complement activation being a core underlying mechanism, although the nature and extent of complement involvement can vary. A further complicated factor is the cross talk between complement, neutrophils, and coagulation pathways in the pathophysiology of TMAs. Therefore, a thorough and systematic clinical history and laboratory evaluation are critical to establish the cause and pathophysiology of a TMA. Furthermore, TMAs are associated with significant morbidity and mortality, and timely diagnosis is key for appropriate management and to prevent end-stage kidney disease and other associated complications. In this review, we focus on the pathology, mechanisms, diagnostic work up and treatment of TMAs associated with various etiologies. We also define the complement evaluations that should be conducted in these patients and further highlight the currently approved complement therapies as well as others in the pipeline.
Collapse
Affiliation(s)
- Anuja Java
- Division of Nephrology, Department of Medicine, Washington University School of Medicine, St. Louis, MO.
| | - Richard Burwick
- Maternal Fetal Medicine, San Gabriel Valley Perinatal Medical Group, Pomona Valley Hospital Medical Center, Pomona, CA
| | - Anthony Chang
- Department of Pathology, The University of Chicago, Chicago, IL
| |
Collapse
|
15
|
Salem R, Al Mulla I, Alhouda N, Iqbal J, Gmati G. Thrombotic Microangiopathy Post-COVID-19 Vaccination. Cureus 2024; 16:e60506. [PMID: 38883042 PMCID: PMC11180482 DOI: 10.7759/cureus.60506] [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: 05/17/2024] [Indexed: 06/18/2024] Open
Abstract
The emergence of COVID-19 has caused a wide spectrum of symptoms, ranging from asymptomatic to devastating symptoms, leading to death. One of the most serious complications of COVID-19 is the thromboembolic phenomenon, which has led to increased morbidity and mortality. Several vaccines were developed to protect against this infection and used widely across the globe. However, thromboembolic events were observed in the vaccinated population and were certainly the most commonly reported events following the COVID-19 vaccination. Although the thrombotic complications of COVID-19 were poorly understood, hyper-inflammatory responses were thought to be one of the main explanations for this infection sequel. In the setting of COVID-19 vaccines, there is still no clear understanding of the thrombosis pathophysiology, and, again, exaggerated pro-inflammatory and immune-mediated processes seem to be leading causes. Definitely, with the rise in reported cases of serious complications and increased awareness of these phenomena, we learn new theories and explanations that help us understand and manage those patients. We report the case report of two patients we managed over the last three years who presented with thrombotic microangiopathy following the COVID-19 vaccination.
Collapse
Affiliation(s)
- Rahaf Salem
- Department of Internal Medicine, King Abdulaziz Medical City, Riyadh, SAU
| | | | - Noure Alhouda
- Department of Pathology and Laboratory Medicine, King Abdulaziz Medical City, Riyadh, SAU
| | - Junaid Iqbal
- Division of Nephrology, Department of Medicine, King Abdulaziz Medical City, Riyadh, SAU
| | - Giamal Gmati
- Department of Oncology, Mid and South Essex NHS Foundation Trust, Chelmsford, GBR
| |
Collapse
|
16
|
Ito Y, Takeuchi S, Tozawa T, Hisada S, Yamada Y, Kodera M, Kobayashi M, Shirahata M, Matsubara A. Anti-melanoma differentiation-associated gene 5 antibody-positive dermatomyositis with possible complication of thrombotic microangiopathy. J Dermatol 2024; 51:448-452. [PMID: 37830409 DOI: 10.1111/1346-8138.17004] [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: 04/18/2023] [Revised: 09/05/2023] [Accepted: 09/28/2023] [Indexed: 10/14/2023]
Abstract
This case study illustrates a 63-year-old Japanese woman who presented with anti-melanoma differentiation-associated gene 5 antibody-positive dermatomyositis. She was administered a therapeutic regimen consisting of corticosteroids, tacrolimus, and cyclophosphamide. However, after a month of treatment, symptoms of confusion and depressive tendencies emerged, followed by the manifestation of hematuria, thrombocytopenia, and fragmented erythrocytes. A disintegrin-like and metalloprotease with thrombospondin type 1 motifs 13 activity was 45%. Thrombotic microangiopathy was contemplated, yet a definitive diagnosis remained elusive. She died 2 months after admission. Although the occurrence of thrombotic microangiopathy in patients with dermatomyositis is rare, the prognosis is poor, emphasizing the importance of prompt diagnosis and treatment.
Collapse
Affiliation(s)
- Yumi Ito
- Department of Dermatology, Japan Community Health Care Organization Chukyo Hospital, Nagoya, Japan
| | - Saki Takeuchi
- Department of Dermatology, Japan Community Health Care Organization Chukyo Hospital, Nagoya, Japan
| | - Takahisa Tozawa
- Department of Dermatology, Japan Community Health Care Organization Chukyo Hospital, Nagoya, Japan
| | - Satoko Hisada
- Department of Dermatology, Japan Community Health Care Organization Chukyo Hospital, Nagoya, Japan
| | - Yoshihiro Yamada
- Department of Dermatology, Japan Community Health Care Organization Chukyo Hospital, Nagoya, Japan
| | - Masanari Kodera
- Department of Dermatology, Japan Community Health Care Organization Chukyo Hospital, Nagoya, Japan
| | - Masahiro Kobayashi
- Department of Respiratory Medicine, Japan Community Health Care Organization Chukyo Hospital, Nagoya, Japan
| | - Mizuho Shirahata
- Department of Hematology, Japan Community Health Care Organization Chukyo Hospital, Nagoya, Japan
| | | |
Collapse
|
17
|
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.
Collapse
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
| |
Collapse
|
18
|
Al-Awadhi A, Marouf R, Jadaon MM, Al-Awadhy MM. Determination of vWF, ADAMTS-13 and Thrombospondin-1 in Venous Thromboembolism and Relating Them to the Presence of Factor V Leiden Mutation. Clin Appl Thromb Hemost 2024; 30:10760296231223195. [PMID: 38225166 PMCID: PMC10793187 DOI: 10.1177/10760296231223195] [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: 07/12/2023] [Revised: 11/26/2023] [Accepted: 12/12/2023] [Indexed: 01/17/2024] Open
Abstract
Thrombophilia in venous thromboembolism (VTE) is multifactorial. Von Willebrand factor (vWF) plays a major role in primary hemostasis. While elevated vWF levels are well documented in VTE, findings related to its cleaving protease (ADAMTS-13) are contradicting. The aim of this study was to determine vWF, ADAMTS-13, and the multifactorial Thrombospondin-1 (TSP-1) protein levels in patients after 3-6 months following an unprovoked VTE episode. We also explored a possible association with factor V Leiden (FVL) mutation. vWF, ADAMTS-13 and TSP-1 were analyzed using ELISA kits in 60 VTE patients and 60 controls. Patients had higher levels of vWF antigen (P = .021), vWF collagen-binding activity (P = .008), and TSP-1 protein (P < .001) compared to controls. ADAMTS-13 antigen was lower in patients (P = .046) compared to controls but ADAMTS-13 activity was comparable between the two groups (P = .172). TSP-1 showed positive correlation with vWF antigen (rho = 0.303, P = .021) and negative correlation with ADAMTS-13 activity (rho = -0.244, P = .033) and ADAMTS-13 activity/vWF antigen ratio (rho = -0.348, P = .007). A significant association was found between the presence of FVL mutation and VTE (odds ratio (OR): 9.672 (95% confidence interval (CI) 2.074-45.091- P = .004), but no association was found between the mutation and the studied proteins (P > .05). There appears to be an imbalance between vWF and ADAMTS-13 in VTE patients even after 3-6 months following the onset of VTE. We report that the odds of developing VTE in carriers of FVL mutation are 9.672 times those without the mutation, but the presence of this mutation is not associated with the studied proteins.
Collapse
Affiliation(s)
- Anwar Al-Awadhi
- Department of Medical Laboratory Sciences, Faculty of Allied Health Sciences, Health Sciences Center, Kuwait University, Kuwait
| | - Rajaa Marouf
- Department of Pathology, Faculty of Medicine, Health Sciences Center, Kuwait University, Kuwait
| | - Mehrez M. Jadaon
- Department of Medical Laboratory Sciences, Faculty of Allied Health Sciences, Health Sciences Center, Kuwait University, Kuwait
| | | |
Collapse
|
19
|
Kunwor B, Sharma B, Chhetri ST, Joshi P, Pradhan D. Atypical hemolytic uremic syndrome in a child: A rare case report. Clin Case Rep 2024; 12:e8356. [PMID: 38161638 PMCID: PMC10753129 DOI: 10.1002/ccr3.8356] [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: 07/24/2023] [Revised: 11/07/2023] [Accepted: 12/14/2023] [Indexed: 01/03/2024] Open
Abstract
Atypical hemolytic uremic syndrome, a rare thrombotic microangiopathy, necessitates early diagnosis and comprehensive care due to its potential severity, emphasizing the importance of a multidisciplinary approach to improve outcomes.
Collapse
Affiliation(s)
- Bishal Kunwor
- Nepalese Army Institute of Health SciencesKathmanduNepal
| | - Bishal Sharma
- Nepalese Army Institute of Health SciencesKathmanduNepal
| | | | | | | |
Collapse
|
20
|
de Boisriou I, Ellouze S, Kassasseya C, Feral-Pierssens AL, Gerlier C, Chauvin A, Beaune S, Dubreucq E, Pereira L, Chocron R, Khellaf M, Mariotte É, Zafrani L, Peyrony O. Misdiagnosis of thrombotic microangiopathy in the emergency department: a multicenter retrospective study. Intern Emerg Med 2024; 19:115-124. [PMID: 37914919 DOI: 10.1007/s11739-023-03457-8] [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: 07/28/2023] [Accepted: 10/08/2023] [Indexed: 11/03/2023]
Abstract
To estimate the rate of inappropriate diagnosis in patients who visited the ED with thrombotic microangiopathy (TMA) and to assess the factors and outcomes associated with emergency department (ED) misdiagnosis. Retrospective multicenter study of adult patients admitted to the intensive care unit (ICU) for TMA from 2012 to 2021 who had previously attended the ED for a reason related to TMA. Patient characteristics and outcomes were compared in a univariate analysis based on whether a TMA diagnosis was mentioned in the ED or not. Forty patients were included. The diagnosis of TMA was not mentioned in the ED in 16 patients (40%). Patients for whom the diagnosis was mentioned in the ED had more frequently a request for schistocytes research, and therefore had more often objectified schistocytes. They also had more frequently a troponin dosage in the ED (even if the difference was not significant), an ECG performed or interpreted, and were admitted more quickly in the ICU (0 [0-0] vs 2 [0-2] days; P = 0.002). Hemoglobin levels decreased significantly in both groups, and creatinine levels increased significantly in the misdiagnosis group between ED arrival and ICU admission. In patients with a final diagnosis of TTP, the time to platelets durable recovery was shorter for those in whom the diagnosis was mentioned in the ED without reaching statistical significance (7 [5-11] vs 14 [5-21] days; P = 0.3).
Collapse
Affiliation(s)
| | - Sami Ellouze
- Emergency Department, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, 1 Avenue Claude Vellefaux, 75010, Paris, France
| | - Christian Kassasseya
- Emergency Department, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Paris, France
| | | | - Camille Gerlier
- Emergency Department, Groupe Hospitalier Paris-Saint-Joseph, Paris, France
| | - Anthony Chauvin
- Emergency Department, Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Sebastien Beaune
- Emergency Department, Hôpital Ambroise Paré, Assistance Publique-Hôpitaux de Paris, Paris, France
- Université Versailles St Quentin- UFR Simone Veil santé, Montigny-le-Bretonneux, France
| | - Evelyne Dubreucq
- Emergency Department, Hôpital Tenon, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Laurent Pereira
- Emergency Department, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Richard Chocron
- Emergency Department, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France
- INSERM, UMR-S970, Paris Cardiovascular Research Center, Team "Integrative Epidemiology of Cardiovascular Diseases", Université Paris Cité, Paris, France
| | - Mehdi Khellaf
- Emergency Department, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Éric Mariotte
- Intensive Care Unit, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Lara Zafrani
- Intensive Care Unit, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Olivier Peyrony
- Emergency Department, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, 1 Avenue Claude Vellefaux, 75010, Paris, France.
| |
Collapse
|
21
|
Chen FF, Yu XJ, Wang H, Zhang X, Tan Y, Qu Z, Wang SX, Yu F, Chen M, Zhao MH. Clinical value of the renal pathologic scoring system in complement-mediated thrombotic microangiopathy. Ren Fail 2023; 45:2161396. [PMID: 36648027 PMCID: PMC9848373 DOI: 10.1080/0886022x.2022.2161396] [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] [Indexed: 01/18/2023] Open
Abstract
OBJECTIVES This study was initiated to establish a renal thrombotic microangiopathy (TMA) scoring system based on clinical needs and investigate its predictive value for patients' long-term outcomes. METHODS Kidney biopsy-proven Complement-mediated TMA (C-TMA) patients from January 2000 to December 2017 in Peking University First Hospital were retrospectively studied. Both acute and chronic TMA-related lesions, including 15 pathologic indices, were semiquantitatively scored. The interobserver and intraobserver reproducibility and correlation between the pathologic indices and clinical parameters were analyzed. Furthermore, the patients were divided into 2 groups by dialysis use at baseline, and the association of these pathologic indices with their prognostic outcomes was assessed between the two groups. RESULTS Ninety-two patients with renal biopsy-proven C-TMA were enrolled. All fifteen included pathology indices showed good or moderate interobserver and intraobserver reproducibility and correlated well with several clinical parameters. Several clinicopathological indices were worse in the dialysis group than in the nondialysis group, such as serum creatinine, hemoglobin, platelet count, and estimated glomerular filtration rate. Moreover, morphologic features in the dialysis group presented with more severe vascular lesions. Interstitial fibrosis and chronic tubulointerstitial lesions were related to a trend of high risk of continuous dialysis in the dialysis group. Based on univariate and multivariable Cox regression analysis, more severe glomerular lesions, including glomerular mesangiolysis, glomerular basement membrane double contours and glomerular mesangial proliferation, were identified as risk factors predicting worse prognosis. CONCLUSIONS Our renal C-TMA semiquantitative scoring system is reliable with good reproducibility and prognostic value in clinical practice, which needs further validation.
Collapse
Affiliation(s)
- Fei-Fei Chen
- Renal Division, Department of Medicine, Peking University First Hospital; Institute of Nephrology, Peking University; Renal Pathology Center, Institute of Nephrology, Peking University First Hospital; Key Laboratory of Renal Disease, Ministry of Health of China; Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, PR China
| | - Xiao-Juan Yu
- Renal Division, Department of Medicine, Peking University First Hospital; Institute of Nephrology, Peking University; Renal Pathology Center, Institute of Nephrology, Peking University First Hospital; Key Laboratory of Renal Disease, Ministry of Health of China; Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, PR China
| | - Hui Wang
- Renal Division, Department of Medicine, Peking University First Hospital; Institute of Nephrology, Peking University; Renal Pathology Center, Institute of Nephrology, Peking University First Hospital; Key Laboratory of Renal Disease, Ministry of Health of China; Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, PR China,Department of Electron Microscopy, Pathological Centre, Peking University First Hospital, Beijing, PR China
| | - Xu Zhang
- Renal Division, Department of Medicine, Peking University First Hospital; Institute of Nephrology, Peking University; Renal Pathology Center, Institute of Nephrology, Peking University First Hospital; Key Laboratory of Renal Disease, Ministry of Health of China; Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, PR China,Department of Electron Microscopy, Pathological Centre, Peking University First Hospital, Beijing, PR China
| | - Ying Tan
- Renal Division, Department of Medicine, Peking University First Hospital; Institute of Nephrology, Peking University; Renal Pathology Center, Institute of Nephrology, Peking University First Hospital; Key Laboratory of Renal Disease, Ministry of Health of China; Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, PR China
| | - Zhen Qu
- Department of Nephrology, Peking University International Hospital, Beijing, PR China,CO-CONTACT Zhen Qu Renal Division, Peking University International Hospital, Beijing, PR China
| | - Su-Xia Wang
- Renal Division, Department of Medicine, Peking University First Hospital; Institute of Nephrology, Peking University; Renal Pathology Center, Institute of Nephrology, Peking University First Hospital; Key Laboratory of Renal Disease, Ministry of Health of China; Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, PR China,Department of Electron Microscopy, Pathological Centre, Peking University First Hospital, Beijing, PR China,CO-CONTACT Su-Xia Wang Department of Electron Microscopy, Pathological Centre, Peking University First Hospital, Beijing100034, PR China
| | - Feng Yu
- Renal Division, Department of Medicine, Peking University First Hospital; Institute of Nephrology, Peking University; Renal Pathology Center, Institute of Nephrology, Peking University First Hospital; Key Laboratory of Renal Disease, Ministry of Health of China; Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, PR China,Department of Nephrology, Peking University International Hospital, Beijing, PR China,CONTACT Feng Yu Renal Division, Department of Medicine, Peking University First Hospital; Institute of Nephrology, Peking University; Key Laboratory of Renal Disease, Ministry of Health of China; Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China; Department of Nephrology, Peking University International Hospital, Beijing102206, PR China
| | - Min Chen
- Renal Division, Department of Medicine, Peking University First Hospital; Institute of Nephrology, Peking University; Renal Pathology Center, Institute of Nephrology, Peking University First Hospital; Key Laboratory of Renal Disease, Ministry of Health of China; Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, PR China
| | - Ming-Hui Zhao
- Renal Division, Department of Medicine, Peking University First Hospital; Institute of Nephrology, Peking University; Renal Pathology Center, Institute of Nephrology, Peking University First Hospital; Key Laboratory of Renal Disease, Ministry of Health of China; Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, PR China,Peking-Tsinghua Center for Life Sciences, PR China
| |
Collapse
|
22
|
Awamura T, Nakasone ES, Gangcuangco LM, Subia NT, Bali AJ, Chow DC, Shikuma CM, Park J. Platelet and HIV Interactions and Their Contribution to Non-AIDS Comorbidities. Biomolecules 2023; 13:1608. [PMID: 38002289 PMCID: PMC10669125 DOI: 10.3390/biom13111608] [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: 10/05/2023] [Revised: 10/29/2023] [Accepted: 10/31/2023] [Indexed: 11/26/2023] Open
Abstract
Platelets are anucleate cytoplasmic cell fragments that circulate in the blood, where they are involved in regulating hemostasis. Beyond their normal physiologic role, platelets have emerged as versatile effectors of immune response. During an infection, cell surface receptors enable platelets to recognize viruses, resulting in their activation. Activated platelets release biologically active molecules that further trigger host immune responses to protect the body against infection. Their impact on the immune response is also associated with the recruitment of circulating leukocytes to the site of infection. They can also aggregate with leukocytes, including lymphocytes, monocytes, and neutrophils, to immobilize pathogens and prevent viral dissemination. Despite their host protective role, platelets have also been shown to be associated with various pathophysiological processes. In this review, we will summarize platelet and HIV interactions during infection. We will also highlight and discuss platelet and platelet-derived mediators, how they interact with immune cells, and the multifaceted responsibilities of platelets in HIV infection. Furthermore, we will give an overview of non-AIDS comorbidities linked to platelet dysfunction and the impact of antiretroviral therapy on platelet function.
Collapse
Affiliation(s)
- Thomas Awamura
- Department of Tropical Medicine, Medical Microbiology, and Pharmacology, John A. Burns School Medicine, University of Hawai‘i at Mānoa, Honolulu, HI 96813, USA; (T.A.); (N.T.S.); (A.-J.B.)
| | - Elizabeth S. Nakasone
- University of Hawai‘i Cancer Center, University of Hawai‘i at Mānoa, Honolulu, HI 96813, USA;
- Department of Medicine, John A. Burns School of Medicine, University of Hawai‘i at Mānoa, Honolulu, HI 96813, USA;
| | - Louie Mar Gangcuangco
- Hawai‘i Center for AIDS, John A. Burns School of Medicine, University of Hawai‘i at Mānoa, Honolulu, HI 96813, USA; (L.M.G.); (C.M.S.)
| | - Natalie T. Subia
- Department of Tropical Medicine, Medical Microbiology, and Pharmacology, John A. Burns School Medicine, University of Hawai‘i at Mānoa, Honolulu, HI 96813, USA; (T.A.); (N.T.S.); (A.-J.B.)
| | - Aeron-Justin Bali
- Department of Tropical Medicine, Medical Microbiology, and Pharmacology, John A. Burns School Medicine, University of Hawai‘i at Mānoa, Honolulu, HI 96813, USA; (T.A.); (N.T.S.); (A.-J.B.)
| | - Dominic C. Chow
- Department of Medicine, John A. Burns School of Medicine, University of Hawai‘i at Mānoa, Honolulu, HI 96813, USA;
- Hawai‘i Center for AIDS, John A. Burns School of Medicine, University of Hawai‘i at Mānoa, Honolulu, HI 96813, USA; (L.M.G.); (C.M.S.)
| | - Cecilia M. Shikuma
- Hawai‘i Center for AIDS, John A. Burns School of Medicine, University of Hawai‘i at Mānoa, Honolulu, HI 96813, USA; (L.M.G.); (C.M.S.)
| | - Juwon Park
- Department of Tropical Medicine, Medical Microbiology, and Pharmacology, John A. Burns School Medicine, University of Hawai‘i at Mānoa, Honolulu, HI 96813, USA; (T.A.); (N.T.S.); (A.-J.B.)
- Hawai‘i Center for AIDS, John A. Burns School of Medicine, University of Hawai‘i at Mānoa, Honolulu, HI 96813, USA; (L.M.G.); (C.M.S.)
| |
Collapse
|
23
|
Durak C, Sahin EG, Yusuf Can Y, Varol F, Cam H. Why has plasma exchange failed in TRACK syndrome? Lessons from a new variant of the atypical hemolytic uremic syndrome. J Clin Apher 2023; 38:647-650. [PMID: 37338178 DOI: 10.1002/jca.22070] [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: 04/11/2023] [Revised: 06/07/2023] [Accepted: 06/08/2023] [Indexed: 06/21/2023]
Abstract
Atypical hemolytic uremic syndrome (aHUS) is a rare and life-threatening form of thrombotic microangiopathy, associated with high mortality and morbidity. Most cases present with hemolytic anemia, thrombocytopenia, and renal insufficiency. However, it can have unusual multiple end-organ injuries including extrarenal organ and system involvements such as neurologic, cardiac, gastrointestinal, and respiratory systems. We describe a 4-year-old girl who developed aHUS due to the TSEN2 mutation and had cardiac involvement. She did not benefit from plasma exchange, as stated in previous cases. It should be kept in mind that therapeutic plasma exchange may not be beneficial in some cases of aHUS, especially due to genetic mutations.
Collapse
Affiliation(s)
- Cansu Durak
- Department of Pediatrics, Division of Pediatric Intensive Care Unit, Sancaktepe Sehit Prof. Dr. Ilhan Varank Training and Research Hospital, University of Health Science, Istanbul, Turkey
| | - Ebru Guney Sahin
- Department of Pediatrics, Division of Pediatric Intensive Care Unit, Sancaktepe Sehit Prof. Dr. Ilhan Varank Training and Research Hospital, University of Health Science, Istanbul, Turkey
| | - Yasar Yusuf Can
- Department of Pediatrics, Division of Pediatric Intensive Care Unit, Sancaktepe Sehit Prof. Dr. Ilhan Varank Training and Research Hospital, University of Health Science, Istanbul, Turkey
| | - Fatih Varol
- Department of Pediatrics, Division of Pediatric Intensive Care Unit, Sancaktepe Sehit Prof. Dr. Ilhan Varank Training and Research Hospital, University of Health Science, Istanbul, Turkey
| | - Halit Cam
- Department of Pediatrics, Division of Pediatric Intensive Care Unit, Sancaktepe Sehit Prof. Dr. Ilhan Varank Training and Research Hospital, University of Health Science, Istanbul, Turkey
| |
Collapse
|
24
|
Adachi T, Inoue Y, Okada S, Eguchi S. Haemolytic uraemic syndrome managed with subtotal colectomy. BMJ Case Rep 2023; 16:e256585. [PMID: 37751977 PMCID: PMC10533651 DOI: 10.1136/bcr-2023-256585] [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] [Indexed: 09/30/2023] Open
Abstract
A man in his early 70s was transferred to our hospital due to rapid decline in renal function and inflammation throughout the colon, indicating severe ischaemic enteritis. On the day following the start of intensive care, a stool specimen tested positive for verotoxin, and haemolytic uraemic syndrome (HUS) was diagnosed. On the same day, his vital signs deteriorated suddenly, and emergency surgery was performed due to the possibility of intestinal necrosis and perforation. Severe inflammation extending to the serosal surface of the whole colon was observed, but there was no obvious intestinal necrosis or perforation. Advanced mucosal necrosis of the entire colon suggested sepsis due to bacterial translocation, and subtotal colectomy was performed to remove the infection source. Postoperative management was successful. This case demonstrates the importance of considering HUS in patients with severe renal dysfunction and bloody stools, as well as the significance of colectomy in such patients.
Collapse
Affiliation(s)
- Toshiyuki Adachi
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Yusuke Inoue
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Satomi Okada
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Susumu Eguchi
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| |
Collapse
|
25
|
Narayan SK, Gudivada KK, Sivakoti S, Krishna B. Outcomes of patients with thrombotic thrombocytopenic purpura treated in an intensive care unit. THE NATIONAL MEDICAL JOURNAL OF INDIA 2023; 36:295-300. [PMID: 38759978 DOI: 10.25259/nmji_205_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/19/2024]
Abstract
Background Thrombotic thrombocytopenic purpura (TTP) is a multisystem disorder characterized by widespread microthrombosis that can predispose to multiple organ failure. The literature is sparse on the outcomes of critically ill patients with TTP managed in intensive care units (ICUs). We aimed to determine the mortality of ICU patients admitted with TTP and evaluate the predictors of survival. We also compared the incidence of nosocomial infection among those who did or did not receive plasma exchange (PE). Methods We conducted a retrospective study in a tertiary ICU. Two authors screened patients for eligibility from the hospital information system based on peripheral smear reports. Adult critically ill TTP patients managed in ICU were included. Patients with a diagnosis of haemolytic uraemic syndrome, autoimmune causes of haemolysis and pregnancy-related conditions, etc. were excluded. Two authors extracted data from medical charts. No imputation of missing variables was done. Non-parametric statistics were used to report data. Statistical analyses were performed using Stata version 16. Results Of the 535 records that were screened, 33 patients were deemed eligible. Mortality among TTP patients was 14 (42%). The women to men ratio was 7:3. At admission, greater degree of anaemia, thrombocytopenia, and higher lactate dehydrogenase levels were observed in non-survivors compared to survivors (5.4 g/dl [4.8-7.1] v. 7.6 g/dl [6.1-8.9], p=0.05; 17x103 μl v. 21x103 μl, p=0.63; and 2987 (1904-3614) U/L v. 2126 U/L (1941-3319), p=0.71; respectively]. Nineteen (57%) patients had acute kidney injury (AKI), of which 11 survived: 6 recovered completely from renal failure and 5 progressed to end-stage renal disease. Nosocomial infection rates were not different among those receiving and not receiving PE therapy (7 [33%] v. 3 [25%], respectively). Conclusion TTP is more common in women and has a high mortality. Older age, low haemoglobin and higher platelet transfusions are predictors of poor survival. Nosocomial infection rates were similar irrespective of receiving PE therapy.
Collapse
Affiliation(s)
- Shiva Kumar Narayan
- Department of Critical Care Medicine, St John's Medical College, Bengaluru, Karnataka 560034, India
| | - Kiran Kumar Gudivada
- Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Bibinagar, Hyderabad Metropolitan Region, Telangana 508126, India
| | - Sumitra Sivakoti
- Department of Pathology and Laboratory Medicine, All India Institute of Medical Sciences, Bibinagar, Hyderabad Metropolitan Region, Telangana 508126, India
| | - Bhuvana Krishna
- Department of Critical Care Medicine, St John's Medical College, Bengaluru, Karnataka 560034, India
| |
Collapse
|
26
|
Kirsanova TV, Balakireva AI, Fedorova TA, Pyregov AV, Rogachevskiy OV. [Various phenotypes of postpartum atypical hemolytic uremic syndrome: the role of genetic testing in determining prognosis. Case report]. TERAPEVT ARKH 2023; 95:511-515. [PMID: 38158972 DOI: 10.26442/00403660.2023.06.202233] [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: 08/14/2023] [Accepted: 08/14/2023] [Indexed: 01/03/2024]
Abstract
We report a case of atypical hemolytic uremic syndrome (aHUS) that occurred after childbirth in a patient with a history of numerous recurrent episodes of TMA with nephrotic proteinuria and impaired renal function. At 33 weeks of the first spontaneous pregnancy, proteinuria up to 0.8 g/l was first registered, at 38 weeks she was hospitalized with proteinuria, reaching a maximum of 13 g/l, she was delivered promptly, after which progressive thrombocytopenia was noted over the next few days (up to 44×109/l) and anemia and severe arterial hypertension, which could not be corrected by several groups of antihypertensive drugs. Initiated plasma therapy had no effect. After exclusion of all other causes of TMA, therapy with eculizumab was initiated, which made it possible to quickly and completely stop the phenomena of TMA. The presented observation demonstrates the successful treatment of recurrent course of aHUS with eculizumab with the achievement of complete recovery of kidney function in a patient with a homozygous mutation in the MCP gene. It is worth noting the importance of genetic research even in those situations where clinically aHUS is beyond doubt.
Collapse
Affiliation(s)
- T V Kirsanova
- Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology
| | | | - T A Fedorova
- Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology
| | - A V Pyregov
- Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology
| | - O V Rogachevskiy
- Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology
| |
Collapse
|
27
|
Bruzzese A, Vigna E, Terzi D, Greco S, Martino EA, Vangeli V, Mendicino F, Lucia E, Olivito V, Labanca C, Morelli R, Neri A, Morabito F, Zinno F, Mastroianni A, Gentile M. Safe and Effective Administration of Caplacizumab in COVID-19-Associated Thrombotic Thrombocytopenic Purpura. Hematol Rep 2023; 15:448-453. [PMID: 37489376 PMCID: PMC10366750 DOI: 10.3390/hematolrep15030046] [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: 03/27/2023] [Revised: 04/28/2023] [Accepted: 07/12/2023] [Indexed: 07/26/2023] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a potentially life-threatening, rare acute thrombotic microangiopathy (TMA), caused by a severe ADAMTS13 deficiency. As the COVID-19 pandemic rapidly spread around the globe, much data about the pathogenicity of this virus were published. Soon after the detection of the first cases of COVID-19, it was clear that there was a wide range of COVID coagulopathy manifestations, such as deep venous thrombosis, pulmonary thromboembolism, and thrombotic microangiopathies. In the literature, little data have been reported about the association between TTP and COVID-19, and the treatment of COVID-19-associated TTP is still under debate. Here we present the case of a 46-year-old woman who developed a COVID-associated TTP, successfully treated with plasma exchange (PEX), steroids, and caplacizumab.
Collapse
Affiliation(s)
| | - Ernesto Vigna
- Hematology Unit, Azienda Ospedaliera Annunziata, 87100 Cosenza, Italy
| | - Dario Terzi
- Immunohaematology Section, Annunziata Hospital, 87100 Cosenza, Italy
| | - Sonia Greco
- Infectious & Tropical Diseases Unit, Annunziata Hospital, 87100 Cosenza, Italy
| | | | - Valeria Vangeli
- Infectious & Tropical Diseases Unit, Annunziata Hospital, 87100 Cosenza, Italy
| | | | - Eugenio Lucia
- Hematology Unit, Azienda Ospedaliera Annunziata, 87100 Cosenza, Italy
| | - Virginia Olivito
- Hematology Unit, Azienda Ospedaliera Annunziata, 87100 Cosenza, Italy
| | - Caterina Labanca
- Hematology Unit, Azienda Ospedaliera Annunziata, 87100 Cosenza, Italy
| | - Rosellina Morelli
- Medicine Department, "Annunziata" Hospital of Cosenza, 87100 Cosenza, Italy
| | - Antonino Neri
- Scientific Directorate IRCCS of Reggio Emilia, 42123 Reggio Emilia, Italy
| | | | - Francesco Zinno
- Immunohaematology Section, Annunziata Hospital, 87100 Cosenza, Italy
| | - Antonio Mastroianni
- Infectious & Tropical Diseases Unit, Annunziata Hospital, 87100 Cosenza, Italy
| | - Massimo Gentile
- Hematology Unit, Azienda Ospedaliera Annunziata, 87100 Cosenza, Italy
- Department of Pharmacy, Health and Nutritional Science, University of Calabria, 87036 Rende, Italy
| |
Collapse
|
28
|
Singh K, Madarati H, Sohrabipour S, Sparring T, Teney C, Kretz CA. Metalloprotease domain latency protects ADAMTS13 against broad-spectrum inhibitors of metalloproteases while maintaining activity toward VWF. J Thromb Haemost 2023; 21:1789-1801. [PMID: 36990157 DOI: 10.1016/j.jtha.2023.03.021] [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: 12/22/2022] [Revised: 02/26/2023] [Accepted: 03/21/2023] [Indexed: 03/30/2023]
Abstract
BACKGROUND ADAMTS13 is a circulating metalloprotease that cleaves von Willebrand factor (VWF) in a shear-dependent manner. ADAMTS13 is secreted as an active protease but has a long half-life, suggesting that it is resistant to circulating protease inhibitors. These zymogen-like properties indicate that ADAMTS13 exists as a latent protease that is activated by its substrate. OBJECTIVES To investigate the mechanism of ADAMTS13 latency and resistance to metalloprotease inhibitors. METHODS Probe the active site of ADAMTS13 and variants using alpha-2 macroglobulin (A2M), tissue inhibitors of metalloproteases (TIMPs), and Marimastat. RESULTS ADAMTS13 and C-terminal deletion mutants are not inhibited by A2M, TIMPs, or Marimastat, but cleave FRETS-VWF73, suggesting that the metalloprotease domain is latent in the absence of substrate. Within the metalloprotease domain, mutating the gatekeeper triad (R193, D217, D252) or substituting the calcium-binding (R180-R193) or the variable (G236-S263) loops with corresponding features from ADAMTS5 did not sensitize MDTCS to inhibition. However, substituting the calcium-binding loop and an extended variable loop (G236-S263) corresponding to the S1-S1' pockets with those from ADAMTS5, resulted in MDTCS-GVC5 inhibition by Marimastat, but not by A2M or TIMP3. Substituting the MD domains of ADAMTS5 into full-length ADAMTS13 resulted in a 50-fold reduction in activity compared with the substitution into MDTCS. However, both chimeras were susceptible to inhibition, suggesting that the closed conformation does not contribute to the latency of the metalloprotease domain. CONCLUSION The metalloprotease domain protects ADAMTS13 from inhibitors and exists in a latent state that is partially maintained by loops flanking the S1 and S1' specificity pockets.
Collapse
Affiliation(s)
- Kanwal Singh
- Department of Medicine, Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Hasam Madarati
- Department of Medicine, Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Sahar Sohrabipour
- Department of Medicine, Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Taylor Sparring
- Department of Medicine, Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Cherie Teney
- Department of Medicine, Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Colin A Kretz
- Department of Medicine, Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada.
| |
Collapse
|
29
|
Gallant TL, Zheng E, Hobbs AM, Becka AJ, Bertsch RA. Complement-Mediated Thrombotic Microangiopathy in a Patient With Antiphospholipid Syndrome and Anti-glomerular Basement Membrane Antibodies. Cureus 2023; 15:e42410. [PMID: 37637585 PMCID: PMC10448002 DOI: 10.7759/cureus.42410] [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: 07/24/2023] [Indexed: 08/29/2023] Open
Abstract
Thrombotic microangiopathy (TMA) is a range of diseases characterized by thrombocytopenia, microangiopathic hemolytic anemia, and organ injury. Complement-mediated TMA is a rare, life-threatening subtype of TMA that occurs due to the uncontrolled activation of the alternative complement pathway in the absence of normal regulation, often resulting from deficiencies of various regulatory proteins. Anti-glomerular basement membrane (anti-GBM) disease, previously known as Goodpasture syndrome, is a life-threatening form of vasculitis in which immunoglobulin G autoantibodies bind to the alpha-3 chain of type IV collagen in alveolar and glomerular basement membranes. We present the case of a patient with a history of antiphospholipid syndrome who was diagnosed with complement-mediated TMA during hospital admission for elevated anti-GBM antibody titers discovered during an outpatient evaluation for elevated creatinine levels. Upon admission, treatment was started for presumed anti-GBM disease, including high-dose intravenous methylprednisolone injections and multiple plasmapheresis sessions. However, renal biopsy results showed no evidence of anti-GBM disease, but rather evidence of TMA. Subsequent laboratory studies revealed decreased complement levels, suggestive of a diagnosis of complement-mediated TMA. The patient was started on rituximab and eculizumab infusions, and she was discharged in stable condition after a 15-day hospitalization with outpatient appointments scheduled for genetic testing and further infusions. This case illustrates the importance of recognizing the key clinical and diagnostic features of complement-mediated TMA to promptly initiate appropriate therapy.
Collapse
Affiliation(s)
- Tara L Gallant
- College of Medicine, California Northstate University College of Medicine, Elk Grove, USA
| | - Emily Zheng
- College of Medicine, California Northstate University College of Medicine, Elk Grove, USA
| | | | | | | |
Collapse
|
30
|
Airola C, Pallozzi M, Cerrito L, Santopaolo F, Stella L, Gasbarrini A, Ponziani FR. Microvascular Thrombosis and Liver Fibrosis Progression: Mechanisms and Clinical Applications. Cells 2023; 12:1712. [PMID: 37443746 PMCID: PMC10341358 DOI: 10.3390/cells12131712] [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: 05/09/2023] [Revised: 06/14/2023] [Accepted: 06/16/2023] [Indexed: 07/15/2023] Open
Abstract
Fibrosis is an unavoidable consequence of chronic inflammation. Extracellular matrix deposition by fibroblasts, stimulated by multiple pathways, is the first step in the onset of chronic liver disease, and its propagation promotes liver dysfunction. At the same time, chronic liver disease is characterized by alterations in primary and secondary hemostasis but unlike previously thought, these changes are not associated with an increased risk of bleeding complications. In recent years, the role of coagulation imbalance has been postulated as one of the main mechanisms promoting hepatic fibrogenesis. In this review, we aim to investigate the function of microvascular thrombosis in the progression of liver disease and highlight the molecular and cellular networks linking hemostasis to fibrosis in this context. We analyze the predictive and prognostic role of coagulation products as biomarkers of liver decompensation (ascites, variceal hemorrhage, and hepatic encephalopathy) and liver-related mortality. Finally, we evaluate the current evidence on the application of antiplatelet and anticoagulant therapies for prophylaxis of hepatic decompensation or prevention of the progression of liver fibrosis.
Collapse
Affiliation(s)
- Carlo Airola
- Hepatology Unit, CEMAD Centro Malattie dell'Apparato Digerente, Medicina Interna e Gastroenterologia, Fondazione Policlinico Universitario Gemelli IRCCS, 00168 Rome, Italy; (C.A.); (M.P.); (L.C.); (F.S.); (L.S.); (A.G.)
| | - Maria Pallozzi
- Hepatology Unit, CEMAD Centro Malattie dell'Apparato Digerente, Medicina Interna e Gastroenterologia, Fondazione Policlinico Universitario Gemelli IRCCS, 00168 Rome, Italy; (C.A.); (M.P.); (L.C.); (F.S.); (L.S.); (A.G.)
| | - Lucia Cerrito
- Hepatology Unit, CEMAD Centro Malattie dell'Apparato Digerente, Medicina Interna e Gastroenterologia, Fondazione Policlinico Universitario Gemelli IRCCS, 00168 Rome, Italy; (C.A.); (M.P.); (L.C.); (F.S.); (L.S.); (A.G.)
| | - Francesco Santopaolo
- Hepatology Unit, CEMAD Centro Malattie dell'Apparato Digerente, Medicina Interna e Gastroenterologia, Fondazione Policlinico Universitario Gemelli IRCCS, 00168 Rome, Italy; (C.A.); (M.P.); (L.C.); (F.S.); (L.S.); (A.G.)
| | - Leonardo Stella
- Hepatology Unit, CEMAD Centro Malattie dell'Apparato Digerente, Medicina Interna e Gastroenterologia, Fondazione Policlinico Universitario Gemelli IRCCS, 00168 Rome, Italy; (C.A.); (M.P.); (L.C.); (F.S.); (L.S.); (A.G.)
| | - Antonio Gasbarrini
- Hepatology Unit, CEMAD Centro Malattie dell'Apparato Digerente, Medicina Interna e Gastroenterologia, Fondazione Policlinico Universitario Gemelli IRCCS, 00168 Rome, Italy; (C.A.); (M.P.); (L.C.); (F.S.); (L.S.); (A.G.)
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Francesca Romana Ponziani
- Hepatology Unit, CEMAD Centro Malattie dell'Apparato Digerente, Medicina Interna e Gastroenterologia, Fondazione Policlinico Universitario Gemelli IRCCS, 00168 Rome, Italy; (C.A.); (M.P.); (L.C.); (F.S.); (L.S.); (A.G.)
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| |
Collapse
|
31
|
Basrawala H, Finley K, Jaglal M, Mohanty BD. First description of atrial fibrillation and congenital thrombotic thrombocytopenic purpura treated by left atrial appendage occlusion. EJHAEM 2023; 4:428-431. [PMID: 37206280 PMCID: PMC10188452 DOI: 10.1002/jha2.659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 02/15/2022] [Accepted: 01/31/2023] [Indexed: 05/21/2023]
Abstract
Given an increased risk of both thrombosis and bleeding, thrombotic thrombocytopenic purpura (TTP) presents a unique challenge when anticoagulation is required for comorbid disease, particularly in the setting of major bleeding events. We present for the first time a patient with TTP and atrial fibrillation, presenting with recurrent stroke, but unable to tolerate anticoagulation due to prior intra-cerebral hemorrhage. To address both issues concomitantly, we describe the successful application of a novel management approach to facilitate left atrial appendage occlusion, there by offering a non-pharmacologic means of stroke prevention without added bleeding risk.
Collapse
Affiliation(s)
- Hussain Basrawala
- Department of Cardiovascular Sciences, University of South FloridaMorsani College of MedicineTampaFloridaUSA
| | - Katherine Finley
- Department of Internal Medicine, University of South FloridaMorsani College of MedicineTampaFloridaUSA
| | - Michael Jaglal
- Department of Hematology and Oncology, University of South FloridaMorsani College of MedicineTampaFloridaUSA
| | - Bibhu D. Mohanty
- Department of Cardiovascular Sciences, University of South FloridaMorsani College of MedicineTampaFloridaUSA
| |
Collapse
|
32
|
Bhandari A, Pokhrel B, Oli PR, Le Q, Basnet B, Freitag EC, Nayani A. A Rare Case of Thrombotic Thrombocytopenic Purpura (TTP) With Concurrent Renal Cell Carcinoma: Diagnostic and Therapeutic Challenges. Cureus 2023; 15:e39494. [PMID: 37362465 PMCID: PMC10290543 DOI: 10.7759/cureus.39494] [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: 05/13/2023] [Indexed: 06/28/2023] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a potentially life-threatening thrombotic microangiopathy (TMA) that needs prompt identification and treatment. Disseminated malignancy-related TMA can potentially be misdiagnosed as TTP, and patients may be inappropriately subjected to therapeutic plasma exchange (TPE) with serious implications. Likewise, the presence of a concurrent cancer diagnosis in a patient with microangiopathic hemolytic anemia and thrombocytopenia may lead to suspicion of disseminated malignancy as the cause, delaying the TPE with serious outcomes. Testing for ADAMTS13 activity is diagnostic of TTP, but the results may take time. This poses a diagnostic and therapeutic dilemma that includes weighing the benefits of TPE for treating TTP and cancer treatment. We describe a rare case of immune-mediated TTP in a patient concurrently diagnosed with metastatic renal cell cancer. To our knowledge, this is the first case of TTP reported in patients with metastatic renal cell carcinoma (RCC) in a non-treatment-naive patient.
Collapse
Affiliation(s)
- Amit Bhandari
- Internal Medicine, St John's Hospital, Springfield, USA
| | - Bidushi Pokhrel
- Intensive Care Unit, Hospital for Advanced Medicine and Surgery, Kathmandu, NPL
| | | | - Quang Le
- Hospital Medicine, University of Missouri School of Medicine, Columbia, USA
| | - Bibhusan Basnet
- Internal Medicine, Frye Regional Medical Center, Hickory, USA
| | - Eric C Freitag
- Pathology and Laboratory Medicine, St. John's Hospital, Springfield, USA
| | - Archana Nayani
- Hematology and Oncology, Springfield Clinic, Springfield, USA
| |
Collapse
|
33
|
Wada H, Teranishi H, Shimono A, Kato N, Maruyama S, Matsumoto M. Application of a scoring system in Japanese patients diagnosed with atypical hemolytic uremic syndrome to assess the relationship between the score and clinical responses to eculizumab. Thromb J 2023; 21:43. [PMID: 37072821 PMCID: PMC10114489 DOI: 10.1186/s12959-023-00489-0] [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: 01/25/2023] [Accepted: 04/12/2023] [Indexed: 04/20/2023] Open
Abstract
BACKGROUND Atypical hemolytic uremic syndrome (aHUS) is caused by complement dysregulation and is generally diagnosed by exclusion from other disorders of thrombotic microangiopathy (TMA). Eculizumab, a terminal complement inhibitor, has been approved for aHUS treatment since 2013 in Japan. Recently, a scoring system was published to support diagnosis of aHUS. Herein we modified this scoring system to apply it to patients diagnosed with aHUS and treated with eculizumab, and assessed the association between the score and clinical responses to eculizumab. METHODS One hundred eighty-eight Japanese patients who were clinically diagnosed with aHUS, treated with eculizumab, and enrolled in post-marketing surveillance (PMS) were included in this analysis. Some of parameters in the original scoring system were replaced with clinically similar parameters collected in the PMS to modify the system, hereafter referred to as the TMA/aHUS score, which ranges from -15 to 20 points. Treatment responses within 90 days after eculizumab initiation were also assessed, and the relationship between treatment response and TMA/aHUS scores calculated at TMA onset was explored. RESULTS The median (range) TMA/aHUS score was 10 (3-16). Receiver operating characteristic curve analysis showed that the cutoff value of TMA/aHUS score to predict treatment response to eculizumab was estimated as 10, and negative predictive value indicated that ≥ 5 points was appropriate to consider assessing the treatment response to eculizumab; 185 (98%) patients had ≥ 5 points and 3 (2%) had < 5 points. Among the patients with ≥ 5 points, 96.1% showed partial response and 31.1% showed complete response. One of the three patients with < 5 points met partial response criteria. No significant difference in the TMA/aHUS scores was observed between survivors and non-survivors, suggesting that the score was not appropriate to predict the outcome (i.e., survival/death) in patients treated with eculizumab. CONCLUSION Almost all patients clinically diagnosed with aHUS scored ≥ 5 points and responded to eculizumab. The TMA/aHUS score system could become a supporting tool for the clinical diagnosis of aHUS and probability of response to treatment with a C5 inhibitor. TRIAL REGISTRATION This study was conducted as per good PMS practice guidelines for drugs (MHLW Ministerial Ordinance No. 171 of 2004).
Collapse
Affiliation(s)
- Hideo Wada
- Department of General and Laboratory Medicine, Mie Prefectural General Medical Center, Hinaga, Yokkaichi, Mie, 5450-132, Japan.
| | | | | | - Noritoshi Kato
- Department of Nephrology, Nagoya University Graduate School of Medicine, Tsurumai-Cho 65, Showa-ku, Nagoya, Aichi, Japan
| | - Shoichi Maruyama
- Department of Nephrology, Nagoya University Graduate School of Medicine, Tsurumai-Cho 65, Showa-ku, Nagoya, Aichi, Japan
| | - Masanori Matsumoto
- Department of Blood Transfusion Medicine, Nara Medical University, Shijyo-Cho 840, Kashihara, Nara, Japan
| |
Collapse
|
34
|
Joffre J, Raia L, Urbina T, Bonny V, Gabarre P, Missri L, Baudel JL, Coppo P, Guidet B, Maury E, Ait-Oufella H. Reversible skin microvascular hyporeactivity in patients with immune-mediated thrombocytopenic thrombotic purpura. Crit Care 2023; 27:116. [PMID: 36944989 PMCID: PMC10028781 DOI: 10.1186/s13054-023-04405-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 03/15/2023] [Indexed: 03/23/2023] Open
Abstract
BACKGROUND Immune-mediated thrombotic thrombocytopenic purpura (iTTP) is a rare disease characterized by arteriolar and capillary microthrombosis precipitating organ failure. However, the contribution of endothelial dysfunction on impaired microvascular blood flow in iTTP patients has been poorly explored. This pilot observational study aimed to explore endothelial-mediated vasoreactivity in iTTP patients at admission and its changes after plasma exchange therapy (PE). METHODS We conducted a prospective observational study in patients (> 18-year old) admitted in ICU for iTTP. Using laser Doppler flowmetry and acetylcholine (Ach) iontophoresis in the forearm, we recorded the skin microvascular blood flow and the endothelium-mediated vasoreactivity at admission and after PE. Demographics, biological, clinical courses, and outcomes were also collected. As a control group, we used a previously published cohort of young diabetic patients after correction of ketoacidosis. RESULTS Eighteen confirmed iTTP patients and 34 controls were included in the study, mainly female (72%) aged 43 ± 16-year-old. At admission, 55% had neurological abnormalities, 50% cardiac issues and 27.8% an acute kidney injury. Median platelet count was 19 G/mL [10-37]. Baseline microvascular blood flow was decreased in iTTP patients when compared to controls (5.97 ± 4.5 vs. 10.1 ± 6.3 PU, P = 0.03), associated with markedly impaired endothelial-mediated skin microvascular reactivity (AUC: 9627 ± 8122 vs. 16,475 ± 11,738, P = 0.03). Microvascular reactivity improved after the first PE session (AUC: 9627 ± 8122 vs 16,558 ± 10,699, P = 0.007, respectively, baseline and post-PE1) and much more after the second session (26,431 ± 23,181, P = 0.04 post-PE1 vs post-PE2). Hemolysis biomarkers (LDH and bilirubin) negatively correlated with skin microvascular flow and vasoreactivity. CONCLUSION We highlighted a marked yet reversible skin endothelium-mediated microvascular hyporeactivity in iTTP patients that could participate in organ injury pathophysiology.
Collapse
Affiliation(s)
- Jérémie Joffre
- Intensive Care Unit, Saint-Antoine University Hospital, APHP, Sorbonne University, 75012, Paris, France
- Centre de Recherche Saint-Antoine Inserm UMR-S 938, Sorbonne University, 75012, Paris, France
| | - Lisa Raia
- Intensive Care Unit, Saint-Antoine University Hospital, APHP, Sorbonne University, 75012, Paris, France
| | - Tomas Urbina
- Intensive Care Unit, Saint-Antoine University Hospital, APHP, Sorbonne University, 75012, Paris, France
| | - Vincent Bonny
- Intensive Care Unit, Saint-Antoine University Hospital, APHP, Sorbonne University, 75012, Paris, France
| | - Paul Gabarre
- Intensive Care Unit, Saint-Antoine University Hospital, APHP, Sorbonne University, 75012, Paris, France
| | - Louai Missri
- Intensive Care Unit, Saint-Antoine University Hospital, APHP, Sorbonne University, 75012, Paris, France
| | - Jean-Luc Baudel
- Intensive Care Unit, Saint-Antoine University Hospital, APHP, Sorbonne University, 75012, Paris, France
| | - Paul Coppo
- Hematology Department, AP-HP, Saint Antoine University Hospital, APHP, Sorbonne University, 75012, Paris, France
- French Reference Center for Thrombotic Microangiopathies (CNR-MAT), Saint Antoine University Hospital, APHP, Sorbonne University, 75012, Paris, France
| | - Bertrand Guidet
- Intensive Care Unit, Saint-Antoine University Hospital, APHP, Sorbonne University, 75012, Paris, France
| | - Eric Maury
- Intensive Care Unit, Saint-Antoine University Hospital, APHP, Sorbonne University, 75012, Paris, France
| | - Hafid Ait-Oufella
- Intensive Care Unit, Saint-Antoine University Hospital, APHP, Sorbonne University, 75012, Paris, France.
- Paris Cardiovascular Research Center, Inserm U970, University Paris Cité, Paris, France.
| |
Collapse
|
35
|
Cohen CT, Zobeck M, Kim TO, Sartain SE, Raffini L, Srivaths L. Adolescent acquired thrombotic thrombocytopenic purpura: An analysis of the Pediatric Health Information System database. Thromb Res 2023; 222:63-67. [PMID: 36577346 PMCID: PMC10712080 DOI: 10.1016/j.thromres.2022.12.011] [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: 10/17/2022] [Revised: 12/14/2022] [Accepted: 12/15/2022] [Indexed: 12/24/2022]
Abstract
The outcomes and characteristics of acquired thrombotic thrombocytopenic purpura (TTP) in adolescents is poorly understood due to an absence of studies focused on this population. To better understand the life-threatening disorder in this age, we performed an analysis of adolescent patients (ages 10-21) with TTP in the Pediatric Health Information Systems database from 2009 to 2020. The primary outcomes evaluated were in-hospital mortality and rate of TTP relapse. Secondary outcomes included rates of hemorrhagic and thrombotic complications during hospitalizations for TTP. Patients were included if they had a thrombotic microangiopathy diagnostic code, ADAMTS13 lab obtained, and received therapeutic plasmapheresis. Patients that received treatment for other non-TTP microangiopathies were excluded. A total of 99 patients with 123 hospitalizations for TTP treatment were identified. In-patient mortality occurred in 6 % (n = 6) and TTP relapse in 20 % (n = 20) of the cohort. Median time from initial admission to relapse was 33 days (IQR 15, 92). A hemorrhagic complication was identified in 29 % (n = 36) and thrombotic complication in 15 % (n = 19) of the cohort. The presence of underlying comorbidities was not associated with TTP relapse and only a diagnosis of cancer was associated with increased mortality. The rate of mortality and relapse in adolescent TTP is lower than that seen in adult registries. Long term prospective studies are needed to understand the long-term consequences of adolescent onset acquired TTP.
Collapse
Affiliation(s)
- Clay T Cohen
- Department of Pediatrics, Division of Hematology/Oncology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, United States of America.
| | - Mark Zobeck
- Department of Pediatrics, Division of Hematology/Oncology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, United States of America
| | - Taylor O Kim
- Department of Pediatrics, Division of Hematology/Oncology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, United States of America
| | - Sarah E Sartain
- Department of Pediatrics, Division of Hematology/Oncology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, United States of America
| | - Leslie Raffini
- Department of Pediatrics, Division of Hematology, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Lakshmi Srivaths
- Department of Pediatrics, Division of Hematology, McGovern Medical School at the University of Texas Health Science Center at Houston (UTHealth Houston) and Children's Memorial Hermann Hospital, Gulf States Hemophilia and Thrombophilia Treatment Center, Houston, TX, United States of America
| |
Collapse
|
36
|
Yamaguchi M, Mizuno M, Kitamura F, Iwagaitsu S, Nobata H, Kinashi H, Banno S, Asai A, Ishimoto T, Katsuno T, Ito Y. Case report: Thrombotic microangiopathy concomitant with macrophage activation syndrome in systemic lupus erythematosus refractory to conventional treatment successfully treated with eculizumab. Front Med (Lausanne) 2023; 9:1097528. [PMID: 36698804 PMCID: PMC9868404 DOI: 10.3389/fmed.2022.1097528] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 12/19/2022] [Indexed: 01/11/2023] Open
Abstract
Thrombotic microangiopathy (TMA) is a rare but life-threatening complication of systemic lupus erythematosus (SLE). Macrophage activation syndrome (MAS) is also a rare, life-threatening hyperinflammatory condition that is comorbid with SLE. However, the association between TMA and MAS in patients with SLE has rarely been assessed, and the difficulty of diagnosing these conditions remains prevalent. The efficacy of eculizumab has been reported for SLE patients whose conditions are complicated with TMA. However, no study has investigated the therapeutic efficacy of eculizumab for TMA concomitant with SLE-associated MAS. Herein, we report the first case of TMA concomitant with SLE-associated MAS that was initially refractory to conventional immunosuppressive therapy but showed remarkable recovery after eculizumab treatment. Furthermore, we evaluated serum syndecan-1 and hyaluronan levels, which are biomarkers of endothelial damage. We found that these levels decreased after the administration of eculizumab, suggesting that TMA was the main pathology of the patient. This case illustrates that it is important to appropriately assess the possibility of TMA during the course of SLE-associated MAS and consider the use of eculizumab as necessary.
Collapse
Affiliation(s)
- Makoto Yamaguchi
- Department of Nephrology and Rheumatology, Aichi Medical University, Nagakute, Japan
| | - Masashi Mizuno
- Renal Replacement Therapy, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Fumiya Kitamura
- Department of Nephrology and Rheumatology, Aichi Medical University, Nagakute, Japan
| | - Shiho Iwagaitsu
- Department of Nephrology and Rheumatology, Aichi Medical University, Nagakute, Japan
| | - Hironobu Nobata
- Department of Nephrology and Rheumatology, Aichi Medical University, Nagakute, Japan
| | - Hiroshi Kinashi
- Department of Nephrology and Rheumatology, Aichi Medical University, Nagakute, Japan
| | - Shogo Banno
- Department of Nephrology and Rheumatology, Aichi Medical University, Nagakute, Japan
| | - Akimasa Asai
- Department of Nephrology and Rheumatology, Aichi Medical University, Nagakute, Japan
| | - Takuji Ishimoto
- Department of Nephrology and Rheumatology, Aichi Medical University, Nagakute, Japan
| | - Takayuki Katsuno
- Department of Nephrology and Rheumatology, Aichi Medical University, Nagakute, Japan,Department of Nephrology and Rheumatology, Aichi Medical University Medical Center, Okazaki, Japan
| | - Yasuhiko Ito
- Department of Nephrology and Rheumatology, Aichi Medical University, Nagakute, Japan,*Correspondence: Yasuhiko Ito,
| |
Collapse
|
37
|
Van Hove S, Werion A, Anantharajah A, Belkhir L, van Dievoet MA, Hantson P. Streptococcus Pneumoniae Bacteremia with Acute Kidney Injury and Transient ADAMTS13 Deficiency. Case Rep Infect Dis 2023; 2023:3283606. [PMID: 37159753 PMCID: PMC10163968 DOI: 10.1155/2023/3283606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 03/30/2023] [Accepted: 04/13/2023] [Indexed: 05/11/2023] Open
Abstract
A 43-year-old woman with a medical history of splenectomy for immune thrombocytopenic purpura was diagnosed with Streptococcus pneumoniae bacteremia. Her initial complaints were fever and more importantly painful extremities that appeared cyanotic. During her hospitalisation, she never developed cardiocirculatory failure but presented acute kidney injury (AKI) with oliguria. Laboratory investigations confirmed AKI with serum creatinine 2.55 mg/dL which peaked at 6.49 mg/dL. There was also evidence for disseminated intravascular coagulation (DIC) with decreased platelet count, low fibrinogen levels, and high D-dimer levels. There were no signs of haemolytic anaemia. The initial ADAMTS13 activity was low (17%) but slowly recovered. Renal function progressively improved with supportive therapy, as opposed to the progressing skin necrosis. The association of DIC and low ADAMTS13 activity may have contributed to the severity of microthrombotic complications, even in the absence of thrombotic microangiopathy as thrombotic thrombocytopenic purpura (TTP) or pneumococcal-associated haemolytic uremic syndrome (pa-HUS).
Collapse
Affiliation(s)
- Sam Van Hove
- Department of Intensive Care, Cliniques Universitaires Saint-Luc, 1200 Brussels, Belgium
| | - Alexis Werion
- Department of Intensive Care, Cliniques Universitaires Saint-Luc, 1200 Brussels, Belgium
- Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, Neuve, Belgium
| | | | - Leila Belkhir
- Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, Neuve, Belgium
- Department of Internal Medicine and Infectious Diseases, Cliniques Universitaires Saint-Luc, 1200 Brussels, Belgium
| | | | - Philippe Hantson
- Department of Intensive Care, Cliniques Universitaires Saint-Luc, 1200 Brussels, Belgium
- Louvain Centre for Toxicology and Applied Pharmacology, Université Catholique de Louvain, 1200 Brussels, Belgium
| |
Collapse
|
38
|
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.
Collapse
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.
| |
Collapse
|
39
|
A Life-Threating Postpartum Atypical Hemolytic-Uremic Syndrome with Multiorgan Involvement. J Clin Med 2022; 11:jcm11236957. [PMID: 36498532 PMCID: PMC9738905 DOI: 10.3390/jcm11236957] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 11/14/2022] [Accepted: 11/23/2022] [Indexed: 11/29/2022] Open
Abstract
Atypical Hemolytic Uremic Syndrome is a very rare condition that can be triggered in predisposed patients. It can remain undiagnosed and can result in a life-threatening event or permanent renal failure. We report a case of a 36-year-old pregnant woman who developed atypical hemolytic uremic syndrome postpartum. She underwent an emergency caesarean section due to abruptio placenta, and she developed biochemical alterations suggestive of a thrombotic microangiopathy. Due to worsening of renal function after plasma exchange therapy, we decided to start therapy with eculizumab. Therapy was carried out with a weekly dose of 900 mg IV for five weeks. An improvement of clinical and biochemical parameters was rapidly observed, and her renal function completely recovered. The therapy was continued for six months, with a dose of 1200 mg of eculizumab every two weeks. One year after discontinuation of the therapy, her blood pressure and renal function were still normal. Our case confirms that it is important to promptly identify a pregnancy-related thrombotic microangiopathy and that early therapy can be life-saving for the patient and can preserve renal function, avoiding dialysis.
Collapse
|
40
|
Lemmer D, Schmidt J, Kummer K, Lemmer B, Wrede A, Seitz C, Balcarek P, Schwarze K, Müller GA, Patschan D, Patschan S. Impairment of muscular endothelial cell regeneration in dermatomyositis. Front Neurol 2022; 13:952699. [PMID: 36330424 PMCID: PMC9623165 DOI: 10.3389/fneur.2022.952699] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 09/01/2022] [Indexed: 11/22/2022] Open
Abstract
Background and aim Inflammatory myopathies are heterogeneous in terms of etiology, (immuno)pathology, and clinical findings. Endothelial cell injury, as it occurs in DM, is a common feature of numerous inflammatory and non-inflammatory vascular diseases. Vascular regeneration is mediated by both local and blood-derived mechanisms, such as the mobilization and activation of so-called proangiogenic cells (PACs) or early endothelial progenitor cells (eEPCs). The current study aimed to evaluate parameters of eEPC integrity in dermatomyositis (DM), compared to necrotizing myopathy (NM) and to non-myopathic controls. Methods Blood samples from DM and NM patients were compared to non-myositis controls and analyzed for the following parameters: circulating CD133+/VEGFR-2+ cells, number of colony-forming unit endothelial cells (CFU-ECs), concentrations of angiopoietin 1, vascular endothelial growth factor (VEGF), and CXCL-16. Muscle biopsies from DM and NM subjects underwent immunofluorescence analysis for CXCR6, nestin, and CD31 (PECAM-1). Finally, myotubes, derived from healthy donors, were stimulated with serum samples from DM and NM patients, subsequently followed by RT-PCR for the following candidates: IL-1β, IL-6, nestin, and CD31. Results Seventeen (17) DM patients, 7 NM patients, and 40 non-myositis controls were included. CD133+/VEGFR-2+ cells did not differ between the groups. Both DM and NM patients showed lower CFU-ECs than controls. In DM, intramuscular CD31 abundances were significantly reduced, which indicated vascular rarefaction. Muscular CXCR6 was elevated in both diseases. Circulating CXCL-16 was higher in DM and NM in contrast, compared to controls. Serum from patients with DM but not NM induced a profound upregulation of mRNS expression of CD31 and IL-6 in cultured myotubes. Conclusion Our study demonstrates the loss of intramuscular microvessels in DM, accompanied by endothelial activation in DM and NM. Vascular regeneration was impaired in DM and NM. The findings suggest a role for inflammation-associated vascular damage in the pathogenesis of DM.
Collapse
Affiliation(s)
- D. Lemmer
- Department of Nephrology and Rheumatology, University Medical Center Göttingen, Göttingen, Germany
- Immanuel Krankenhaus Berlin, Medical Center of Rheumatology Berlin-Buch, Berlin, Germany
| | - J. Schmidt
- Department of Neurology and Pain Treatment, Immanuel Klinik Rüdersdorf, University Hospital of the Brandenburg Medical School Theodor Fontane, Rüdersdorf bei Berlin, Germany
- Faculty of Health Sciences Brandenburg, Brandenburg Medical School Theodor Fontane, Rüdersdorf bei Berlin, Germany
- Department of Neurology, Neuromuscular Center, University Medical Center Göttingen, Göttingen, Germany
| | - K. Kummer
- Department of Neurology, Neuromuscular Center, University Medical Center Göttingen, Göttingen, Germany
| | - B. Lemmer
- Department of Physics, Georg-August-University Göttingen, Göttingen, Germany
| | - A. Wrede
- Department of Neuropathology, University Medical Center Göttingen, Göttingen, Germany
| | - C. Seitz
- Department of Dermatology, Allergology and Venereology, University Medical Center Göttingen, Göttingen, Germany
| | - P. Balcarek
- Department of Trauma Surgery, Orthopedics and Plastic Surgery, University Medical Center Göttingen, Göttingen, Germany
- Arcus Klinik, Pforzheim, Germany
| | - K. Schwarze
- Department of Nephrology and Rheumatology, University Medical Center Göttingen, Göttingen, Germany
| | - G. A. Müller
- Department of Nephrology and Rheumatology, University Medical Center Göttingen, Göttingen, Germany
| | - D. Patschan
- Faculty of Health Sciences Brandenburg, Brandenburg Medical School Theodor Fontane, Rüdersdorf bei Berlin, Germany
- Department of Medicine 1, Cardiology, Angiology, and Nephrology, University Hospital Brandenburg of the Brandenburg Medical School Theodor Fontane, Branderburg, Germany
| | - S. Patschan
- Faculty of Health Sciences Brandenburg, Brandenburg Medical School Theodor Fontane, Rüdersdorf bei Berlin, Germany
- Department of Medicine 1, Cardiology, Angiology, and Nephrology, University Hospital Brandenburg of the Brandenburg Medical School Theodor Fontane, Branderburg, Germany
- *Correspondence: S. Patschan
| |
Collapse
|
41
|
Gheith Z, Kilani A, Al-Taweel O. Unusual Presentation of Thrombotic Thrombocytopenic Purpura With Non-ST-Elevation Myocardial Infarction. Cureus 2022; 14:e29499. [DOI: 10.7759/cureus.29499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/23/2022] [Indexed: 11/05/2022] Open
|
42
|
de Castro JTDS, Appenzeller S, Colella MP, Yamaguti-Hayakawa G, Paula EVD, Annichinno-Bizzachi J, Cendes F, Fabiano R, Orsi FA. Neurological manifestations in thrombotic microangiopathy: Imaging features, risk factors and clinical course. PLoS One 2022; 17:e0272290. [PMID: 36129939 PMCID: PMC9491546 DOI: 10.1371/journal.pone.0272290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 07/15/2022] [Indexed: 11/19/2022] Open
Abstract
Background and purpose Thrombotic microangiopathy (TMA) is a group of microvascular occlusive disorders that presents with neurological involvement in up to 87% of the cases. Although the central nervous system (CNS) is an important target organ in TMA, the role of neurological manifestations in the disease clinical course is not well established. In this study, we described the neurological manifestations and CNS radiological aspects in patients with a first, acute TMA event. We also examined the association between severe neurological involvement and adverse clinical outcomes in TMA. Methods A cohort of patients diagnosed with a first TMA event between 1995 and 2016 was included, their medical charts and imaging tests were retrospectively evaluated. Results A total of 49 patients were included, 85.7% were women and the mean age was 36.5 years-old (SD 13.0). Neurological manifestations were described in 85.7% of the patients, most of them (88%) were considered severe and consisted of confusion, compromised sensorimotor function, stupor, seizures, and personality change. Imaging tests were performed in 62% of the patients with neurological manifestations and detected acute CNS lesions, such as posterior reversible encephalopathy syndrome, hemorrhagic and ischemic stroke were observed, in 7 (27%) of them. While the need for intensive care unit admission was greater and longer among patients with severe neurological manifestations, the number of plasma exchange sessions, the total duration of hospitalization and in-hospital death were similar between groups. Conclusions Severe neurological manifestations are common in first TMA events and are responsible for a worse disease presentation at admission. While the effect of neurological manifestations on acute TMA clinical course seems to be modest, these manifestations may have an important impact on the development of chronic cognitive impairment, which highlights the need for proper diagnosis and treatment.
Collapse
Affiliation(s)
- José Thiago de Souza de Castro
- School of Medical Sciences, University of Campinas, (UNICAMP), Campinas, São Paulo, Brazil
- Department of Radiology, University of Campinas, (UNICAMP), Campinas, São Paulo, Brazil
- * E-mail:
| | - Simone Appenzeller
- Rheumatology Unit, School of Medical Science, University of Campinas, Campinas, São Paulo, Brazil
| | - Marina Pereira Colella
- Thrombosis and Hemostasis Unit, Hematology and Hemotherapy Center, University of Campinas, (UNICAMP), Campinas, São Paulo, Brazil
| | - Gabriela Yamaguti-Hayakawa
- Thrombosis and Hemostasis Unit, Hematology and Hemotherapy Center, University of Campinas, (UNICAMP), Campinas, São Paulo, Brazil
| | - Erich Vinícius De Paula
- Thrombosis and Hemostasis Unit, Hematology and Hemotherapy Center, University of Campinas, (UNICAMP), Campinas, São Paulo, Brazil
- Discipline of Hematology and Hemotherapy, Department of Internal Medicine, School of Medical Sciences, University of Campinas, (UNICAMP), Campinas, São Paulo, Brazil
| | - Joyce Annichinno-Bizzachi
- Thrombosis and Hemostasis Unit, Hematology and Hemotherapy Center, University of Campinas, (UNICAMP), Campinas, São Paulo, Brazil
- Discipline of Hematology and Hemotherapy, Department of Internal Medicine, School of Medical Sciences, University of Campinas, (UNICAMP), Campinas, São Paulo, Brazil
| | - Fernando Cendes
- Department of Neurology, School of Medical Sciences, University of Campinas, Campinas, São Paulo, Brazil
| | - Reis Fabiano
- School of Medical Sciences, University of Campinas, (UNICAMP), Campinas, São Paulo, Brazil
- Department of Radiology, University of Campinas, (UNICAMP), Campinas, São Paulo, Brazil
| | - Fernanda Andrade Orsi
- Department of Clinical Pathology, School of Medical Sciences, University of Campinas, (UNICAMP), Campinas, São Paulo, Brazil
| |
Collapse
|
43
|
Thompson GL, Kavanagh D. Diagnosis and treatment of thrombotic microangiopathy. Int J Lab Hematol 2022; 44 Suppl 1:101-113. [PMID: 36074708 PMCID: PMC9544907 DOI: 10.1111/ijlh.13954] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 07/28/2022] [Indexed: 12/01/2022]
Abstract
Thrombotic microangiopathy (TMA) is characterized by thrombocytopenia, microangiopathic haemolytic anaemia and end organ damage. TMAs have varying underlying pathophysiology and can therefore present with an array of clinical presentations. Renal involvement is common as the kidney is particularly susceptible to the endothelial damage and microvascular occlusion. TMAs require rapid assessment, diagnosis, and commencement of appropriate treatment due to the high morbidity and mortality associated with them. Ground-breaking research into the pathogenesis of TMAs over the past 20 years has driven the successful development of targeted therapeutics revolutionizing patient outcomes. This review outlines the clinical presentations, pathogenesis, diagnostic tests and treatments for TMAs.
Collapse
Affiliation(s)
- Gemma L Thompson
- Complement Therapeutics Research Group, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK.,National Renal Complement Therapeutics Centre, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - David Kavanagh
- Complement Therapeutics Research Group, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK.,National Renal Complement Therapeutics Centre, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| |
Collapse
|
44
|
Ghumman GM, Fatima H, Johnston TL, Leis R, Khatri V. Gemcitabine-Induced Thrombotic Microangiopathy Managed Conservatively in a Patient of Breast Cancer. Cureus 2022; 14:e28433. [PMID: 36176826 PMCID: PMC9509686 DOI: 10.7759/cureus.28433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/26/2022] [Indexed: 12/03/2022] Open
Abstract
Thrombotic microangiopathy (TMA) consists of a group of occlusive microvascular disorders, which include thrombotic thrombocytopenic purpura (TTP) and hemolytic uremic syndrome (HUS). TMA can be classified as primary or secondary based on the etiology. Gemcitabine-induced TMA is a rare side effect of the drug with varying clinical presentations. We present a case involving the classic triad of microangiopathic hemolytic anemia (MAHA), thrombocytopenia, and renal failure associated with gemcitabine. Gemcitabine was immediately stopped, and our patient's condition improved with conservative management.
Collapse
|
45
|
Merlen C, Pépin E, Barry O, Cormier A, Dubois C, Lapeyraque AL, Troyanov S, Rivard GE, Bonnefoy A. Incidence of thrombotic microangiopathies in Quebec: insight from a laboratory centralizing ADAMTS-13 testing. Orphanet J Rare Dis 2022; 17:308. [PMID: 35927768 PMCID: PMC9351225 DOI: 10.1186/s13023-022-02409-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 06/26/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Thrombotic microangiopathies (TMA) are serious medical conditions requiring a prompt diagnosis to adapt treatment. The determination of ADAMTS-13 activity enables discriminating thrombotic thrombocytopenic purpura (TTP) from other forms of TMA. The purpose of this study was to provide an estimate of the incidence of TTP and TMA in the Canadian Quebec province using data collected from a laboratory centralizing ADAMTS-13 testing for the whole province. RESULTS From 2012 to 2019, 846 patients were evaluated for plasma ADAMTS-13 activity due to a suspicion of TMA. TTP was identified in 147 patients. Of these, 118 patients with a median age of 51.5 years and a male-female ratio of 1:1.4 had their first episode of TTP during the study period. The number of ADAMTS-13 tests performed and the number of patients with suspected TMA increased annually by 19% and 21% respectively. While the incidence of non-TTP TMA increased annually, that for TTP remained unchanged. This averaged 10.2 (95% CI 5.9-14.4) per million persons per year for suspected non-TTP TMA and 1.8 (95% CI 1.3-2.4) for confirmed TTP. The incidence rate of TMA other than TTP was higher in the age group 70-79 years (21.8; 95% CI 5.4-38.1) for females and in the age group 80-89 years (24.4; 95% CI 7.2-41.7) for males compared to other age groups. The incidence rate of TTP was higher in the age group 40-49 years (4.0; 95% CI 2.0-5.9) for women and in the age group 60-69 years (3.4; 95% CI 1.1-5.6) for men compared to other age groups. CONCLUSION The analysis of centralized data measuring ADAMTS-13 activity allowed us to adequately establish the incidence rate and demographic characteristics of TMA, particularly TTP, in Quebec. TTP incidence remained stable while suspected non-TTP TMA steadily increased from 2012 to 2019.
Collapse
Affiliation(s)
- Clémence Merlen
- Division of Hematology-Oncology, CHU Sainte-Justine, Université de Montréal, 3175, chemin de la Côte-Ste-Catherine, Montreal, QC, H3T 1C5, Canada
| | - Emmanuelle Pépin
- Division of Hematology-Oncology, CHU Sainte-Justine, Université de Montréal, 3175, chemin de la Côte-Ste-Catherine, Montreal, QC, H3T 1C5, Canada
- Department of Clinical Laboratory Medicine, OPTILAB Montréal-CHU Sainte-Justine, Montreal, QC, Canada
| | - Ousmane Barry
- Division of Hematology-Oncology, CHU Sainte-Justine, Université de Montréal, 3175, chemin de la Côte-Ste-Catherine, Montreal, QC, H3T 1C5, Canada
| | - Anik Cormier
- Department of Clinical Laboratory Medicine, OPTILAB Montréal-CHU Sainte-Justine, Montreal, QC, Canada
| | - Caroline Dubois
- Department of Clinical Laboratory Medicine, OPTILAB Montréal-CHU Sainte-Justine, Montreal, QC, Canada
| | - Anne-Laure Lapeyraque
- Division of Nephrology, CHU Sainte-Justine, Université de Montréal, Montreal, QC, Canada
| | - Stéphan Troyanov
- Division of Nephrology, Hôpital du Sacré-Cœur, Université de Montréal, Montreal, QC, Canada
| | - Georges-Etienne Rivard
- Division of Hematology-Oncology, CHU Sainte-Justine, Université de Montréal, 3175, chemin de la Côte-Ste-Catherine, Montreal, QC, H3T 1C5, Canada
- Department of Clinical Laboratory Medicine, OPTILAB Montréal-CHU Sainte-Justine, Montreal, QC, Canada
| | - Arnaud Bonnefoy
- Division of Hematology-Oncology, CHU Sainte-Justine, Université de Montréal, 3175, chemin de la Côte-Ste-Catherine, Montreal, QC, H3T 1C5, Canada.
- Department of Clinical Laboratory Medicine, OPTILAB Montréal-CHU Sainte-Justine, Montreal, QC, Canada.
| |
Collapse
|
46
|
Lim KH, Park J, Cho SH. Risk factors of trauma-induced thrombotic microangiopathy-like syndrome: A retrospective analysis. Medicine (Baltimore) 2022; 101:e29315. [PMID: 35866764 PMCID: PMC9302357 DOI: 10.1097/md.0000000000029315] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Patients with trauma may develop thrombocytopenia. We encountered cases wherein patients experienced symptoms resembling thrombotic microangiopathies (TMAs) following severe trauma. As the condition of these patients did not meet the diagnostic criteria of thrombotic thrombocytopenic purpura and there was no mention of trauma among the several causes of TMAs, it was termed as "trauma-induced thrombotic microangiopathy-like syndrome" (t-TMAS). In this study, we aimed to analyze the risk factors that may affect the incidence of t-TMAS in patients with severe trauma. This retrospective study was conducted in the trauma intensive care unit at the Kyungpook National University Hospital between January 2018 and December 2019. The medical records of 1164 of the 1392 enrolled participants were analyzed. To assess the risk factors of t-TMAS, we analyzed age, sex, mechanism of trauma, abbreviated injury scale (AIS) score, injury severity score (ISS), hematological examination, and red blood cell volume transfused in 24 hours. Among the 1164 patients, 20 (1.7%) were diagnosed with t-TMAS. The univariate analysis revealed higher age, ISS, and myoglobin, lactate, creatine kinase-myocardial band (on admission), creatine phosphokinase, lactate dehydrogenase (LDH), and lactate (day 2) levels in the t-TMAS group than in the non-t-TMAS group. The red blood cell volume transfused in 24 hours was higher in the t-TMAS group than in the non-t-TMAS group. t-TMAS was more common in patients with injuries in the chest, abdomen, and pelvis (AIS score ≥3) than in those with head injuries (AIS score ≥3) alone. The higher the sum of AIS scores of the chest, abdomen, and pelvis injuries, the higher the incidence of t-TMAS. Multivariate analysis revealed age, ISS, and LDH level (day 2) to be independent predictors of t-TMAS. Trauma surgeons should consider the possibility of t-TMAS if thrombocytopenia persists without any evidence of bleeding, particularly among older patients with multiple severe torso injuries who have high LDH levels on day 2. Early diagnosis and treatment of t-TMAS could improve patients' prognosis.
Collapse
Affiliation(s)
- Kyoung Hoon Lim
- Department of Surgery, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, South Korea
- *Correspondence: Kyoung Hoon Lim, Department of Surgery, Kyungpook National University Hospital, 130, Dongduk-ro, Jung-gu, Daegu, 41944, South Korea (e-mail: )
| | - Jinyoung Park
- Department of Surgery, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Sung Hoon Cho
- Department of Surgery, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, South Korea
| |
Collapse
|
47
|
Saner FH, Hoyer DP, Hartmann M, Nowak KM, Bezinover D. The Edge of Unknown: Postoperative Critical Care in Liver Transplantation. J Clin Med 2022; 11:jcm11144036. [PMID: 35887797 PMCID: PMC9322367 DOI: 10.3390/jcm11144036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 06/29/2022] [Accepted: 07/07/2022] [Indexed: 02/04/2023] Open
Abstract
Perioperative care of patients undergoing liver transplantation (LT) is very complex. Metabolic derangements, hypothermia, coagulopathy and thromboses, severe infections, and graft dysfunction can affect outcomes. In this manuscript, we discuss several perioperative problems that can be encountered in LT recipients. The authors present the most up-to-date information regarding predicting and treating hemodynamic instability, coagulation monitoring and management, postoperative ventilation strategies and early extubation, management of infections, and ESLD-related pulmonary complications. In addition, early post-transplant allograft dysfunction will be discussed.
Collapse
Affiliation(s)
- Fuat H. Saner
- Department of General-, Visceral- and Transplant Surgery, Medical Center University Duisburg-Essen, 45147 Essen, Germany; (D.P.H.); (K.M.N.)
- Correspondence: ; Fax: +49-201-723-1145
| | - Dieter P. Hoyer
- Department of General-, Visceral- and Transplant Surgery, Medical Center University Duisburg-Essen, 45147 Essen, Germany; (D.P.H.); (K.M.N.)
| | - Matthias Hartmann
- Department of Anaesthesia and Critical Care, Medical Center University Duisburg-Essen, 45147 Essen, Germany;
| | - Knut M. Nowak
- Department of General-, Visceral- and Transplant Surgery, Medical Center University Duisburg-Essen, 45147 Essen, Germany; (D.P.H.); (K.M.N.)
| | - Dmitri Bezinover
- Department of Anesthesiology and Perioperative Medicine, Penn State Hershey Medical Center, Penn State College of Medicine, Hershey, PA 17033, USA;
| |
Collapse
|
48
|
Hemophagocytic Lymphohistiocytosis Associated With Hemolytic Uremic Syndrome in a Child: A Case Report and Systematic Literature Review. J Pediatr Hematol Oncol 2022; 44:e905-e910. [PMID: 35731942 DOI: 10.1097/mph.0000000000002265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 06/08/2021] [Indexed: 11/26/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening disorder resulting from excessive activation and nonmalignant proliferation of T-lymphocytes and macrophages. Hemolytic uremic syndrome (HUS) is a disease characterized by microangiopathic hemolytic anemia, thrombocytopenia, and acute renal failure. Reports pertaining to the association between HLH and HUS are rarely published; however, we report on a 4-year-old boy who was diagnosed with both conditions and treated successfully with high-dose steroid and intravenous immunoglobulin. Differentiating HUS from HLH can be challenging because of their clinical similarities. Therefore, prompt diagnosis and immunosuppressive treatment are essential and life-saving to these patients.
Collapse
|
49
|
Raina R, Sethi SK, Dragon-Durey MA, Khooblall A, Sharma D, Khandelwal P, Shapiro R, Boyer O, Yap HK, Bagga A, Licht C. Systematic review of atypical hemolytic uremic syndrome biomarkers. Pediatr Nephrol 2022; 37:1479-1493. [PMID: 35118546 DOI: 10.1007/s00467-022-05451-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 01/11/2022] [Accepted: 01/12/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND AND OBJECTIVES Observing biomarkers that affect alternative pathway dysregulation components may be effective in obtaining a new and more rapid diagnostic portrayal of atypical hemolytic uremic syndrome. We have conducted a systematic review on the aHUS biomarkers: C3, C5a, C5b-9, factor B, complement factor B, H, and I, CH50, AH50, D-dimer, as well as anti-CFH antibodies. METHODS An exhaustive literature search was conducted for aHUS patient population plasma/serum, collected/reported at the onset of diagnosis. A total of 60 studies were included with the data on 837 aHUS subjects, with at least one biomarker reported. RESULTS The biomarkers C3 [mean (SD): 72.1 (35.0), median: 70.5 vs. reference range: 75-175 mg/dl, n = 752]; CH50 [28.3 (32.1), 24.3 vs. 30-75 U/ml, n = 63]; AH50 [27.6% (30.2%), 10% vs. ≥ 46%, n = 23]; and CFB [13.1 (6.6), 12.4, vs. 15.2-42.3 mg/dl, n = 19] were lower among aHUS subjects as compared with the reference range. The biomarkers including C4 [mean (SD): 20.4 (9.5), median: 20.5 vs. reference range: 14-40 mg/dl, n = 343]; C4d [7.2 (6.5), 4.8 vs. ≤ 9.8 μg/ml, n = 108]; CFH [40.2 (132.3), 24.5 vs. 23.6-43.1 mg/dl, n = 123 subjects]; and CFI [8.05 (5.01), 6.55 mg/dl vs. 4.4-18.1 mg/dl, n = 38] were all observed to be within the reference range among aHUS subjects. The biomarkers C5a [mean (SD): 54.9 (32.9), median: 48.8 vs. reference range: 10.6-26.3 mg/dl, n = 117]; C5b-9 [466.0 (401.4), 317 (186-569.7) vs. ≤ 250 ng/ml, n = 174]; Bb [2.6 (2.1), 1.9 vs. ≤ 1.6 μg/ml, n = 77] and D-dimer [246 (65.05), 246 vs. < 2.2 ng/ml, 2, n = 2 subjects] were higher among patients with aHUS compared with the reference range. CONCLUSION If a comprehensive complement profile were built using our data, aHUS would be identified by low levels of C3, CH50, AH50, and CFB along with increased levels of C5a, C5b-9, Bb, anti-CFH autoantibodies, and D-dimer. A higher resolution version of the Graphical abstract is available as Supplementary information.
Collapse
Affiliation(s)
- Rupesh Raina
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA. .,Department of Nephrology, Akron Children's Hospital, Akron, OH, USA.
| | - Sidharth K Sethi
- Kidney and Renal Transplant Institute, Medanta, The Medicity Hospital, Gurgaon, Haryana, India
| | | | - Amrit Khooblall
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA.,Department of Nephrology, Akron Children's Hospital, Akron, OH, USA
| | - Divya Sharma
- Department of Medicine, Northeast Ohio Medical University, Rootstown, OH, USA
| | - Priyanka Khandelwal
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | | | - Olivia Boyer
- Service de Néphrologie Pédiatrique, AP-HP, Centre de Référence de maladies rénales rares de l'enfant et de l'adulte (MARHEA), Hôpital Necker - Enfants Malades, 149 Rue de Sèvres, 75015, Paris, France.,Institut Imagine, Laboratoire des maladies rénales héréditaires, INSERM UMR 1163, Université de Paris, Paris, France
| | - Hui Kim Yap
- Shaw-NKF-NUH Children's Kidney Centre, Khoo Teck Puat-National University Children's Medical Institute, National University Hospital, Kent Ridge, Singapore.,Department of Pediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Arvind Bagga
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Christoph Licht
- Cell Biology Program, SickKids Research Institute, Toronto, ON, Canada.,Department of Paediatrics, Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Division of Nephrology, The Hospital for Sick Children, Toronto, ON, Canada
| |
Collapse
|
50
|
Wang Z, Xu H, Gu B, Jin Y, Wang T, Ma J, Lu Y, Yu X, Zheng B, Zhang Y. Flavorubredoxin, a Candidate Trigger Related to Thrombotic Thrombocytopenic Purpura: Screening of the Complete Genome of a Salmonella enterica Serovar Typhimurium Isolate From an AIDS Case. Front Cell Infect Microbiol 2022; 12:864087. [PMID: 35755834 PMCID: PMC9226561 DOI: 10.3389/fcimb.2022.864087] [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: 01/28/2022] [Accepted: 05/13/2022] [Indexed: 12/01/2022] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) is one of the two classic thrombotic microangiopathy (TMA) diseases which could be induced by infections. To the best of our knowledge, this is the first report of an acquired immunodeficiency syndrome (AIDS) patient with acquired TTP induced by infection with Salmonella enterica serovar Typhimurium (hereafter, S. Typhimurium) isolate, S. Typhimurium_zhang, which was confirmed by serology and genetic taxonomy. The literature review identified 17 TMA-related genes encoding the candidate triggers, which were searched in the annotated genome sequence of S. Typhimurium_zhang. Anaerobic nitric oxide reductase flavorubredoxin (FlRd), encoded by norV which is related to another TMA, haemolytic uraemic syndrome (HUS), was found in S. Typhimurium_zhang. Basic local alignment search tool (BLAST) analysis revealed that norV and FlRd in S. Typhimurium_zhang, as well as eight S. Typhimurium type strains, have high identity with HUS-related Escherichia coli O157:H7 strain TW14359. Similar results were obtained from the BLAST analysis of 73 S. enterica isolates for congenital TTP which was also previously reported to be triggered by S. enterica. Phylogenetic analysis and amino acid sequence alignment revealed that FlRd was functional and highly conservative on 69 Enterobacteriaceae, including S. Typimurium_zhang and TW14359. In brief, we found norV in the genome of a S. Typhimurium clinical isolate that induced TTP in an AIDS patient. FlRd, the protein encoded by norV, probably triggered the TTP and was highly conservative, functional, and widespread in S. enterica and Enterobacteriaceae. More in vitro and in vivo studies are required to confirm our findings and determine the underlying mechanism.
Collapse
Affiliation(s)
- Zhouhan Wang
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Hao Xu
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Beiqing Gu
- Department of Clinical Laboratory, The First Affiliated Hospital, College of Medicine, Zhejiang University, Haining, China
| | - Yanqi Jin
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Tianyuan Wang
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Jindi Ma
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Yingfeng Lu
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Xiaopeng Yu
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Beiwen Zheng
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Yimin Zhang
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China.,Department of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Haining, China
| |
Collapse
|