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Barcellini W, Fattizzo B. The evolving management algorithm for the patient with newly diagnosed cold agglutinin disease. Expert Rev Hematol 2024; 17:287-294. [PMID: 38872338 DOI: 10.1080/17474086.2024.2366540] [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: 04/04/2024] [Accepted: 06/06/2024] [Indexed: 06/15/2024]
Abstract
INTRODUCTION Cold agglutinin disease (CAD) is driven by IgM autoantibodies reactive at <37°C and able to fix complement. The activation of the classical complement pathway leads to C3-mediated extravascular hemolysis in the liver and to intravascular hemolytic crises in case of complement amplifying conditions. C3 positivity at direct Coombs test along with high titer agglutins are required for the diagnosis. Treatment is less standardized. AREAS COVERED This review recapitulates CAD diagnosis and then focus on the evolving management of the disease. Both current approach and novel targeted drugs are discussed. Literature search was conducted in PubMed and Scopus from 2000 to 2024 using 'CAD' and 'autoimmune hemolytic anemia' as keywords. EXPERT OPINION Rituximab represents the frontline approach in patients with symptomatic anemia or disabling cold-induced peripheral symptoms and is effective in 50-60% of cases. Refractory/relapsing patients are an unmet need and may now benefit from complement inhibitors, particularly the anti-C1s sutimlimab, effective in controlling hemolysis thus improving anemia in >80% of patients, but not active on cold-induced peripheral symptoms. Novel drugs include long-acting complement inhibitors, plasma cells, and B-cell targeting agents (proteasome inhibitors, anti-CD38, BTKi, PI3Ki, anti-BAFF). Combination therapy may be the future answer to CAD unmet needs.
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Affiliation(s)
- Wilma Barcellini
- SC Ematologia, SS Fisiopatologia delle Anemie, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Bruno Fattizzo
- SC Ematologia, SS Fisiopatologia delle Anemie, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
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2
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Elattar KM, Al-Otibi FO, El-Hersh MS, Attia AA, Eldadamony NM, Elsayed A, Menaa F, Saber WI. Multifaceted chemical and bioactive features of Ag@TiO 2 and Ag@SeO 2 core/shell nanoparticles biosynthesized using Beta vulgaris L. extract. Heliyon 2024; 10:e28359. [PMID: 38560145 PMCID: PMC10979172 DOI: 10.1016/j.heliyon.2024.e28359] [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: 12/15/2023] [Revised: 02/25/2024] [Accepted: 03/18/2024] [Indexed: 04/04/2024] Open
Abstract
Due to increasing concerns about environmental impact and toxicity, developing green and sustainable methods for nanoparticle synthesis is attracting significant interest. This work reports the successful green synthesis of silver (Ag), silver-titanium dioxide (Ag@TiO2), and silver-selenium dioxide (Ag@SeO2) nanoparticles (NPs) using Beta vulgaris L. extract. Characterization by XRD, SEM, TEM, and EDX confirmed the successful formation of uniformly distributed spherical NPs with controlled size (25 ± 4.9 nm) and desired elemental composition. All synthesized NPs and the B. vulgaris extract exhibited potent free radical scavenging activity, indicating significant antioxidant potential. However, Ag@SeO2 displayed lower hemocompatibility compared to other NPs, while Ag@SeO2 and the extract demonstrated reduced inflammation in a carrageenan-induced paw edema animal model. Interestingly, Ag@TiO2 and Ag@SeO2 exhibited strong antifungal activity against Rhizoctonia solani and Sclerotia sclerotium, as evidenced by TEM and FTIR analyses. Generally, the findings suggest that B. vulgaris-derived NPs possess diverse biological activities with potential applications in various fields such as medicine and agriculture. Ag@TiO2 and Ag@SeO2, in particular, warrant further investigation for their potential as novel bioactive agents.
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Affiliation(s)
- Khaled M. Elattar
- Unit of Genetic Engineering and Biotechnology, Faculty of Science, Mansoura University, El-Gomhoria Street, Mansoura, 35516, Egypt
| | - Fatimah O. Al-Otibi
- Botany and Microbiology Department, Faculty of Science, King Saud University, Riyadh, 11451, Saudi Arabia
| | - Mohammed S. El-Hersh
- Microbial Activity Unit, Department of Microbiology, Soils, Water and Environment Research Institute, Agricultural Research Center, Giza, 12619, Egypt
| | - Attia A. Attia
- Department of Botany and Microbiology, Faculty of Science, Benha University, Benha, Egypt
| | - Noha M. Eldadamony
- Seed Pathology Department, Plant Pathology Research Institute, Agricultural Research Center, Giza, 12619, Egypt
| | - Ashraf Elsayed
- Botany Department, Faculty of Science, Mansoura University, Elgomhouria St., Mansoura, 35516, Egypt
| | - Farid Menaa
- Department of Biomedical and Environmental Engineering (BEE), Fluorotronics, Inc. California Innovation Corporation, San Diego, CA 92037, USA
| | - WesamEldin I.A. Saber
- Microbial Activity Unit, Department of Microbiology, Soils, Water and Environment Research Institute, Agricultural Research Center, Giza, 12619, Egypt
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Loriamini M, Cserti-Gazdewich C, Branch DR. Autoimmune Hemolytic Anemias: Classifications, Pathophysiology, Diagnoses and Management. Int J Mol Sci 2024; 25:4296. [PMID: 38673882 PMCID: PMC11049952 DOI: 10.3390/ijms25084296] [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: 03/11/2024] [Revised: 04/01/2024] [Accepted: 04/03/2024] [Indexed: 04/28/2024] Open
Abstract
Autoimmune hemolytic anemias (AIHAs) are conditions involving the production of antibodies against one's own red blood cells (RBCs). These can be primary with unknown cause or secondary (by association with diseases or infections). There are several different categories of AIHAs recognized according to their features in the direct antiglobulin test (DAT). (1) Warm-antibody AIHA (wAIHA) exhibits a pan-reactive IgG autoantibody recognizing a portion of band 3 (wherein the DAT may be positive with IgG, C3d or both). Treatment involves glucocorticoids and steroid-sparing agents and may consider IVIG or monoclonal antibodies to CD20, CD38 or C1q. (2) Cold-antibody AIHA due to IgMs range from cold agglutinin syndrome (CAS) to cold agglutin disease (CAD). These are typically specific to the Ii blood group system, with the former (CAS) being polyclonal and the latter (CAD) being a more severe and monoclonal entity. The DAT in either case is positive only with C3d. Foundationally, the patient is kept warm, though treatment for significant complement-related outcomes may, therefore, capitalize on monoclonal options against C1q or C5. (3) Mixed AIHA, also called combined cold and warm AIHA, has a DAT positive for both IgG and C3d, with treatment approaches inclusive of those appropriate for wAIHA and cold AIHA. (4) Paroxysmal cold hemoglobinuria (PCH), also termed Donath-Landsteiner test-positive AIHA, has a DAT positive only for C3d, driven upstream by a biphasic cold-reactive IgG antibody recruiting complement. Although usually self-remitting, management may consider monoclonal antibodies to C1q or C5. (5) Direct antiglobulin test-negative AIHA (DAT-neg AIHA), due to IgG antibody below detection thresholds in the DAT, or by non-detected IgM or IgA antibodies, is managed as wAIHA. (6) Drug-induced immune hemolytic anemia (DIIHA) appears as wAIHA with DAT IgG and/or C3d. Some cases may resolve after ceasing the instigating drug. (7) Passenger lymphocyte syndrome, found after transplantation, is caused by B-cells transferred from an antigen-negative donor whose antibodies react with a recipient who produces antigen-positive RBCs. This comprehensive review will discuss in detail each of these AIHAs and provide information on diagnosis, pathophysiology and treatment modalities.
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Affiliation(s)
- Melika Loriamini
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON M5B 1W8, Canada; (M.L.); (C.C.-G.)
- Centre for Innovation, Canadian Blood Services, Keenan Research Centre, Room 420, 30 Bond Street, Toronto, ON M5B 1W8, Canada
| | - Christine Cserti-Gazdewich
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON M5B 1W8, Canada; (M.L.); (C.C.-G.)
- Laboratory Medicine Program, Blood Transfusion Laboratory, University Health Network, Toronto, ON M5G 2C4, Canada
- Blood Disorders Program, Department of Medical Oncology and Hematology, University Health Network, Toronto, ON M5G 2C4, Canada
| | - Donald R. Branch
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON M5B 1W8, Canada; (M.L.); (C.C.-G.)
- Centre for Innovation, Canadian Blood Services, Keenan Research Centre, Room 420, 30 Bond Street, Toronto, ON M5B 1W8, Canada
- Department of Medicine, University of Toronto, Toronto, ON M5B 1W8, Canada
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4
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Zhao K, Varghese P J G, Chen P, Hu J. Developing a transcatheter injectable nanoclay- alginate gel for minimally invasive procedures. J Mech Behav Biomed Mater 2024; 152:106448. [PMID: 38335649 PMCID: PMC10923083 DOI: 10.1016/j.jmbbm.2024.106448] [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: 12/03/2023] [Revised: 01/16/2024] [Accepted: 01/29/2024] [Indexed: 02/12/2024]
Abstract
Shear-thinning materials have held considerable promise as embolic agents due to their capability of transition between solid and liquid state. In this study, a laponite nanoclay (NC)/alginate gel embolic agent was developed, characterized, and studied for transcatheter based minimally invasive procedures. Both NC and alginate are biocompatible and FDA-approved. Due to electrostatic interactions, the NC/alginate gels exhibit shear-thinning properties that are desirable for transcatheter delivery. The unique shear-thinning nature of the NC/alginate gel allows it to function as a fluid-like substance during transcatheter delivery and as a solid-like embolic agent once deployed. To ensure optimal performance and safety in clinical applications, the rheological characteristics were thoroughly investigated to optimize the mechanical properties of the NC/alginate gel, including storage modulus, yield stress/strain, and thixotropy. To improve physicians' experience and enhance the predictability of gel delivery, a combination of experimental and theoretical approaches was used to assess the injection force required for successful delivery of the gel through clinically employed catheters. Overall, NC/alginate gel exhibited excellent stability and tunable injectability by optimizing the composition of each component. These findings highlight the gel's potential as a robust embolic agent for a wide range of minimally invasive procedures.
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Affiliation(s)
- Keren Zhao
- Department of Mechanical and Aerospace Engineering, North Carolina State University, Raleigh, NC, 27606, USA
| | - George Varghese P J
- Department of Mechanical and Aerospace Engineering, North Carolina State University, Raleigh, NC, 27606, USA
| | - Peng Chen
- Department of Mechanical and Aerospace Engineering, North Carolina State University, Raleigh, NC, 27606, USA
| | - Jingjie Hu
- Department of Mechanical and Aerospace Engineering, North Carolina State University, Raleigh, NC, 27606, USA.
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5
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Tao E, Zhou H, Zheng M, Zhao Y, Zhou J, Yuan J, Yuan T, Zheng C. Ceftriaxone-induced severe hemolytic anemia, renal calculi, and cholecystolithiasis in a 3-year-old child: a case report and literature review. Front Pharmacol 2024; 15:1362668. [PMID: 38560354 PMCID: PMC10978768 DOI: 10.3389/fphar.2024.1362668] [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: 12/28/2023] [Accepted: 02/21/2024] [Indexed: 04/04/2024] Open
Abstract
Ceftriaxone is widely used in pediatric outpatient care for its efficacy against respiratory and digestive system infections, yet its increasing association with severe immune hemolytic reactions requires heightened vigilance from pediatricians. This report details a rare and severe case of ceftriaxone-induced severe immune hemolytic anemia (IHA), hemolytic crisis, myocardial injury, liver injury, renal calculi, and cholecystolithiasis in a previously healthy 3-year-old child. The child, treated for bronchitis, experienced sudden pallor, limb stiffness, and altered consciousness following the fifth day of ceftriaxone infusion, with hemoglobin (Hb) levels precipitously dropping to 21 g/L. Immediate cessation of ceftriaxone and the administration of oxygen therapy, blood transfusion, intravenous immunoglobulin (IVIG), and corticosteroids led to a gradual recovery. Despite initial improvements, the patient's condition necessitated extensive hospital care due to complications including myocardial injury, liver injury, renal calculi, and cholecystolithiasis. After a 12-day hospital stay and a 3-month follow-up, the child showed complete normalization of Hb and liver function and resolution of calculi. In children, ceftriaxone infusion may trigger severe, potentially fatal, hemolytic reactions. Pediatricians must promptly recognize symptoms such as pallor, limb stiffness, and unresponsiveness, indicative of ceftriaxone-induced severe IHA, and immediately discontinue the drug. Effective management includes timely blood transfusion, respiratory support, IVIG administration, and corticosteroids when necessary, along with rigorous vital signs monitoring. Continued vigilance is imperative, even after cessation of ceftriaxone, to promptly address any residual adverse effects.
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Affiliation(s)
- Enfu Tao
- Department of Neonatology and NICU, Wenling Maternal and Child Healthcare Hospital, Wenling, Zhejiang Province, China
| | - Huangjia Zhou
- Department of Pediatrics, Wenling Maternal and Child Healthcare Hospital, Wenling, Zhejiang Province, China
| | - Meili Zheng
- Department of Pediatrics, Wenling Maternal and Child Healthcare Hospital, Wenling, Zhejiang Province, China
| | - Yisha Zhao
- Department of Pediatrics, Wenling Maternal and Child Healthcare Hospital, Wenling, Zhejiang Province, China
| | - Junfen Zhou
- Department of Pediatrics, Wenling Maternal and Child Healthcare Hospital, Wenling, Zhejiang Province, China
| | - Junhui Yuan
- Department of Pediatrics, Wenling Maternal and Child Healthcare Hospital, Wenling, Zhejiang Province, China
| | - Tianming Yuan
- Department of Neonatology, Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, National Children’s Regional Medical Center, Hangzhou, Zhejiang Province, China
| | - Changhua Zheng
- Department of Pediatrics, Wenling Maternal and Child Healthcare Hospital, Wenling, Zhejiang Province, China
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6
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Barcellini W, Fattizzo B. Novel pharmacotherapy for drug-induced immune hemolytic anemia. Expert Opin Pharmacother 2023; 24:1927-1931. [PMID: 38037866 DOI: 10.1080/14656566.2023.2291075] [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] [Received: 10/13/2023] [Accepted: 11/22/2023] [Indexed: 12/02/2023]
Affiliation(s)
- Wilma Barcellini
- Hematology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Bruno Fattizzo
- Hematology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
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7
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Balaja W, Schmidt P, Fenando A. Cold agglutinin disease: A case report with atypical clinical findings. SAGE Open Med Case Rep 2023; 11:2050313X231191899. [PMID: 37654547 PMCID: PMC10467205 DOI: 10.1177/2050313x231191899] [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: 07/06/2023] [Accepted: 07/17/2023] [Indexed: 09/02/2023] Open
Abstract
A female in her 60s presented to the allergy and immunology clinic for further investigation of ongoing dermatitis. She presented with chronic acrocyanosis, mainly in her left lower extremity, extending distally from her mid thigh with concurrent ulcerations in her foot resulting in immobility secondary to pain. She experienced these symptoms for years without a definitive diagnosis. The lack of diagnosis was due, in part, to her atypical symptoms and laboratory findings that required a high level of clinical suspicion to diagnose. Extensive autoimmune workup was largely unrevealing with the exception of a cold agglutinin titer of 1:250 and a positive anticomplement C3b direct antiglobulin test. A diagnosis of cold agglutinin disease was made and treatment with rituximab monotherapy was initiated.
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Affiliation(s)
- Warren Balaja
- Department of Rheumatology & Internal Medicine, University of Kansas School of Medicine, Kansas City, KS, USA
| | - Paul Schmidt
- Department of Rheumatology & Internal Medicine, University of Kansas School of Medicine, Kansas City, KS, USA
| | - Ardy Fenando
- Department of Rheumatology & Internal Medicine, University of Kansas School of Medicine, Kansas City, KS, USA
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8
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Bortolotti M, Barcellini W, Fattizzo B. Molecular pharmacology in complement-mediated hemolytic disorders. Eur J Haematol 2023. [PMID: 37308291 DOI: 10.1111/ejh.14026] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 05/30/2023] [Accepted: 06/01/2023] [Indexed: 06/14/2023]
Abstract
In the last decade, a deeper understanding of the pathogenesis of complement mediated hemolytic disorders, such as paroxysmal nocturnal hemoglobinuria (PNH), cold agglutinin disease (CAD), warm type autoimmune hemolytic anemia (AIHA) with complement activation (wAIHA), and atypical hemolytic uremic syndrome (aHUS), paved the way to the therapeutic shift from purely supportive approaches to complement-targeted therapies. This resulted in a significant improvement in disease management, survival, and quality of life. In this review, we will provide a snapshot of novel therapies for complement-mediated hemolytic anemias with a focus on those ready to use in clinical practice. C5 inhibitors eculizumab and the long-acting ravulizumab, are the established gold standard for untreated PNH patients, whilst the C3 inhibitor pegcetacoplan should be considered for suboptimal responders to anti-C5 drugs. Several additional compounds targeting the complement cascade at different levels (other C5 inhibitors, factor B and D inhibitors) are under active investigation with promising results. In CAD, immunosuppression with rituximab remains the first-line. However, recently FDA and EMA approved the anti-C1s monoclonal antibody, sutimlimab, that showed dramatic responses and whose regulatory approval is soon awaited in many countries. Other drugs under investigation in AIHA include the C3 inhibitor pegcetacoplan, and the anti-C1q ANX005 for warm AIHA with complement activation. Finally, aHUS is an indication for complement inhibitors. Eculizumab and ravulizumab have been approved, whilst other C5 inhibitors, and novel lectin pathway inhibitors are under active investigation in this disease.
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Affiliation(s)
- Marta Bortolotti
- Hematology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Oncology and Oncohematology, University of Milan, Milan, Italy
| | - Wilma Barcellini
- Hematology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Bruno Fattizzo
- Hematology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Oncology and Oncohematology, University of Milan, Milan, Italy
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Liu J, Dong S, Ru Y. Ultrastructural analysis of nucleated erythrocyte in patients with autoimmune hemolytic anemia (AIHA). Ultrastruct Pathol 2023:1-7. [PMID: 37158191 DOI: 10.1080/01913123.2023.2211358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
Autoimmune hemolytic anemia (AIHA) is a group of diseases characterized by immune-mediated lysis of mature red blood cells (RBCs). It is mainly classified into primary and secondary types based on etiology and mechanisms underlying autoantibody production. AIHA is diagnosed using morphological observation of bone marrow smears under a light microscope and monospecific direct antiglobulin test to detect hemolysis. Here, we retrospectively studied ultrastructural abnormalities of nucleated erythroid cells in bone marrows from 10 patients with AIHA using transmission electron microscopy. Our results revealed severe damage and injury to nucleated erythroid cells, including morphological irregularity, pyknosis, karyolysis, expansion of perinuclear cisternae and cytoplasmic lysis. These results indicate that aberrant immunity attacks not only mature RBCs but also nucleated erythroid cells, and ineffective hematopoiesis is partly involved in the pathogenesis of AIHA.
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Affiliation(s)
- Jing Liu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Shuxu Dong
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Yongxin Ru
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
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Fattizzo B, Bortolotti M, Fantini NN, Glenthøj A, Michel M, Napolitano M, Raso S, Chen F, McDonald V, Murakhovskaya I, Vos JMI, Patriarca A, Mingot-Castellano ME, Giordano G, Scarrone M, González-López TJ, Trespidi L, Prati D, Barcellini W. Autoimmune hemolytic anemia during pregnancy and puerperium: an international multicenter experience. Blood 2023; 141:2016-2021. [PMID: 36706358 PMCID: PMC10646778 DOI: 10.1182/blood.2022018890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 12/20/2022] [Accepted: 01/04/2023] [Indexed: 01/28/2023] Open
Abstract
Relapsing or occurring de novo autoimmune hemolytic anemia (AIHA) during pregnancy or puerperium is a poorly described condition. Here, we report 45 pregnancies in 33 women evaluated at 12 centers from 1997 to 2022. Among the 20 women diagnosed with AIHA before pregnancy, 10 had a relapse. An additional 13 patients developed de novo AIHA during gestation/puerperium (2 patients had AIHA relapse during a second pregnancy). Among 24 hemolytic events, anemia was uniformly severe (median Hb, 6.4 g/dL; range, 3.1-8.7) and required treatment in all cases (96% steroids ± intravenous immunoglobulin, IVIG, 58% transfusions). Response was achieved in all patients and was complete in 65% of the cases. Antithrombotic prophylaxis was administered to 8 patients (33%). After delivery, rituximab was administered to 4 patients, and cyclosporine was added to 1 patient. The rate of maternal complications, including premature rupture of membranes, placental detachment, and preeclampsia, was 15%. Early miscarriages occurred in 13% of the pregnancies. Fetal adverse events (22% of cases) included respiratory distress, fetal growth restriction, preterm birth, AIHA of the newborn, and 2 perinatal deaths. In conclusion, the occurrence of AIHA does not preclude the ability to carry out a healthy pregnancy, provided close monitoring, prompt therapy, and awareness of potential maternal and fetal complications.
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Affiliation(s)
- Bruno Fattizzo
- Hematology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Oncology and Oncohematology, University of Milan, Milan, Italy
| | - Marta Bortolotti
- Hematology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Oncology and Oncohematology, University of Milan, Milan, Italy
| | - Norma N. Fantini
- Department of Transfusion Medicine and Hematology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Andreas Glenthøj
- Department of Hematology, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Marc Michel
- Centre de Référence Maladies Rares sur les Cytopénies Auto-Immunes de l'Adulte, Centre Hospitalier Universitaire Henri Mondor, Assistance Publique-Hôpitaux de Paris, Créteil Université ParisEst Créteil, Paris, France
| | - Mariasanta Napolitano
- Hematology Unit, Thrombosis and Hemostasis Reference Regional Center, University of Palermo, Palermo, Italy
| | - Simona Raso
- Department of Hematology and Rare Diseases, Azienda Ospedaliera Ospedali Riuniti Villa Sofia-Cervello, Palermo, Italy
| | - Frederick Chen
- Clinical Hematology, Barts Health National Health Service Trust, Queen Mary University, London, United Kingdom
| | - Vickie McDonald
- Clinical Hematology, Barts Health National Health Service Trust, Queen Mary University, London, United Kingdom
| | - Irina Murakhovskaya
- Department of Hematology and Oncology, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY
| | - Josephine Mathilde Iris Vos
- Department of Hematology, Amsterdam University Medical Center, University of Amsterdam, Sanquin, Amsterdam, The Netherlands
| | - Andrea Patriarca
- Department of Translational Medicine, Azienda Ospedaliera-Universitaria “Maggiore della Carità,” University of Eastern Piedmont, Novara, Italy
| | | | - Giulio Giordano
- UOC Medicina, Servizio e Ambulatorio di Ematologia Ospedale di Riferimento Regionale “Antonio Cardarelli,” Campobasso, Italy
| | - Margherita Scarrone
- Department of Obstetrics and Gynecology, Fondazione Ca Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Laura Trespidi
- Department of Obstetrics and Gynecology, Fondazione Ca Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Daniele Prati
- Department of Transfusion Medicine and Hematology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Wilma Barcellini
- Hematology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
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11
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Fattizzo B, Motta I. Rise of the planet of rare anemias: An update on emerging treatment strategies. Front Med (Lausanne) 2023; 9:1097426. [PMID: 36698833 PMCID: PMC9868867 DOI: 10.3389/fmed.2022.1097426] [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: 11/13/2022] [Accepted: 12/14/2022] [Indexed: 01/12/2023] Open
Abstract
Therapeutic options for rare congenital (hemoglobinopathies, membrane and enzyme defects, congenital dyserythropoietic anemia) and acquired anemias [warm autoimmune hemolytic anemia (wAIHA), cold agglutinin disease CAD, paroxysmal nocturnal hemoglobinuria (PNH), and aplastic anemia (AA)] are rapidly expanding. The use of luspatercept, mitapivat and etavopivat in beta-thalassemia and pyruvate kinase deficiency (PKD) improves transfusion dependence, alleviating iron overload and long-term complications. Voxelotor, mitapivat, and etavopivat reduce vaso-occlusive crises in sickle cell disease (SCD). Gene therapy represents a fascinating approach, although patient selection, the toxicity of the conditioning regimens, and the possible long-term safety are still open issues. For acquired forms, wAIHA and CAD will soon benefit from targeted therapies beyond rituximab, including B-cell/plasma cell targeting agents (parsaclisib, rilzabrutinib, and isatuximab for wAIHA), complement inhibitors (pegcetacoplan and sutimlimab for CAD, ANX005 for wAIHA with complement activation), and inhibitors of extravascular hemolysis in the reticuloendothelial system (fostamatinib and FcRn inhibitors in wAIHA). PNH treatment is moving from the intravenous anti-C5 eculizumab to its long-term analog ravulizumab, and to subcutaneous and oral proximal inhibitors (anti-C3 pegcetacoplan, factor D and factor B inhibitors danicopan and iptacopan). These drugs have the potential to improve patient convenience and ameliorate residual anemia, although patient compliance becomes pivotal, and long-term safety requires further investigation. Finally, the addition of eltrombopag significantly ameliorated AA outcomes, and data regarding the alternative agent romiplostim are emerging. The accelerated evolution of treatment strategies will need further effort to identify the best candidate for each treatment in the precision medicine era.
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Affiliation(s)
- Bruno Fattizzo
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, SC Ematologia, Milan, Italy,Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy,*Correspondence: Bruno Fattizzo,
| | - Irene Motta
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, SC Medicina ad Indirizzo Metabolico, Milan, Italy,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
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Berentsen S, Fattizzo B, Barcellini W. The choice of new treatments in autoimmune hemolytic anemia: how to pick from the basket? Front Immunol 2023; 14:1180509. [PMID: 37168855 PMCID: PMC10165002 DOI: 10.3389/fimmu.2023.1180509] [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: 03/06/2023] [Accepted: 04/13/2023] [Indexed: 05/13/2023] Open
Abstract
Autoimmune hemolytic anemia (AIHA) is defined by increased erythrocyte turnover mediated by autoimmune mechanisms. While corticosteroids remain first-line therapy in most cases of warm-antibody AIHA, cold agglutinin disease is treated by targeting the underlying clonal B-cell proliferation or the classical complement activation pathway. Several new established or investigational drugs and treatment regimens have appeared during the last 1-2 decades, resulting in an improvement of therapy options but also raising challenges on how to select the best treatment in individual patients. In severe warm-antibody AIHA, there is evidence for the upfront addition of rituximab to prednisolone in the first line. Novel agents targeting B-cells, extravascular hemolysis, or removing IgG will offer further options in the acute and relapsed/refractory settings. In cold agglutinin disease, the development of complement inhibitors and B-cell targeting agents makes it possible to individualize therapy, based on the disease profile and patient characteristics. For most AIHAs, the optimal treatment remains to be found, and there is still a need for more evidence-based therapies. Therefore, prospective clinical trials should be encouraged.
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Affiliation(s)
- Sigbjørn Berentsen
- Department of Research and Innovation, Haugesund Hospital, Helse Fonna Hospital Trust, Haugesund, Norway
- *Correspondence: Sigbjørn Berentsen,
| | - Bruno Fattizzo
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, and Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Wilma Barcellini
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
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Kuter DJ. Warm autoimmune hemolytic anemia and the best treatment strategies. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2022; 2022:105-113. [PMID: 36485114 PMCID: PMC9821065 DOI: 10.1182/hematology.2022000405] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Warm autoimmune hemolytic anemia (wAIHA) is characterized by evidence of red blood cell (RBC) hemolysis and a direct antiglobulin test positive for IgG and sometimes complement. While varying with the extent of the compensatory increase in RBC production, symptoms of anemia predominate, as does jaundice, the latter often exacerbated by concurrent Gilbert's syndrome. Initial treatment with corticosteroids is highly effective, with over 85% of patients responding but with less than one-third maintaining that response upon weaning. Subsequent rituximab administration in those failing corticosteroids provides complete remission in over 75% of patients and may be long-lasting. Over 50% of patients failing rituximab respond to erythropoiesis-stimulating agents or immunosuppressive agents. Splenectomy is best deferred if possible but does offer long-term remission in over two-thirds of patients. A number of new treatments for wAIHA (fostamatinib, rilzabrutinib, and FcRn inhibitors) show promise. A treatment algorithm for wAIHA is proposed to avoid the excessive use of corticosteroids.
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Affiliation(s)
- David J. Kuter
- Correspondence David J. Kuter, Hematology Division, Massachusetts General Hospital, Ste 118, Rm 110, Zero Emerson Pl, Boston, MA 02114; e-mail:
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